Classification of Young Children's Sleep Problems: A Pilot Study

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<ul><li><p>The psychosocial and cultural contexts in which youngchildrens sleep patterns and bedtime routines developinfluence how sleep problems are defined. It is importantto consider how parentchild bedtime and middle-of-thenight interactions change with age and differ across ethnicand socioeconomic groups. Is night waking a problemonly when the child disturbs the parents sleep? At whatage should children sleep through the night? Whenshould cosleeping be considered a problem? Researchersand clinicians have only recently begun to systematicallydefine terms, describe cultural practices, and conductempirical assessments of developmental changes. Varyingviews about what constitutes a sleep disorder during thefirst few years of life persist.</p><p>In this report, preliminary results of a pilot study arepresented that attempt to systematically quantify sleepbehaviors in toddlers. A nosology that modifies DSM-IVdyssomnia criteria for younger children (aged 1248</p><p>months) is described. Because young children rarelymeet strict DSM-IV criteria for diagnosis, the term pro-todyssomnias is used, suggesting a potential precursor of alater full-blown dyssomnia. Finally, a potential earlyindicator of later sleep disruption is reported.</p><p>Current Classification Schemes</p><p>The DSM-IV (American Psychiatric Association, 1994)defines dyssomnias as a group of disorders characterized bydifficulty in initiating or maintaining sleep. Few infantsand toddlers meet the impairment and/or severity criterianecessary to make a definitive DSM-IV diagnosis. TheInternational Classification of Sleep Disorders: Diagnosticand Coding Manual (ICSD-DCM) (American Sleep Dis-orders Association, 1990) subclassifies extrinsic sleep dis-orders into categories using terms such as inadequate sleephygiene, adjustment sleep disorder, insufficient sleep syndrome,or sleep onset association disorder. For each of these syn-dromes there are duration and acuity criteria; however,some of the labels are cumbersome and the criteria areneither empirically nor developmentally determined.Moreover, family health practitioners generally are notfamiliar with the ICSD-DCM. The Diagnostic Classifica-tion of Mental Health and Developmental Disorders ofInfancy and Early Childhood (DC 03) (Zero to Three,1994) is yet another nosology, developed by infancy spe-cialists, that focuses on young children from birth to 3</p><p>Classification of Young Childrens Sleep Problems:A Pilot Study</p><p>ERIKA E. GAYLOR, M.S., BETH L. GOODLIN-JONES, PH.D., AND THOMAS F. ANDERS, M.D.</p><p>ABSTRACT</p><p>Objectives: This study examines videotaped sleep in infancy in an attempt to predict the development of disturbed sleep</p><p>during toddlerhood. In addition, a tentative classification scheme that quantifies night waking and sleep onset problems in</p><p>young children is proposed. Method: The sleep patterns of 33 children were assessed at two points in time. At 12 months</p><p>of age (time 1), sleep was videotaped on two consecutive nights. A self-soothing/signaling index for 12-month-olds was</p><p>constructed. At time 2 (mean age = 39 months), a follow-up telephone interview assessed current sleep patterns and the</p><p>presence or absence of sleep problems. Results: The data suggest that the self-soothing/signaling index obtained at 12</p><p>months of age predicts night waking approximately 2 years later. Conclusions: The preliminary classification scheme for</p><p>night waking and sleep onset problems in young children warrants further study. Night waking in toddlers might be predict-</p><p>able from sleep behaviors at 1 year of age. J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(1):6167. Key Words: sleep</p><p>disorders, young children, classification.</p><p>J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 40 :1 , JANUARY 2001 61</p><p>Accepted July 14, 2000.From the Family-Infant Development Laboratory, Department of Psychiatry,</p><p>University of California, Davis.Supported, in part, by the Hibbard E. Williams Fund, UC Davis (Dr. Goodlin-</p><p>Jones) and MH50741 (Dr. Anders).The authors thank the families for their participation.Reprint requests to Dr. Goodlin-Jones, Department of Psychiatry, UCDMC,</p><p>2230 Stockton Blvd., Sacramento, CA 95817; e-mail: blgoodlinjones@ucdavis.edu.0890-8567/01/4001-0061q2001 by the American Academy of Child</p><p>and Adolescent Psychiatry.</p></li><li><p>years. Again, there are no empirically derived, quantitativemetrics in the DC 03 to aid in classification of sleep prob-lems. Richman (1981) published criteria that defined ageneric infant sleep disorder. Her criteria include nightwaking 3 or more times per night, cosleeping with a par-ent, 20 minutes of awake time during the night, or requir-ing parental presence to fall asleep/refusing to go to bed formore than 30 minutes. Symptoms must be present 5 to 7nights per week and for a 3-month duration. A compositescore is derived that distinguishes between severe, mod-erate, and mild sleep problems (Richman, 1981, 1985).These criteria have been used in several research studies butgenerally have not been used by clinicians. It is importantto develop an age-appropriate and culturally sensitive clas-sification scheme that can be used reliably by researchersand clinicians alike. Using DSM-IV as a prototype poten-tially ensures wide dissemination and acceptance.</p><p>Sleep Problems in Infants and Toddlers</p><p>Previous research has documented several develop-mental trends in young childrens sleep habits. Most mea-surements have focused on frequency and duration ofnight waking, and/or sleep onset difficulties (Lozoff et al.,1984; Richman, 1981; Wolke et al., 1995; Zuckermanet al., 1987), the most common sleep concerns of parents(Ferber, 1985, 1987). The rates of these problems are highin toddlers (Beltramini and Hertzig, 1983; Kataria et al.,1987; Ragins and Schachter, 1971). It also appears thatsleep problems, once present, tend to persist through earlychildhood, with percentages ranging from 25% to 84%over a 3-year period (Jenkins et al., 1984; Kataria et al.,1987; Van Tassel, 1985; Wolke et al., 1995; Zuckermanet al., 1987).</p><p>In general, it appears that the prevalence of sleepproblems during early childhood is remarkably similarthroughout industrialized nations. For example, largesurveys in Australia, the United States, and Israel consis-tently report sleep problem rates between 28% and 35%(Armstrong et al., 1994; Johnson, 1991; Scher et al.,1995). What is still unclear is what predicts the devel-opment and maintenance of a sleep problem.</p><p>There are two current unresolved controversies in thechildhood sleep problems literature: First, should paren-tal distress about the childs sleep be the primary criterionfor diagnosis? Second, under what circumstances shouldcosleeping be considered a problem? Cosleeping patternsdiffer by culture, the childs age, socioeconomic status,and even region (Crowell et al., 1987; Elias et al., 1986;</p><p>Lozoff et al., 1984; Madansky and Edelbrock, 1990;Wolf and Lozoff, 1989). Moreover, cosleeping can eitherbe a reaction to a childs sleep problem or proactivelyadopted as a primary child-rearing style. In this report,both observed and reported behaviors are used and co-sleeping is considered problematic only when reactive.</p><p>Video Recording</p><p>Time-lapse video recordings of sleep onset and nightwaking behaviors have demonstrated that night awaken-ings per se do not constitute a sleep problem (Anders andKeener, 1985). Infants, on average, tend to wake two tothree times per night during the first year of life. Seventypercent of 1-year-olds, however, are able to self-sootheback to sleep after a middle-of-the-night awakeningwithout alerting their parents. It is the 30% of signalinginfants, who cry after an awakening, that are likely to beidentified as having a sleep problem by their parents(Anders et al., 1992; Goodlin-Jones et al., 1997). Thus, itis the signaling behavior, not the awakening per se thatconcerns the parents and defines the problem. Theseresults have been confirmed by others (Minde et al.,1993; Sadeh et al., 1991).</p><p>It is not clear yet what predicts a self-soothing or signal-ing response at 1 year of age. The video studies suggestthat an important correlate of middle-of-the-night signal-ing is the manner of falling asleep at bedtime. If an infantis customarily rocked or fed while falling asleep, and thenplaced into the crib already asleep, there is a seeminglylearned expectation that this routine will be repeatedafter a middle-of-the-night awakening. If, on the otherhand, the infant is routinely put into the crib awake at thebeginning of the night and falls asleep on its own, thenmiddle-of-the-night awakenings usually result in a self-soothing return to sleep. This relationship between sleeponset interaction patterns and responses after a middle-of-the-night awakening (signaling versus self-soothing) canbe observed as early as 6 months of age (Goodlin-Joneset al., 1997).</p><p>A Provisional Developmental Classification Scheme</p><p>A developmental classification scheme for toddlers andyoung children that relates to the category of dyssomniain DSM-IV has been proposed. It should be empiricallytested to become useful for clinicians (Anders et al.,2000). The syndrome of difficulty in initiating sleep islabeled sleep onset protodyssomnia, and the syndrome ofdifficulty in maintaining sleep is termed night waking pro-</p><p>GAYLOR ET AL.</p><p>62 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 40 :1 , JANUARY 2001</p></li><li><p>todyssomnia. The proposed scheme quantifies symptomsby age and controls for duration and severity by furtherdefining each of the two protodyssomnias as a perturba-tion, disturbance, or disorder (Anders, 1989). This subclas-sification provides an intensity and duration componentpermitting the tracking of nonclinical cases, which areoften present in young children (Cantwell, 1996). Fur-thermore, these three levels are aligned with those of mild,moderate, and severe in DSM-IV. The quantitative crite-ria for classifying night waking and sleep onset protodys-somnias are presented in Tables 1 and 2.</p><p>Perturbations are part of normal development. Inter-ventions are not indicated. Disturbances are consideredrisk conditions. The assumption is that if no interven-tion occurs, it may likely progress to a disorder. Interven-tions are brief in duration and usually educational in</p><p>nature. Disorders are considered more serious and requiremore active, therapeutic intervention. If untreated, it ishypothesized that protodyssomnia disorders are likely toprogress to full-blown DSM-IV disorders and/or generalizeinto a broader array of behavioral symptoms and diag-noses. It is useful to distinguish these three subclasses ofprotodyssomnia to understand better the natural historyand response to treatment of the currently broadly de-fined childhood sleep problem.</p><p>Sleep onset protodyssomnias are associated with parentchild interactions that are labeled reunions in order tocapture the similarity between these bedtime interactionsand the separation-reunion concept of attachment re-search (Anders et al., 2000). Reunions may involve thechilds request for another glass of water, bedtime story,or one more final hug. Multiple reunions or continued</p><p>CLASSIFYING SLEEP PROBLEMS IN CHILDREN</p><p>J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 40 :1 , JANUARY 2001 63</p><p>TABLE 1Classification of Night Waking Protodyssomniaa in Young Children</p><p>Frequency and Duration of Night-Time Awakeningsb</p><p>(in the Past 3 Months)</p><p>Perturbation (1 episode/wk)1224 mo of age 2 AW/night and/or removalc2436 mo of age 1 AW/night and/or removal&gt;36 mo of age 1 AW/night and/or removal</p><p>Disturbance (24 episodes/wk for longer than 1 mo)1224 mo of age 2 AW/night and/or removal2436 mo of age 1 AW/night and/or removal&gt;36 mo of age 1 AW/night and/or removal</p><p>Disorder (57 episodes/wk for longer than 1 mo)1224 mo of age 2 AW/night and/or removal2436 mo of age 1 AW/night and/or removal&gt;36 mo of age 1 AW/night and/or removal</p><p>a Occurs after infant has been asleep for more than 10 minutes.b Awakenings (AW) that require parental intervention.c Removal to parental bed.</p><p>TABLE 2Classification of Sleep Onset Protodyssomniaa in Young Children</p><p>Settling to Sleep and Reunionsb</p><p>Perturbation (1 episode/wk)1224 mo of age &gt;30 min to fall asleep, and/or parent remains in room for sleep onset, and/or &gt;2 reunions&gt;24 mo of age &gt;20 min to fall asleep, and/or parent remains in room for sleep onset, and/or &gt;1 reunion</p><p>Disturbance (24 episodes/wk for longer than 1 mo)1224 mo of age &gt;30 min to fall asleep, and/or parent remains in room for sleep onset, and/or &gt;2 reunions&gt;24 mo of age &gt;20 min to fall asleep, and/or parent remains in room for sleep onset, and/or &gt;1 reunion</p><p>Disorder (57 episodes/wk for longer than 1 mo)1224 mo of age &gt;30 min to fall asleep, and/or parent remains in room for sleep onset, and/or &gt;2 reunions&gt;24 mo of age &gt;20 min to fall asleep, and/or parent remains in room for sleep onset, and/or &gt;1 reunion</p><p>a Occurs at bedtime or naptime.b Reunions reflect resistances going to bed (e.g., repeated bids, protests, struggles).</p></li><li><p>parental presence to fall asleep are the basis for classifyinga sleep onset protodyssomnia (Anders and Eiben, 1997).Even though reunions may not be bothersome to somefamilies, and vary by culture, it is nevertheless importantto quantify these bedtime interactions to assess their rela-tionship to other nighttime and daytime behaviors.</p><p>Attachment research focuses on the parentinfant rela-tionship, and our terminology attempts to capture theflavor of the attachment relationship in sleep interac-tions. Although one parent may be more or less anxiousthan another, or one infant may be more sensitive tostimuli than another, each partner of the dyad interactswith the other to establish the nighttime relationship.</p><p>The nosology contains three caveats: A protodyssomniais not diagnosed before 1 year of age because sleep-wakepatterns, parental attitudes and responses, and environ-mental factors are too fluid (Anders et al., 1992; Andersand Keener, 1985). Second, the criteria do not apply tocosleeping families for whom cosleeping is preferred. Reac-tive cosleeping, on the other hand, is one of the responsesthat families use to ameliorate disrupted sleep and isincluded in the classification. Finally, the nosology doesnot require parental complaint.</p><p>METHOD</p><p>Subjects were 40 full-term, normally developing infants and theirfamilies. The families had been recruited from childbirth classes,pediatric practices, and media announcements. They began the studyduring the first year of their infants life and continued to the firstbirthday. A follow-up protocol was not part of the original study. Sixof the initial 40 families could not be located at follow-up and onedeclined to participate, resulting in 33 children (83%). No apparentdifferences distinguished the families who participated from thosewho were lost. Informed consent was obtained for both protocols.</p><p>The study is prospective, reporting on sleep-wake behavior at 2 ages.Time 1 uses video recordings obtained at 12 months of age, and time 2uses a structured telephone interview obtained between 24 and 57(mean = 39) months of...</p></li></ul>

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