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The psychosocial and cultural contexts in which youngchildren’s sleep patterns and bedtime routines developinfluence how sleep problems are defined. It is importantto consider how parent–child 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 parent’s 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.

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 12–48

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.

Current Classification Schemes

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 0–3) (Zero to Three,1994) is yet another nosology, developed by infancy spe-cialists, that focuses on young children from birth to 3

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

ERIKA E. GAYLOR, M.S., BETH L. GOODLIN-JONES, PH.D., AND THOMAS F. ANDERS, M.D.

ABSTRACT

Objectives: This study examines videotaped sleep in infancy in an attempt to predict the development of disturbed sleep

during toddlerhood. In addition, a tentative classification scheme that quantifies night waking and sleep onset problems in

young children is proposed. Method: The sleep patterns of 33 children were assessed at two points in time. At 12 months

of age (time 1), sleep was videotaped on two consecutive nights. A self-soothing/signaling index for 12-month-olds was

constructed. At time 2 (mean age = 39 months), a follow-up telephone interview assessed current sleep patterns and the

presence or absence of sleep problems. Results: The data suggest that the self-soothing/signaling index obtained at 12

months of age predicts night waking approximately 2 years later. Conclusions: The preliminary classification scheme for

night waking and sleep onset problems in young children warrants further study. Night waking in toddlers might be predict-

able from sleep behaviors at 1 year of age. J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(1):61–67. Key Words: sleep

disorders, young children, classification.

J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 40 :1 , JANUARY 2001 61

Accepted July 14, 2000.From the Family-Infant Development Laboratory, Department of Psychiatry,

University of California, Davis.Supported, in part, by the Hibbard E. Williams Fund, UC Davis (Dr. Goodlin-

Jones) and MH50741 (Dr. Anders).The authors thank the families for their participation.Reprint requests to Dr. Goodlin-Jones, Department of Psychiatry, UCDMC,

2230 Stockton Blvd., Sacramento, CA 95817; e-mail: [email protected]/01/4001-0061q2001 by the American Academy of Child

and Adolescent Psychiatry.

years. Again, there are no empirically derived, quantitativemetrics in the DC 0–3 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.

Sleep Problems in Infants and Toddlers

Previous research has documented several develop-mental trends in young children’s 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).

In general, it appears that the prevalence of sleep“problems” 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.

There are two current unresolved controversies in thechildhood sleep problems literature: First, should paren-tal distress about the child’s sleep be the primary criterionfor diagnosis? Second, under what circumstances shouldcosleeping be considered a problem? Cosleeping patternsdiffer by culture, the child’s age, socioeconomic status,and even region (Crowell et al., 1987; Elias et al., 1986;

Lozoff et al., 1984; Madansky and Edelbrock, 1990;Wolf and Lozoff, 1989). Moreover, cosleeping can eitherbe a reaction to a child’s 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.

Video Recording

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).

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 seemingly“learned” 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).

A Provisional Developmental Classification Scheme

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-

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62 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 40 :1 , JANUARY 2001

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.

Perturbations are part of normal development. Inter-ventions are not indicated. Disturbances are considered“risk” 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

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.”

Sleep onset protodyssomnias are associated with parent–child 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 thechild’s request for another glass of water, bedtime story,or one more final hug. Multiple reunions or continued

CLASSIFYING SLEEP PROBLEMS IN CHILDREN

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 40 :1 , JANUARY 2001 63

TABLE 1Classification of Night Waking Protodyssomniaa in Young Children

Frequency and Duration of Night-Time Awakeningsb

(in the Past 3 Months)

Perturbation (1 episode/wk)12–24 mo of age ≥2 AW/night and/or removalc

24–36 mo of age ≥1 AW/night and/or removal>36 mo of age ≥1 AW/night and/or removal

Disturbance (2–4 episodes/wk for longer than 1 mo)12–24 mo of age ≥2 AW/night and/or removal24–36 mo of age ≥1 AW/night and/or removal>36 mo of age ≥1 AW/night and/or removal

Disorder (5–7 episodes/wk for longer than 1 mo)12–24 mo of age ≥2 AW/night and/or removal24–36 mo of age ≥1 AW/night and/or removal>36 mo of age ≥1 AW/night and/or removal

a Occurs after infant has been asleep for more than 10 minutes.b Awakenings (AW) that require parental intervention.c Removal to parental bed.

TABLE 2Classification of Sleep Onset Protodyssomniaa in Young Children

Settling to Sleep and Reunionsb

Perturbation (1 episode/wk)12–24 mo of age >30 min to fall asleep, and/or parent remains in room for sleep onset, and/or >2 reunions>24 mo of age >20 min to fall asleep, and/or parent remains in room for sleep onset, and/or >1 reunion

Disturbance (2–4 episodes/wk for longer than 1 mo)12–24 mo of age >30 min to fall asleep, and/or parent remains in room for sleep onset, and/or >2 reunions>24 mo of age >20 min to fall asleep, and/or parent remains in room for sleep onset, and/or >1 reunion

Disorder (5–7 episodes/wk for longer than 1 mo)12–24 mo of age >30 min to fall asleep, and/or parent remains in room for sleep onset, and/or >2 reunions>24 mo of age >20 min to fall asleep, and/or parent remains in room for sleep onset, and/or >1 reunion

a Occurs at bedtime or naptime.b Reunions reflect resistances going to bed (e.g., repeated bids, protests, struggles).

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.

Attachment research focuses on the parent–infant 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.

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.

METHOD

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 infant’s 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.

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 age. The range of ages at time 2 resulted becausefamilies were recruited initially over a 3-year period and the follow-upinterview was completed during one 3-month period. The classificationof protodyssomnias was made using the telephone reports obtained attime 2.

The sample was highly educated, with most parents having eithera college or advanced/professional degree (78%) and middle- toupper-class status (83%) according to Hollingshead’s 2-factor model(Hollingshead, 1975). The average age of mothers at time 1 was 32years (range = 19–42 years). The ethnic distribution was 80% white,12.5% Asian/Pacific Islander, 5% Hispanic, and 2.5% AfricanAmerican.

Time 1

The time 1 data included two consecutive nights of sleep for eachinfant recorded at home with time-lapse video equipment. The

video equipment had been used at earlier ages so both parents andinfants were familiar with its presence. A detailed description of thismethod, including the coding of sleep-wake states reliably, has beenpresented elsewhere (Anders and Sostek, 1976; Goodlin-Jones et al.,1997). This report focuses on the manner in which infants fell asleepat the beginning of the night and whether they responded with self-soothing or signaling after a middle-of-the-night awakening.

Signaling is defined as an awakening that requires parental inter-vention to return to sleep, including the possibility of removal to theparent’s bed. Since only a few 12-month-old infants were consistentthroughout the whole night, and between two consecutive nights, interms of self-soothing or signaling after middle-of-the-nightawakenings, a self-soothing index (SSI) for each night was computed(SSI = number of self-soothing awakenings/number of totalawakenings 3 100). The median SSI for the group of infants was80%. The SSI was then transformed into a dichotomous variable, soinfants with SSI . 80% were classified as self-soothing infants forthe night. An infant who had fewer than 80% self-soothingawakenings was classified as a signaling infant for the night. Aninfant who had a consistent classification on both nights was labeledeither as a self-soothing or signaling infant at time 1. An infantwhose classification differed from the first night to the second nightwas labeled as a mixed self-soothing/signaling infant at time 1.

Time 2At time 2, a 30-minute follow-up telephone interview was con-

ducted with the parent by an interviewer who was blind to the 1-yearSSI. The interview was adapted from the Sleep Habits Questionnaire(SHQ), a reliable and valid measure of sleep behavior in preschoolchildren (Seifer et al., 1996). The SHQ asks a variety of specific ques-tions about sleep and waking behaviors that have occurred over thepast week, month, and 3-month period. To classify protodyssomnias,scoring focused on bedtime and middle-of-the-night behaviors. If aparticular behavior was present, the interviewer probed to determinethe infant’s state of health, how often the behavior occurred in a typ-ical week, and the duration of the behavior over the past severalmonths. Any sleep behavior that was atypical but related to a periodof illness was not scored, and the time period was realigned to a moretypical week. The items were scored on a 3-point weekly scale: rarely(0–1), sometimes (2–4), or regularly (5–7).

To assess subjective concern, in contrast to the more quantitativeresponses of the SHQ, parents were initially asked whether theirchild had a sleep problem at present or at any time since the video-taping. Global impressions were tallied separately from SHQresponses. Thus time 2 involved both a current (global and specific)and retrospective (global) account of the child’s sleep behaviors asreported by a parent. The quantitative information from the SHQabout the child’s current sleep was used to determine whether thechild met criteria for protodyssomnia.

RESULTS

Time 1

At 1 year of age, on average, infants spontaneouslyawakened 2.97 times per night on night 1 and 2.83 timeson night 2 of the video recording. Infants who were con-sidered self-soothers (above the 80% median) comprised52% of the sample on night 1 and 55% on night 2. Con-versely, 48% were considered signalers on night 1 and

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45% on night 2. Collapsing nights 1 and 2, as describedabove, 16 infants (48%) were classified as self-soothers, 12(36%) as signalers, and 5 (15%) as mixed. For the time 2predictions, the 5 infants classified as mixed were com-bined with the 12 infants classified as signalers assumingthat, as yet, they had not developed fully into self-soothers.Thus, at 12 months of age, 17 (52%) of the 33 subjectswere considered signalers after a night awakening.

An examination of sleep onset, at the beginning of thenight, demonstrated that 66% of infants on night 1 and61% of infants on night 2 were placed in their crib whilestill awake and allowed to fall asleep on their own. Col-lapsing both nights, more than half of the infants wereput to bed awake (55%). Almost one third (30%) of theinfants were put into their cribs already asleep on bothnights, and 15% of the infants had mixed sleep onsets.

Time 2

Results of the SHQ are summarized in Table 3. Usingthe developmental criteria for sleep onset and night wakingprotodyssomnia (Tables 1 and 2), we summarized inter-view items of the young children according to the age ofthe child at the time of the interview.

Of the 15 children who woke at night, 11 (33%) metcriteria for night waking disturbance (n = 5) or disorder (n =6). Thus, one third of the sample of young children werereported to awaken at least one time per night and requirea parental intervention to return to sleep. Sixteen children(48%) met criteria for sleep onset disturbance (n = 2) ordisorder (n = 14). Of the 14 with disorders, 7 met criteriabecause they took longer than 20 minutes to settle atnight, 5 because they required parental presence to fallasleep, and 2 because of excessive struggles during the bed-time routine. The 2 toddlers who met criteria for distur-

bance required parental presence to fall asleep on 2 to 4nights per week. Of the 27 toddlers (out of the total groupof 33) who met criteria for one or the other disturbance/disorder, only 4 children (12%) met criteria for both asleep onset and night waking disturbance/disorder.

Time 1–Time 2 Relationships

Chi-square analyses and t tests were used to examinerelationships between time 1 variables and time 2 classifica-tions. Night waking and sleep onset classifications at time 2were not related to total number of awakenings at 12months (t30 = 0.85, not significant [NS]; t30 = 1.55, NS) orto asleep/awake bedtime status at 12 months (χ2 [1, N =33] = 0.138, NS; χ2 [1, N = 33] = 0.00, NS). Signaler statusat 12 months, however, was related to night waking pro-todyssomnia at follow-up (χ2 [1, N = 33] = 4.38, p = .04).

As shown in Table 4, of the 11 subjects classified as hav-ing a night waking protodyssomnia, 9 had been signalersat 12 months and only 2 had been self-soothers. Of the 16self-soothing infants at 1 year, only 2 developed a nightwaking protodyssomnia as a toddler, whereas half of thesignaling infants did so. Since signaling predicts only 50%of the outcome, other factors must explain why some sig-nalers do not develop a night waking protodyssomnia.Nevertheless, signaling at 1 year of age seems to be a statis-tically significant risk factor of a later sleep problem.

Comparing the Nosology With Parental Reportof a Sleep Problem

Time 1 signaling was not significantly related to theparent’s global impression of a sleep problem at time 2.Ten parents of the 33 at time 2 reported that their childhad had a sleep problem that had lasted at least a month atsome time since the child’s first birthday. Signaling at time1 was not significantly related to the global sleep problemin these 10 infants, a seemingly transient problem as de-fined by the parent. Only 1 child of the 33 was currentlylabeled as having a sleep problem at time 2. It is interesting



TABLE 3Frequency of Toddler Behaviors

That Occurred Regularly at Time 2 (N = 33)

Behaviors n %

Fell asleep ≤20 minutes 25 76Required parental presence to fall asleep 7 21Resisted bedtime with 1 reunion 12 36Refused bedtime and/or >1 reunions 5 15Uses sleep aid 20 61“Sleeping through the night” 18 55Waking at night 15 45Cosleepinga 5 15

Note: “Regularly” is defined as occurring 5–7 nights per week.a Part of the night or after an awakening during the night.

TABLE 4Predicting Night Waking Protodyssomnia

From Signaling at 12-Month Video Recordings

Time 2

Time 1 No Protodyssomnia Protodyssomnia Total

Self-soothing 14 2 16Signaling 8 9 17Total 22 11 33

Note: χ2 = 4.38 (p ≤ .04).

that this one current, persistent problem sleeper at time 2had been a signaler at time 1. The finding that only oneparent labeled a child as having a sleep problem at time 2supports the notion that objective measurements of sleep-wake behaviors are distinct from parental concerns, yet areessential for studies of developmental change and treat-ment outcomes.

DISCUSSION

This study represents an initial attempt to classify sleepproblems systematically, using developmental criteria.Even though the sample size is small and the age range iswide, the tentative finding that 33% of young childrenexhibit either a night waking sleep disturbance or dis-order is in accord with other reports of approximately30% of night waking difficulties (e.g., Armstrong et al.,1994). The number of young children in the sample whoexhibited sleep onset difficulties (48%) also appears con-sistent with previous findings (Kataria et al., 1987;Zuckerman et al., 1987). The settling difficulties at thisage are viewed by many as a developmental phase thatcoincides with issues of separation anxiety.

It is interesting that discordance was noted betweenparental report of a sleep problem and the objective classi-fication criteria. Perhaps parents were unwilling to labelthe behavior as problematic, or it may be that the familyhad accepted the behavior as the child’s established sleeproutine. Wolke and colleagues’ (1995) longitudinal studyof sleep problems concluded that parents report more dis-tress at 5 months of age (10%–15%) than when reassessedat 5 years of age (7%), suggesting that parents adapt totheir child’s sleep. If this is so, might parental adaptationsdetrimentally affect the development of healthy sleephabits in their child? Furthermore, many of the parents inthis study reported lengthy bedtime rituals and/or theneed for parental presence to fall asleep but did not reportthat their children had a sleep problem. It is important toconsider clinically whether parental distress or noncha-lance should be considered the sole criterion for classify-ing childhood sleep disorders.

The current results provide preliminary support forusing signaled night awakenings at 12 months as a poten-tial risk factor for predicting a subsequent night wakingprotodyssomnia. The study does not address whether sig-naling is a temperamental trait or a response to environ-mental and interactional irregularity. In this study, theproportion of signalers at 12 months was higher thanreported previously. That is, on average, it has been noted

that approximately 20% to 30% of 1-year-old infants areconsidered signalers (Gaylor et al., 1998; Goodlin-Joneset al., 1997). When the percentage of subjects in this studywho signaled after awakenings on both nights was calcu-lated (36%), the results are similar to these previous find-ings. However, adding the mixed group to the signalersmay have inflated the results. Previous studies have notexamined the night-to-night stability of signaling behaviorand, therefore, have not described a mixed group.

It is interesting that none of the five reactive cosleep-ing families in the current study reported that their childhad a sleep problem. Nevertheless, two required parentalpresence to fall asleep and three were waking (signaling)1 or 2 times per night on a regular basis. These five fam-ilies were included in the current study because the par-ents felt that their child should sleep alone.

Future studies should use both objective and subjec-tive measures of sleep behavior, and classification shouldbe based on a combination of these assessments and ondevelopmental norms. Videotaping and actigraphy havebeen shown to be reliable and valid objective methodsfor measuring sleep-wake behavior (Sadeh, 1996; Sadehet al., 1991). The SHQ also has been shown to be aparental report questionnaire with robust psychometricproperties. Only through systematic investigation usingboth objective and subjective sources of information willit be possible to accurately describe the nature of sleepproblems in this noncomplaining population.

Limitations

Some of the limitations of this pilot study include thefollowing: (1) The time 2 follow-up assessment occurred atan arbitrary point in time. A more systematic longitudinalstudy at multiple ages is necessary. (2) Because no subjectswere between 1 and 2 years of age, it was not possible toassess sleep problems in children between the first and sec-ond year of life. (3) The questions on the SHQ, in terms offrequency and duration, were not exactly aligned to thecriteria of the proposed nosology. Thus, parent responseshad to be interpolated. In future studies, the SHQ shouldbe revised to fit the classification scheme. (4) It is impor-tant to acknowledge that the sample is one of convenienceand thus the preliminary results may not generalize tomore representative sociodemographic populations.

Clinical Implications

We have presented a developmental nosology thatattempts to classify the most common sleep complaints

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that parents have about their young children, namely,problems around bedtime and falling asleep and problemsrelated to waking in the middle of the night. These prob-lems have been defined as sleep onset and night waking pro-todyssomnias, respectively, and a metric has been presentedto quantify them in terms of intensity, frequency, andduration. A continuum has been suggested from pertur-bation to disturbance to disorder that may be useful inmonitoring the development of sleep behaviors and, pos-sibly, responses to treatment. At this point, the definitionsthat delineate the subclasses and the age-related intensity/duration criteria are derived from clinical experience andsmall research data sets. Only larger, more representativesamples will clarify the most appropriate cutpoints. How-ever, a template from which future studies can be mountedhas been established. Finally, from the results of this study,it is concluded that infants who continue to signal regu-larly upon awaking in the middle of the night by 1 year ofage are a potentially useful risk population for studies ofemerging sleep disorders.

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