ARTICLE
The LongitudinalAssociation of YoungChildren’s EverydayRoutines to Sleep Duration
Christina Koulouglioti, PhD, RN, Robert Cole, PhD,Marian Moskow, BS, Brenda McQuillan, LCSW,Margaret-Ann Carno, PhD, MBA, RN, CPNP, D,ABSM, FNAP, FAAN,& Annette Grape, LMSWABSTRACTIntroduction: Everyday routines promote children’s health.In the present study, we examined whether children’s partic-
Christina Koulouglioti, Assistant Professor, School of Nursing,
University of Rochester, Rochester, NY, and Senior Research
Fellow, Western Sussex Hospitals NHS Trust, Worthing Hospital,Worthing, UK.
Robert Cole, Associate Professor, School of Nursing, University of
Rochester, Rochester, NY.
Marian Moskow, Research Project Coordinator, School of
Nursing, University of Rochester, Rochester, NY.
Brenda McQuillan, Doctoral Student, School of Nursing,
University of Rochester, Rochester, NY.
Margaret-Ann Carno, Assistant Professor, School of Nursing,
University of Rochester, Rochester, NY.
Annette Grape, Doctoral Student, School of Nursing, University of
Rochester, Rochester, NY.
The Rochester Preschool Children’s Injuries Study was supported
by a grant from the Centers for Disease Control and Prevention
awarded to Dr. Robert Cole.
Conflicts of interest: None to report.
Correspondence: Christina Koulouglioti, PhD, RN, University of
Rochester, School of Nursing, Box SON, 601 Elmwood Ave,
Rochester, NY 14642; e-mail: [email protected], or [email protected].
0891-5245/$36.00
CopyrightQ 2014 by theNationalAssociationofPediatricNurse
Practitioners. Published by Elsevier Inc. All rights reserved.
Published online January 28, 2013.
http://dx.doi.org/10.1016/j.pedhc.2012.12.006
80 Volume 28 � Number 1
ipation in everyday routines at ages 4 and 6 years predictedtheir sleep duration at age 6 years.Method: A secondary analysis of data was performed for 177families who participated in the Rochester Preschool Chil-dren Injuries Study. Mothers were interviewed when theirchildren were ages 4 and 6 years and reported on their chil-dren’s everyday routines and perceived sleep duration. Rela-tionships were examined by multiple hierarchical regressionanalysis.Results: It was found that children who participated in morefrequent routines at age 4 years were more likely to do so atage 6 years. Children’s inadequate sleepdurationat age6 yearswas predicted by less frequent routines at age 6 years and byinadequate sleep duration at age 4 years after controlling formothers’ ethnicity, mothers’ education, and family structure.An indirect relationship of routines at age 4 years to sleep atage 6 years through routines at age 6 years was found.Discussion: Continuous engagement in everyday routinesseems to play an important role in children’s sleep acquisi-tion. J Pediatr Health Care. (2014) 28, 80-87.
KEY WORDSRoutines, sleep, children
Sleep is essential for a child’s physical growth andop-timal functioning. The National Sleep Foundation(2009) recommends that preschool children, ages 3 to5 years, sleep about 11 to 13 hours every night. How-ever, national surveys from around the world revealthat children sleep fewer hours every day than thoserecommended, and parents often report sleep prob-lems such as difficulties around bedtime (e.g., goingto bed and staying in bed), falling asleep, and staying
Journal of Pediatric Health Care
asleep through the night (Liu, Liu, Owens, & Kaplan,2005; Mindell & Owens, 2003). An estimated 50% ofparents surveyed in the United States reported suchsleep problems every day, and 77% reported sleepproblems at least one night a week (Mindell,Carskadon, Chervin, &Meltzer, 2004). Similarly, amongAustralian families surveyed, one in five children wasaffected with night wakings, and one in eight childrenhad difficulty falling asleep (Hiscock, Canterford,Ukoumunne, & Wake, 2007).
Short sleep duration and sleep problems putchildren at risk for physical and behavioralproblems. Insufficient sleep increases a child’s risk forbecoming overweight (Carter, Taylor, Willliams, &Taylor, 2011; Spruyt, Molfese, & Gozal, 2011), sustain-
Short sleepduration and sleepproblems putchildren at risk forphysical andbehavioralproblems.
ing anunintentional in-jury (Boto et al., 2012;Koulouglioti, Cole,& Kitzman, 2008),and experiencing bothinternalizing and ex-ternalizing behaviorproblems (Hall, Scher,Zaidman-Zait, Espezel,&Warnock, 2012; Reid,Hong, & Wade, 2009).Sleep also has an im-
pact on executive functioning, with lack of sleep beingrelated to attention deficits (Sadeh, Gruber, & Raviv,2002) and children being inattentive and tired duringthe day (Fallone, Acebo, Arnedt, Seifer, & Carskadon,2001; Vriend et al., 2012). It is also possible that the ef-fect of sleep on executive function could partially ex-plain the documented relation of sleep problems tochildren’s academic underperformance (Curcio,Ferrara, & De Gennaro, 2006).Many sleep problems in children are related to poorsleep practices, including the absence of a regular bed-time routine, inconsistent sleep and wake-up times,poor quality of sleep environments, and activities thateither interfere with sleep (e.g., a TV in a bedroomand consumption of caffeinated drinks) or reduced ex-ercise (e.g., extensive TV viewing; Hale, Berger,LeBourgeois, & Brooks-Gunn, 2009; LeBourgeois,Giannotti, Cortesi, Wolfson, & Harsh, 2005; Paavonen,Pennonen, Roine, Valkonen, & Lahikainen, 2006).The use of electronic media such as video games, com-puters, and television viewing has been found to relatewith shorter sleep duration and delayed bedtimeamong school-age children and adolescents (Cain &Gradisar, 2010), and the negative effects of media useon children’s health, including aggressive behavior,lack of attention, and obesity have been attributed to in-sufficient sleep (Barlett, Gentile, Barlett, Eisenmann, &Walsh, 2012).
Preschool-age children with regular and consistentbedtime routines usually have less difficulty falling
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asleep and staying asleep through the night (Mindell,Meltzer, Carskadon, & Chervin, 2009); therefore theearly establishment of bedtime routines is consideredcritical in ensuring adequate sleep acquisition amongyoung children. Unpredictable timing and frequencyof everyday activities cultivates insecure feelings andundermines sleep acquisition, possibly by increasingthe child’s anxiety and by not providing the necessarycues for going to bed.Routines are observable, repetitive behavior pat-
terns. Maintenance of routines is believed to be protec-tive of a child’s health through the provision of structureand by facilitating adjustment during transitional pe-riods (Zisberg, Young, Schepp, & Zysberg, 2007). Chil-dren living in unpredictable and less routinized homeenvironments, as described by the ecological theory,are at risk for adverse outcomes. The ecological theorystates that children’s socioemotional functioning andsleep acquisition are particularly at risk for children liv-ing in chaotic home environments characterized bylack of structure, lack of routines, and high levels ofnoise (Bronfenbrenner & Evans, 2000; Evans, 2006).Preschool children living in noisy home environmentshavebeen found to go tobed later, to sleep fewer hours,and to have more difficulty falling asleep (Bruni,Novelli, & Ferri, 2011).Everyday routines are particularly challenging dur-
ing the preschool years when children become moreactive participants in family life. During this develop-mental period, young children are ready to share andvoice their opinions about food choices and when,where, and how to go to sleep (Fiese, 2006). In addi-tion, mothers’ education, mothers’ ethnicity, and familystructure are related to the frequency and nature of ev-eryday routines (Flores, Tomany-Korman, & Olson,2005). Higher maternal education is positively relatedto school-age children’s educational activities(Hofferth & Sandberg, 2001), more frequent family rou-tines (Churchill & Stoneman, 2004), and an increasedprobability for daily reading (Kuo, Franke, Regalado,& Halfon, 2004). Mothers with a college degree reportmore frequent routines compared with those whohave a high school diploma (Koulouglioti, Cole, &Kitzman, 2009), and single-parent families report fewerroutines compared with two-adult families (DeMore,Adams, Wilson, & Hogan, 2005; Koulouglioti et al.,2009). In addition, rates of bedtime routines havebeen found to be slightly lower in African Americanand Latino families than in White families with pre-school children (Milan, Snow & Belay, 2007).It is often said that ‘‘children thrive on routines,’’ but
despite its popularity, this hypothesis is not often tested.In addition, very few studies have explored the stabilityof routines over time and its positive consequences forchildren. Stability of routines over time has been foundto positively relate with children’s academic achieve-ment and negatively with behavior problems and
January/February 2014 81
TABLE 1. Sociodemographic characteristics(N = 177)
Characteristic N %
Educationa
High school or less 74 42.0Some college 37 21.0College graduate or higher 65 36.9
Ethnicity (mother’s race)Majority 86 48.6Minority 91 51.4
Income (per year)a
< $25,000 73 41.5$26,000-$50,000 31 17.6$51,000-$75,000 54 30.7> $76,000 18 10.2
Family structureOne-adult families 46 26.0Two-adult families 114 64.4More than two adults 17 9.6
Child’s genderMale 86 48.6Female 91 51.4
an = 176.
substance use. In particular, children who experiencedregular family routines in a 5-year period had higher ac-ademic achievement scores compared with childrenwho experienced unpredictable family routines forthe same period (Spagnola & Fiese, 2007). Similarly,family stability in everyday activities was related tofewer internalizing behavior problems in school-agechildren (Ivanova & Israel, 2006), and regular familymeals during adolescent years was associated withlower rates of substance use, such as smoking and alco-hol (Eisenberg, Neumark-Sztainer, Fulkerson, & Story,2008).
Given the concurrent association of routines withhealthy sleep among young children, the current studyexplores the lasting effect of children’s participation ineveryday routines at ages 4 and 6 years on sleep dura-tion at age 6years.Withuseof longitudinal data and tak-ing into account sociodemographic risk factors, weexamined the predictive value of everyday routineson sleep acquisition as described by mothers. We con-ducted a secondary data analysis examining the follow-ing research question: Is children’s participation ineveryday routines at ages 4 and 6 years a significant pre-dictor of perceived sleep duration at age 6 years, takinginto account sociodemographic variables and sleepscores at age 4 years? Parents of young children are en-couraged by health care providers to maintain regulareveryday routines, especially bedtime routines, toensure their children’s adequate sleep acquisition.The exploration of routines as a predictor of children’ssleep will provide additional evidence for this recom-mendation.
METHODSParticipantsData for this study were taken from the Rochester Pre-school Children’s Injuries Study. Mothers were inter-viewed when children were ages 3 years (N = 278), 4years (N = 264), and again at 6 years (N = 181). Inter-views were conducted from 2002 to 2007. Data on themainoutcomevariable (sleep at age 6 years)were avail-able for 177 children, who constituted the final sample.The study was approved by the University of Roches-ter’s Research Subjects ReviewBoard, and participatingmothers signed an informed consent at enrollment. Formore information on the scope of the Rochester Pre-school Children Injuries Study, refer to the article byCole, Koulouglioti, Kitzman, Sidora-Arcoleo, and An-son (2009).
The study sample had an almost equal number ofboys (48.6%) and girls (51.4%) and an almost equalnumber of minority (African American and Hispanic)andmajority (White) families. Themean age ofmotherswas 31 (SD = 6.7), with a range from ages 18 to 46 years;in addition, 42% of mothers had a high school/or lesseducation, 21% had some college, and 36.9% had a col-lege degree. The majority of the sample consisted of
82 Volume 28 � Number 1
two-adult families (64.4%), with 26% of families classi-fied as one-adult families (see Table 1).
Main Measures
Children’s routinesRoutines were assessed with the daily living routinessubscale of the Child Routines Questionnaire (Sytsma,Kelley, & Wymer, 2001). The daily living subscale iscomposed of 11 questions rated on a 5-point Likert-type scale ranging from 0 = never to 4 = nearly always.Routines were measured at age 4 and 6 years, and 10 ofthe 11 questions were identical and were included inthe analysis for consistency and simple interpretationof the results. The 10 questions were: (1) has a set rou-tine for getting ready in themorning, (2) eatsmealswithfamily at the table each day, (3) hugs/kisses parent be-fore bed, (4) spends special time talking/reading withparent each day, (5) does the same things each night be-fore bed, (6) wakes up at about the same time onweek-days, (7) eats dinner at about the same time each day,(8) brushes teeth before bed, (9) goes to bed at aboutthe same time on weeknights, and (10) eats breakfastat about the same time and place each day. Mothers re-ported on how regularly each one of these daily activi-ties occurred during the past month. A sum score ofthese 10 questions was computed for ages 4 and 6 yearsand could range from0 to 40,with higher scores indicat-ing more frequent routines of daily living. Internal con-sistency of the 10-item subscale was assessed by thecomputation of Cronbach’s a coefficient, which was0.78 at age 4 years and 0.79 at age 6 years.
Journal of Pediatric Health Care
TABLE 2. Pearson correlation coefficient (r)among main variables
(2) (3) (4)
(1) Sleep age 4 years 0.261** �0.241** �0.166*(2) Sleep age 6 years — �0.220** �0.295**(3) Routines age 4 years — 0.505**(4) Routines age 6 years —
*p < .05.
**p < .001.
Children’s sleepPerceived sleep duration was assessed at ages 4 and 6years with the Sleep Duration subscale (three items)of the Children’s Sleep Habits Questionnaire (Owens,Spirito, & McGuinn, 2000). The Children’s Sleep HabitsQuestionnaire is a validated and widely used screeningtool of children’s sleep problems for children ages 24 to66months (Goodlin-Jones, Sitnick, Tang, Liu,&Anders,2008). Mothers were asked to think of the most typicalweek, meaning a week that was not unusual due to aninjury, vacation, or illness, and respond to the followingthree statements: (1) my child sleeps the right amount,(2) my child sleeps about the same amount each day,and (3) my child sleeps too little. Mothers were askedto rate how often during the week this happened usinga three-point Likert-type scale (i.e., 1 = rarely, 2 = some-times, and 3 = usually). Following the scoring guide-lines for the scale, the computation of the total sumscore of questions 1 and 2 were reverse scored. The fi-nal sum score can range from 3 to 9; a higher score is in-dicative of more disturbed sleep, whereas a low scoreon the scale indicates adequate sleep duration. Internalconsistency was assessed by computation of the Cron-bach’s a coefficient and ranged from 0.67 to 0.69.
DemographicsMaternal educationwasoperationalized as a three-levelcategorical variable and the participants in the studywere categorized into three groups, representing (a)those with a high school diploma or less education,(b) those with ‘‘some college,’’ and (c) those witha bachelor’s degree or higher level of education. Familystructure was operationalized as a three-level categori-cal variable classifying the families of the sample intothree groups: one-adult families, two-adult families,and more-than-two-adult families. Mother’s race wasoperationalized as a two-level categorical variable,with one group representing the mothers identified as‘‘Caucasian’’ (majority) and the second group includingthe mothers identified as ‘‘Black, Hispanic, and Bira-cial’’ (minority).
Statistical AnalysesData were analyzed with SPSS software version 17.Pearson correlation coefficients were calculated be-tween the routines and sleepmeasures. Amultiple hier-archical regression analysis was performed to predictchildren’s sleep at age 6 years by sleep and routinesscores at age 4 years, controlling for maternal educa-tion, maternal ethnicity, and family structure. Further-more, a mediation model was tested, with routines atage 6 years as a mediator to the relationship betweenroutines at age 4 years to sleep at age 6 years. We con-ducted a full mediation analysis using a causal stepapproach and by conducting a bootstrapping regres-sion analysis using a simple sampling method and
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k = 1,000 number of samples (Hayes, 2009; Zhao,Lynch, & Chen, 2010).
RESULTSThe majority of mothers reported that their children re-ceived enough sleep at both time points, with 80.4% ofmothers reporting a low total sleep duration score(scoring 3 and 4 on the sleep duration subscale) atage 4 years and 19.6% of the sample reporting a scorehigher and/or equal to 5 (low scores = adequate sleepduration; high scores = disturbed sleep duration). Sim-ilarly, when children were age 6 years, 83.4% ofmothers reported a low score on the scale (scores 3and 4), with 16.5% of mothers reporting a score higherand/or equal to 5. At age 4 years, the average total sleepduration score was 3.8 (SD = 1.1), and scores rangedfrom 3 to 9. Similarly, at age 6 years, the average totalsleep duration score was 3.5 (SD = 1.1), and scoresranged from 3 to 8. These average scores are similarto previously reported results among community sam-ples (M = 3.4, SD = 0.93), whereas parents of childrendiagnosed with a sleep behavior disorder score at leastone to two points higher on the same subscale (M =4.94, SD = 1.98; Owens et al., 2000).The vast majority of mothers reported that their chil-
dren regularly engaged in everyday routines at bothage 4 and 6 years. The distribution of routines scoreswas negatively skewed at both time points, with a smallpercentage of mothers (10.8%) at age 4 years and only2.8% at age 6 years receiving a score#20 and reportingthat their children rarely and/or sometimes engagedin everyday routines. Routines scores at age 4 yearsranged from 13 to 40, with a mean of 33.4 (SD = 5.4)and median of 35, and at age 6 years they rangedfrom 19 to 40, with a mean of 35.3 (SD = 4.5) andmedian of 37. The inter-correlations among all routinesand sleep measures were statistically significant andranged from r = 0.16 (P < .05) to r = 0.50 (P < .001;see Table 2).A hierarchical multiple regression analysis was per-
formed to predict children’s sleep duration scores atage 6 years based on their overall routines scores atage 4 years, controlling for sleep scores at age 4 years,
January/February 2014 83
TABLE 3. Final regression model for sleep at age 6 years by sleep scores at age 4 years, routinescores at age 6 years, and routines scores at age 4 years
Variable B SE Beta t (p value) Adjusted R square
Constant 5.497 0.868Ethnicity 0.064 0.193 0.028 �0.330 (0.742)EducationCollege graduate or higher 0.105 0.235 0.045 0.445 (0.657)Some college 0.182 0.228 0.066 0.801 (0.424)
Family structureOne-adult families �0.185 0.309 �0.072 �0.599 (0.550)Two-adult families �0.348 0.295 �0.148 �1.182 (0.239)
Sleep age 4 years 0.202 0.074 0.209 2.751 (0.007)*Routines age 6 years �0.063 0.021 �0.253 �2.938 (0.004)*Routines age 4 years �0.009 0.018 �0.043 �0.501 (0.617)
0.11**
Values reported are unstandardized coefficients (B), standard error of B (SE), and standardized regression coefficients (Beta), with signifi-
cance of t and R2 with significance of F. Sociodemographics were dummy coded with minority as the reference group for race, high school
or less as the reference group for education, and families with more than two adult members in the household as the reference group for
family structure.
*p < .01.
**p < .000.
maternal education, maternal ethnicity, and familystructure. Both routines and sleep at age 4 years weresignificant predictors of sleep duration at age 6 years,with lower routines scores and short sleep duration atage 4 years predicting short sleep duration scores atage 6 years.
We further testedwhether routines at age 6 years me-diate the relationship between routines at age 4 years tosleep at age 6 years. Routines at age 6 years were re-gressed on routines at age 4 years, and it was foundthat children who participated in frequent routines atage 4 years were more likely to do so at age 6 years.Then we regressed sleep at age 6 years, on routines atage 4 years, routines at age 6 years, and sleep at age 4years, controlling again for maternal education, ethnic-ity, and family structure (see Table 3). As seen in theFigure, only sleep at age 4 years and routines at age 6years remain significant predictors of sleep at age 6years, whereas the previously identified relationshipbetween routines at age 4 years and sleep at age 6 yearsvanishes. The bootstrap analysis revealed identical re-gression coefficients.
FIGURE. The mediation model.
84 Volume 28 � Number 1
DISCUSSIONIn the present study, we examined children’s participa-tion in everyday routines over a 2-year period and therelationship of routines to children’s sleep duration.The majority of the families in this sample reportedhigh participation in everyday routines when their chil-dren were 4 years and again when they were 6 years ofage. This finding is consistent with the developmentaltrajectories of everyday activities, such as family meals,which are more frequent among young children andexperience a slight decrease among older adolescents(Fiese & Schwartz, 2008). School attendance and im-posed school schedules also might have affectedmothers’ reports of everyday routines. School starttime has been found to strongly predict young chil-dren’s sleep/wake patterns (Zhang, Li, Fok, & Wing,2010), and therefore the high reported rates of routinescould be a reflection of children’s school age and atten-dance.Overall, mothers reported adequate sleep duration
for their children. Consistent with previous reports,however, about 14% of participating families reportedinadequate sleep duration across time. In addition,inadequate sleep duration at age 4 years was a con-sistent significant predictor of children’s inadequatesleep duration at age 6 years, thus validating thefact that children’s sleep problems tend to persist.Children’s inadequate sleep has an effect on theirhealth (Sadeh, 2007) and on family health, with par-ents being more likely to report parental stress andfamily conflict (Smaldone, Honig, & Byrne, 2009).Sleep quality has been found to relate to better schoolfunctioning (Meijer, 2008; Meijer, Habekoth�e, & VanDen Wittenboer, 2000), and sleep problems are
Journal of Pediatric Health Care
related to children’s emotional and behavioral prob-lems (Gregory & Sadeh, 2012); therefore, it is criticalfor clinicians to find effective ways to work withfamilies and solve sleep-related issues early in a child’slife.
We also found that the effects of routines at age 4years on sleep at age 6 years was entirely mediated byroutines at age 6 years. Children who had regular rou-tines at age 4 years were more likely to have routinesat age 6 years, and it was that sustained participation
Regular routinescontribute to thestability andpredictability offamily life and canserve asa protective factorfor an individual’shealth and optimaldevelopment.
in routines that con-tributed to the predic-tion of children’s sleepduration at age 6 years.In addition, althoughthe cross-sectional andlongitudinal inter-correlations amongsleep and routineswere of small to me-dium magnitude, theyremained statisticallysignificant over time.A similar stability insleep/wake scheduleswas found in a longitu-
dinal study among Canadian young children (4 to 6years old), with children’s sleep/wake patterns beingrelated to sleep duration as well (Touchette,Mongrain, Petit, Tremblay, & Montplaisir, 2008). Thestability of these associations supports the hypothesisthat consistent routines are important for the child’shealth andalsopresents evidence that routines are a sta-ble index of family life and have great potential for in-terventions. Moving beyond simple correlations toa predictive model, the present findings provide addi-tional evidence for the National Sleep Foundation rec-ommendations regarding children’s participation inregular routines (National Sleep Foundation, 2009).Regular routines contribute to the stability and predict-ability of family life and can serve as a protective factorfor an individual’s health and optimal development.Regular sleep/wake times and bedtimes are criticalfor sleep onset and sleep acquisition, but consistentwith previous reports, the nature of bedtime activitiesis also important. We know that children whose bed-time routine includes reading/storytelling or singingget more sleep than do children whose bedtimeroutine includes watching TV (Hale, Berger,LeBourgeois, & Brooks-Gunn, 2011; Mindell, et al.,2004). Parents who struggle to establish or maintainregular sleep/wake cycles might find it helpful tohave as a starting point an early focus on pre-bedtimeactivities. Helping mothers to identify pre-bedtime ac-tivities that are developmentally appropriate, calming,and enjoyable for both the mother and child might bea significant start for the development of other critical
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routines, such as regular sleep/wake times. A recent in-tervention promoting a consistent bedtime routine forinfants and toddlers was found to be effective in reduc-ing problematic sleep behaviors, number and durationof night wakings, and latency to sleep onset (Mindell,Telofski, Wiegand, & Kurtz, 2009).Bedtime routines and sleep/wake patterns are im-
portant for sleep acquisition, but in this study, routinesaround eating (such as having regular family meals)also were part of mothers’ report in the children’s rou-tines measure. Knowing that children’s food consump-tion (e.g., the consumption of caffeinated drinks) isassociated with their sleep (Calamaro, Mason, &Ratcliffe, 2009) is important; therefore, we need to ac-knowledge these inter-connections and expand our as-sessments of children’s routines beyond bedtimeroutines. In addition, it was recently reported that sleepbehavior problems and feeding problems tend to coex-ist among young children (Tauman et al., 2011). By ex-ploring the nature and structure of children’s everydayroutines, along with the frequency and consistency ofa set of everyday routines that are critically connectedto children’s diet and sleep acquisition,wewill bebetterpositioned to assist families and help their childrensleep better. Future studies should include objectivemeasures of sleep and measures of other possible con-founders, such as additional aspects of sleep hygiene(e.g., children’s room environment), which also are as-sociated with the experience of sleep problems amongchildren (Spruyt, O’Brien, Cluydts, Verleye, & Ferri,2005).The major limitations of this study are the self-
reported nature of the data and having a singleinformant, only the children’s mother. However, thetemporal sequence of the data provided the opportu-nity to test a predictive model.Finally, the present findings provide additional evi-
dence for clinicians in supporting parental efforts forconsistent everyday routines. Nurses, especially pediat-ric nurses, are usually the first to observe and/or hearparents’ concerns about sleep. They also care for chil-dren from different ethnic and cultural backgrounds,and even though bedtime routines are a common activ-ity across cultures, the way that young children are putto bed,where they sleep, andwithwhom they sleep aresignificantly influenced by culture. Knowing that pa-rental behaviors during bedtime and during the nighthave been found to be the best predictors of young chil-dren’s sleep duration across cultures (Mindell, Sadeh,Kohyama, &Hwei Howd, 2010) emphasizes the impor-tance for clinicians to dedicate enough time when con-sulting with families about sleep. Clinicians couldemphasize to parents who struggle with institutingand maintaining bedtime routines that parents’ effortscan have a profound impact on children’s sleep asthey go through stages of development. Cliniciansalso need to address these issues with sensitivity and
January/February 2014 85
should be aware of the associations between children’ssleep problems and the mother’s emotional health.Mothers’ depressive symptoms usually are related tochildren’s sleep problems (El-Sheikh, Kelly, Bagley, &Wetter, 2012), and therefore these consultations needto happen with the understanding that children’s sleepproblems are family health issues and cannot be ad-dressed in isolation and without considering the bestways to engage and partner with parents for achievingbest outcomes. Adopting a family-centered approachby being responsive and acknowledging the family’sneeds has been considered a successful way to consultwith parents of overweight children (Farnesi, Newton,Holt, Sharma, & Ball, 2012), and clinicians could utilizesimilar practices while talking with parents of youngchildren about sleep and the initiation andmaintenanceof everyday routines.
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