The Longitudinal Association of Young Children's Everyday Routines to Sleep Duration

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    The LongitudinaAssociation of YoChildrens EveryRoutines to SleepChristina Koulouglioti, PhD, RN, Robert CMarian Moskow, BS, Brenda McQuillan, LMargaret-Ann Carno, PhD, MBA, RN, CPN& Annette Grape, LMSW

    ABSTRACTIntroduction: Everyday routines promote childrens health.In the present study, we examined whether childrens partic-

    analysis.Results: It was found that children who participated in morefrequent routines at age 4 years were more likely to do so at

    t age6 yearsears and bytrolling for

    ly sleep atund.

    Discussion: Continuous engagement in everyday routinesep acquisi-

    th andop-oundation, ages 3 toght. How-rld revealhan thoseeep prob-.g., going

    to bed and staying in bed), falling asleep, and staying

    Robert Cole, Associate Professor, School of Nursing, University of

    Rochester, Rochester, NY.

    Annette Grape, Doctoral Student, School of Nursing, University of Volume 28 Number 1 Journal of Pediatric Health Careseems to play an important role in childrens sletion. J Pediatr Health Care. (2014) 28, 80-87.

    KEY WORDSRoutines, sleep, children

    Sleep is essential for a childs physical growtimal functioning. The National Sleep F(2009) recommends that preschool children5 years, sleep about 11 to 13 hours every niever, national surveys from around the wothat children sleep fewer hours every day trecommended, and parents often report sllems such as difficulties around bedtime (e

    Rochester, Rochester, NY.

    The Rochester Preschool Childrens 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:, or


    CopyrightQ 2014 by theNationalAssociationofPediatricNurse

    Practitioners. Published by Elsevier Inc. All rights reserved.

    Published online January 28, 2013.age 6 years. Childrens inadequate sleepdurationawas predicted by less frequent routines at age 6 yinadequate sleep duration at age 4 years after conmothers ethnicity, mothers education, and famiAn indirect relationship of routines at age 4 yearsage 6 years through routines at age 6 years was fo

    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.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.lungdayDuration

    ole, PhD,CSW,P, D,ABSM, FNAP, FAAN,

    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-drens everyday routines and perceived sleep duration. Rela-tionships were examined by multiple hierarchical regression

  • ). It is also possible that the ef-ve function could partially ex-relation of sleep problems tounderperformance (Curcio,2006).in children are related to poorg the absence of a regular bed-nt sleep and wake-up times,vironments, and activities thatep (e.g., a TV in a bedroomeinated 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 childrens 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 consistent

    bedtime routines usually have less difficulty fallingthe day (Fallone, Acebo2001; Vriend et al., 2012fect of sleep on executiplain the documentedchildrens academicFerrara, & De Gennaro,Many sleep problems

    sleep practices, includintime routine, inconsistepoor quality of sleep eneither interfere with sleand consumption of caffasleep 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 put

    children at risk for physical and behavioralproblems. Insufficient sleep increases a childs risk forbecoming overweight (Carter, Taylor, Willliams, &Taylor, 2011; Spruyt, Molfese, & Gozal, 2011), sustain-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 during

    , Arnedt, Seifer, & Carskadon,

    Short sleepduration and sleepproblems putchildren at risk forphysical andbehavioralproblems.www.jpedhc.orgasleep 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 childs 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 childs 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 childrens 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 childrens 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 childrens academic achieve-ment and negatively with behavior problems andJanuary/February 2014 81

  • two-adult families (64.4%), with 26% of families classi-fied as one-adult families (see Table 1).

    Main Measures

    Childrens 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-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 with

    healthy sleep among young children, the current studyexplores the lasting effect of childrens 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 childrens 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 childrens adequate sleep acquisition.The exploration of routines as a predictor of childrenssleep will provide additional evidence for this recom-mendation.

    METHODSParticipantsData for this study were taken from the Rochester Pre-school Childrens 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-ters 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 of

    boys (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 of82 Volume 28 Number 1ties 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 Cronbachs a coefficient, which was0.78 at age 4 years and 0.79 at age 6 years.

    TABLE 1. Sociodemographic characteristics(N = 177)

    Characteristic N %


    High school or less 74 42.0Some college 37 21.0College graduate or higher 65 36.9

    Ethnicity (mothers 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

    Childs genderMale 86 48.6Female 91 51.4

    an = 176.Journal of Pediatric Health Care

  • Childrens sleep 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 higherPerceived sleep duration was assessed at ages 4 and 6years with the Sleep Duration subscale (three items)of the Childrens Sleep Habits Questionnaire (Owens,Spirito, & McGuinn, 2000). The Childrens Sleep HabitsQuestionnaire is a validated and widely used screeningtool of childrens 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...


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