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 themornin