Parental functioning and pediatric sleep disturbance: An examination of factors associated with parenting stress in children clinically referred for evaluation of insomnia

Abstract

Background

Parenting stress is an aspect of parent functioning relevant in clinical settings. Within the context of behavioral sleep medicine, the role of parenting stress is not well understood.

Methods

Prospective evaluation of patients 1.5–10 years old with insomnia. Subjects were 156 primary caregiver-child pairs who completed the Parenting Stress Index-Short Form (PSI-SF), Child Sleep Habits Questionnaire (CSHQ) and Child Behavior Checklist (CBCL). Aims: (1) determine prevalence of clinically significant parenting stress in primary caregivers of children clinically referred for insomnia; (2) identify childhood sleep problems that play a role in parenting stress; (3) identify relevant correlates of parenting stress within the context of a behavioral sleep medicine clinic; and (4) identify the most salient child sleep and behavioral variables associated with parenting stress.

Results

Forty-seven percent of primary caregivers had clinically significant parenting stress. When examining the relationship between child sleep problems and parenting stress, bedtime resistance (p = 0.030) and daytime sleepiness (p = 0.0003) stood alone as having the most salient associations with parenting stress. When considering a broader range of covariates (child age and child gender) and clinically relevant variables (parent history of sleep problems, parent history of psychiatric conditions, child behavior problems and child sleep problems) in a single regression equation, both child externalizing behavior problems (β = 0.570, p < 0.0001) and child daytime sleepiness (β = 0.152, p = 0.028) independently explained significant variability in parenting stress.

Conclusions

Many primary caregivers of children clinically-referred for insomnia evaluation and treatment have significant parenting stress. Parenting stress is associated with daytime behavioral problems and sleepiness in children with insomnia. Clinicians working with pediatric insomnia patients should carefully evaluate parenting stress and child daytime behavior as these aspects of functioning may have an impact on service delivery and treatment outcomes.

Introduction

The high prevalence of sleep problems in young children has prompted increased efforts to improve early detection and treatment of pediatric sleep disorders in both primary and tertiary care settings [1], [2], [3], [4], [5], [6], [7]. An increased appreciation of the interaction between sleep and physical, emotional, and behavioral well-being has been gained through clinical investigations in a number of important research areas. A key example in pediatric sleep medicine is the growing literature that recognizes obstructive sleep apnea as a likely cause of significant medical and neurobehavioral morbidity in children [8], [9], [10], [11], [12], [13], [14], [15]. Similarly, children with non-respiratory sleep disorders such as insomnia have been observed to be at increased risk for neurobehavioral problems such as impairments in cognition, mood, attention, and behavior [16], [17], [18], [19]. To date, the bulk of the sleep medicine literature examining childhood morbidity has focused primarily on the affected child, however, there is a growing recognition of the need to understand pediatric sleep disturbances within a family context [20], [21], [22], [23], [24], [25], [26], [27].

A number of cross-sectional studies document associations between parent functioning and a range of childhood problems, including externalizing behavior problems, problematic mother–infant interactions and sleep disturbances [28], [29], [30], [31], [32], [33]. Sadeh et al. [25] have proposed a complex bi-directional model that emphasizes the interaction between parent personality, psychopathology, sleep-related behavior/cognitions and infant sleep. Consistent with Sadeh’s transactional model of sleep, a recent large-scale investigation of parental behaviors and sleep in infants and toddlers determined that parental behaviors at bedtime and during the night were the best predictors of nighttime sleep in a large cross-cultural sample [26].

Sepa and colleagues’ [34] epidemiological research specifically examined psychosocial correlates of parenting stress, a construct conceptualized as representing the discrepancy between situational demands and personal resources [35], [36], [37]. Their large scale study found that sleep problems in infants stand out as a predictor of parenting stress relative to a number of other child health problems (e.g., ear infections, allergies and infectious disease) [34]. Several studies have focused specifically on the interaction between parenting stress and pediatric sleep disturbances in community [30], [38], [39], [40], [41], primary care [16], [31], [42] and tertiary care [32], [33], [43], [44], [45] settings.

Parenting stress has been deemed relevant in clinical settings as it may compromise effective treatment outcomes [46], [47]. Behavioral sleep medicine practitioners provide a broad range of clinical services with a focus on the interaction between the physical, cognitive, behavioral and emotional processes that underlie sleep disorders [48]. Within the context of behavioral sleep medicine evaluation and treatment, the role of parenting stress is not well understood. There are limited studies that have examined parenting stress in children seen in pediatric sleep clinics [44], [45]. Thome and Skuladottir [44] examined parenting stress as one of several outcome measures in a study of young children (3–5 year olds) referred to a sleep disorders clinic for treatment of a sleep disturbance (settling and night waking) during infancy. Sleep measures indicated some improvement in sleep from infancy to preschool, but persistence of sleep problems was observed. When compared to an age matched community comparison group of children who did not have sleep problems during infancy, fathers of children with sleep problems were found to have significantly higher (p < 0.004) mean scores on a parenting stress questionnaire [44]. Eckerberg [45] evaluated parenting stress in the caregivers of young children (4–45 months of age) participating in a sleep intervention program to treat frequent night wakings. Sleep treatment lead to statistically significant improvement in the caregivers’ mean parenting stress score. Post-treatment stress scores were similar to that of a population based comparison control group [49]. The findings from both of these studies demonstrated that caregivers of children clinically referred for sleep problems report significantly higher levels of parenting stress when compared to community samples comprised of parents of children without sleep problems. However, neither of these studies examined the prevalence of clinically significant parenting stress, nor did they investigate specific predictors of parenting stress in their samples. We are not aware of any previously published research that has examined factors associated with parenting stress in caregivers of children clinically referred to a pediatric sleep disorders center.

Based on the conceptual model depicted in Fig. 1, the purpose of the current study was to assess parenting stress in a sample of children clinically referred for insomnia evaluation. Clinically relevant correlates of parenting stress, including child sleep problems and child daytime behavioral problems, were examined within a behavioral sleep medicine clinic. The specific aims of the study were to characterize the prevalence of clinically significant parenting stress identify specific sleep problems associated with parenting stress, and determine the clinical variables most closely associated with parenting stress in primary caregivers of children clinically referred for behavioral evaluation of insomnia. Hypotheses of this study were as follows: Hypothesis 1: On average, primary caregivers of children clinically referred for behavioral evaluation of insomnia experience clinically significant levels of parenting stress; Hypothesis 2: Parenting stress will be significantly and positively associated with child sleep problems; Hypothesis 3: Parenting stress will be significantly and positively correlated with child daytime behavioral problems, the primary caregiver’s history of psychiatric illness and the primary caregiver’s history of sleep disturbance; and Hypothesis 4: Child sleep problems will be uniquely associated with parenting stress above and beyond other factors commonly associated with parenting stress such as the primary caregiver’s history of psychiatric illness and sleep disturbance.