SEARCH

SEARCH BY CITATION

Keywords:

  • childhood sleep;
  • parent knowledge;
  • sleep assessment

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Evidence demonstrates that health professionals have limited knowledge about childhood sleep, frequently do not screen for these problems and often rely on parents to raise sleep issues at clinic visits. However, little is known about parents’ sleep knowledge. The goal of this study was to assess parents’ knowledge of sleep and specifically: (i) sleep aspects related to the age of children; (ii) developmentally normal sleep; and (iii) sleep problems that may lead to parents’ ability to raise sleep issues at clinic visits. This study evaluated the knowledge of 170 parents of children aged 2–17 years about infant, child and adolescent sleep patterns and problems. The majority of parents could not answer correctly questions about developmental sleep patterns or sleep problems, but were more likely to answer correctly questions about normal infant sleep patterns and about sleep problems during waking hours. Parents also were more likely to answer ‘don’t know’ to questions about: (i) older children and adolescents; (ii) sleep apnea; and (iii) dreams and nightmares. The implications of these findings for the identification, intervention and prevention of childhood sleep problems are discussed.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Researchers have estimated rates of childhood sleep problems in the general population of children to be 25–50%, with the rate varying with age (see Meltzer and Mindell, 2006; Mindell, 1993). The rate of sleep problems for children with disabilities can be higher, ranging from 24% to 86% (Bartlett et al., 1985; Didden et al., 2002; Quine, 2001). This suggests that millions of children worldwide could be experiencing the potentially debilitating effects of sleep disorders, such as day-time behavior and mental health problems (Fallone et al., 2002).

The daytime negative effects of sleep problems have been associated with a wide variety of family problems. For example, sleep problems have been connected to an increase in anxiety, mood disturbance, and attention deficit hyperactivity disorder (ADHD) behaviors in children, and marital, psychological, and sleep problems for parents (Chu and Richdale, 2009; Lopez-Wagner et al., 2008; Meltzer and Mindell, 2007; see Owens, 2001). In children, sleep negatively affects development in social and behavioral competence, cognitive and academic performance, and physical development (Blunden and Chervin, 2007; Touchette et al., 2009). Despite these possible debilitating consequences, many children with sleep problems may remain undetected due to health professionals’ and parents’ insufficient training in and knowledge of childhood sleep.

Health professional knowledge of childhood sleep problems

Childhood sleep researchers have documented that medical and mental health professionals receive little or no formal training in pediatric sleep. An early survey of medical schools (Orr et al., 1980) showed that 93% of American universities offered no training in sleep medicine. Of the programs that offered training, 38% covered outdated information on sleep topics within classes devoted to other subjects for a total of only 1–4 h of sleep-related instruction. Even after medical school, medical professionals and residents have received few to no hours of formal sleep-related training (Mindell et al., 1994). Surveys of residency programs and pediatricians showed that pediatricians received on average fewer than 5 h of class instruction in pediatric sleep – mainly covering only apnea and sleep patterns of infants and very young children during consultations and speaker series (Mindell et al., 1994).

More recent studies suggest that little has changed. A survey of 626 American pediatricians showed that nearly a quarter of pediatricians answered more than 50% of questions related to pediatric sleep incorrectly (Owens, 2001). Similarly, Boreman et al. (2007) found that practicing American pediatricians did not feel comfortable across a range of developmental/behavioral pediatric areas, including sleep, even after mandated changes to medical training in these areas. Additionally, sleep was one of the most poorly rated areas of training, with a score indicating that training was generally not adequate.

Training for other professionals such as nurse practitioners and psychologists appears equally meager. Studies report that approximately 70–80% of nurse practitioners have never received any formal training or continuing education in pediatric sleep (Mindell and Owens, 2003). Mental health professionals who may also be in a position to identify childhood sleep problems (e.g. psychologists) have also received negligible amounts of training in this area. In fact, surveys of American clinical psychology graduate programs have indicated that 41% offered no training in sleep problems and fewer than 5% offered graduate psychology coursework about sleep (Meltzer et al., 2009). Furthermore, these programs have rated their education of clinical psychologists as mainly ineffective for training concerning sleep disorders (48%), treatment of sleep disorders (41%), sleep and comorbid conditions (20%), and sleep physiology (59%) (Meltzer et al., 2009).

As few health professionals receive specific training in pediatric sleep, many childhood well-child visits and checkups may lack sufficient assessment of the children’s sleep. In fact, while most pediatricians asked about infants sleep, just over half asked about adolescents’ sleep (Owens, 2001). Of the medical workers who specifically asked questions related to pediatric sleep problems, most only screened infants and toddlers for problems, such as co-sleeping, napping, bedtime behavior problems, and scheduled bedtimes – ignoring sleeping problems across the developmental ages (Mindell and Owens, 2003; Owens, 2001). The majority of pediatricians reported asking parents only one question –‘does your child have any sleep problems?’ (Owens, 2001, p. 4). Including pediatricians who assessed sleep with the ‘one-question method’, sleep was addressed inadequately in 42% of infants’, 52% of school-aged children’s and 74% of adolescents’ visits to their pediatrician (Owens, 2001). Pediatricians’ justification for the ‘one-question method’ for assessing childhood sleep primarily proposed that parents would indicate if their child had a sleep problem.

Parent’s knowledge of childhood sleep problems

Based on health practitioner research, it appears that a major determinant of whether children’s sleep difficulties are recognized and treated is whether or not their parents recognize sleep problems and timely access to professional services. Unfortunately, preliminary results indicate that parents (i) do not recognize abnormal sleep as a problem (Robinson and Richdale, 2004; Strocker and Shapiro, 2007; Wiggs and Stores, 1998); (ii) do not seek professional assistance for possible sleep problems (Robinson and Richdale, 2004; Wiggs and Stores, 1996); and (iii) do not feel knowledgeable about sleep problems (Strocker and Shapiro, 2007). Parents may also neglect to address sleep questions with their child’s regular medical practitioner (Blunden et al., 2004). For example, of Australian children aged 4–16 years who were seen by their general practitioner, 24% had parent-determined sleep problems. However, only 4% of their appointments were for the sleep problem and only 11% even had sleep raised during their appointment (Blunden et al., 2004). Therefore, existing research suggests strongly that parents may lack knowledge or hold misconceptions concerning children’s sleep patterns and sleep development and, thus, may not address their child’s sleep problems with their medical practitioner.

We are aware of no specific research concerning parents’ knowledge of children’s sleep development across developmental age ranges. However, preliminary research related to parental knowledge of infant sleep (3–12 months) indicates that mothers with lower levels of education are not able to answer questions about sleep correctly (26% correct) compared to questions about general child development (65% correct) (Reich, 2005). Similarly, Tamos-Lemonda et al. (2002) reported that across developmental domains, adolescent mothers of infants and young children generally underestimated the age that developmental milestones should have appeared, believing that they should occur earlier in development than was typical. Therefore, these mothers may hold unrealistic developmental expectations, including those pertaining to normal sleep patterns, and may have poor knowledge about normal sleep development.

Thus, while parent knowledge of pediatric sleep patterns and problems has been relatively undocumented, current evidence suggests that it is likely to be poor. As health professionals’ enquiries about childhood sleep are also insufficient and reportedly rely upon parent detection of sleep problems, it is likely that in many cases, child sleep problems will be under- or misdiagnosed. Given the potential for sleep problems to impact upon child development and parental wellbeing (Owens, 2001), these possible diagnostic problems and subsequent lack of treatment could be disastrous for families. Therefore, the aims of this project were to identify parents’ knowledge of normative childhood sleep patterns and of childhood sleep problems. It was predicted that parental knowledge about both children’s sleep development and childhood sleep problems would be poor.

Method

  1. Top of page
  2. Summary
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Participants

Parents of children with and without developmental disabilities were recruited from organizations such as early intervention services, state schools, special schools and special developmental schools, parent support groups and children’s support groups via letter, e-mail or the web in Australia and the web in the United States. Due to the mixed recruitment procedures used, it was impossible to calculate the total number of surveys that may have been disseminated by other group members. For example, one group member or parent could have forwarded a link to the questionnaire to other parents without the knowledge of the authors. Thus, a return rate could not be calculated.

Parents of 173 children aged 2–17 years completed the survey. Two parents with medical training were eliminated from further analysis due to the possibility of formal pediatric sleep training. One questionnaire was eliminated due to incomplete Parents’ Sleep Knowledge Inventory (PSKI) responses, leaving 170 parents in the sample. There were 56 parents from the United States and 109 parents from Australia, and five respondents did not provide their country of origin. Of the 170 parents, 91% were mothers and 69% had an education level of bachelor’s degree or higher. English was spoken as a first language by most families (97.6%). The most common family composition consisted of two children per family (range = 1–6), with the majority of the families (91.6%) having three or fewer children in the family and most families having children aged 12 years or younger (79.4%). Thirty-six per cent of the families reported only having female children, while 49% reported having only male children in the family. Children with and without a disability were included in the sample to allow evaluation of parental sleep knowledge for both groups. According to parent report, 61 (35.7%) children had an intellectual or developmental disability (one parent did not indicate) and 14 (8.2%) had a medical or physical disability.

Measures

Parents’ Sleep Knowledge Inventory (PSKI)

As we knew of no questionnaire that addressed parent knowledge of childhood sleep, we constructed this 62-item questionnaire about children’s sleep development. The measure was created by the researchers in consultation with current literature, in particular Mindell and Owens (2003), Sheldon et al. (1992) and Stores (2001). The first section of the PSKI included background information about the parent completing the questionnaire (education, medical training, ethnic background, mother or father, age, postcode) and the children in the family (number, age, gender, medical or developmental disorders).

To ensure comprehensive coverage of sleep dimensions, the PSKI questionnaire was created using the BEARS sleep domains (i.e. bedtime problem; excessive daytime sleepiness; awakenings during the night; regularity and duration of sleep; and snoring) as a guide for what sleep knowledge to evaluate (Mindell and Owens, 2003). Items within each domain covered information related to age groups from birth to adolescence. All items in the PSKI were responded to as 0 (‘not true’), 1 (‘somewhat’ or ‘sometimes true’), 2 (very true) or 3 (‘don’t know’). ‘Somewhat’ or ‘sometimes true’ referred to behaviors that children may exhibit or sometimes exhibit. ‘Very true’ related to items that were almost always true (e.g. questions about hours of sleep). ‘Not true’ designated items that were wrong according to general sleep guidelines (e.g. see Mindell and Owens, 2003; Sheldon et al., 1992; Stores, 2001).

Participants’ total PSKI scores represented their general sleep knowledge for children from infancy to adolescence. Individual PSKI scores were represented as the number of correct responses and the percentage of correct responses was calculated. PSKI questions were further defined according to question theme (i.e. sleep aspects related to age of child, developmentally normal sleep, sleep problems). The ‘sleep aspects related to age of child’ theme was determined according to child development norms for age groups from infancy to adolescence (Berk, 2006). The infancy category was from birth to 2 years (= 25 questions); early childhood (i.e. toddlers and preschoolers) was 2–6 years (= 18 questions); middle childhood (i.e. primary school age children) was 6–11 years (= 19 questions); and adolescence was 11–20 years (= 13 questions). If the question referred directly to ‘children’, ‘pre-schoolers’, ‘toddlers’ or ‘infants’, the question was scored within its corresponding age group category (i.e. children = middle childhood; toddler or preschooler = early childhood; infant = infancy), regardless of any reference to chronological age range that may also have been contained within the question. The ‘developmentally normal sleep’ theme contained questions (= 36 questions) about sleep that related to the appropriate number of hours of sleep or naps that a child of a particular age would require or normal types of sleep habits or dreams. The ‘sleep problems’ theme comprised questions (= 26 questions) related to commonly occurring sleep problems (i.e. daytime sleepiness, apnea/snoring, body movements, waking, settling and dreams/nightmares). Questions could be categorized into more than one domain depending upon the question focus (see Table 1 for PSKI questions and category assignments by theme).

Table 1.   Parents’ Sleep Knowledge Inventory (PSKI) questions, domain designations, correct response for item, average % don’t know (DK), average % correct
PSKI questionDesignationCorrect answerDKCorrect
  1. Question designation codes: I, infancy; E, early childhood; M, middle childhood; A, adolescence; NS, normal sleep; H, hours; N, naps; PS, problem sleep; AS, apnea/snoring; DS, daytime sleepiness; B, body movements; W, waking; S, settling; D, dreams/nightmares.

 1. Infants, aged 1–3 months old, should sleep 3–4 h after each waking periodH, NS, IVery true4.155.6
 2. One-year-olds typically sleep soundly throughout the night and take one nap during the dayN, NS, I, WVery true1.839.8
 3. Children, aged 6–12 years, do not typically take napsN, NS, M, AVery true3.581.9
 4. Children, aged 6–12 years, are less likely to struggle or argue about going to bed than 3–5-year-oldsPS, M, SVery true12.328.1
 5. Nightmares are common among children aged 6–12 yearsPS, D, MVery true30.424.6
 6. Adolescents aged 13–18 years, require10.5–12.5 h of sleep within a 24-h periodNS, A, HNot true13.522.8
 7. It is normal for an infant (up to 24 months) to have difficulty sleeping alone versus sleeping with a parentPS, I, S, WNot true4.729.8
 8. Newborn infants generally wake for 1–2 h before falling back to sleepNS, I, WVery true6.428.1
 9. A newborn infant requires 16–20 h of sleep within a 24-h periodNS, I, HVery true5.367.3
10. It is considered unusual for infants (up to 24 months) to wake periodically at nightI, PS, WNot true2.944.4
11. Two-year-olds sleep approximately 18 h within a 24-h periodNS, I, E, HNot true5.836.8
12. It is considered normal for children, aged 6–12 years, to get out of bed three times throughout the nightPS, M, A, WNot true9.447.4
13. Five-year-olds take a short daytime nap and start to give up nappingNS, N, ESometimes true4.734.5
14. Breastfeeding has been found to decrease an infant’s ability to sleep soundly throughout the nightPS, I, WVery true12.92.9
15. One-year-olds sleep approximately 13–16 h within a 24-h periodNS, I, HNot true5.828.1
16. One-year-olds take 2–3 h of naps during the dayNS, I, NVery true1.231.0
17. Children, aged 2–5 years, typically sleep soundly throughout the nightNS, E, WVery true2.946.8
18. Toddlers, aged 2–3 years, sleep sounder when able to use a security object (i.e. a blanket, teddy bear, etc.)PS, E, WVery true14.031.0
19. Infants, aged 4–8 months, do not experience dreamsNS, I, DNot true38.632.7
20. Children, aged 11–13 years, dream about activities they experienced throughout the dayNS, M, A, DVery true29.228.7
21. Most children, aged 5–10 years, sleep soundly at night and are very alert during the dayNS, M, W, DSVery true7.060.2
22. Children, aged 3–5 years, normally nap during the dayNS, N, ESometimes true3.537.4
23. The degree of attachment between a parent and their infant, aged up to 12 months, impacts an infant’s sleep patternNS, I, HSometimes true33.324.6
24. A newborn will usually take between four and six naps during the dayNS, I, NVery true1.860.2
25. Feeding an infant (up to 24 months) too often at night may cause them to wake more frequently during the nightPS, I, WVery true16.437.4
26. Toddlers, aged 2–3 years, typically have trouble sleeping when they use a security object (i.e. a blanket, teddy bear, etc.) to go to sleepPS, E, W, SNot true22.236.8
27. Adolescents tend to report high rates of sleepless nightsPS, A, WNot true39.222.2
28. A child sleeps more restlessly in cold weather than in hot weatherPS, M, WNot true20.533.3
29. Three-year-olds report that their dreams consist of animal figures that look humanNS, E, DVery true68.40.60
30. Children, aged 6–10 years, normally take at least 20 min to settle or go to sleepNS, M, SVery true21.638.0
31. A newborn infant should spend approximately 70% of every 24-h period asleepNS, I, HVery true12.352.6
32. Bottle-fed infants (up to 24 months) sleep less throughout the night than breastfed infantsPS, I, H, WNot true23.432.7
33. It is considered normal for an infant (up to 24 months) to wake periodically throughout the night, as long as they can fall back to sleep independentlyNS, I, E, WVery true5.357.3
34. Adolescents spend about 12 h of a 24-h period asleepNS, A, HNot true14.027.5
35. It is more common for an infant aged 1–2 months to wake throughout the night than an infant aged 9–12 monthsNS, I, WNot true5.829.2
36. Children, aged 6–7 years, most often dream about ghosts and the supernaturalNS, M, DVery true53.25.8
37. If children nap too often or for too long during the day, they may wake more frequently during the nightPS, M, N, WVery true7.631.0
38. Children, aged 6–7 years, do not typically report dreams of being chased or threatenedNS, M, DNot true52.618.1
39. Toddlers, aged 1–3 years, typically have difficulty falling asleepPS, I, E, SSometimes true8.829.2
40. Sixteen-year-olds require approximately 10.5 h of sleep within a 24-h periodNS, A, HNot true24.616.4
41. Ten-year-olds require approximately 9.5 h sleep within a 24-h periodNS, M, HNot true23.419.3
42. Adolescents sleep more on school nights than on non-school nightNS, A, HNot true30.429.2
43. A toddler, aged 1–3 years, may have a sleep problem if they wake for more than 20 min during the nightPS, I, E, WVery true25.118.7
44. Fifteen-year-olds require approximately 9 h of sleep within a 24-h periodNS, A, HVery true30.428.1
45. Six-year-olds require approximately 13.5 h of sleep within a 24-h periodNS, E, M, HNot true22.819.3
46. If a sleeping infant (up to 24 months) stops breathing for 20 s or more, they may have sleep apnea (an absence of breathing)PS, I, E, ASVery true43.337.4
47. Toddlers, aged 2–3 years, take one nap in the morning and one nap in the afternoonNS, I, E, NNot true5.822.2
48. Children, aged 6–10 years, demonstrate frequent body movements during their sleepPS, M, BVery true28.731.6
49. Ten-year-olds sleep the same amount of time on school nights as on non-school nightsNS, M, HVery true28.731.6
50. Adolescents who snore may have sleep apnea (the absence of breathing)PS, A, ASVery true38.028.1
51. Children begin to report having dreams at approximately age 3 yearsNS, E, DVery true35.726.3
52. Three-year-olds require approximately 14.8 h of sleep within a 24-h periodNS, E, HNot true13.517.0
53. Four-year-olds are often awoken from their sleep by dreamsPS, E, W, DNot true31.611.7
54. Difficulty breathing, sweating and enuresis (bed-wetting) may be a sign of apnea (an absence of breathing) in childrenS, M, ASVery true66.712.3
55. Infants (up to 24 months) usually sleep soundly when they sleep with their parentsPS, I, E, S, WSometimes true9.935.7
56. Children, aged 11–13 years, usually dream about animalsNS, M, A, DNot true70.811.1
57. Infants should be put to bed when they are drowsy, not once they are asleepPS, I, SVery true5.363.2
58. From the age of 3 months, a consistent and pleasant bedtime routine can be establishedPS, I, SVery true1.875.4
59. Up until 2 years of age, television viewing at bedtime can be helpful in getting a child to sleepPS, I, E, SNot true9.944.4
60. Adolescents snore on a nightly basisPS, A, ASNot true32.733.9
61. School-aged children are often sleepy during the dayPS, M, DSNot true13.534.0
62. Sometimes children get a ‘second wind’ late in the day or evening and become overly alert In these cases the child needs sleep and must go to bed, despite their probable resistancePS, M, DS, SNot true11.725.7

Procedure

Ethics approval in Australia was obtained from both the Royal Melbourne Institute of Technology (RMIT) University Human Research Ethics Committee and the then Victorian Department of Education, Employment and Training. Approval in the United States was obtained from the Penn State University Internal Review Board. Schools, early intervention centers, and support groups were contacted via telephone and letter regarding their willingness to participate in this study. Advertisements were placed with family support groups and schools using newsletters, websites and e-mail lists as appropriate. In Australia, questionnaire packages with a reply-paid, return-addressed envelope were sent to groups and schools willing to participate or to families directly indicating interest in participating; at some schools parents could also return the questionnaire via a school drop-box. Responses were anonymous. In the United States, participants were referred to a web address to complete the online questionnaire. All responses were de-identified and informed consent implied by completion of the questionnaire. In both locations, parents were asked to forward the research request to other parents. Participating schools and parent groups were offered a presentation and brief report concerning the outcomes of the study and sleep patterns and development in children at the conclusion of the study.

Analysis

The data analysis was modeled from Owens (2001) descriptive research conducted with pediatricians. For example, we calculated sleep knowledge by the percentage of correct answers for the sleep themes (e.g. general sleep, problem sleep and age-related sleep). Where appropriate, chi-square, analysis of variance or t-tests were used to examine demographic differences or differences across knowledge themes. As some questionnaires had one or two items with missing answers, the number of participants varied across calculations and is either reported or can be calculated from the degrees of freedom associated with the particular analysis.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Demographic relationships to sleep knowledge

No significant differences existed between total scores on the PSKI between (i) parents with a bachelor’s degree or higher and parents with education levels lower than a bachelor’s degree (e.g. trade school, etc.), F36,132 = 1.25, = 0.19; (ii) parents of children with a medical or developmental disorder and parents of typically developing children, F36,133 = 1.23, = 0.20; and (iii) United States and Australian participants, F36,129 = 1.25, = 0.19. Consequently, all responses for these groups were combined for analyses.

General sleep knowledge

Across all participants, the total correct PSKI score (maximum possible score = 62) for each participant was calculated with ‘don’t know’ (DK) items counted as incorrect in this calculation. DK responses were also examined separately. Parents’ general knowledge of overall childhood sleep (PSKI total scores) ranged between one question correct (1.6%) and 39 questions correct (62.9%), with only 13 (7.6%) parents receiving scores >50% correct. The average number of correct PSKI items was 20 (32%).

Although some data were missing due to item non-response for particular items, significantly enough responses were available to conduct analyses for overall sleep knowledge based upon the age of the oldest child in the family. Comparisons of parents’ overall knowledge of pediatric sleep across developmental age ranges (PSKI total scores) indicated significant differences of parental knowledge based upon the age of their oldest child, F2,147 = 9.79, < 0.001. Post-hoc analyses using the Bonferroni post-hoc criterion for significance (adjusted α = 0.0167) showed that parents whose oldest child was younger than 6 years answered correctly significantly fewer questions about general pediatric sleep across all ages [mean = 28.75%, standard deviation (SD) = 12.66] than parents of children whose oldest child was aged 7–12 years (mean = 36.9%, SD = 12.49), < 0.01 or parents of children whose oldest child was aged 13 years or older (mean = 38.01%, SD = 9.34), < 0.001.

Knowledge of sleep aspects related to age of child questions

Analysis of variance (age of oldest child in the family × PSKI question age range) showed that the age of the oldest child in the family significantly influenced parents’ ability to answer items correctly about age-specific sleep patterns and problems, except for questions about infant sleep. Comparisons of parents’ knowledge of sleep across specific developmental age ranges (i.e. infancy, early childhood, middle childhood, and adolescence) indicated significant differences for parental knowledge based upon the age of the oldest child in the family for early childhood sleep, F2,141 = 9.55, < 0.001; middle childhood sleep, F2,141 = 14.378, < 0.001; and adolescent sleep, F2,142 = 21.33, < 0.001. Post-hoc analyses using the Bonferroni post-hoc criterion for significance suggested that parents whose oldest child was younger than 6 years correctly answered significantly fewer questions about early childhood sleep (mean = 25.56%, SD = 16) than parents of children who were 13 years or older (mean = 33%, SD = 12.25), < 0.001. Questions related to middle childhood sleep were answered best by parents whose oldest child was aged 7 years or older (6 and under: mean = 24.59%; SD = 14.61; 7–12 years: mean = 36.43%; SD = 14.60; 13+ years: mean = 37.00%; SD = 11.05), < 0.001. Parents whose oldest child was younger than 6 years also answered correctly significantly fewer questions about adolescent sleep than parents of children older than 7 years (6 and under: mean = 22.75%; SD = 16.38; 7–12 years: mean = 36.09%; SD = 16.76; 13+ years: mean = 42.31%; SD = 11.08), < 0.001.

Knowledge of developmentally normal sleep patterns

To determine parental knowledge of normal sleep patterns, we calculated the percentage of correct responses to PSKI items in the ‘developmentally normal sleep patterns’ theme, regardless of age of the child referred to in the PSKI item. As described previously, these questions (= 36) were chosen if questions related to developmental patterns of sleep in any of the age groups infancy, early childhood, middle childhood and adolescence (e.g. numbers of hours of sleep, napping, etc.).

On average, parents answered 34.7% of questions correctly about normal sleep patterns. In general, parents knew little about normal sleep patterns across the developmental age ranges, with only 10.6% (= 18) of the parents receiving a score of 50% or higher on the ‘developmentally normal sleep patterns’ theme items (mean = 34.7%; range = 0–63.8% correct). A descriptive analysis showed that the average percentage correct for the questions about normal sleep patterns within each age range indicated that parents were more able to answer correctly questions related to normal infant sleep patterns (mean = 44.2%; range 28.1–75.4%) than questions related to early childhood (mean = 30.1%; range 0.6–60.2%), middle childhood (mean = 31.1%; range 5.8–81.9%) and adolescence (mean = 30.7%; range 11.1–81.9%). However, comparisons of parents’ knowledge of normal pediatric sleep across developmental ages [analysis of variance (anova): PSKI items related to infancy, early childhood, middle childhood, and adolescence × age of oldest child in family] indicated no significant differences in parental knowledge based upon the age of the parents’ oldest child.

Parents’ possible uncertainty of children’s sleep generally increased as the age of the child referred to in the PSKI items increased. A descriptive analysis of trends indicated that parents answered fewer questions as the age of the children increased with more DK answers in the older age ranges: infancy (mean = 9.2%), early childhood (mean = 17.0%); middle childhood (mean = 31.3%); and adolescence (mean = 27.1%). Parents less frequently answered DK to items concerning childhood napping (meanDK = 3.7%) than to other areas of sleep aspects related to the age of the child. However, their scores did not indicate accurate knowledge of napping (meancorrect = 42.3%). Knowledge of appropriate number of hours of sleep per night required by children was also relatively low (meanDK = 18.2%; meancorrect = 32.3%). See Fig. 1 for comparison of percentage of correct and DK responses for each age range.

image

Figure 1.  Percentage of correct responses for questions concerning developmentally normal sleep patterns across all age groups and by age groups.

Download figure to PowerPoint

Knowledge of childhood sleep problems

A paired-sample t-test comparing parents’ percentage of correct scores for questions related to normal sleep and problem sleep indicated that parents were less knowledgeable about sleep problems, such as settling problems, night waking, apnea, etc. (meancorrect = 31.67%, SD = 17.37) than developmentally normal sleep patterns (meancorrect = 34.78%, SD = 12.88), t149 = 2.36, = 0.019. A one-way anova using a Bonferroni post-hoc analysis (adjusted α = 0.0167) indicated that as with questions related to developmentally normal sleep patterns for different-aged children, parents whose oldest child was aged 6 years or younger were able to answer correctly fewer questions about pediatric sleep problems than parents of children aged 7 years or older, F2,140 = 15.29, < 0.001 (6 years and under: mean = 23.41%; SD = 15.75; 7–12 years: mean = 36.09%; SD = 16.76; 13+ years: mean = 42.31%; SD = 11.08), < 0.001.

In general, parents knew significantly more about sleep problems observable before the child went to sleep, such as settling and daytime sleepiness (meancorrect = 40.88%; SD = 19.9) than sleep problems that occur typically during the night, such as night waking, apnea, and dreams/nightmares (meancorrect = 27.08%; SD = 16.51), t158 = 9.51, = 0.0001. As for general sleep problems, parents whose oldest child was 6 years or younger were able to answer fewer questions correctly about sleep problems after their child goes to sleep than parents of children aged 7 years or older, sleep F2,140 = 10.94 (6 years and under: mean = 20.43%; SD = 14.21; 7–12 years: mean = 30.44%; SD = 16.91; 13+ years: mean = 33.84%; SD = 14.39), < 0.001. However, no significant difference among correct answers about sleep problems observable before the child went to sleep was detected related to the age of the parents’ oldest child.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Consistent with our prediction, we found that parents’ knowledge of pediatric sleep was generally poor. Fewer than 10% of the parents sampled answered 50% or more of the total PSKI questions correctly. In fact, the average number of general sleep knowledge questions answered correctly was 32%, with the highest score being only slightly above half of the items correct (63%). As might be expected, parents who had younger children, and thus never experienced sleep patterns and problems with older children, answered correctly fewer sleep knowledge items across the entire ranges of children (i.e. infancy to adolescence). Although these parents answered correctly significantly fewer items, parents who had at least one child aged 13 years or older typically only answered fewer than 40% of the questions correctly. This implies that even parents with experience across all ages of children have poor knowledge of pediatric sleep patterns and problems.

Further analysis of parental sleep knowledge across three additional sleep question themes (i.e. sleep aspects related to age of child items, developmentally normal sleep items and sleep problem items) did not indicate that parental sleep knowledge was confined to any particular area. Although all parents, and in particular parents whose children were aged 7 years or older, were more able to answer questions related to infant sleep than early childhood, middle childhood or adolescent sleep, their answers continued to be no more than 40% correct.

Overall, regardless of the age group referred to in the PSKI questions, parents answered correctly approximately a third of the questions related to normal sleep patterns, with only 10% answering correctly more than half of the questions. Specifically, parents answered correctly close to a third of the questions concerning napping and appropriate number of hours of sleep for children, with approximately 20% admitting that they did not know how many hours of sleep would be appropriate for a child.

Parents were even less able to answer correctly items related to sleep problems than to normal sleep patterns. In fact, parents answered correctly around 25% of PSKI items related to childhood sleep problems, such as apnea and nightmares/dreams. However, parents were more likely to answer correctly items related to sleep problems that commonly occur during the day or early in the night before parents go to sleep (e.g. settling and daytime sleepiness).

The results of this study were similar to studies related to medical professionals’ knowledge of sleep problems, which indicated low knowledge about child sleep development by many pediatricians, particularly in specific sleep areas (Owens, 2001). This possible combination of lack of parental and medical professional knowledge of childhood sleep could have a significant impact on children. As research suggests that medical professionals typically rely upon parents to detect and report if their child has a sleep problem (Owens, 2001), parental lack of sleep knowledge may significantly impact children receiving care. As the current findings indicate that parents: (i) have relatively poor knowledge about children’s sleep irrespective of the age of their oldest child; (ii) may be more able to determine developmentally normal sleep patterns (e.g. hours and napping) than sleep problems; and (iii) that parents do not know about a wide variety of sleep problems, it is likely that even when health professionals ask about child sleep, parents’ replies may be misleading. Additionally, as parents rarely ask medical professionals about their child’s sleep (Blunden et al., 2004), health professionals’ reliance upon parents to report any child sleep issues also may explain why childhood sleep problems may be grossly under-reported and under-diagnosed (Owens and Mindell, 2005).

While a wide range of recruitment methods and sources were used to obtain these results and parents from both Australia and the United States completed questionnaires, the samples from the two countries did not differ on any demographic variables. Thus, similar results might be expected in other English-speaking western countries. Although generalization across different countries might be expected, there are some potential limitations of the study. These include: (i) a relatively small sample size; (ii) no previous comparative research data; (iii) a non-standardized questionnaire; and (iv) a bias toward highly educated parents. However, given that the parents in this study were well educated, it might have been expected that their general knowledge about child development and child sleep would be good, particularly as previous research has shown that education is a good predictor of parent knowledge about child development (Reich, 2005). That we found generally poor knowledge about children’s sleep in a well-educated sample implies that most parents in English-speaking western nations such as Australia and the United States probably have inadequate knowledge about children’s normal sleep development or sleep problems.

Our findings have implications for education about children’s sleep development as a preventative treatment for child sleep problems. Although research has supported the efficacy of parent education for infant sleep (Mindell et al., 2006), our results support the need to broaden this parent education to older children and perhaps even to adolescents themselves. Additionally, in our study, the parents of children with an intellectual or developmental disability did not differ from parents of typically developing children in their sleep knowledge. However, children with intellectual or developmental disabilities are more likely to experience sleep problems than are typically developing children, and as parents of the former group are more likely to attribute sleep problems to the child’s disability (Robinson and Richdale, 2004; Wiggs and Stores, 1996), these parents may require a sleep education program that specifically addresses the behavioral or medical issues associated with their child’s disability that may affect their child’s sleep (e.g. communication difficulties, epilepsy, etc.).

Although a consensus of pediatric sleep professionals concluded before this study that a significant effort must be made to educate US medical and psychology students, medical professionals, and parents about childhood sleep (Owens and Mindell, 2005), and health professionals’ education about pediatric sleep is currently a focus in Australia (Australasian Sleep Association, 2009), the results of this study imply that much is yet to be done. The mere experience of parenting children from infancy to adolescence does not result in comprehensive parental knowledge of childhood sleep. If parents and health professionals, particularly medical practitioners, continue to be poorly educated about pediatric sleep, millions of children and parents worldwide will continue to suffer the debilitating mental and physical effects of sleep disorders.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The authors thank Ms Tahlia Carcarello for her contribution to the development of the PSKI and for her assistance with the collection of the Australian data, and Dr Ilhan Kucukaydin for his assistance with the internet database.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References