Questionnaire Helps Identify Children's Sleep Disorders

A questionnaire on children's sleep, completed by parents, alerts clinicians to symptoms of common sleep disorders in young patients. It also highlights the impact of these problems on family life.

Nearly 20 scientific publications to date have reported findings from the Children's Sleep Habits Questionnaire (CSHQ), introduced in 1997. More than 100 studies using it are in progress, Judith Owens, M.D., a CSHQ codeveloper and an associate professor of pediatrics at the Warren Alpert Medical School of Brown University, told Psychiatric News.

The 33-item CSHQ takes about 10 minutes to answer, said Owens, who directs both the pediatric sleep disorders clinic and the learning, attention, and behavior clinic at Hasbro Children's Hospital in Providence, R.I. The CSHQ is designed for parents of children aged 4 to 12 years but has been used successfully in studies of children as young as 2 years and in adolescents.

The CSHQ covers the major categories of behavioral and medical sleep disorders. These include insomnia domains such as bedtime resistance, delayed sleep onset (taking more than 20 minutes to fall asleep), not getting enough sleep, anxiety at bedtime, and night waking. The CSHQ asks about bedwetting, sleepwalking, sleep terrors, and other disorders of partial arousal. It surveys symptoms of sleep-disordered breathing such as snoring and pauses in breathing. Other questions focus on daytime sleepiness, such as whether the child awakens spontaneously or needs to be awakened, wakes up in a negative mood, seems tired, falls asleep while watching television, or suddenly falls asleep in the midst of active behavior.

Previous pediatric sleep questionnaires also asked parents to report the frequency of a child's sleep difficulties, Owens noted. The CSHQ further explores family dynamics by asking, “Is this behavior or activity a problem?”

Parents' answers to the CSHQ steer clinicians to behaviors that need evaluation, Owens said. The CSHQ can help clinicians and researchers assess sleep before and after an intervention. Researchers also find it useful for comparing population groups.

It is unrealistic to expect a single questionnaire to cover all ages from infancy to 18 years, Owens cautioned. She and colleagues have devised a self-report version for children aged 7 and over. They currently are pilot-testing an adolescent self-report version. Both modifications include separate parent questionnaires.

Does Melatonin Work?

Researchers at Vanderbilt University are using the CSHQ to assess the effects of melatonin on insomnia in children with autism spectrum disorders (ASDs).

Children with ASD take longer to fall asleep, go to bed later, wake more often in the night, awaken earlier in the morning, and get less sleep overall than typically developing children, Beth Malow, M.D., M.S., a professor of neurology and medical director of Vanderbilt's sleep disorders center, said at the annual meeting of the Associated Professional Sleep Societies (APSS) in Baltimore in June. Some children with ASD manifest a non-24-hour sleep-wake pattern, she noted, an additional challenge for caretakers (see Original article: Children's Sleep Disorders Tied to Psychiatric Disorders).

She and others have found that children with ASD have lower endogenous levels of melatonin than children without the disorder. Although melatonin is a hormone, it is available over the counter in various dosages as a dietary supplement. According to a 2008 report from the Interactive Autism Network, a Web project of the Kennedy Krieger Institute in Baltimore, nearly 9 percent of parents of children with ASD responding to the network's survey reported they had given their child a melatonin supplement to foster sleep—about the same proportion as had used risperidone to treat autism-related irritability.

Malow and colleagues reviewed records of 107 children with ASD aged 2 to 18 who had taken 0.75 mg to 6 mg melatonin for problems with sleep. All were patients of a single pediatrician. Sleep improved in 85 percent of the children. Because parents also received instruction on behavioral tactics to foster sleep, the improved sleep cannot be attributed to the efficacy of melatonin alone. Melatonin appeared to be a safe and well-tolerated treatment for insomnia in these children, the researchers reported in the May Journal of Child Neurology.

With funding from the National Institute of Child Health and Human Development and Autism Speaks, Malow and colleagues are conducting a pilot study to determine dose-response, tolerability, and adverse effects of melatonin in 30 children aged 4 to 10 with ASD and sleep-onset delay. They use the CSHQ to document parents' perceptions of their child's sleep before and after treatment.

Children Wear Activity Monitors

The researchers ask the children to wear activity monitors on the wrist or in a shirt pocket for 17 weeks to record sleep-wake patterns. The researchers also perform polysomnography and pharmacokinetic studies. They anticipate using results to plan a multicenter, placebo-controlled double-blind, randomized trial of melatonin for sleep in children with ASD.

Researchers at Oregon Health and Science University (OHSU), Baylor College of Medicine, and Columbia University Medical Center are using the CSHQ in their current study of melatonin in children with ASD, Kyle Johnson, M.D., principal investigator at OHSU, told Psychiatric News. Funding comes from Autism Speaks.

Johnson, an associate professor of child and adolescent psychiatry, codirects OHSU's sleep disorders program.

After recruiting 30 children aged 4 to 9 with ASD who have troubled sleep and a matched group of 30 who sleep well, the researchers will assess 24-hour melatonin levels to see whether delayed melatonin production correlates with poor sleep.

In the study's second phase, Johnson said, they will recruit 120 children with ASD and disturbed sleep for a randomized trial of two oral doses of melatonin (3 mg and 6 mg) and a placebo to see whether treatment with melatonin helps the children fall asleep faster and improves daytime behavior.

“Sleep problems in this population can be recognized, characterized, and treated,” Johnson said.

By teaching parents to regularize bedtimes and waketimes, follow predictable bedtime routines, and use other behavioral techniques, Malow asserted, physicians often can avoid use of melatonin or sedative/hypnotics in these children. Physicians also need to explore whether something in the home environment or the way the parent interacts with the child promotes bedtime difficulties and night waking, she said. Her group reported at the APSS meeting that three weekly, two-hour educational workshops for parents, along with aids such as step-by-step picture schedules and checklists, improved subjective and objective sleep parameters and daytime behavior in children with ASD.

The CSHQ may be obtained free online at<www.kidzzzsleep.org/researchinstruments.htm>. Spanish and Chinese translations are available. ▪