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.
Credit: Ronnie Comeau, istockphoto
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
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
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.
Researchers at Vanderbilt University are using the CSHQ to assess the
effects of melatonin on insomnia in children with autism spectrum disorders
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 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
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
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
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
"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
The CSHQ may be obtained free online at<www.kidzzzsleep.org/researchinstruments.htm>.
Spanish and Chinese translations are available. ▪