Open Access Peer-reviewed Research Article

Effects of an online treatment for pediatric sleep problems on emotion dysregulation in young children Findings from the Internet-based sleep Intervention program Mini-KiSS Online

Main Article Content

Friederike Lollies corresponding author
Isabel Brandhorst
Angelika A. Schlarb

Abstract

Background: Pediatric sleep problems are strongly linked to future emotional problems. However, research regarding the effect of internet-based cognitive behavior therapy for insomnia (iCBT-I) in early childhood on the outcome of emotion dysregulation is missing. Participants: 200 children (47% female) aged 7 to 63 months (M = 23.13) suffering from behavioral insomnia participated in the Mini-KiSS 6-week online treatment.
Methods: A prepost- follow-up design was implemented. Sleep disorders were stated according to ICSD-3 and DSM-5 criteria and emotional dysregulation was assessed with an emotion dysregulation profile for children. Difference scores were calculated, a repeated-measures ANOVA, and stepwise multiple linear regression was performed.
Results: After iCBT-I Mini-KiSS for young children, emotion dysregulation significantly declined immediately after the intervention (p = 0.000) and in the follow-up measurement after three months (p = 0.002). Age was associated with the change in emotion dysregulation at follow-up measurement (p = 0.017). Gender or the type of sleep disturbance did not have statistically significant impact on change in emotion dysregulation at any measurement (p ≥ 0.05). Clinically significant improvement of emotional dysregulation was achieved in 14.5% of the children from pre- to post-measurement, and 25.3% improved at follow-up.
Conclusions: The findings show that treatment of pediatric insomnia reduce emotion dysregulation of infants and toddlers. Therefore, early sleep intervention might prevent mental disorder in young children. In future, an extended longitudinal design is needed to examine the preventing power of early-improved sleep on later psychopathological disorders. Beyond, future studies should examine underlying mechanisms in more detail.

Keywords
emotion dysregulation, pediatric sleep, behavioral insomnia in childhood, internetbased intervention, infants, toddlers

Article Details

Supporting Agencies
Professor Schlarb holds the professorship for clinical psychology and psychotherapy for children and adolescents at the Bielefeld University.
How to Cite
Lollies, F., Brandhorst, I., & Schlarb, A. (2021). Effects of an online treatment for pediatric sleep problems on emotion dysregulation in young children. Advances in Health and Behavior, 4(1), 150-163. https://doi.org/10.25082/AHB.2021.01.001

References

  1. Palmer CA and Alfano CA. Sleep and emotion regulation: An organizing, integrative review. Sleep Medicine reviews, 2017, 31: 6-16. https://doi.org/10.1016/j.smrv.2015.12.006
  2. Meltzer LJ. Clinical management of behavioral insomnia of childhood: Treatment of bedtime problems and night wakings in young children. Behavioral Sleep Medicine, 2010, 8(3): 172-189. https://doi.org/10.1080/15402002.2010.487464
  3. Moore M. Bedtime problems and night wakings: Treatment of behavioral insomnia of childhood. Journal of Clinical Psychology, 2010, 66(11): 1195-1204. https://doi.org/10.1002/jclp.20731
  4. Greene G, Gregory AM and Fone D, et al. Childhood sleeping difficulties and depression in adulthood: The 1970 British Cohort Study. Journal of Sleep Research, 2015, 24(1): 19-23. https://doi.org/10.1111/jsr.12200
  5. Hatzinger M, Brand S, Perre S, et al. In pre-school children, sleep objectively assessed via sleep-EEGs remains stable over 12 months and is related to psychological functioning, but not to cortisol secretion. Journal of Psychiatric Research, 2013, 47(11): 1809-1814. https://doi.org/10.1016/j.jpsychires.2013.08.007
  6. Kelly RJ and El-Sheikh M. Reciprocal relations between children’s sleep and their adjustment over time. Developmental Psychology, 2013, 50(4): 1137-1147. https://doi.org/10.1037/a0034501
  7. WaxmonskyJG, Mayes SD, Calhoun SL, et al. The association between disruptive mood dysregulation disorder symptoms and sleep problems in children with and without ADHD. Sleep Medicine, 2017, 37: 180-186. https://doi.org/10.1016/j.sleep.2017.02.00
  8. Legenbauer T, Heiler S, Holtmann M, et al. The affective storms of school children during night time: Do affective dysregulated school children show a specific pattern of sleep disturbances? Journal of Neural Transmission, 2012, 119(9): 989-998. https://doi.org/10.1007/s00702-012-0837-4
  9. Gregory AM and Sadeh A. Annual research review: Sleep problems in childhood psychiatric disorders: A review of the latest science. Journal of Child Psychology and Psychiatry, 2016, 57(3): 296-317. https://doi.org/10.1111/jcpp.12469
  10. Leibenluft E. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. American Journal of Psychiatry, 2011, 168(2): 129-142. https://doi.org/10.1176/appi.ajp.2010.10050766
  11. Brambilla P, Giussani M, Pasinato A, et al. Sleep habits and pattern in 1-14 years old children and relationship with video devices use and evening and night child activities. Italian Journal of Pediatrics, 2017, 43(1): 7. https://doi.org/10.1186/s13052-016-0324-x
  12. Sadeh AVI, Mindell JA, Luedtke K, et al. Sleep and sleep ecology in the first 3 years: A web-based study. Journal of Sleep Research, 2009, 18(1): 60-73. https://doi.org/10.1111/j.1365-2869.2008.00699.x
  13. Meltzer LJ and Mindell JA. Sleep and sleep disorders in children and adolescents. Psychiatric Clinics, 2006, 29(4): 1059-1076. https://doi.org/10.1016/j.psc.2006.08.004
  14. Schlarb A, Gulewitsch MD, Weltzer V, et al. Sleep duration and sleep problems in a representative sample of German children and adolescents. Health, 2015, 7(11): 1397-1408. https://doi.org/10.4236/health.2015.711154
  15. Palmstierna P, Sepa A and Ludvigsson J. Parent perceptions of child sleep: A study of 10 000 Swedish children. Acta Paediatrica, 2008, 97(12): 1631-1639. https://doi.org/10.1111/j.1651-2227.2008.00967.x
  16. Turnbull K, Reid GJ and Morton JB. Behavioral sleep problems and their potential impact on developing executive function in children. Sleep, 2013, 36(7): 1077-1084. https://doi.org/10.5665/sleep.2814
  17. Cho S, Philbrook LE, Davis EL, et al. Sleep duration and RSA suppression as predictors of internalizing and externalizing behaviors. Developmental Psychobiology, 2017, 59(1): 60-69. https://doi.org/10.1002/dev.21467
  18. Spruyt K, Aitken RJ, So K, et al. Relationship between sleep/wake patterns, temperament and overall development in term infants over the first year of life. Early Human Development, 2008, 84(5): 289-296. https://doi.org/10.1016/j.earlhumdev.2007.07.002
  19. Velten-Schurian K, Hautzinger M, Poets CF, et al. Association between sleep patterns and daytime functioning in children with insomnia: The contribution of parent-reported frequency of night waking and wake time after sleep onset. Sleep Medicine, 2010, 11(3): 281-288. https://doi.org/10.1016/j.sleep.2009.03.012
  20. Ross CN and Karraker KH. Effects of fatigue on infant emotional reactivity and regulation. Infant Mental Health Journal: Official Publication of The World Association for Infant Mental Health, 2000, 20(4): 410-428. https://doi.org/10.1002/(SICI)1097-0355(199924)20:4h410::AID-IMHJ4i3.0.CO;2-4
  21. Gross JJ. Emotion regulation: Current Status and Future Prospects. Psychological Inquiry, 2015, 26(1): 1-26. https://doi.org/10.1080/1047840X.2014.940781
  22. Brownell CA, Kopp CB, Brownell C, et al. (2007). Transitions in toddler socioemotional development. Socioemotional development in the toddler years: Transitions and transformations, (p. 1-40). NY: The Guilford Press.
  23. Thompson RA. Emotion regulation: A theme in search of definition. Monographs of the society for research in child development, 1994, 59(2-3): 25-52.
  24. Martin RE and Ochsner KN. The neuroscience of emotion regulation development: Implications for education. Current opinion in behavioral sciences, 2016, 10: 142-148. https://doi.org/10.1016/j.cobeha.2016.06.006
  25. Calkins SD. (2007). The emergence of self-regulation: Biological and behavioral control mechanisms supporting toddler competencies. In Brownell CA, Kopp CB, (Eds.), Socioemotional development in the toddler years: Transitions and transformations, NY: The Guilford Press, 261-284.
  26. Rueda MR, Posner MI and Rothbart MK. The development of executive attention: Contributions to the emergence of self-regulation. Developmental neuropsychology, 2005, 28(2): 573-594. https://doi.org/10.1207/s15326942dn2802_2
  27. Wiater AH, Mitschke AR, Widdern SV, et al. Sleep disorders and behavioural problems among 8-to 11-year-old children. Somnologie-Schlafforschung und Schlafmedizin, 2005, 9(4): 210-214. https://doi.org/10.1111/j.1439-054X.2005.00073.x
  28. Mindell JA, Leichman ES, DuMond C, et al. Sleep and social-emotional development in infants and toddlers. Journal of Clinical Child & Adolescent Psychology, 2017, 46(2): 236-246. https://doi.org/10.1080/15374416.2016.1188701
  29. Whalen DJ, Gilbert KE, Barch DM, et al. Variation in common preschool sleep problems as an early predictor for depression and anxiety symptom severity across time. Journal of Child Psychology and Psychiatry, 2005, 58(2): 151-159. https://doi.org/10.1111/jcpp.12639
  30. Hysing M, Sivertsen B, Garthus-Niegel S, et al. Pediatric sleep problems and social-emotional problems. A population-based study. Infant behavior and development, 2016, 42: 111-118. https://doi.org/10.1016/j.infbeh.2015.12.005
  31. Reynolds KC and Alfano CA. Childhood bedtime problems predict adolescent internalizing symptoms through emotional reactivity. Journal of pediatric psychology, 2016, 41(9): 971-982. https://doi.org/10.1093/jpepsy/jsw014
  32. Saenz J, Yaugher A and Alexander GM. Sleep in infancy predicts gender specific social-emotional problems in toddlers. Frontiers in Pediatrics, 2015, 3: 42. https://doi.org/10.3389/fped.2015.00042
  33. Foley JE and Weinraub M. Sleep, affect, and social competence from preschool to preadolescence: distinct pathways to emotional and social adjustment for boys and for girls. Frontiers in psychology, 2017, 8: 711. https://doi.org/10.3389/fpsyg.2017.00711
  34. Short MA and Louca M. Sleep deprivation leads to mood deficits in healthy adolescents. Sleep medicine, 2015, 16(8): 987-993. https://doi.org/10.1016/j.sleep.2015.03.007
  35. Meltzer LJ, Plaufcan MR, Thomas JH, et al. Sleep problems and sleep disorders in pediatric primary care: Treatment recommendations, persistence, and health care utilization. Journal of Clinical Sleep Medicine, 2014, 10(04): 421-426. https://doi.org/10.5664/jcsm.3620
  36. Troxel WM, Trentacosta CJ, Forbes EE, et al. Negative emotionality moderates associations among attachment, toddler sleep, and later problem behaviors. Journal of Family Psychology, 2013, 27(1): 127-136. https://doi.org/10.1037/a0031149
  37. Petit D, Touchette ´ E, Tremblay RE, et al. Dyssomnias and parasomnias in early childhood. Pediatrics, 2007, 119(5): e1016-e1025. https://doi.org/10.1542/peds.2006-2132
  38. Byars KC, Yolton K, Rausch J, et al. Prevalence, patterns, and persistence of sleep problems in the first 3 years of life. Pediatrics, 2012, 129(2): 276-284. https://doi.org/10.1542/peds.2011-0372
  39. Sivertsen B, Harvey AG, Reichborn-Kjennerud T, et al. Later emotional and behavioral problems associated with sleep problems in toddlers: a longitudinal study. JAMA pediatrics, 2015, 169(6): 575-582. https://doi.org/10.1001/jamapediatrics.2015.0187
  40. Blake MJ, Sheeber LB, Youssef GJ, et al. Systematic review and meta-analysis of adolescent cognitive– behavioral sleep interventions. Clinical child and family psychology review, 2017, 20(3): 227-249. https://doi.org/10.1007/s10567-017-0234-5
  41. El Rafihi-Ferreira R, Pires MLN and de Mattos Silvares EF. Behavioral intervention for sleep problems in childhood: A Brazilian randomized controlled trial. Psicologia: Reflex˜ao e Cr´ıtica, 2019, 32(1): 5. https://doi.org/10.1186/s41155-019-0118-3
  42. Meltzer LJ and McLaughlin Crabtree V. (2015). Pediatric sleep problems: A clinician’s guide to behavioral interventions. American Psychological Association.
  43. Schlarb AA, Velten-Schurian K, Poets CF, et al. First effects of a multicomponent treatment for sleep disorders in children. Nature and Science of Sleep, 2011, 3: 1-11. https://doi.org/10.2147/NSS.S15254
  44. Mindell JA, Du Mond CE, Sadeh A, et al. Efficacy of an internet-based intervention for infant and toddler sleep disturbances. Sleep, 2011, 34(4): 451-458. https://doi.org/10.1093/sleep/34.4.451
  45. Spiegelhalder K, Acker J, Baumeister H, et al. Digitale Behandlungsangebote f¨ur Insomnie–eine U¨ bersichtsarbeit. Somnologie, 2020, 24: 106-114. https://doi.org/10.1007/s11818-020-00238-9
  46. Fox S. (2011). The social life of health information. California Healthcare Foundation, 1-33.
  47. Kouros CD and El-Sheikh M. Daily mood and sleep: Reciprocal relations and links with adjustment problems. Journal of Sleep Research, 2015, 24(1): 24-31. https://doi.org/10.1111/jsr.12226
  48. Faul F, Erdfelder E, Lang AG, et al. G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 2007, 39(2): 175-191. https://doi.org/10.3758/BF03193146
  49. American Psychiatric Association. (2015). Sleep-Wake Disorders: DSM-5® Selections. American Psychiatric Pub.
  50. Sateia MJ. International classification of sleep disorders. Chest, 2014, 146(5): 1387-1394. https://doi.org/10.1378/chest.14-0970
  51. Gaylor EE, Burnham MM, Goodlin-Jones BL, et al. A longitudinal follow-up study of young children’s sleep patterns using a developmental classification system. Behavioral Sleep Medicine, 2005, 3(1): 44-61. https://doi.org/10.1207/s15402010bsm0301_6
  52. Schlarb AA and Brandhorst I. Mini-KiSS Online: An Internet-based intervention program for parents of young children with sleep problems–influence on parental behavior and children’s sleep. Nature and science of sleep, 2012, 4: 41-52. https://doi.org/10.2147/NSS.S28337
  53. Achenbach TM and Ruffle TM. The Child Behavior Checklist and related forms for assessing behavioral/emotional problems and competencies. Pediatrics in review, 2000, 21(8): 265-271. https://doi.org/10.1542/pir.21-8-265
  54. Spencer TJ, Faraone SV, Surman CB, et al. Toward defining deficient emotional self-regulation in children with attention-deficit/hyperactivity disorder using the Child Behavior Checklist: a controlled study. Postgraduate medicine, 2011, 123(5): 50-59. https://doi.org/10.3810/pgm.2011.09.2459
  55. Biederman J, Petty C, Monuteaux MC, et al. The CBCL-pediatric bipolar disorder profile predicts a subsequent diagnosis of bipolar disorder and associated impairments in ADHD youth growing up: a longitudinal analysis. The Journal of clinical psychiatry, 2009, 70(5): 732. https://doi.org/10.4088/JCP.08m04821
  56. Salkind NJ. (Ed.). (2010). Encyclopedia of research design, Vol. 1. Sage.
  57. Jacobson NS, Truax P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 1991, 59(1): 12-19. https://doi.org/10.1037/0022-006x.59.1.12
  58. Heckman JJ and Smith JA. Assessing the case for social experiments. Journal of economic perspectives, 1995, 9(2): 85-110. https://doi.org/10.1257/jep.9.2.85
  59. Li C. Little’s test of missing completely at random. The Stata Journal, 2013, 13(4): 795-809. https://doi.org/10.1177/1536867X1301300407
  60. Myers TA. Goodbye, listwise deletion: Presenting hot deck imputation as an easy and effective tool for handling missing data. Communication Methods and Measures, 2011, 5(4): 297-310. https://doi.org/10.1080/19312458.2011.624490
  61. Andridge RR and Little RJ. A review of hot deck imputation for survey non-response. International statistical review, 2010, 78(1): 40-64. https://doi.org/10.1111/j.1751-5823.2010.00103.x
  62. Guyatt GH, Osoba D, Wu AW, et al. Methods to explain the clinical significance of health status measures. Mayo Clinic Proceedings, 2002, 77(4): 371-383. https://doi.org/10.4065/77.4.371
  63. Vriend JL, Davidson FD, Corkum PV, et al. Manipulating sleep duration alters emotional functioning and cognitive performance in children. Journal of Pediatric Psychology, 2013, 38(10): 1058-1069. https://doi.org/10.1093/jpepsy/jst033
  64. Gruber R, Cassoff J, Frenette S, et al. Impact of sleep extension and restriction on children’s emotional lability and impulsivity. Pediatrics, 2012, 130(5): 1155-1161. DOI: https://doi.org/10.1542/peds.2012-0564
  65. Talbot LS, McGlinchey EL, Kaplan KA, et al. Sleep deprivation in adolescents and adults: changes in affect. Emotion, 2010, 10(6): 831-841. https://doi.org/10.1037/a0020138
  66. De Leon CW and Karraker KH. Intrinsic and extrinsic factors associated with night waking in 9-month-old infants. Infant Behavior and Development, 2007, 30(4): 596-605. https://doi.org/10.1016/j.infbeh.2007.03.009
  67. Kahn M, Scheppes G and Sadeh A. Sleep and emotions: Bidirectional links and underlying mechanisms. International Journal of Psychophysiology, 2013, 89(2): 218-228. https://doi.org/10.1016/j.ijpsycho.2013.05.010
  68. Schlarb AA, Brandhorst I and Hautzinger M. Mini-KiSS–ein multimodales Gruppentherapieprogramm f¨ur Eltern von Kleinkindern mit Schlafst¨orungen. Zeitschrift f¨ur Kinder-und Jugendpsychiatrie und Psychotherapie. 2011, 39: 197-206. https://doi.org/10.1024/1422-4917/a000106
  69. Lind DA, Marchal WG and Wathen SA. (2014). Statistical techniques in business & economics. New York.
  70. Deng Y, Wang G, Li W, et al. Persistence, Remission, Acquisition Of Sleep Disturbances Contributes To The Transition Of Emotional/behavioral Problems In Preschool Children.Sleep, 2020, 43(1): 369-369. https://doi.org/10.1093/sleep/zsaa056.968
  71. Wang B, Eastwood PR, Becker A, et al. Concurrent developmental course of sleep problems and emotional/behavioral problems in childhood and adolescence as reflected by the dysregulation profile. Sleep, 2019, 42(3): 1-12. https://doi.org/10.1093/sleep/zsy243
  72. Sadeh A. Consequences of sleep loss or sleep disruption in children. Sleep Medicine Clinics, 2007, 2(3): 513-520. https://doi.org/10.1016/j.jsmc.2007.05.012
  73. Gregory AM and O’connor TG. Sleep problems in childhood: a longitudinal study of developmental change and association with behavioral problems. Journal of the American Academy of Child & Adolescent Psychiatry, 2002, 41(8): 964-971. https://doi.org/10.1097/00004583-200208000-00015
  74. Bastien L, T´etreault ´E and Bernier A. Disentangling the direction of associations between sleep and temperament in toddlers. Behavioral sleep medicine, 2020, 18(4): 523-536.
  75. Owens LJ, France KG and Wiggs L. Behavioural and cognitive-behavioural interventions for sleep disorders in infants and children: A review. Sleep Medicine Reviews, 1999, 3(4): 281-302. https://doi.org/10.1053/smrv.1999.0082
  76. Cole PM, Michel MK and Teti LOD. The development of emotion regulation and dysregulation: A clinical perspective. Monographs of the Society for Research in Child Development, 1994, 59(2-3): 73-102. https://doi.org/10.1111/j.1540-5834.1994.tb01278.x
  77. Lam P, Hiscock H and Wake M. Outcomes of infant sleep problems: A longitudinal study of sleep, behavior, and maternal well-being. Pediatrics, 2003, 111(3): e203-e207. https://doi.org/10.1542/peds.111.3.e203
  78. Dawson R. (2018). Child’s Gender, Father’s Parenting and Emotion Regulation in School Aged Children, Doctoral dissertation, The Ohio State University.
  79. Adrian M, Zeman J and Veits G. Methodological implications of the affect revolution: A 35-year review of emotion regulation assessment in children. Journal of Experimental Child Psychology, 2011, 110(2): 171-197. https://doi.org/10.1016/j.jecp.2011.03.009
  80. Bellani M, Negri GA and Brambilla P. The dysregulation profile in children and adolescents: a potential index for major psychopathology? Epidemiology and Psychiatric Sciences, 2012, 21(2): 155-159. https://doi.org/10.1017/S2045796011000849