A pilot bedtime routine intervention for toddlers in primary care: variation by caregiver educational attainment

Frontiers in Sleep · 2026-01-06

Background: A consistent bedtime routine (≥5 nights per week) is an empirically supported intervention associated with better sleep outcomes. However, few studies have examined the impacts of a bedtime routine on outcomes beyond sleep, and among families of lower educational attainment. Objective: This pilot randomized controlled trial (RCT) examined initial outcomes (sleep, development, caregiver stress), feasibility, and acceptability of a primary care-based bedtime routine intervention for toddlers, and explored variation in outcomes by caregiver educational attainment. Method: = 12.89 months, 67.4% Black/African American, 23.3% Hispanic/Latine; United States) were randomly assigned to a bedtime routine intervention or usual care at their 12-month well-child visit (age-based preventative care). At their 15- and 24-month well visits, child sleep (Brief Infant Sleep Questionnaire-R SF), social-emotional development (Brief Infant-Toddler Social and Emotional Assessment), caregiver stress (Parenting Stress Inventory-SF), and intervention acceptability were assessed. Results: There were no differences in outcomes between the groups, however, the intervention positively impacted sleep consolidation, social-emotional outcomes, and caregiver stress, primarily at 24 months of age, for toddlers of caregivers with lower educational attainment. Additionally, families in the intervention were more likely to include reading in their bedtime routine at 15 months. Caregivers assigned to the intervention also reported strong acceptability and 85% completed both sessions. Conclusions: This pilot study suggests that bedtime routine intervention for toddlers is acceptable, feasible, and results in increased integration of reading at 15 months of age. Caregivers of lower educational attainment in the intervention condition reported improvements in aspects of child sleep health, social-emotional concerns, and caregiver stress, highlighting the potential for this intervention to reduce sleep health disparities. Future research should continue to examine potential bedtime routine benefits beyond sleep in larger-scale RCTs.

The role of parenting in associations of weight status with sleep duration and timing for children with mild sleep-disordered breathing

Journal of Clinical Sleep Medicine · 2026-04-07

A Matter of Minutes? The Magnitude of Pediatric Sleep Extension Interventions

PEDIATRICS · 2026-02-04 · 1 citations

When caregivers discuss their children’s habitual sleep duration, they typically reference sleep hours, not minutes. Indeed, national consensus panel recommendations for optimal functioning are provided in hours, by age, driving clinician assessment practices and patient/family-facing sleep health education. Recommendations for young children (aged 3–5 years) are 10 to 13 hours total (including naps), 9 to 12 hours for school-aged children (aged 6–12 years), and, ambitiously, 8 to 10 hours for those aged 13 to 18 years. For many caregivers, anything shorter than the minimum recommended number of sleep hours can feel like a failure, with ominous warnings about consequences for attention, behavior, and learning. These recommendations may be especially challenging for caregivers of children with developmental differences, who tend to have short sleep duration and were not well represented in consensus panel data.Yet, for all children, families, and pediatric clinicians, a dose of practical optimism is needed here. Experimental research with adolescents also shows that extending sleep by a little as 13 minutes benefits cognitive functioning and reduces depressive symptoms.1,2 Another experimental study of school-aged children found that extending sleep by about 28 minutes was associated with better emotional and behavioral regulation and less daytime sleepiness.3 A meta-analysis of experimental at-home sleep extension interventions also found benefits for externalizing and internalizing symptoms, cognitive functioning, and physical activity for adolescents.4 Longer extensions in sleep are associated with even larger benefits at both the individual and societal level. At the individual level, in a meta-review of 39 systematic reviews, which included experimental data, longer sleep duration was consistently associated with reduced adiposity and better emotional-behavioral functioning.5 And at the societal level, moderate extensions in sleep can lead to safer roads. For instance, after Fairfax County, Virginia, implemented a later school start time, adolescents were sleeping about 30 minutes more per school night.6 This extension led to a reduction in adolescent car crashes by about 6%, whereas other parts of the state without delayed start times showed no change over time.6 Data from the National Highway Traffic Safety Administration indicate that there were 5588 fatalities due to teenager drivers in the US in 2023.7 A rough calculation shows that a 6% reduction in fatal crashes translates into 335 fewer fatalities per year—a meaningful reduction given that car crashes remain one of the top causes of pediatric deaths.Although awareness of the minimum sleep duration thresholds by age is important, caregivers and clinicians should focus on how to improve sleep health in smaller, more manageable and sustainable increments. Indeed, the American Academy of Pediatrics suggests that pediatricians support healthy sleep and other lifestyle behaviors through plans that involve “small changes” and emphasize “practical changes that are likely to be sustainable for the child and family.”8 Decades of research indicate that although there are a variety of strategies to benefit child sleep duration, most successful interventions extend sleep by less than 20 minutes per night. We argue that even 10 to 15 minutes of sleep extension is valuable, can be beneficial for daytime functioning, and is achievable with the integration and tailoring of existing intervention strategies. In Table 1, we summarized the average effectiveness of common psychoeducational, cognitive-behavioral, and structural interventions on extending child sleep duration. Meta-analytic data from the most recent high-quality peer-reviewed publications are included. In the absence of a meta-analysis, we reference experimental data with strong study designs.A meta-analysis of interventions focused on reducing overall child screen time and promoting healthy lifestyle habits, including healthy sleep, benefited sleep duration by about 11 minutes per night.9 An intervention that focused on restricting mobile devices 1 hour before bedtime in teens yielded about a 21-minute extension in sleep duration.10 Another experimental study of teens included both sleep hygiene psychoeducation and gradual sleep schedule advancement by 5 minutes per night (max = 55 minutes),1 which improved actigraphy-assessed sleep duration by 13 minutes among teens in the intervention compared with controls.1 A meta-analysis of interventions explicitly focused on extending child sleep duration found that the average benefit was 11 minutes per night. Additionally, interventions that included certain behavior change techniques (sleep psychoeducation, role-playing to practice bedtime routines, developing time management and bedtime routines) yielded a benefit of 14 minutes per night, although this was not statistically different than the 8 minutes per night benefit of interventions without those techniques.11 As a comparison, at the structural level, a meta-analysis of school start time data shows that delaying school start time by 1 hour improves sleep duration by about 40 minutes more per night.12A total of 10 to 15 more minutes of sleep per night amounts to 4 to 7 more hours per month. These additional hours of sleep can translate into meaningful improvements in physical, mental, and cognitive functioning. For example, the teen sleep extension study that improved sleep duration by 13 minutes also found statistically significant improvements in depressive symptoms,1 which are increasingly common in adolescence and a major public health concern. And the literature on delaying high school start times is rife with examples of far-reaching benefits for teens.12 Additional research to estimate the full range of impacts that habitual sleep extension—in minutes as well as hours—can have on pediatric performance and well-being may strengthen the case for families and communities to prioritize sleep health.Table 1 is instructive but only provides part of the story. The mean changes reported in total sleep duration can mask individual variation in effectiveness. That is, some individuals may experience limited or no intervention-related improvements, whereas others may benefit in a much larger way. Those who are most sleep deficient are more likely to benefit the most. Second, some strategies may not be appropriate, depending on the child. For instance, children with insomnia (difficulty falling/staying asleep) should receive cognitive-behavioral treatment, which includes additional strategies and typically involves initially reducing rather than extending time in bed. Of note, meta-analytic research indicates that treating childhood insomnia also extends sleep duration by 11.5 minutes.13 Finally, other aspects of sleep, such as regularity (consistency of sleep schedule), are important to consider and evaluate. Lastly, although existing sleep extension strategies are effective when implemented as individual treatment approaches, combining multiple strategies through tiered approaches may lead to even larger gains in sleep health and beneficial sequelae. For instance, enacting later school start time policies in conjunction with universal healthy lifestyle education (ie, sleep hygiene, reduced bedtime screen use, physical activity) and targeted insomnia treatment for children identified with symptoms could collectively improve sleep health.9Future pediatric sleep duration extension interventions for short-sleeping children should further examine the potentially synergistic benefits of combining multiple strategies (eg, screentime reduction, sleep schedule advancement) and specific behavior change techniques.11 Applying these approaches and setting an initial, achievable goal for sleep extension can build self-efficacy and motivation, which are crucial for initiating and sustaining health behavior change.14 In the study restricting smartphone use 1 hour before bedtime, only 26% of adolescents approached agreed to participate, suggesting a need to integrate motivational interviewing strategies10 and, perhaps, a “harm reduction” approach with more gradual reductions in screen use before bedtime or taking steps toward an end goal of removing devices from the bedroom altogether. Focusing on consistent improvements in sleep health, even if this looks like getting into bed 10 to 15 minutes earlier for now or turning off devices 15 to 20 minutes before bedtime (or ideally, removing them from the bedroom altogether), may be more feasible and sustainable for many families. Habitual sleep extension by 10 to 15 minutes is both realistic and beneficial. As with other health behaviors, establishing healthy habits takes time and consistency. We encourage clinicians and families to consider starting with small sleep duration extensions that are feasible, sustainable, and tailored to the child and family. This approach can benefit pediatric sleep and overall well-being, particularly for a child that is already sleep deprived, in addition to enhancing broader family functioning.

0980 Discrepancies in Caregiver-Reported and Laboratory-Assessed Early Childhood Sleep Problems

SLEEP · 2025-05-01

Abstract Introduction Sleep disordered breathing (SDB) and insufficient sleep are common in early childhood and linked to neurobehavioral functioning, highlighting the importance of screening for these sleep problems. However, few studies have examined variation in multi-method evaluations of these concerns. This study compared caregiver-reported symptoms of child SDB and sleep duration to subsequent polysomnography (PSG) and actigraphy. Methods Data from 95 3-5-year-olds (43% boys, 49% Black, 51% Non-Latine White; 96% maternal caregiver) were drawn from a larger study. Caregivers reported on symptoms of child SDB using the Pediatric Sleep Questionnaire (PSQ) and on insufficient sleep using the Brief Child Sleep Questionnaire (BCSQ). Preschoolers were initially categorized into 4 groups based on measure cut-offs and sleep duration guidelines: (A) SDB only (PSQ score □0.33 clinical cut-off, total 24-hour sleep duration >=10 hours); (B) insufficient sleep only (PSQ < 0.33, total sleep duration < 10 hours); (C) both SDB and insufficient sleep (PSQ □0.33, total sleep duration < 10 hours); (D) no sleep problems. Children then completed PSG scored according to diagnostic guidelines and # nights/weeks of actigraphy scored using validated procedures with daily sleep diaries. Results Based on initial caregiver-report, 29 (31%) preschoolers had SDB only (A); 10 (11%) had insufficient sleep only (B); 13 (14%) had both SDB and insufficient sleep (C); and 43 (45%) had no sleep problems (D). After PSG/actigraphy, 62% were reassigned from their initial caregiver-reported group. Twenty-one percent were reassigned based on PSG results only, 27% reassigned based on actigraphy only, and 14% reassigned based on both actigraphy and PSG. Initially, based on caregiver-report, the largest group (45%) were the no sleep problem group (D). However, after PSG and actigraphy, the no sleep problem group (D) only reflected 21% of the sample. Importantly, after PSG and actigraphy, the group reflecting co-occurring SDB and insufficient sleep (C) increased from 14% to 38% of the sample. Conclusion Early childhood sleep-disordered breathing and insufficient sleep may be underrecognized when based on caregiver report compared to more objective measures. Additional multi-method studies with early childhood samples may be needed to re-evaluate caregiver report-based clinical cutoffs for sleep issues in young children. Support (if any) R01HL163798 (AAW)

1041 Parental Sleep Knowledge and Toddler Sleep: Associations with Cultural Values and Acculturation Among Mexican American Families

SLEEP · 2025-05-01

Abstract Introduction Cultural values and acculturation strongly influence parenting behavior, yet few studies have considered how they may influence toddler sleep. This study characterized parental sleep knowledge, values, acculturation, and bedtime among toddlers from Mexican American families. Methods 158 parents (156 mothers; 19-45 years; mean education 12.3±3.0 years) of Mexican American toddlers (62% boys; 12-16 months) completed surveys in Spanish (54.4%) or English. Toddlers wore an actigraph for 7 days/nights to estimate average bedtime. Participants were asked about Mexican American cultural values of respect (V-Resp, 8 items, range 1-5, higher score indicating stronger endorsement), acculturation to non-Hispanic U.S. culture (6 items, range 1-4, ≥2.5=high acculturation), and sleep knowledge (10 True/False items; range 1-10). Results Parents averaged 7.5 + 1.7 correct on the sleep knowledge measure, with the most common incorrect responses for the items “children who do not get enough sleep are more likely to be overweight” (SK-OV, 50.7% incorrect) and “children only need a bedtime routine if they have trouble falling asleep” (SK-BR, 41.8% incorrect). More parents that incorrectly answered SK-OV (vs. correct) had high acculturation scores (72.7% vs. 27.3%, X2=4.0, p=.046). More parents that incorrectly answered SK-BR (vs. correct) had low acculturation scores (57.6% vs. 42.4%, X2=24.3, p=<.001). Parents that incorrectly answered SK-BR and SK-OV had higher V-Resp scores (SK-BR: x̄=4.0 vs. 3.7, F=10.2, p=.002; SK-OV: x̄=4.0 vs. 3.7, F=11.3, p=.001). Toddlers of parents that incorrectly answered SK-BR and SK-OV had significantly later bedtimes (22 min, p=.033; and 24 min, p=.021 respectively). In a stepwise regression controlling for parental age and education, V-Resp was significantly associated with later toddler bedtime (R2=.211, β=.364, p=.002). Conclusion High acculturation and Mexican American cultural values of respect were associated with parent sleep knowledge and toddler bedtime in Mexican American families. The measure used to assess cultural values focuses on intergenerational behaviors and the influence of elder wisdom, suggesting perhaps parental knowledge and toddler sleep routines are based on what has been learned from family vs. health professionals. Understanding cultural values and acculturative differences is crucial for personalizing sleep education and addressing common misconceptions about toddler sleep health for Mexican American families in both clinical and community settings. Support (if any) R01HL163859

Performance of an automated sleep scoring approach for actigraphy data in children and adolescents

SLEEP · 2025-09-18 · 2 citations

STUDY OBJECTIVES: GGIR is an R package for processing raw acceleration data to estimate sleep health parameters. We aimed to (1) assess the performance of three sleep algorithms within GGIR against PSG for detecting sleep/wake in clinically referred, typically-developing children (criterion validity); and (2) describe GGIR-derived sleep estimates from typically developing children enrolled in multiple cohort studies (face validity). METHODS: For criterion evaluation, children (8-16 years, N = 30) wore an actigraphy device for one night during in-lab polysomnography with performance assessed using epoch-by-epoch analyses. For face validity evaluation, four community/free living datasets were used: (1) Bone Mineral Accretion in Young Children (3-5 years, N = 310), (2) School Summer Sleep (5-8 years, N = 118), (3) Sleep and Growth Study 2 (12-13 years; N = 291), and (4) Early Life Exposure to Environmental Toxicants (9-18 years; N = 543). All raw acceleration data were processed using GGIR (v.3.0-0) with the Cole-Kripke (CK), Sadeh (S), and van Hees (vH) algorithm settings. RESULTS: Following the in-lab test, 60 per cent of children were diagnosed with mild to severe obstructive sleep apnea (OSA). For criterion evaluation, the 30-s epoch-by-epoch analyses revealed that average balanced accuracies were 0.80 (Sensitivity = 0.80; Specificity = 0.79), 0.76 (Sensitivity = 0.86; Specificity = 0.65), and 0.67 (Sensitivity = 0.95, Specificity = 0.39) for GGIR-CK, GGIR-vH, and GGIR-S, respectively. For face validity evaluation, sleep estimates mirrored the in-lab performance metrics (e.g. sleep duration estimates were similar when using GGIR-CK and GGIR-VH but approximately 1 h longer when using GGIR-S). CONCLUSIONS: The in-lab performance metrics from typically developing children with and without OSA and cohort-based descriptive statistics from samples of typically developing children provide benchmark data to guide investigators on the suitability of GGIR for automated processing of raw acceleration data for pediatric sleep estimation.

Barriers to and facilitators of integrated primary care engagement: Convergent and divergent perspectives of care team members and caregivers.

Families Systems & Health · 2025-07-03

BACKGROUND: Integrated primary care (IPC) can improve access to behavioral health (BH) care, reduce stigma, and facilitate early intervention. However, few studies have examined key informants' perceptions of IPC engagement. OBJECTIVE: We qualitatively identified convergent and divergent perspectives of care team members and caregivers on pediatric IPC-related engagement barriers, facilitators, and suggestions for improvements. METHOD: = 10, 100% female, 10.0%. Asian, 30.0% Black/African American, 60.0% non-Hispanic/Latine White) completed semistructured interviews on IPC engagement in a large pediatric primary care network. Thematic analysis was used to iteratively identify patterns of meaning, as well as convergent and divergent themes across informant groups. RESULTS: Convergent barriers included stigma, prolonged wait times, limited BH knowledge, difficulty navigating services, and limited BH provider availability. Whereas care team members identified more family-related barriers (e.g., beliefs, experiences), caregivers identified divergent barriers such as limited childcare. Perceived engagement facilitators converged across groups and mostly pertained to systems-related factors such as the colocation of services. Converging recommendations included additional behavioral clinicians and support staff, provision of psychoeducational resources, and expanding IPC services. CONCLUSION: Although key informant groups similarly perceived many IPC benefits, including increased BH access, there are continued patient/family barriers to IPC engagement, with divergence in care team members' versus caregivers' views about the nature of these barriers. Findings suggest a need for systems-level changes to address these barriers and highlight the importance of including the unique perspectives of care team members and caregivers in future research examining IPC effectiveness. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

1062 Mothers’ and Fathers’ Beliefs About Bedtime Screen Use and Toddlers’ Sleep in Mexican American Families

SLEEP · 2025-05-01

Abstract Introduction Parental beliefs about sleep are associated with sleep-related parenting behaviors and child sleep. However, few studies have considered parental beliefs about bedtime screen use and their relationship with children’s sleep, especially in early childhood. Further, most studies focus on mothers, despite the important role that fathers play in early child development. This study examined mothers’ and fathers’ beliefs about screen use at bedtime and toddler sleep in Mexican American families. Methods 42 mother-father dyads (mothers 21-43 years, education mean=13.0 years, sd=2.9; fathers 21-45 years; education mean=12.0 years, sd=2.8) of Mexican American toddlers (64.3% boys; 12-16 months) completed a measure regarding beliefs about bedtime screen use in Spanish (40.5%) or English. Toddlers wore an actigraph for 7 days/nights. T-tests compared bedtime and sleep duration between parents who agreed vs. disagreed with each belief. Due to the small sample size, meaningful effect sizes (Cohen’s d) vs. p-values are reported. Results 12% of mothers and 19% of fathers agreed that using a screen device at bedtime helps toddlers relax, with toddlers whose mothers agreed (vs. disagreed) having later bedtimes (31 minutes, d=.46) and shorter sleep duration (24 minutes, d=.52). Among fathers who agreed (vs. disagreed), toddlers had later bedtimes (50 minutes, d=.77) and shorter sleep duration (18 minutes, d=.36). Approximately 43% of mothers and 41% of fathers agreed that watching a screen device at bedtime helps toddlers remain quiet. Among mothers who agreed (vs. disagreed), toddlers slept 19 minutes less (d=.38). Finally, 10% of mothers and 21% of fathers agreed that using a screen device at bedtime helps toddlers fall asleep, with toddlers whose fathers agreed (vs. disagreed) having shorter sleep duration (16 minutes, d=.32). Conclusion More fathers than mothers were positive about screen use at bedtime. Positive parental beliefs in both mothers and fathers were associated with clinically meaningful sleep differences, including later toddler bedtimes and shorter toddler sleep duration. It is important to identify both mother and father sleep-related screen beliefs when addressing toddler sleep in clinical and community settings. Data collection is ongoing in a large, longitudinal study of Mexican American families. Support (if any) R01HL163859

Family partnerships to support equity and cultural humility in pediatric intervention research

Journal of Pediatric Psychology · 2025-05-20

OBJECTIVE: Family partnerships in community-engaged research (CEnR) can promote family-centered, equitable interventions. This paper describes the process (meeting frequency, content) of a collaborative research family partnership and related methodological modifications to support equity and cultural humility during a multi-phase project adapting and evaluating an early childhood sleep intervention (Sleep Well!) for families of primarily lower socioeconomic status (SES) backgrounds in urban (large, metropolitan) primary care. METHODS: The Children's Hospital of Philadelphia Research Family Partners Program consulted on initial project development. Research family partners collaborated to modify intervention content, delivery methods, and research procedures in an open-pilot (NCT04046341) and randomized controlled trial (NCT04473222). We reviewed family partners meeting agendas, presentations, and minutes to identify meeting frequency, content, and resulting project modifications and to generate related themes. Family partners also provided recommendations for researchers, including for those without existing institutional CEnR resources. RESULTS: Ten 60-120-min meetings with 4-6 family partners occurred over 4 years. Themes representing the partnership process and project modifications included enhancing flexibility, centering cultural humility, and incorporating contextual factors (coronavirus pandemic, police violence, racism). These factors were especially relevant as project participants were primarily Black mothers and/or of lower-SES backgrounds. Family partner recommendations highlighted the need for collaborative, meaningful, and communicative relationships in pediatric intervention research. CONCLUSIONS: The extent of recommended project modifications highlights the importance of family partnerships to support equity and cultural humility in pediatric psychology research and practice. Findings also underscore the need for representation of racial and ethnic minoritized scholars and families in this work.

1029 Longitudinal Linkages Among Neighborhood Quality, Sleep Quality, and Adolescent Depressive Symptoms

SLEEP · 2025-05-01

Abstract Introduction During adolescence, girls become disproportionately vulnerable to depression, while also undergoing marked changes in sleep. Although sleep and mood are robustly linked, environmental factors like neighborhood quality can impact both sleep and mood. This study examined linkages among neighborhood quality, sleep quality, and depressive symptoms longitudinally in a cohort of adolescent girls. Methods This study leverages data from the Transitions in Adolescent Girls (TAG) study, a prospective longitudinal examination of biological and psychosocial changes in adolescence. Wave 1 included N=174 adolescents, aged 10.0-13.0 years at enrollment (4.7% African American/Black, 10.3% Hispanic/Latine, 4.2% Native American or Native Alaskan, 65.7% White, 4.7% Asian, 0.5% Native Hawaiian or Pacific Islander, 6.6% Multiracial, 2.3% Other; 10.1% non-cisgender-identifying, 46.8% sexual minority identifying). Neighborhood quality was measured using the Child Opportunity Index 3.0 (COI), with scores (range= 1-100) reported by Census tract and normed at the state level, with higher scores reflecting better neighborhood quality. Wave 1 scores ranged from 5-91 (M=43.36; SD=26.77). At each wave, depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale for Children. Sleep was assessed using the Pittsburgh Sleep Quality Index, which has been validated in adolescent samples and reflects global sleep quality. We used linear regression to examine whether wave 1 neighborhood quality and wave 3 sleep quality were associated with depressive symptoms at wave 4, controlling for depressive symptoms at wave 3. Results Girls living in higher quality neighborhoods (i.e., higher wave 1 COI scores) subsequently experienced less severe depressive symptoms compared to those living in neighborhoods of poorer quality (b =.002, p =.055). When looking at the interaction between neighborhood quality and wave 3 sleep quality, those with the poorest quality sleep experienced significantly elevated depressive symptoms in wave 4, regardless of neighborhood quality. Further, those living in neighborhoods with the lowest COI scores experienced significantly greater depressive symptoms, regardless of sleep quality. Conclusion Initial findings suggest that neighborhood and sleep quality are independently and longitudinally associated with greater adolescent depressive symptoms. Future work will examine the impacts of neighborhood and sleep quality on the emergence and worsening of depressive symptoms over multiple study waves. Support (if any) R01/R56MH107418, R01MH127408 (JHP)