Description

Fall 2009 SODBP Newsletter

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Screening for Sleep Problems
in Children
By Gerald M. Rosen, MD, FAAP

Sleep problems are common in children of all ages with prevalence estimates of between 10 and 60%. The severity of these problems range from the common, but not serious; to the uncommon but life-threatening. This makes screening for sleep problems a very reasonable strategy in any general pediatric practice. There are 2 general sleep questionnaires that have been validated in children and are commonly used in both clinical and research settings.

The Children’s Sleep Habits Questionnaire (CHSQ): The CHSQ is a 35 item, 3-page questionnaire validated for 4 to 10 year old children, but often used in children from 2 to 18 years. The questions in the CHSQ characterize 8 subscales—bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, nightwaking, parasomnias, sleep disordered breathing, and daytime sleepiness. The CHSQ queries about sleep symptoms which occur (a) usually (5 to 7 nights per week), (b) sometimes (2 to 4 nights per week) or (c) rarely (0 to 1 night per week); which leads to an overall score as well as subscale scores. The CHSQ has been used in clinical research, but is applicable to screening as well.

The Pediatric Sleep Questionnaire (PSQ): The PSQ is a 67 item instrument which has been validated in a wider age range, 4 to 18 years. The answers to the questions on the PSQ are: yes/no/don’t know, which makes it simpler to use. The PSQ covers a wide range of sleep problems in children and has a sleepiness subscale, and a sleep related breathing disorder subscale, (which is the only non-PSG tool found to be useful in identifying obstructive sleep apnea). The PSQ has been used in clinical research and is applicable to screening as well.

There are 2 specific questionnaires for the evaluation of daytime sleepiness in children. These provide a more focused measure of sleepiness than either of the general sleep questionnaires. They are the Cleveland Adolescent Sleepiness Questionnaire (CASQ) for 11 to 17-year-olds and the Pediatric Daytime Sleepiness Scale (PDSS) for 11 to 15 year olds. Both were developed for research use but are easy to administer 1-page questionnaires that can be used in a clinical setting and outside of the prescribed age range.

For the purposes of clinical screening, an alternative to using the validated questionnaires described above, is for primary care pediatricians to incorporate several sleep questions into whatever health questionnaires are already in use in your practice. Since most sleep problems fall under just 5 broad categories, consider asking: (1) Does your child have difficulty falling asleep at bedtime? (2) Does your child awaken frequently during the night? (3) Does your child snore loudly during sleep? (4) Is it hard for your child to awaken at the desired time in the morning? (5) Does your child fall asleep inappropriately during activities during the day. Any “yes” response to these 5 questions will alert you to most of the significant sleep problems in children. You will then need to decide if it necessary to pursue the problem with a more thorough assessment.
Before introducing a screening questionnaire for sleep problems into your practice, be sure that you’re ready to address the problems which will be uncovered, because identifying the sleep symptoms is just the first step in evaluating and successfully treating sleep problems. For many sleep problems, especially the common ones including insomnia, nighttime awakenings, and daytime sleepiness, there are many different causes that may lead to the identical symptom. For example, in a 3-year-old child with a complaint of insomnia, the parents describe that it takes over an hour for the child to get to sleep at night. The underlying cause for the symptom of insomnia in this child may be any or all of the following reasons: the bedtime is too early, the nap time is too late, drinking a caffeine-containing beverage in the afternoon, separation anxiety, restless leg syndrome, or a temper tantrum. Obviously, the most appropriate treatment for these different causes, all of which may lead to the same symptom of insomnia, will be very different. For a treatment strategy to be effective it must address the fundamental cause that underpins the sleep symptoms and not just be directed to the symptom itself. For this reason it is essential for the clinician to have an understanding of the causes of the sleep problem in order to treat them effectively.

There are 9 fundamental sleep process domains that are important for understanding the development of sleep problems. These are: circadian, homeostatic, ultradian, developmental, cardiorespiratory, neurologic, psychiatric, behavioral, drugs/alcohol-related, and secondary to other medical problems. These fundamental sleep process domains form the conceptual foundation for building an understanding of sleep and for developing effective treatment strategies for solving them. The sleep process matrix (below) is a tool for organizing and analyzing how these fundamental sleep process domains interact with each other and lead to specific sleep symptoms.

In a child who is experiencing difficulty falling asleep, waking at the desired time in the morning, or falling asleep at inappropriate times during the day, a prospectively collected sleep log is the most useful tool for assessing the problem. The log is helpful in both the diagnosis and treatment for all of these problems.

References for the sleep questionnaire (CHSQ, PSQ, CASQ, and PDSS), the sleep process matrix, and sleep logs are:

1. Chervin RD, Hedger KM, Dillon JE, Pituch KJ. Pediatric Sleep Questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med 2000; 1:21-32.
2. Chervin RD, Weatherly RA, Garetz SL et al. Pediatric sleep questionnaire: Prediction of sleep apnea and outcomes. Archives of Otolaryngology-Head & Neck Surgery 2007; 133(3):216-222.
3. Owens JA, Spirito A, McGuinn M. The Children’s Sleep Habits Questionnaire (CSHQ): psychometric properties of a survey instrument for school-aged children. Sleep. Dec 15 2000;23(8):1043-1051.PMID:11145319.
4. Spilsbury JC, Drotar D, Rosen CL, Redline S. The Cleveland adolescent sleepiness questionnaire: a new measure to assess excessive daytime sleepiness in adolescents. J Clin Sleep Med. Oct 15 2007;3(6):603-612.PMID:17993042.
5. Drake C, Nickel C, Burduvali E, Roth T, Jefferson C, Pietro B. The pediatric daytime sleepiness scale (PDSS): sleep habits and school outcomes in middle-school children. Sleep. Jun 15 2003;26(4):455-458.PMID:12841372.
6. Rosen GM. Evaluation of the patient who has sleep complaints: a case based method using a sleep process matrix. Primary Care Clinics in Office Practice.2005;32:319-325.

The CHSQ can be downloaded with instructions free on the Web. Search “Children’s sleep habits questionnaire.”

The PSQ is proprietary, but can be downloaded and used for a modest cost at the University of Michigan Web site: http://techtransferstore.umich.edu/ProductDetails.asp?ProductCode=PSQ-3766

The PDSS is included at the end of the cited article.
CASQ can be downloaded free on the Web, search with the full name spelled out. A variety of sleep logs are available on the Web.
The sleep process matrix is included in the cited article and is below.

Biography

Dr. Gerald M. Rosen is the director of the Pediatric Sleep Center at Children’s Hospitals and Clinics of Minnesota. He has survived his own child’s conditioned sleep disorder, has practiced general pediatrics at HCMC for 25 years, and sleep medicine for the past 20 years. He can be contacted at rosen052@umn.edu.

Sleep Process Matrix

Sleep Process	Circadian	Homeostatic	Ultradian	Develop- mental	Cardio respiratory	Neuro	Psych/ Behavior	Drugs/ Alcohol	Other/ Medical
Hypothesis
Data to Gather
Anaylsis Synthesis
Treatment

 

Keywords:
Publication date: Dec 11, 2009
Revise date: Dec 11, 2009
TextID: 696

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