PEDIATRICS Vol. 115 No. 1 January 2005, pp. 201-203 (doi:10.1542/peds.2004-0815A)
SUPPLEMENT ARTICLE |
Introduction: Culture and Sleep in Children
Department of Pediatrics, Rhode Island Hospital, Providence, Rhode Island
Abbreviations: IPSE, International Pediatric Sleep Education
At some fundamental level, sleep-related behaviors and sleep problems in children represent a complex interpolation of biological, psychologic/developmental/environmental, and social influences, the relative contributions of which are oftentimes difficult, if not impossible, to separate out. Biological determinants of sleep, including sleep homeostatic mechanisms and chronobiological principles,1,2 and the ways in which culture and biology interact both play a major role in the establishment of sleep patterns.3,4 In addition, children are also active participants in shaping sleep practices through such individual characteristics as temperament and social relatedness5 as well as an emerging understanding of their own individual cultures.6 As an inherently biopsychosocial phenomenon, sleep is embedded in its sociocultural context and thus is impacted on by such variables as cultural beliefs about the perceived function and meaning of sleep, cultural norms for sleep practices, and social interactions, networks, and relationships, to name a few. The biology of sleep architecture and regulation notwithstanding, there is unlikely to be one universally applicable "right way" (or time or place) to sleep. Ultimately, cross-cultural comparisons among societies of different political, economic, ideological, and historical backgrounds are invaluable in providing the opportunity to better understand the neurobiology and chronobiology of sleep itself, as well as to delineate the respective roles of culture and biology on sleep behavior and its interpretation.7
Sleep disorders and sleep practices in children are uniquely suited to serve as the focus for an examination of the interplay between the biological and the sociocultural, because so many of the variables that affect sleep problems, patterns, and practices are highly culturally based. Furthermore, because sleep problems are almost universally present in childhood and have negative health and well-being effects common to all children, the impact of sleep problems on children and families transcends all cultures. In addition, the evolution of sleep practices and behaviors across childhood is particularly sensitive to the important interplay between culture and child development. On a practical level, in recent years, pediatric providers have increasingly been expected to work with families of widely differing cultural origins. Thus, the ability and willingness of health care practitioners to appreciate the family, ethnic/racial, socioeconomic, and cultural context of pediatric sleep disorders and to incorporate that sensitivity to these issues in evaluating etiologic factors and in planning interventions for the individual child and family have a highly significant impact on the quality of care in clinical practice. Finally, the opportunity for disease prevention and health promotion in pediatric sleep is substantial and must also be informed by awareness and incorporation of the cultural issues that impact sleep practices and sleep health in children.
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THE INTERNATIONAL PEDIATRIC SLEEP EDUCATION TASK FORCE |
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To begin to examine the cultural variables that impact on children's sleep in a more comprehensive and systematic way, a group of pediatric sleep experts from around the world (including Israel, China, India, Australia, Spain, Switzerland, Sweden, Italy, and Canada) came together at the first meeting of the International Pediatric Sleep Education (IPSE) Task Force in the spring of 2003 in Chicago, Illinois. This exploratory venture, sponsored by Johnson & Johnson, was initiated to galvanize a dialogue on 2 fronts: addressing educational gaps that exist for both parents and professionals regarding healthy sleep in children and exploring the cultural differences (and similarities) that impact on a host of issues related to children's sleep. It was felt that the IPSE project would represent a unique opportunity to benefit physicians, children, and families worldwide in an important and long-lasting way. A focus on physician education would also enable the program to include components on identification and management of specific sleep disorders and also to incorporate patient education and anticipatory guidance, thus having a potentially long-term impact on the prevention of sleep problems as well.
The task force's mission was to (1) begin to examine cultural similarities and differences potentially impacting sleep practices in infants, children, and adolescents, (2) identify and support a core group of individuals dedicated to developing pediatric sleep medicine education programs in a variety of cultures, and (3) set parameters for developing culturally relevant pediatric sleep medicine educational materials for pediatric practitioners and for parents and patients. In addition, the fostering of cross-cultural pediatric sleep research was included as another important objective.
During the day-long meeting of the IPSE Task Force, each member gave 2 formal background presentations to the group: one on the unique cultural issues that impact on sleep practices in their respective countries and the other on the "state of the science" in pediatric sleep medicine and pediatric sleep education in their nation. The following key points emerged from these presentations and the discussions that followed:
- Pediatric sleep problems are universal and exist across all cultures. Prevalence rates from studies in community samples from quite diverse cultures are remarkably similar in many cases; for example, the overall 25% figure for parent-reported sleep problems in children often quoted is surprisingly consistent. There are a number of interesting age prevalence differences across cultures in such behaviors as night wakings and bedtime resistance and also in parental awareness and interpretation of sleep-related behaviors (such as nightmares, night terrors, sleep walking, and sleep talking), which in turn may affect prevalence rates.
- Many types of pediatric sleep problems are common to both Western and Eastern cultures. These problems include bedtime resistance, night wakings, inadequate sleep, and daytime sleepiness. Although prevalence rates may vary and the etiologic and contributing factors may differ somewhat across cultures, the similarities are often more striking than the differences. In particular, specific sleep issues that were perceived as being universally present across cultures included insufficient sleep in both school-aged children and adolescents, the influence of television and other electronic media on sleep behavior, the impact of academic demands and school schedules, and the integration of sleep practices with family lifestyles. The heavy emphasis on academic achievement in many cultures and intense competition for school placements and jobs was a commonly cited reason for insufficient sleep at many levels, which may imply some degree of "homogenization" across cultures, especially in urban areas (which tend to look quite different from the more rural and thus less "Westernized" areas in terms of sleep problems).
- There are also many sleep issues in children that seem particularly influenced by unique cultural factors, either in prevalence or clinical presentation or in etiology. For example, cosleeping was discussed at length as one important sleep practice that varies in prevalence and acceptance quite dramatically across cultures, as well as across age groups, socioeconomic groups, etc. The cultural basis of cosleeping also often differs widely; in China, this practice is thought to be influenced by the "1 couple-1 child" national family-planning policy, whereas in India, overcrowding is an important factor. In Italy, the integration of children and adolescents into adults' evening social activities results in later bedtimes, whereas in the United States, after-school jobs play a much more important role in delaying bedtimes. In aboriginal populations in Canada, on the other hand, bedtime and bedtime routines are far more fluid and less formalized. Thus parenting practices, culturally determined values, lifestyle factors, etc have an enormous impact on sleep behaviors and practices.
- There is universal agreement that sleep problems impact on children's health, learning and school performance, and quality of life, as well as on the family. In addition, there is increasing recognition that inadequate sleep may coexist with other unhealthy behaviors such as tobacco and alcohol use. The level of awareness of both practitioners and parents of the interaction between poor sleep and poor functioning/poor health also varies widely. There was a general acknowledgment among the participants that sleep problems are fundamentally a public health issue and need to be addressed as such.
- There is a critical need for patient/parent educational materials regarding normal sleep, healthy sleep patterns and behaviors, and signs of sleep problems. For example, in China, a child's snoring during sleep is viewed by parents as a sign of health ("our child's breathing is like that of a strong man"). Many parental beliefs are based on the prevailing child care theories contained in popular culturally based books on child rearing, which may not contain accurate or up-to-date information about sleep. Educational materials for parents must be appropriately tailored for differences in literacy level, language, cultural values, and knowledge level of the target audience.
- Pediatricians around the world are commonly faced with sleep problems in clinical practice, but their level of awareness of sleep problems and knowledge base varies widely. There was universal agreement that, in general, pediatricians are poorly prepared during all levels of training to recognize, diagnose, and treat sleep problems in children. This poor preparation often results, at best, in practitioners minimizing parental concerns about sleep ("children will ‘outgrow’ sleep problems") or in ineffective or even contraindicated treatments being recommended for patients. Creative ways of addressing these knowledge gaps (eg, mailing abstracts of sleep papers to local practitioners, offering continuing medical education through local professional societies) must be developed and implemented.
- The availability of clinical sleep diagnostic and treatment services for children in most countries, especially subspecialty expertise, in general is inadequate, even in urban centers. In China, for example, the field of pediatric sleep medicine has only been recognized since 2001, and in India, clinical sleep services for children do not really exist on any significant scale. Even in more "Westernized" countries such as Spain and Sweden, clinical sleep services for children are considered less than adequate in number, accessibility, and comprehensiveness of services.
- As a corollary of the above, there is an urgent need to share clinical resources regarding the diagnosis and treatment of sleep problems in children, such as educational materials, sleep questionnaires, behavioral treatment strategies, technologic advances and diagnostic tools, etc. Although treatment should be evidence-based whenever possible, because many of the treatments available in clinical practice (particularly those that are pharmacologically based) have little empirical data to support their use, there is also a need to provide more opportunities to share clinical experiences.
- Cross-cultural pediatric sleep research is critically needed, not only to improve the standard of care across nations but to enhance basic knowledge about the causes and impact of pediatric sleep disorders. In particular, parental cognitions, what they think about sleep, how they interpret sleep problems in their child, and what interventions they consider appropriate, are important to study cross-culturally. The state of pediatric sleep research in many countries is, at best, rudimentary. A key component of cross-cultural research involves the development and testing of consistent methodologies and culturally sensitive epidemiologic tools such as surveys that are also comparable across cultures.
A final important short-term goal identified at the meeting by the IPSE was to develop the following supplement to the journal Pediatrics on cultural issues impacting on children's sleep. It was the intent of the task force that such a collection of review and original articles on the topic from contributors around the world would be seen as a resource for future work in what is a relatively new field in pediatrics. To that end, original research articles were solicited both from the IPSE Task Force members and from the international pediatric sleep community. The final articles presented in this supplement represent a broad range of cultures, age groups, and subtopics and include several cross-cultural comparison studies (LeBourgeois et al and Liu et al), a longitudinal study conducted over a 10-year period (Jenni et al), and a comprehensive review of the literature (Jenni and O'Connor). They explore a number of the most important cultural issues in the pediatric sleep field including cosleeping (Fukumizu et al and Valentin), adolescent sleep patterns (Lebourgeois et al and Yang et al), and napping (Crosby et al) and together comprise a body of work that is both unique and exciting. It is the hope of the task force that the scientific work presented here will provide inspiration and an impetus for more cross-cultural pediatric sleep research and collaboration in the future.
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FOOTNOTES |
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Accepted Aug 5, 2004.
Address correspondence to Judith A. Owens, MD, MPH, Department of Pediatrics, Potter Building, Suite 200, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903. E-mail: owensleep{at}aol.com
No conflict of interest declared.
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REFERENCES |
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- Steger B. Negotiating sleep patterns in Japan. In: Steger B, Brunt L, eds. Night-time and Sleep in Asia and the West: Exploring the Dark Side of Life. London, England: Routledge Curzon; 2003:65–86
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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