PEDIATRICS Vol. 119 No. 5 May 2007, pp. 947-955 (doi:10.1542/10.1542/peds.2006-2569)
ARTICLE |
Adverse Associations of Infant and Child Sleep Problems and Parent Health: An Australian Population Study
a Centre for Community Child Health
b Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, Australia
c Department of Paediatrics, University of Melbourne, Parkville, Australia
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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OBJECTIVE. Infant sleep problems are strongly associated with poorer maternal mental health. It is not known whether they are also associated with poorer paternal mental health, nor whether sleep problems in older children are associated with maternal or paternal mental health. We aimed to examine relationships between child sleep problems and maternal and paternal mental health and general well-being in each of the infant and preschool-aged groups.
METHODS. Participants of this cross-sectional survey included families of infants (n = 5107) and preschool-aged children (n = 4983) participating in the first wave of the nationally representative Longitudinal Study of Australian Children, surveyed March through November 2004. The primary outcomes were mother and father serious psychological distress (measured by the Kessler-6) and general health (parent report of general health taken from the 12-item Short Form Health Survey and dichotomized into poor versus good health). A primary caregiver's report of the child's sleep problem was dichotomized into moderate/severe versus none/mild.
RESULTS. The prevalence of severe psychological distress ranged from 3% to 5%, and prevalence of poor general health ranged from 8% to 11%. Moderate to severe sleep problems affected 17% of infants and 14% of preschool-aged children. Infant sleep problems were associated with poor general health in mothers and with poor general health in fathers. Preschool sleep problems were associated with poor maternal general health. In mothers with no past history of depression, infant sleep problems had a greater effect on severe psychological distress compared with mothers with a past history of depression.
CONCLUSIONS. Sleep problems are common in infants and preschool-aged children. Infant sleep problems, in particular, are associated with poorer health in both parents, especially the mental health of mothers with no past history of depression.
Key Words: sleep problems • infant • preschool • parent mental health • parent general health
Abbreviations: PND—postnatal depression • LSAC—Longitudinal Study of Australian Children • K6—Kessler-6 screening scale for psychological distress • SF-12—12-item Short Form Health Survey • OR—odds ratio • CI—confidence interval
Mental health problems are common in parents of young children. Postnatal depression (PND) affects 
15% of Australian mothers,1 similar to other developed countries.2 In fathers, the prevalence of depression in the postpartum period may reach 50% if the mother is also depressed.3 Prevalence in parents of preschool-aged children has received less attention, but in a community sample of 174 English parents of preschool-aged children, 18% of mothers and 6% of fathers scored in the clinical depression range on a validated PND screening measure.2 Depression impacts adversely on a parent's mood, cognition, and ability to conduct day-to-day tasks.4 Maternal and paternal PND are associated with later child behavior problems5,6 and maternal PND with later child developmental problems.7
Maternal depression may result, in part, from sleep problems in children.8 In Australia, 46% of mothers of infants aged 6 to 12 months reported a problem with their child's sleep9 as did almost 30% of parents of children aged 1 to 3 years, and 14% to 27% of parents of preschool-aged children.10 Mothers who report a sleep problem in their child are twice as likely to report clinically significant symptoms of depression,8,9 and improving problem sleep in infants also improves maternal mood.11 In preschool-aged children, sleep problems are associated with maternal report of greater limitations on daily functioning.8 However, the impact of sleep problems on fathers’ mental health and general health is unknown.
In addition to infant sleep problems, other risk factors for maternal PND include a past history of depression, depression in a partner,12 reduced partner and social support,13 marital conflict,12 and recent negative life events.14 Paternal PND risk factors include a past history of depression, employment in manual or working-class occupations,3,15 partner depression, and relationship dissatisfaction.16,17 Less is known about the risk factors for depression in parents of older children. In a study of depression in mothers of 2-year-old children, risk factors included depression at 8 months, less partner and social support, more negative life events, poor health, and having a "difficult" toddler.13 No study has examined risk factors for depression in fathers of preschool children.
Drawing on a large, representative, Australian sample, we therefore aimed to determine the relationship between (1) infant sleep problems and (a) maternal and paternal mental health and (b) maternal and paternal general well-being, and (2) preschool sleep problems and (a) maternal and paternal mental health and (b) maternal and paternal general well-being. We hypothesized that sleep problems would be common and would be associated with poor mental and general health in mothers and fathers, even after adjusting for other known maternal and paternal depression risk factors.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Data were drawn from the first wave (March to November 2004) of the Longitudinal Study of Australian Children (LSAC), a national study targeting 5000 infants and 5000 4- to 5-year-old preschool-aged children. LSAC used a 2-stage cluster sampling design with Australian postcodes as the primary sampling units (stratified by state of residence and urban versus rural status) and children enrolled on the Medicare Australia database as the secondary sampling units. Families for whom a post office box but no street address existed were excluded, as were very remote postcodes, and only 1 child per family was included in the study. Of those who were resident in the sampled postcodes and contactable, response rates were 64% for infants (n = 5107) and 59% for preschool children (4983).
Procedures and Inclusion Criteria
As well as a face-to-face interview in the child's home (conducted by trained researchers), both the primary and secondary caregivers completed written questionnaires that were distributed to them at the interview. Data for this article were drawn from both the face-to-face and written questionnaires. We included available data from mothers ("female primary caregivers": 99% and 97% of infant and child primary caregivers, respectively) and fathers ("male secondary caregivers": 89% and 84%, respectively). The study was approved by the Australian Institute of Family Studies Ethics Committee.
Exclusion Criteria
The small proportion of fathers who were primary caregivers was excluded from the study because their completed questionnaire did not include data regarding a past history of depression, which was considered a potential confounding factor.
Measures
The primary outcomes were maternal and paternal mental health and general well-being. Mental health was measured by using the Kessler-6 (K6), a validated, 6-item screen for psychological distress, with a score 
18 indicative of serious psychological distress.18 General health was measured with the widely used single global health item from the 36-item Short Form Health Survey and the 12-item Short Form Health Survey (SF-12),19 in which parents rated the quality of their general health on a 5-point Likert scale (1 = poor, 5 = excellent). Responses were dichotomized into poor health (fair/poor) and good health (good/very good/excellent).20
The primary exposures were infant or preschool-aged child sleep problem. The primary caregiver (mothers) reported whether their child's sleep was a problem (no, mild, moderate or severe problem). Responses were dichotomized into no/mild and moderate/severe problem.
Potential confounding variables of the relationship between child sleep problems and maternal outcomes included (1) a past history of depression (depressive symptoms lasting >2 weeks in the past year or depression experienced for at least the last 2 years), (2) partner support, determined by using a study-designed, single item asking "How often is your partner a resource or support to you in raising your child(ren)?" (1 = never, 4 = always); (3) overall support, determined by using a study-designed, single item asking "Overall, how do you feel about the amount of support or help you get from family or friends living elsewhere?" (1 = I get enough help, 3 = I don't get any help at all; "I don't need any help" was combined with the response "I get enough help"); (4) 2 or more stressful life events; and (5) overall relationship satisfaction (1 = extremely unhappy, 7 = perfect) determined by using a single item from Spanier's Dyadic Adjustment Scale, a validated measure of relationship satisfaction.21 For children in the preschool-aged sample only, child temperament was included and was measured by taking the average score on each of the 3 subscales (Sociability, Persistence, and Reactivity) of the 12-item Short Toddler Temperament Scale22; an overall score of >1 SD above the mean was considered a "difficult" temperament and all others as an "easy/normal" temperament. For fathers, potential confounding variables differed in that serious psychological distress in their partner was included, but items regarding a past history of depression, overall support, and stressful life events were not included because these were not measured.
Potential sociodemographic confounding variables included number of caregivers in the home (mothers only), country of birth (Australia/New Zealand versus other, mothers of infants only), and employment status (fathers only).
Analysis
Separate analyses were conducted for children in the infant and preschool-aged cohorts. Children with and without missing data on the K6 and general health item were compared by using 
2 analyses on child gender, birth order, prevalence of sleep problems, and parental age and education level. To demonstrate differences in the key parent outcomes, we conducted 2 analyses of the relationships between moderate/severe infant or preschool sleep problems and maternal/paternal (1) serious psychological distress and (2) poor general health. Unadjusted and adjusted odds ratios were calculated by using logistic regression for the effect of a moderate/severe infant or preschool sleep problem on maternal/paternal (1) serious psychological distress and (2) poor general health.
Tests of interaction assessed whether the impact of (1) an infant sleep problem on maternal serious psychological distress and general health was greater among mothers with a past history of depression than those without and (2) a preschool sleep problem on maternal serious psychological distress and poor general health was greater among mothers who reported a "difficult" child temperament than those who did not.
Analyses were weighted for the multistage sampling design, allowing for unequal probabilities of selection into the sample, and for nonresponse. First-order Taylor linearization was used to obtain estimates of standard error taking account of the correlation of responses within postcodes. Analyses were conducted by using Stata 9.1 (Statacorp, College Station, TX).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Sample Characteristics
A total of 75% to 85% of mothers and fathers who completed the K6 and general health item (see Fig 1) did not differ from the remainder in terms of parental age, child gender, birth order, or severity of sleep problem (P > .05). However, parents who completed the K6 and general health item were more likely to have completed secondary school than those who did not (P < .001). Table 1 outlines sample characteristics. Moderate/severe sleep problems were reported in 17% and 14% of infants and preschool-aged children, respectively. The prevalence of serious psychological distress ranged from 3% (fathers of preschool children) to 5% (mothers of preschool children), and of poor general health from 8% (mothers of infants) to 11% (fathers of preschool children). Compared with 2001 Australian census data, LSAC families were more likely to have a mother who had completed secondary education in infant (66.9% in LSAC vs 56.6% in census) and child (58.6% in LSAC vs 48.3% in census) cohorts. Children from lower income families were underrepresented (31.7% of infants in LSAC vs 41.2% in census, and 29.2% of preschool-aged children in LSAC vs 40.6% census, had a combined parental income of <$800 per week).23
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Bivariate Analyses
In the
2 analyses in mothers, there was strong evidence that both infant and preschool sleep problems were associated with serious psychological distress and poor general health (P < .01; Table 2). In fathers, infant sleep problems were associated with serious psychological distress and poor general health, whereas preschool sleep problems were associated with poor general health only (P < .05; Table 2).
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Unadjusted and Adjusted Analyses: Infant Sleep Problems
Table 3 shows unadjusted and adjusted odds ratios for the effect of infant sleep problems on parent mental and general health. In mothers, on average, an infant sleep problem almost doubled the odds of serious psychological distress (unadjusted odds ratio [OR]: 1.76; 95% confidence interval [CI]: 1.18–2.63) and poor general health (unadjusted OR 1.83; 95% CI: 1.39–2.41). After adjusting for potential confounding variables, this relationship persisted only for general health (adjusted OR: 1.50; 95% CI: 1.07–2.09). A past history of depression was the most important predictor of both psychological distress and poor general health (unadjusted OR: 19.08; 95% CI: 11.08–32.86). In the adjusted analysis, infant sleep problems seemed to have a greater effect on psychological distress in those without (adjusted OR: 4.58; 95% CI: 1.35–15.61) than those with a past history of depression (adjusted OR: 1.04; 95% CI: 0.62–1.75; P = .02 for test of interaction).
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In fathers, an infant sleep problem increased the odds of poor general health (adjusted OR: 1.47; 95% CI: 1.11–1.94) whereas serious psychological distress in a partner increased the odds of serious psychological distress in the father (adjusted OR: 2.34; 95% CI: 1.13–4.85). Relationship happiness and partner support showed strong evidence of a protective effect on both the unadjusted and adjusted analyses, reducing the odds of serious psychological distress on average by almost half (P < .01).
Unadjusted and Adjusted Analyses: Preschool Sleep Problems
In preschool-aged children, relationships between sleep problems and parental mental and general health were weaker than in children the infant cohort (see Table 4). In the unadjusted analyses, sleep problems were 1 of 3 negative risk factors showing strong evidence of an association with maternal serious psychological distress and poor general health. The other 2 risk factors were past history of depression and stressful life events (P < .001). After adjusting, there was weak evidence of a relationship between sleep problems and mental and general health, (P = .06 and P = .05, respectively) whereas the other 2 negative risk factors continued to show strong evidence of a relationship (P < .001). There was no evidence that sleep problems in preschool-aged children had an impact on paternal mental health (adjusted P = .12) and borderline evidence of an association with general health (P = .06).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Infant sleep problems were common and were associated with serious psychological distress and poor general health in mothers and with poor general health but not serious psychological distress in fathers. Sleep problems in preschool-aged children were also common, and an adjusted analysis provides weak evidence of an association with poor maternal mental health and poor maternal and paternal general health.
This is the first study, to our knowledge, to examine in a nationally representative sample the associations between infant and child sleep problems and the mental health of fathers and the general health of both mothers and fathers. The large sample size enabled calculation of precise estimates of parent-reported sleep problems and mental and general health, and well-validated measures were used for the primary outcomes.
The study has some limitations. First, only 59% of the eligible children in the preschool sample and 64% of children in the eligible infant sample took part in LSAC. Although weighting was used for all analyses to account for differences in nonresponders, this may limit generalizability to those population groups underrepresented in LSAC. Second, parents who did not complete the K6 or the general health question were less likely to have completed secondary school education and were more likely to report a lower household income; thus, the results of this study may not generalize to this group. Noncompleters may also have been more depressed but, if this were the case, the relationship between child sleep problems and parent mental health would have most likely strengthened had they participated. Third, because the data are cross-sectional, causal directions cannot be assumed. Fourth, the sleep measure was based on subjective parent report. However, parent report is an established marker of problematic child sleep patterns, and there are strong indications of the reliability of parent reporting.24 Finally, maternal report of child sleep could be influenced by depression. However, in a previous community study of >600 families, we found that mothers who reported a sleep problem in their child also reported more frequent and longer night wakings and longer sleep onset delay, irrespective of maternal depression status.9
The prevalence of infant (17%) and preschool (14%) sleep problems is less than shown in previous Australian community samples (30% and 46%, respectively).9,10 This may result from a difference in how sleep problems were recorded, because our study classified those with a "mild" sleep problem as not having a problem. When we reclassified "mild" sleep problems as a problem in the children in the preschool cohort, the prevalence of sleep problems rose to a comparable 34%.
Similar to previous studies, we found that report of an infant sleep problem increased the odds of a mother reporting poor mental health.8,9 For mothers without a past history of depression, infant sleep problems played a major role in their mental health. However, mothers with a past history of depression also had high levels of psychological distress, but their child's current sleep problem added little to this burden. For these mothers, genetic or biological factors may play a greater role in their mental health than external factors such as a child's sleep. General health of mothers reporting infant sleep problems was also poorer. This is not surprising given the physical demands that motherhood entails which, when coupled with disturbed sleep or sleep deprivation, may lead to or exacerbate existing health concerns.
Sleep problems in preschool-aged children affected parents to a lesser degree. Mothers of preschool-aged children may adjust to their child's sleep disturbance over time, or the difficulties may be related to settling to sleep (rather than waking overnight), thus disturbing parent sleep less. Sleep problems had little effect on fathers after adjusting for confounding variables, possibly because, as the authors’ clinical experience suggests, fathers play less of a role than mothers in managing the sleep problems of older children.
Given the high prevalence and co-occurrence of parent psychological distress and child sleep problems (particularly in infants), health professionals in regular contact with families should ask about both. This is important because of the known adverse impacts of depression on child health, development,25 and later behavior problems.6 If sleep problems are identified, effective approaches to their management should be offered.11 This may lead to improvement in parent mental health,11 especially in mothers with no past history of depression. Fathers should be actively engaged in the assessment and management of child sleep problems, because their health is also at risk. Future research should determine whether child sleep management strategies could also improve general health in mothers and fathers.
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ACKNOWLEDGMENTS |
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This article uses a confidentialized unit record file from the Longitudinal Study of Australian Children Project, which was initiated and is funded by the Commonwealth Department of Families, Community Services, and Indigenous Affairs and is managed by the Australian Institute of Family Studies. Dr Hiscock was supported by a Murdoch Childrens Research Institute part-time research salary grant and Dr Wake by National Health and Medical Research Council Population Health Career Development Award 284556 for the duration of this manuscript's preparation.
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FOOTNOTES |
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Accepted Dec 20, 2006.
Address correspondence to Harriet Hiscock, MBBS, FRACP, MD, GradDip, Centre for Community Child Health, Royal Children's Hospital, Flemington Road, Parkville 3052, Australia. E-mail: harriet.hiscock{at}rch.org.au
The authors have indicated they have no financial relationships relevant to this article to disclose.
The views in this article are those of the authors and do not necessarily represent the views of Family and Community Services and Indigenous Affairs or the Australian Institute of Family Studies.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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