Elsevier

Sleep Medicine Reviews

Volume 15, Issue 1, February 2011, Pages 19-32
Sleep Medicine Reviews

Clinical Review
Pediatric sleep questionnaires as diagnostic or epidemiological tools: A review of currently available instruments

https://doi.org/10.1016/j.smrv.2010.07.005Get rights and content

Summary

An extensive list of published and unpublished instruments used to investigate or evaluate sleep issues in children was collected and assessed based on the fundamental operational principles of instrument development (11 steps). Of all the available tools identified, only a few were validated and standardized using appropriate psychometric criteria. In fact, only 2 fulfill all desirable criteria and approximately 11 instruments seem to adhere to most of the psychometric tool development requirements, and were therefore assessed in greater detail. Notwithstanding, in the rapidly developing scientific world of pediatric sleep, there are too many tools being used that have not undergone careful and methodical psychometric evaluation, and as such may be fraught with biased or invalid findings. It is hoped that this initial effort in categorizing and assessing available tools for pediatric sleep will serve as recognition of the relatively early developmental stage of our field, and provide the necessary impetus for future tool development using multicentered approaches and adequate methodologies.

Introduction

The great popularity with questionnaires is that they provide a “quick fix” for research methodology. No single method has been so abused.1

The last several decades have taught us that a long list of potentially misleading conclusions can be drawn when practitioners in the field of pediatrics continue to overlook sleep in their professional activities. There is a pervasive lack of awareness to the relatively frequent presence of sleep problems in children, which in turn can manifest in a myriad of clinical presentations that may be easily misconstrued as other pediatric conditions and mistreated accordingly. In other words: questions about sleep should always be included!

A systematic screening for sleep issues might assist in early identification of academic, behavioral, health and quality of life problems, which if treated will result in a better learning, happier, and healthier child. In the field of pediatric sleep research, a trend toward implementation of large-scale sleep surveys has surfaced. Unfortunately, only a fraction of the manuscripts seems to report on reliability or validity, and rarely, if at all, will describe endorsement rates. Surprisingly, even the survey itself is missing in a large number of those studies. Notwithstanding, is any sleep question asked a ‘good’ question to ask? In other words, are surveys merely straightforward question-answer scenarios? How valid and comparable are the results from such surveys? Survey instruments are increasingly being created, adapted or translated with little scrutiny regarding their psychometric qualities, their structure, reliability and validity, and therefore, substantial doubts and concerns should emerge regarding their findings. Another consequence of the lack of psychometric validity is that direct comparison(s) of pediatric sleep problems, their prevalence, as well as the understanding of their impact on every day functioning is also substantially hampered. Likewise, the treatment of sleep disorders in children should benefit from well-designed, psychometrically sound tools. The field of pediatric sleep can only continue to grow and exert its impact on other fields if researchers and clinicians thoroughly investigate and report the psychometric properties of the tool(s) they develop and use. In this manuscript, we have tabulated ‘all’ existing subjective tools within the field of pediatric sleep medicine, and have attempted to describe their psychometric qualities. As a preamble to this review, we described in greater detail in the preceding paper the 11 methodological steps needed to develop and evaluate a sleep assessment tool, and inherent potential pitfalls were also discussed in greater detail.2 The methodological steps should include: 1. Purpose; 2. Research Question; 3. Response Format; 4. Generation of Items; 5. Pilot; 6. Item-analyses and non-response analyses; 7. Structure; 8. Reliability; 9. Validity; 10. Confirmatory analyses; and 11. Standardization and norms development. These psychometric approaches should be implemented using appropriate manuals and scholarly manuscripts on this topic, because inappropriate tools and lack of rigor inevitably lead to poor quality data, misleading conclusions, and inaccurate recommendations.

The dynamic and accelerated expansion of pediatric sleep science has inevitably led to development and utilization of numerous survey instruments that have enabled important discoveries and overall advancement of the discipline. As we now reach a more mature stage in our field, we believe that time has arrived to critically examine the constructs of existing instruments, and delineate not only the specific questions being sought, but also evaluate the steps taken to validate their implementation. An extensive list of published and unpublished instruments used to investigate or evaluate sleep issues in children was therefore collected and assessed based on our 11 step-by-step guide as outlined in the preceding paper.2

Section snippets

Procedure

The MeSH search terms combined were “Sleep” AND (“infant*” OR “child*” OR “adolescent*”) AND (questionnaire*, instrument*, scale*, checklist*, assessment*, log*, diary*, record*, report*, interview*, test*, measure*), and implemented in the following search engines: PubMed, PsycINFO, Child Development and Adolescent Studies, Health and Psychosocial Instruments, Mental Measurements Yearbook, CINAHL, Scopus (also Web crawling), ClinicalTrials.gov, Dissertations and Theses, Google Scholar (Web

Results

This comprehensive review led to tabulation of the subjective tools in which psychometric properties as described in the preceding paper were evaluated. Next, tools for which no psychometric properties were evaluated were divided into those that are reported or published, those that are part of established tools, and those that are unpublished or used in clinical practice. As a rule, we focused on the original tool unless translations, modifications etc. were found to contribute clinical

Short history

The potentially first ‘diagnostic’ sleep questions, historically and not surprisingly, were embedded in daytime ‘psychopathology’ tools, such as Achenbach’s Child Behaviour Checklist (CBCL)3 and Sines Missouri Children’s Picture Series (MCPS),4 Conners’5 and the Louisville Behavior Checklist,6, 7 all of which were developed in the 1970s. As such, ‘a’ connection between mental health and sleep was made, although their interrelation remained unspecified. Prior to these tools, questions on sleep

Tools in which psychometric properties were evaluated

57 Tools were found to have been psychometrically evaluated to some extent (Table 1, and tabulated in detail in Supplementary Tables 1–3). Tools are ranked chronologically on the lowest age boundary (an alphabetical list for easy reference can be found at the end of this manuscript) being an important criteria upon deciding which tool to use.

Approximately half of the tools (52.6%) are printed together with the paper or are accessible online. The majority of the reported tools(43) were published

Diaries, logs and other tools

Instruments were grouped according to self-report13 or parental report.16 29 diaries and logs are described in Supplementary Table 4. The literature search revealed that these terms are used interchangeably, and that a clear distinction was not made from the often concomitantly applied actigraphy and its parameter report. Even in these tools, heterogeneity is remarkably apparent in the wording, the order, the lay-out, the number of questions, when to fill-out and in the time-frame, or even

Tools in which psychometric properties were not evaluated

This list is not exhaustive since an overwhelming amount of papers implement a certain ‘subjective tool’. The contrast of these unevaluated tools with the limited number of tools that are actually psychometrically evaluated should prompt caution in their use based on the assumption that they are a priori valid. The 70 instruments were ranked based upon the lower age boundary (an alphabetical list can be found at the end of this manuscript). These include not only questionnaires, but also

Sleep questions in other existing tools

Contact with publishers yielded limited results with most instruments probably having just a few items or the publisher being unaware of any ‘sleep items’ (Supplementary Table 6). Therefore the list tabulated, again chronologically on lower age boundary, is based upon 21 instruments to which we had access. In contrast to the sleep instruments, it becomes apparent that these daytime tools are mostly created in 70–90s. Only a handful of sleep items appear in each of the instruments, and their

Unpublished tools

This list probably represents only a minority of the tools available, and was created primarily through the willingness of colleagues in the field to share their tool (Supplementary Table 7). 28 instruments are listed. We would like to draw special attention to instruments in development or in press: RLS rating scale [nr. 3], RLS/PLMD pediatric screening questionnaire [nr. 4], sleep paralysis [nr. 5], dream habits [nr. 7], treatment evaluation inventory [nr. 11], hospitalized children’s sleep

Synopsis

“Begin at the beginning”, the King said gravely, “and then go on till you come to the end; then stop” – Alice’s adventures in Wonderland

From this review it is clear that much remains to be done, even if in recent years the psychometric evaluation of tools created and applied within the field of pediatric sleep medicine is growing. Sleep-related breathing and sleepiness disorder questionnaires are probably leading this trend.

The Brouillette’s30 questionnaire assessing sleep-related breathing

Conclusions

In 1981, the textbook ‘The Mismeasure of Man” symbolized the previous hazards of measuring intelligence as a single quantity and its possible adverse consequences (e.g., Goddard’s belief in intelligence testing). This review was written solely to allow critical reflection upon the risk of ‘the mismeasure of sleep’, and thus promote and enhance collaborative studies on measurement of pediatric sleep. This interesting journey in the world of pediatric sleep tools revealed that efforts have been

Conflict of interest

The authors have no conflict of interest to declare pertaining to this manuscript.

Acknowledgments

We would like to express our gratitude to Drs. Oliviero Bruni and Avi Sadeh for distributing our request via their pediatric sleep listservers. The following individuals not only expressed their enthusiasm towards the review, but each added to its value by providing tools or contact persons or references (alphabetically): Thomas M. Achenbach, Rosana Cardoso Alves, Jessica M. Bennett, Sarah Biggs, Luigia Brunetti, Oliviero Bruni, Sandra Carvalho Bos, Ronald Chervin, Martin Delatycki, Pernilla

References* (87)

  • H. Sohn et al.

    Evaluation of sleep-disordered breathing in children

    Otolaryngol Head Neck Surg

    (2003)
  • A.M. Strocker et al.

    The validity of the OSA-18 among three groups of pediatric patients

    Int J Pediatr Otorhinolaryngol

    (2005)
  • J.F. Simonds et al.

    Prevalence of sleep disorders and sleep behaviors in children and adolescents

    J Am Acad Child Psychiatry

    (1982)
  • S. Carvalho Bos et al.

    Sleep and behavioral/emotional problems in children: a population-based study

    Sleep Med

    (2009)
  • O. Bruni et al.

    Relationships between headache and sleep in a non-clinical population of children and adolescents

    Sleep Med

    (2008)
  • S. Warner et al.

    Holiday and school-term sleep patterns of Australian adolescents

    J Adolesc

    (2008)
  • M. Tomas Vila et al.

    An Pediatr (Barc)

    (2007 Feb)
  • B. Gillham

    Developing a questionnaire

    (2008)
  • T.M. Achenbach

    Child behavior checklist

  • J.O. Sines et al.

    Identification of clinically relevant dimensions of children’s behavior

    J Consult Clin Psychol

    (1969)
  • C.K. Conners

    Conners rating scales

  • L.C. Miller et al.

    Children’s deviant behavior within the general population

    J Consult Clin Psychol

    (1971)
  • L.C. Miller et al.

    Factor-analytically derived scales for the louisville behavior checklist

    J Consult Clin Psychol

    (1988)
  • Education Bo

    The restoring power of sleep

    J Educ

    (1924)
  • L.W. Baker

    Sleep

    J Educ

    (1884)
  • N. Chant et al.

    A study of sleeping habits of children

    Genet Psychol Monogr

    (1928)
  • O. Bruni et al.

    The sleep disturbance scale for children (SDSC) construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence

    J Sleep Res

    (1996)
  • M. Luginbuehl et al.

    Pediatric sleep disorders: validation of the sleep disorders inventory for students

    Sch Psych Rev

    (2008)
  • Luginbuehl ML. The initial development and validation study of the sleep disorders inventory for students. Ph.D. United...
  • O. Bruni et al.

    Development and validation of a dream content questionnaire for school age children

    Sleep and Hypnosis

    (1999)
  • J.C. Spilsbury et al.

    The cleveland adolescent sleepiness questionnaire: a new measure to assess excessive daytime sleepiness in adolescents

    J Clin Sleep Med

    (2007)
  • J.A. Henderson et al.

    Development and preliminary evaluation of the bedtime routines questionnaire

    J Psychopathol Behav Assess

    (2009)
  • S. Matthey

    The sleep and settle questionnaire for parents of infants: psychometric properties

    J Paediatr Child Health

    (2001)
  • J.M.B. Morrell

    The role of maternal cognitions in infant sleep problems as assessed by a new instrument, the maternal cognitions about infant sleep questionnaire

    J Child Psychol Psychiatry

    (1999)
  • J. Morell et al.

    The developmental change in strategies parents employ to settle young children to sleep, and their relationship to infant sleeping problems, as assessed by a new questionnaire: the parental interactive bedtime behaviour scale

    Infant Child Dev

    (2002)
  • J.A. McGreavey et al.

    The Tayside children’s sleep questionnaire: a simple tool to evaluate sleep problems in young children

    Child Care Health Dev

    (2005)
  • LeBourgeois MK. Validation of the children’s sleep–wake scale. Ph.D. United States – Mississippi: The University of...
  • K. Spruyt et al.

    Pediatric sleep disorders: exploratory modulation of their relationships

    Sleep

    (2004)
  • R.D. Chervin et al.

    Pediatric sleep questionnaire: prediction of sleep apnea and outcomes

    Arch Otolaryngology–Head Neck Surg

    (2007)
  • K.A. Schreck et al.

    Development of the behavioral evaluation of disorders of sleep scale

    J Child Fam Stud

    (2003)
  • N. Clarck et al.

    Investigating sleep problems in children using drawings: an experimental paradigm, SLEEP 2009

    (2009)
  • C.C. Maldonado et al.

    A pictorial sleepiness scale based on cartoon faces

    Sleep

    (2004)
  • S.J. Dollinger et al.

    The Missouri Children’s Picture Series: utility of the sleep disturbance scale with a clinical sample

    J Pediatr Psychol

    (1979)
  • Cited by (0)

    The most important references are denoted by an asterick.

    View full text