Received: 22 November 2019 | Accepted: 29 March 2020

DOI: 10.1002/nur.22023

RESEARCH ARTICLE

Sleep health in young children living with socioeconomic

adversity

Monica R. Ordway1 | Lois S. Sadler2 | Sangchoon Jeon1 | Meghan O'Connell1 |

Nancy Banasiak1 | Ada M. Fenick3 | Angela A. Crowley1 | Craig Canapari3 |
Nancy S. Redeker1

1
Yale School of Nursing, West Haven,
Connecticut Abstract
2
Yale Child Study Center, Yale University
Racially and ethnically diverse young children who live with socioeconomic adversity
School of Nursing, West Haven, Connecticut
3
Department of Pediatrics, Yale School of are at high risk for sleep deficiency, but few behavioral sleep interventions (BSIs) are
Medicine, New Haven, Connecticut tailored to their needs. To support the future development of a feasible, acceptable,
Correspondence and culturally relevant sleep intervention, we conducted a community‐engaged,
Monica R. Ordway, Yale School of Nursing, mixed‐methods study with 40 low‐income, racially, and ethnically diverse parents to
West Haven 06516, CT.
Email: Monica.ordway@yale.edu and describe sleep characteristics, sleep habits, and parental sleep knowledge of their
monica.ordway@gmail.com 6–36‐month‐old children and to examine the associations between children's sleep

Funding information
National Institute of Nursing Research,
Grant/Award Numbers: 5K23NR016277‐03,
P20NR014126, R21NR01690
characteristics and sleep habits. This report presents quantitative data from this
mixed‐methods study. We measured objective (actigraphy) and parent‐reported
sleep (Brief Infant Sleep Questionnaire) characteristics, sleep habits at bedtime,
sleep onset, and during night awakenings, parental sleep knowledge, psychological
function (Brief Symptom Inventory), and parenting stress (Parenting Stress Index).
Children had low sleep duration (537.2 ± 54.7 nighttime and 111.2 ± 29.8 nap
minutes), late bedtimes (22:36 ± 1.5 hr), and high bedtime variability (mean squared
successive difference = 3.68 ± 4.31 hr) based on actigraphy. Parental knowledge
about sleep recommendations was limited. Sleep habits before bedtime, at sleep
onset, and during night awakenings were varied. Sixty‐five percent of parents
reported co‐sleeping. Feeding near bedtime or during the night was associated with
later bedtimes, more fragmented sleep, and increased bedtime variability. These
findings suggest the need for BSIs to support earlier bedtimes and improve sleep
duration and continuity by addressing modifiable behaviors. Tailored BSIs that
consider socioecological influences on the development of sleep habits are needed.

KEYWORDS

actigraphy, community‐engaged research, health disparities, infants, sleep, toddlers

1 | INTRODUCTION performance, memory consolidation, and learning (Diekelmann &

Sleep health and good sleep habits begin early in life (National
Scientific Council on the Developing Child & National Forum
on Early Childhood Policy and Programs, 2010) and are essential for
children's wellbeing, growth and development, healthy metabolism,
Born, 2010; Walker & Stickgold, 2006; Xie et al., 2013). Yet, sleep
deficiency, including insufficient sleep duration (Combs, Goodwin,
Quan, Morgan, & Parthasarathy, 2016; Koulouglioti et al., 2014;
Magee, Gordon, & Caputi, 2014), irregular bedtimes (Kelly, Kelly, &
Sacker, 2013; Staples, Bates, & Petersen, 2015), and poor sleep

Res Nurs Health. 2020;1–12. wileyonlinelibrary.com/journal/nur © 2020 Wiley Periodicals, Inc. | 1

2 |
quality (Gruber et al., 2014; Soffer‐Dudek, Sadeh, Dahl, &
Rosenblat‐Stein, 2011) are common in young children. The occur-
rence of sleep problems in >25–40% of children by the preschool
years (2.5–5 years) suggests the importance of modifying con-
tributing behaviors early in life, while they are still modifiable
(Byars, Yolton, Rausch, Lanphear, & Beebe, 2012; Mindell,
Leichman, Puzino, Walters, & Bhullar, 2015; Owens & Jones, 2011;
Owens, Jones, & Nash, 2011).
Racially and ethnically diverse families who live with socio-
economic adversity are at especially high risk for sleep deficiency
and its negative consequences (El‐Sheikh et al., 2013; Guglielmo,
Gazmararian, Chung, Rogers, & Hale, 2018; Smith, Hardy, Hale, &
Gazmararian, 2019). The reasons for this are multifactorial but
may include individual, family, home, neighborhood, cultural, and
societal factors, as characterized by the social ecological model
(Bronfenbrenner, 1979, 1986; Grandner, Williams, Knutson,
Roberts, & Jean‐Louis, 2016; Owens & Ordway, 2019). Family
members' behaviors and sleep habits (e.g., co‐sleeping; Caldwell,
Ordway, Sadler, & Redeker, 2019; Sadler et al., in press), parental
knowledge about children's sleep, parental psychosocial func-
tioning (e.g., depression, anxiety, parenting stress; Caldwell &
Redeker, 2015), and living in crowded or unsafe environments all
contribute to sleep habits among children and their parents
(Caldwell et al., 2019; Martinez & Thompson‐Lastad, 2015; Yip
et al., 2019). These behavioral and socioecological factors may also
interact with young children's sleep to influence the development
of future health problems that may be associated with health
disparities (Doane et al., 2019).
There is a critical need for effective strategies to address
sleep health in young children. While behavioral interventions for
young children are available and efficacious (Jones, Owens, &
Pham, 2013; Mindell et al., 2011b; Paul et al., 2016), few have
addressed the family, social, or ecological contexts of children
who live with socioeconomic adversity, many of whom are
members of multiethnic families (Schwichtenberg, Abel, Keys, &
Honaker, 2019). To be culturally relevant, these interventions
must consider diverse child‐rearing traditions, expectations of
children's and parent's behaviors, and distinctive family stressors
and resources (Lau, 2006).
We conducted a community‐engaged mixed methods study
to support the future development of a feasible, acceptable, and
culturally relevant sleep intervention for young children (Redeker
et al., 2018; Sadler et al., in press) (NCT03045874), and to learn
about sleep from parents who were raising infants and toddlers in a
racially and ethnically diverse, low‐income urban community. We
previously reported our qualitative findings (Sadler et al., in press)
and report the quantitative findings from that study in this paper.
The purposes were to examine (a) parent‐reported and actigraph‐
measured characteristics of sleep and sleep habits; (b) parent
knowledge about child sleep; (c) associations among parents'
psychosocial health, knowledge about sleep, and child sleep char-
acteristics; and (d) associations between child sleep behaviors and
parent‐reported and actigraphy‐measured sleep characteristics.
ORDWAY ET AL.
2 | METHO DS
2.1 | Design
We conducted a cross‐sectional convergent mixed methods study
(Redeker et al., 2018), framed by the socioecological model, to under-
stand sleep within the layers of parenting, family, household, neigh-
borhood, and cultural factors that may influence sleep in early
childhood, parent sleep behaviors, and parent knowledge about child
sleep (Owens & Ordway, 2019). The overall purpose of the mixed
methods study was to obtain qualitative and quantitative data to assess
the need for and determine the focus of a possible future sleep health
intervention designed specifically for families living with socioeconomic
adversity. We previously described the protocol in‐depth, including a
detailed overview of the community‐engaged research approach we
used to partner with community stakeholders and a community ad-
visory committee who helped to guide the design of the study, interview
questions, and interpretation of data (Redeker et al., 2018)
(NCT03045874). The University Human Subjects Protection and pe-
diatric research committees and the research committee in the clinical
setting approved the study. All parents provided written informed
consent and permission for their children's participation.
2.2 | Setting and sample
We conducted the study in a U.S. Northeastern city that has over
130,000 residents who are racially and ethnically diverse and where
26% of families with children under age 18 years living in poverty (US
Census Bureau, 2019). We recruited families who received care at
the local academic medical center's comprehensive pediatric primary
care center that serves >7,000 families living in the city and sur-
rounding area. This center serves 40% Hispanic, 50% Black, 5% Asian
people, and 5% of people of other races/ethnicities. The primary care
center predominantly serves families from lower socioeconomic
backgrounds who receive Medicaid health insurance and the Women,
Infants, and Children nutritional support program.
We previously reported eligibility criteria (Redeker
et al., 2018; Sadler et al., in press). In brief, we included English and
Spanish‐speaking families with children between the ages of 6–36
months. Families with children with developmental delays or ser-
ious medical conditions and children in the custody of child pro-
tective services were excluded. We used stratified purposive
sampling to assure ethnic diversity and representation of families
with 6–18‐month and 19–36‐month‐old children. We included
these age ranges because sleep habits begin early in life and this is
a formative time (Tierney & Nelson, 2009).
We determined the need for a sample size of 40 based on the
mixed methods design in the larger study and estimated that 40
participants would be sufficient to reach thematic saturation for
the qualitative strand (Redeker et al., 2018). This sample size was
adequate for quantitative descriptive purposes and to address the
goal of obtaining foundational information to support a possible
ORDWAY ET AL.
future intervention within this community. Therefore, we did not
conduct a power analysis.
2.3 | Procedures
Pediatric health care providers at the health care center screened
medical records to identify potentially eligible children between 6 and 36
months of age who were scheduled for routine clinic visits. Trained re-
search assistants (RAs) met families in the clinic to explain the study,
obtain informed consent, and schedule the first study visit. Two 1‐hr
visits were held at the parents' convenience in their homes. During the
first visit, we instructed parents on the use of the actigraph and ac-
companying sleep diaries. We asked them to complete two parent‐report
sleep questionnaires and participated in interviews for the qualitative
strand of the study (Sadler et al., in press). After 7 days and nights during
which the children wore the actigraphs, the RAs returned to the families'
homes to retrieve the actigraphs, review the sleep diaries, and ask the
parents to complete two questionnaires on parental psychosocial health.
Parents received $25 at each of the two data collection visits.
Because of our interest in the sleep of children from diverse
English and Spanish‐speaking families who often are not included in
research on behavioral sleep interventions, we used questionnaires
available in Spanish (Brief Symptom Inventory [BSI] and Parenting
Stress Index [PSI], see descriptions below). Professional translators
translated the consent forms and surveys that were not available in
Spanish with a translation‐back translation approach. A Spanish‐
speaking RA collected data from Spanish‐speaking families and spoke
in their language of choice.
2.4 | Variables and measures
2.4.1 | Demographic and health information
We collected parent demographic and health information, including
age, gender, race and ethnicity, education, employment, shiftwork,
marital status, number of people in the household, type of dwelling
(house, apartment, etc.), and type of health insurance. Health in-
surance (Medicaid, private, or no insurance) was used as a proxy for
income level. Connecticut's eligibility standards to qualify for Medi-
caid insurance is 196 percent of the federal poverty level for children
ages 0–18 years (Norris, 2018). Parents also reported their child's
age, gender, race and ethnicity, and their childcare arrangements.
2.4.2 | Parent‐reported child sleep
We used the 26‐item Brief Infant Sleep Questionnaire (BISQ)‐Extended
(Sadeh, 2004), to elicit parent‐reported child sleep characteristics
(bedtime, nighttime sleep duration, minutes wake after sleep onset
[WASO], nap duration, and total 24‐hr sleep duration) and sleep habits
(bedtime routine activities, sleep onset behaviors, and night awakening
| 3
approaches). The BIS‐Extended is valid for children ages 0–36 months
and has a grade 5 reading level (Sadeh, 2004; Sadeh, Mindell, Luedtke, &
Wiegand, 2009) The items are correlated with a daily sleep diary and
caregiver reports of sleep. It has test–retest reliability of 0.82–0.95 for
individual items (Sadeh, 2004).
2.4.3 | Actigraphy‐measured child sleep
We used the Actiwatch 2 (Philips Respironics, Murrysville, PA) to
measure sleep characteristics. Actigraph measures of sleep are valid
and reliable beginning in infancy (see review Meltzer, Montgomery‐
Downs, Insana, & Walsh, 2012). Reliability estimates for age 12
months range from 0.77 to 0.89 for sleep efficiency and 0.70–0.85
for sleep duration based on 3–7 nights of data (Acebo et al., 1999).
We used the medium sensitivity setting and a wake threshold value
of 40 activity counts, and immobile minutes for sleep equal to 10 min to
evaluate the data that were collected in 30‐s epochs, consistent with
the literature (Sadeh, Sharkey, & Carskadon, 1994). We used event
marker recordings and parent‐recorded sleep diary entries to indicate
nap time onset and offset in preparing the data for analysis.
We requested that children wear the actigraph for 7 days to assure
that we would obtain at least 3 days of data (Acebo et al., 1999) and
instructed parents to keep the actigraph on their children for the entire
7 days, including bathing unless the child was going to swim in water
over one meter in depth. To address safety recommendations (Bélanger,
Bernier, Paquet, Simard, & Carrier, 2013), the children wore the acti-
graph on their ankle. We covered the black actigraph bands with col-
orful child‐themed duct tape to make them more appealing to the child
and family. We instructed parents to press the actigraph event markers
at sleep and wake times, including nap times. Parents recorded bedtime,
wake times, naps, and bed‐sharing in a sleep diary to assist with scoring
the actigraph data, consistent with standard actigraph protocols
(Bélanger et al., 2013). We sent text messages or called parents every 2
days to remind them to keep the actigraphs on the children.
2.4.4 | Parent knowledge about sleep
We measured parent knowledge and beliefs about sleep with the
10‐item Owens and Jones questionnaire developed by experts with
clinical experience with children's sleep (Owens et al., 2011). Each of
the 10 questions is a yes/no question and a total score between
0 and 10 is calculated, with 10 indicating the highest level of sleep
knowledge. While there are no reliability statistics published, this
questionnaire is widely used in pediatric sleep research (McDowall,
Galland, Campbell, & Elder, 2017).
2.4.5 | Parental psychosocial health
The BSI (Derogatis, 1993) is an 18‐item symptom inventory that
measures parents' psychological distress. It has three subscales
4 |
(depression, somatization, and anxiety symptoms) and contains a
Global Severity Index that reflects symptoms across domains.
The BSI has good internal reliability showing an average rating
above 0.70 for each of the subscales and a test–retest reliability
range of 0.68–0.91 (Derogatis, 1993).
The 36‐item Parenting Stress Index‐Short Form (PSI‐SF;
Abdin, 1995) was used to measure the magnitude of stress in
the parent–child system. There are four subscales in the PSI‐SF:
Parent Distress, Parent–Child Difficulty, Difficult Child, and
Total Stress. The PSI‐SF subscales have concurrent validity
with the full‐length PSI. Alpha coefficients ranged from .88 to .95
across the subscales in similar samples (Reitman, Currier, &
Stickle, 2002).
2.5 | Statistical analysis
We scored the actigraph data with Actiware v6 software
(Philips Respironics Mini‐Mitter Inc.). For each day, we computed
bedtime and wake up time (time of sleep offset) for
the nighttime sleep period to compute time in bed. We used
custom intervals confirmed by review of the parent‐recorded
sleep diaries to determine the onset and offset of nap intervals
and computed nap duration and number of naps. As the
number of nights available for analysis varied across individuals
(ranging between 3 and 9 nights; mean = 7.0 ± 1.6 nights),
weighted means were calculated for each child and used for the
overall group means.
We calculated night‐to‐night variability in bedtimes and night-
time sleep duration by creating a series of successive differences
from the differences calculated between nights within the same
toddler (e.g., Night 4 − Night 3, Night 3 − Night 2, etc.) and then
squaring them to account for potential negative values. These
squared successive differences were used to compute a mean, an
index of variability/instability that is more sensitive to fluctuations
across successive observations (Jahng, Wood, & Trull, 2008; Meltzer,
Sanchez‐Ortuno, Edinger, & Avis, 2015).
We computed descriptive statistics for the demographic,
sleep, parental sleep knowledge, and psychosocial variables and
evaluated these data for missing data and skewness. Nonpara-
metric tests (Wilcoxon rank‐sum and Kruskal–Wallis test) were
used to compare the children's sleep characteristics and parents'
sleep knowledge by categorical demographic characteristics of the
children and parents. Pearson coefficients (r) were used to ex-
amine the associations between continuous measures of sleep
characteristics and sleep knowledge, and point‐biserial coefficient
(rpb) was used to examine the association between those con-
tinuous measures and binary items of BISQ for sleep behaviors.
We also computed parametric and nonparametric bivariate cor-
relations to examine associations between clinical and demo-
graphic characteristics of the children and parents, parent
psychosocial distress, actigraph and parent‐reported sleep char-
acteristics, and sleep habits and knowledge.
ORDWAY ET AL.
3 | RE SU LTS
3.1 | Sample description
The sample included 40 racially and ethnically diverse children between
the ages of 6–36 months and their parents (18 boys and 22 girls; see
Table 1). All but one of the parents was the child's mother. All of the
children were recruited from the primary care center, and 90% reported
having Medicaid insurance or no insurance. We obtained at least three
nights of actigraphy data from 28 children (15 boys, 13 girls; M age =
19.11 months, standard deviation [SD] = 8.54, range = 6–35 months). Six
children did not wear the actigraphs (two parents refused and four
parents never put the actigraph on the children), four actigraphs did not
collect data (actigraph error), and two actigraphs had fewer than 3 days/
nights of data and were excluded from the analyses. There were no
differences between the groups with and without actigraph data on age,
race, gender, parent knowledge of healthy sleep, or parent‐reported
sleep characteristics (sleep duration, regular bedtime).
3.2 | Sleep characteristics
Data on the actigraph‐measured and parent‐reported sleep character-
istics are presented in Table 2. There was a difference between parent‐
reported and actigraph‐measured bedtime (W = 175.5; p < .01) and
WASO (W = 149; p < .01), with parents reporting earlier bedtimes and
fewer WASO minutes than recorded by the actigraphs. Parent‐reported
bedtime was 9 p.m. Actigraph‐measured bedtime was 10:30 p.m.
Parent‐reported WASO was a half hour. Actigraph‐measured WASO
was an hour and a quarter. There were no differences between parent‐
reported and actigraph‐measured sleep duration. Nighttime sleep
duration was 8–9 hr, depending on parent or actigraph source, re-
spectively. Daytime naps were about 2 hr total. Thus, total sleep daily
was 10.2 hr (actigraphy) to 10.8 hr (parent‐reported).
The parent‐reported data on children's sleep (BISQ) are presented
in Table 3. Sleep onset latency (time to fall asleep) was 30 min or less for
most children (n = 33; 82.5%). Slightly more than half (n = 21; 52.5%)
reported that their child had consistent bedtimes at least 5 nights a
week. Twenty‐six (65%) children woke up at least one night per week,
with eleven (27.5%) waking every night. The average number of awa-
kenings at night was 1.33 ± 1.02. None of the parent‐reported sleep
characteristics differed between infants and toddlers. Overall, 12 par-
ents (30%) perceived that their children had sleep problems.
3.3 | Sleep habits
3.3.1 | Bedtime routine activities
Parents reported that their children were engaged in an average of 5.8
(SD = 2.3) activities during the hour before bed, including bathing (n = 30;
75%), drinking fluids (n = 28; 70%), playing (n = 27; 67.5%), watching TV
(n = 23; 57.5%), reading (n = 19; 47.5%), and brushing teeth (n = 18; 45%).
ORDWAY ET AL. | 5

T A B L E 1 Demographic characteristics of parents and children and

parent psychosocial health characteristics

(69.0)
(186)
(SD)
Total 24‐hr sleep
Full sample (N = 40)

Mean/N (SD)/%

Children

Mean

613.5
648
Age (months) 18.4 (8.7)
Sex (Male) 18 45%
Race/ethnicity

(76.7)

(29.8)
Non‐Hispanic white 12 27.5%

Nap duration (min)

(SD)
Black 11 25%
Asian 3 7.5%
Multiracial 7 17.5%

Mean

134.4

111.2
Other/unknown 7 17.5%

Abbreviations: BISQ, Brief Infant Sleep Questionnaire; MSSD, mean squared successive differences; SD, standard deviation; WASO, wake after sleep onset.
Hispanic 22 55%
Attend childcare center 10 25%

Parents

Nighttime sleep duration (min)

Parent age (years) 28.8 (5.6)

(173.2)
Parent sex (male) 1 2.5%

(54.7)
(SD)
Education (years) 12.5 (3.3)
Race/ethnicity
Non‐Hispanic white 9 22.5%
Black 11 27.5%
Asian 3 7.5%
Mean

499.0

537.2
Multiracial 4 10%
Other/unknown 13 32.5%
Hispanic 18 45%
(45.57)

(25.3)
Marital status
(SD)
WASO (min)*

Single 28 70%
Married 12 30%
Mean

Number living in home 4.1 (1.8)

74.7
28

Dwelling
Apartment 31 77.5%
House 7 17.5%
(SD)
T A B L E 2 Parent‐reported and actigraph‐measured sleep characteristics

Other 2 5%
(4.31)

Employed 17 42.5%
MSSD bedtime

Full‐time 9 22.5%
Part‐time 8 20%
Mean

Shiftwork 10 25%
3.68
NA

Unemployed 23 57.5%
Health insurance
(1.1 hr)

(1.5 hr)

Medicaid 30 75%
(SD)

Private 4 10%
Bedtime*

None 6 15%
21:06

22:36
Mean

Global Severity Index 43.5 (10.9)

Parenting Stress Index‐Total Stress 69.2 (20.9)

Abbreviation: SD, standard deviation.

Parent‐reported (BISQ) N = 40

Actigraph‐measured N = 28

3.3.2 | Sleep onset behaviors

Parents reported that their children most commonly fall asleep “in
his/her own crib/bed and with a parent in the room” (30%), “in his/
her own crib/bed alone in the room” (40%), “in the parents' bed with
*p < .01.

a parent” (40%), and “in the parents' bed alone” (10%; parents could
select more than one option). Children also fell asleep while bottle
6 | ORDWAY ET AL.

T A B L E 3 Parent‐reported sleep habits (BISQ): Bedtime routine, TABLE 3 (Continued)

sleep onset, nighttime awakening, and sleep characteristics
Full sample (N = 40)
Full sample (N = 40)
Sleep latency >30 min 33 (82.5%)
Bedtime routine: Which of the following usually N (%) Sleeps through the night 10 (25%)
occurs on most nights for your child in the
Wakes up at least one night per week 26 (65%)
hour before bedtime? (Check all that apply)
Wakes up every night 11 (27.5%)
Bath 30 (75)
Number of night awakening 1.33 (1.2)
Massage 4 (10)
Child's sleep considered a problem by 12 (30%)
Read books/being read to 19 (47.5)
parent
Watch TV 23 (57.5)
Child sleeps poorly 2 (5%)
Have dinner or a snack 26 (65)
Number of parent–child bedtime 5.8 (2.3)
Have a bottle, nurse, drink 28 (70) interactions
Run around 11 (27.5) Excessive bedtime interactions (>5 20 (50%)
Brush teeth 18 (45) activities)
Play 27 (67.5)
Sleep location
Cuddle 19 (47.5)
Bed share with parents 11 (27.5%)
Say prayers 8 (20)
Room share with parents 15 (37.5%)
Sing songs 9 (22.5)
Independent sleep 14 (35.0%)
Listen to music 9 (22.5)
How many nights child has the same bedtime
Other 1 (2.5)
Never 5 (12.5%)
Sleep onset: How does your child fall asleep N (%) 1–2 nights per week 3 (7.5%)
most of the time? (Check all that apply)
3–4 nights per week 11 (27.5%)
Bottle‐fed 11 (27.5)
5–6 nights per week 9 (22.5%)
Breast‐fed 3 (7.5)
Every night 12 (30.0%)
In crib/bed alone 16 (40)
Abbreviations: BISQ, Brief Infant Sleep Questionnaire; SD, standard
In parent's bed alone 4 (10)
deviation.
Being rocked 10 (25)
In crib with parent present 1 (12)
Being held 9 (22.5) feeding (n = 1; 27.5%), being rocked to sleep (n = 10; 25%), being held
In parent's bed with parent present 16 (40)
(n = 9; 22.5%), and watching TV (n = 12; 30%).
Watching TV 12 (30)
In another room 2 (5)
In a swing 3 (7.5)
3.3.3 | Approaches to night awakenings
Other 3 (7.5)

Night awakening: When your child wakes up N (%)

Twenty‐three (57.5%) parents reported that they offered a feeding to get
during the night, what do you do? (Check
their child back to sleep when awakened at night. Most parents attended
all that apply)
Picked up and rocked 12 (30) to their children as soon as they woke up at night; some parents (n = 17;
Put down awake 6 (15) 42.5%) reported that they waited a few minutes to see if their children
Pat but not picked up 10 (25) would go back to sleep unattended. Sixty percent (n = 24) reported
Bottle‐fed 19 (47.5) changing their child's diapers, 12 (30%) picked their child up and rocked
Breast‐fed 4 (10) back to sleep, and 6 (5%) patted them on the back but did not pick them
Pacifier 6 (15) up. Fewer than 15% of parents reported the other options for activities
Change diaper 24 (60) asked on the BISQ (e.g., offer a pacifier, sing, play) during nighttime
Comfort verbally 6 (15) awakenings. Four (10%) parents reported that their children were diffi-
Bring to parent's bed 5 (12.5) cult to put to bed. Twenty‐six (65%) parents reported co‐sleeping. Eleven
Let cry 4 (10) (28%) shared beds with their children, and fifteen (38%) slept in the same
Give a few minutes to fall back to sleep 17 (42.5)
room as their children. Fourteen (35%) children slept in separate rooms
Play with child 4 (10)
from their parents.
Watch TV with child 3 (7.5)
Sing to child 4 (10)
Other 2 (5)
3.4 | Knowledge about sleep
Sleep characteristics N/Mean (%/SD)
Child snores 25 (62.5%)
Overall, parents scored <50% (48.9 ± 16.2%) on the Sleep Knowledge
Child is difficult to put to sleep 4 (10%)
Questionnaire. Only about half answered correctly on children's
ORDWAY ET AL. | 7

normal sleep duration, and less than a fifth responded correctly on
the need for consistent bedtimes and sleep routines (Table 4). The
sleep knowledge scores were not associated with self‐reported or
actigraph‐recorded sleep characteristics. Parents with higher sleep
knowledge were less likely to report that their children watch TV
before bedtime (rpb = −.32; p = .04), but sleep knowledge was not
associated with any other child's sleep habits.
3.5 | Associations between sleep habits and sleep
characteristics
3.5.1 | Bedtime routine activities and sleep
characteristics
Having something to drink before bed was associated with later
bedtimes (rpb = −.40; p = .04), lower sleep efficiency (rpb = −.51;
p = .005) and more fragmented sleep (rpb = .44; p = .02) as measured
by actigraphy. Children who cuddled in the hour before bedtime
(rpb = −.40; p = .04) had less bedtime variability and longer total
nighttime sleep (rpb = .33; p = .03). Listening to music was associated
with more variability in bedtimes (rpb = .41; p = .03) as measured
by actigraphy. Watching TV in the hour before bedtime was asso-
ciated with poorer sleep quality (“how well your child usually sleeps
at night”; rpb = .40; p = .01) and parent‐reported sleep problems
(rpb = −.34; p = .03).
measured sleep characteristics. Being bottle‐fed to fall asleep was
associated with later bedtimes (rpb = .51; p = .006) and breastfeeding
was associated with more variability in bedtime (rpb = .54; p = .003).
Children who fell asleep in their parents' beds with a parent in the
room had more fragmented sleep (rpb = .41; p = .03), but earlier
median bedtimes (rpb = .40; p = .04) than other children. Rocking
children to sleep was associated with more WASO according to
parent report (rpb = .51; p < .001), but higher total sleepover 24 hr as
measured by actigraphy (rpb = .40; p = .03).
3.5.3 | Night awakening approaches and sleep
characteristics
When children woke up at night, bottle‐fed children had more
fragmented sleep (rpb = .48; p = .01) and breast‐fed children had more
variable bedtimes (rpb = .41; p = .03). Children left to cry when they
woke at night had lower nighttime (rpb = −.54; p = .003) and 24‐hr
(rpb = −.45; p = .01) sleep durations. Children who had diaper changes
if they woke at night had lower sleep efficiency (rpb = −.40; p = .03),
longer nap duration (rpb = .50; p < .01) and shorter parent‐reported
longest period of sleep (rpb = −.41; p = .008). Sleep location (bed‐
sharing, rooming‐in, independent sleeping) was not significantly as-
sociated with any of the parent‐reported or actigraph‐measured
sleep characteristics.

3.6 | Parent psychosocial function and children's

3.5.2 | Sleep onset behaviors and sleep
characteristics
The types of methods parents reported helping their children fall
asleep were associated with both parent‐reported and actigraph‐
sleep, sleep habits, and sleep knowledge
We evaluated the associations between parents' self‐reported psy-
chosocial functioning and children's sleep characteristics. Total
parenting stress was moderately associated with actigraph‐recorded

T A B L E 4 Parental Knowledge of Sleep Questionnaire responses

Full sample (N = 40)

Parent Knowledge of Sleep Questionnaire items Correct answers (N) (%)

Children who do not get enough sleep are more likely to be underweight than overweight 10 (25)

Snoring in a child indicates that he or she is sleeping well 9 (22.5)

Being under‐ or overactive can both be warning signs that a child is not getting enough sleep 12 (30)

Watching TV in their bedroom makes it more difficult for children to fall asleep 9 (22.5)

Children should have the same bedtime and waketime on weekdays and weekends 8 (20)

Children only need a bedtime routine if they are having trouble falling asleep 6 (15)

Well‐rested children do not need an alarm clock to wake up 19 (47.5)

The average preschooler (3–5 years) needs about 10 hr of sleep/24 hr 21 (52.5)

Being overweight can increase a child's risk of sleep problems 3 (7.5)

The average school‐aged child (6–12 years) needs about 8 hr of sleep 29 (72.5)

Total number of correct answers (mean (SD)) 4.9 (1.6)

Abbreviation: SD, standard deviation.

8 |
variability in bedtime (r = .38; p = .04). Parent anxiety was negatively
associated with consistency in the bedtime routine (r = −.33; p = .04),
but there were no statistically significant associations between
parental distress, difficult child, parents' report of depression or
somatization and children's sleep characteristics.
4 | D I S C U S SI O N
This study adds new information to explain sleep and sleep habits
among multiethnic infants and toddlers living in socioeconomically dis-
advantaged homes and confirms the presence of sleep deficiency in these
children. The children had shorter sleep durations than clinical re-
commendations (a minimum of 11–12 hr per 24 hr; Paruthi et al., 2016).
Bedtimes were much later than recommended (Mindell, Meltzer, Cars-
kadon, & Chervin, 2009) and were more variable (Paruthi et al., 2016).
Parents had limited knowledge about sleep health recommendations and
interacted with their children in a variety of ways during the time before
and at bedtime and during the night. Some of these behaviors may be
adaptive; others may have a negative impact on sleep.
Our finding that close to half of the children did not have regular
bedtime routines is consistent with previous reports among low‐
income families. (Hale, Berger, Lebourgeois, & Brooks‐Gunn, 2009;
Henderson & Jordan, 2010; Yoo, Slack, & Holl, 2010). Sleep
deficiency may result from increased household stress, less struc-
tured routines, and/or lack of awareness of the benefits of children's
bedtime routines, as evident in the literature (e.g., Hale et al., 2009),
and in the previously reported qualitative findings collected from
these parents (Sadler et al., in press). Although some of these social
and environmental influences may not be readily modifiable (e.g.,
mother's work schedule, noise in the neighborhood), sleep inter-
ventions (behavioral sleep interventions) that address modifiable
factors (e.g., bedtime, bedtime behaviors) and are tailored to families'
needs may support parents to improve children's sleep.
Our findings suggest a need to focus on earlier and more regular
bedtimes and improve sleep efficiency. Because we found low levels
of parental sleep knowledge, education about the importance of early
and regular bedtimes may be a first step to raise awareness. Moving
bedtimes to the recommended time of 9:00 p.m. or earlier may in-
crease sleep opportunity. Even a 45‐min increase in sleep opportu-
nity can make a meaningful difference in children's physical,
cognitive, and behavioral health (Gruber, Cassoff, Frenette, Wiebe, &
Carrier, 2012; Sadeh, Gruber, & Raviv, 2003). Helping parents
recognize improvements in children's daytime behavior after
lengthening and regularizing sleep may help to reinforce this beha-
vior. It may be helpful to share the importance of quality sleep and
recommended sleep duration by emphasizing the active role of sleep
on children's brain maturation, information processing of early
childhood experiences, and memory consolidation (Sadeh, 2007). The
result of quality sleep and meeting sleep duration recommendations
is likely to favor children's optimal cognitive function and lead to
favorable dispositions for learning, which is critical for the developing
brains of infants, toddlers, and preschoolers (Sadeh, 2007).
ORDWAY ET AL.
Sleep habits and behaviors can be organized into three distinct
categories based on their timing relative to the sleep interval
(bedtime/the hour before bedtime; sleep onset; and the time after
sleep onset) and their potential influence on bedtime, sleep onset,
and sleep continuity (Hager et al., 2016). Behaviors related to each of
these time frames are discussed below.
The most common parent‐reported bedtime routine activities
were bathing, drinking milk or juice, playing, watching TV, reading,
and brushing teeth. Some behaviors are likely to be adaptive (e.g.,
brushing teeth, praying, reading a story), while others may be ma-
ladaptive or arousing (e.g., watching TV, engaging in play). However,
specific behaviors may be less important than the ways in which
parents cluster prebedtime activities (Henderson & Jordan, 2010).
Identifying and choosing adaptive activities from the broad domains
of nutrition, hygiene, communication, and physical contact that last
no more than 30 min may help to improve bedtime routines (Mindell
& Williamson, 2018). These activities may be tailored to specific
cultural or social practices (e.g., prayer in families with religious
traditions or healthy snacks of specific cultural foods). The strate-
gies could also be tailored for families that experience high levels of
psychosocial and/or economic adversity and use different strategies
(Cronin, Halligan, & Murray, 2008; Sheridan et al., 2013). Best
approaches to BSIs for these families should likely be flexible to
accommodate family schedules (e.g., parent work schedules), en-
vironments (crowded and noisy living space and neighborhoods),
and cultural traditions, while promoting the importance of bedtime
routines. For example, suggestions for simple types of bedtime
activities that consider the families’ traditions and resources (i.e.,
access to specific kinds of books, parental literacy level, availability
of pajamas) with instructions to choose four to five activities for the
same time at night might be helpful. These approaches could be
enhanced with the use of a visual bedtime routine chart that is
commonly used in interventions for children with autism (Vriend,
Corkum, Moon, & Smith, 2011), and inclusion of free online re-
sources, but they should be selected to be consistent with the
characteristics of individual families (e.g., depictions of children that
look like the target group).
Parental presence at bedtime including rocking, holding or
feeding children, was associated with more variable sleep and poorer
sleep continuity in this study. Caregiver presence at sleep onset
can create a sleep‐onset association and/or limit‐setting problems
that have a negative influence on sleep continuity (Allen, Howlett,
Coulombe, & Corkum, 2016; Mindell, Kuhn, Lewin, Meltzer, &
Sadeh, 2006). These behavioral sleep problems are most often as-
sociated with difficulty maintaining sleep, as we found in more than
half of the children in our study who were attended by parents
during night awakenings. The negative impact of difficulty main-
taining sleep on children's emotional, behavioral, and cognitive
function (Sadeh et al., 2003; Vriend et al., 2013) supports the im-
portance of our findings and the need to help parents assist their
children to settle to sleep without the parental presence (e.g., self‐
soothing; Allen et al., 2016). This is an important focus for education,
counseling, and feedback to assist with sustained behavior.
ORDWAY ET AL.
Studies of BSIs in early childhood demonstrate modest improve-
ments in sleep duration and quality (Hall et al., 2015; Meltzer &
Mindell, 2014; Mindell et al., 2011a, 2011b; Paul et al., 2016). Few
studies, however, included children during toddlerhood or racially and
ethnically diverse families who live with socioeconomic adversity—
factors that may limit the feasibility, acceptability, and efficacy of these
interventions because of environmental differences or lack of re-
sources (Schwichtenberg et al., 2019). One study of a brief sleep
education program provided through the head start for preschool‐
aged children (3–5 years) improved parent‐reported preschoolers'
sleep, parent knowledge, and parent self‐efficacy at the immediate
conclusion of the program, but these improvements were not sus-
tained at 1 month, and beliefs about sleep did not change (Wilson,
Miller, Bonuck, Lumeng, & Chervin, 2014). Reasons for this are not
known, but it is possible that the intervention was not sufficiently
personalized and tailored with strategies to address the practice of
skills (Arlinghaus & Johnston, 2017) or the specific needs and stressors
of families living with socioeconomic adversity.
Another potential shortcoming of existing BSIs is the focus
on a singular aspect of sleep health such as sleep duration
(Santos et al., 2019) or parent‐identified bedtime problems (Mindell
et al., 2006). Our findings highlight the multidimensional nature of sleep
health by identifying the variation in sleep duration, timing, regularity,
and quality within our sample of low‐income children. The idea that
sleep quality may be more important to health than sleep duration is
gaining increasing interest among sleep researchers (Bin, 2016).
A Lancet series on child development included a review of the
best strategies to promote child development and concluded that
approaches should focus on early intervention targeted to dis-
advantaged children; inclusion of high quality, direct learning ex-
periences for the child and family; and integration with family
support, health (e.g., dental), nutrition, and educational services
(Engle et al., 2007). Our findings of the low prevalence of tooth
brushing at bedtime (45%) and high prevalence of drinking juice or
milk before bed (70%) and/or when waking at night (57.5%) are
concerning because of the association between nighttime feedings
and early childhood caries (American Academy of Pediatric Den-
tistry, 2017). Considering the higher rates of dental caries among
children who live in socioeconomically disadvantaged communities
(Kim Seow, 2012) and the arguable synergy between sleep, nutri-
tion, and dental hygiene at bedtime, it makes sense to integrate
these topics as part of the bedtime routine, similar to the American
Academy of Pediatrics (2017) recommendations. However, recent
reviews of efficacy trials of children's sleep interventions have
identified possible diluted effects from including too many
behavior‐change messages that consequently stretch caregivers'
capacity to actually use them on a daily basis (Hurley, Yousafzai, &
Lopez‐Boo, 2016).
There is considerable evidence that parental stress, depression,
and anxiety contribute to poor sleep health in early childhood
(Caldwell & Redeker, 2015; Cortesi, Giannotti, Sebastiani, Vagnoni, &
Marioni, 2008; Meltzer & Mindell, 2007). Our findings of associations
between parenting stress and anxiety and inconsistent bedtimes are
| 9
consistent with that literature. However, the lack of an association
between parent depression and other aspects of child sleep conflicts
with these findings. Although the reason for this difference is not
clear, these findings might be explained by the small sample size in
this study. Future study is needed to expand on these results.
4.1 | Study strengths and limitations
The strengths of this study include its community‐engaged approach
and the racial and ethnic diversity of the sample of very young
children that enabled an improved understanding of sleep from the
perspectives of these families. This is especially important, given that
most published sleep research has been limited to older children
from primarily white families with higher incomes and education
(Schwichtenberg et al., 2019). However, because our goal was to
conduct research within the population of interest and was not de-
signed to compare the data from these families with other groups, we
cannot quantify differences from those groups. We used health in-
surance type as a proxy for income; and 90% of our sample were
among people with the lowest incomes in the state based on their
enrollment with Medicaid insurance or having no health insurance,
thus limiting our ability to stratify for income. A measure of socio-
economic status that we did not collect was a measure of food
insecurity that would allow us to examine the impact of hunger on
sleep in early childhood. While food insecurity may be related to the
need to feed children during the night, most of these families parti-
cipated in the Women, Infants, and Children program and therefore,
this may have been less of a concern. The potential role of food
insecurity should be considered in future studies.
The sample size was adequate for the overall aim of the larger
mixed‐methods study designed to obtain foundational data to in-
form the development of an intervention that would be sensitive
to sociocultural factors (Redeker et al., 2018; Sadler et al., in
press). However, the sample size was small and under‐powered for
the correlational analyses that we conducted. Therefore, the
results of the correlational analyses should be interpreted
cautiously. It is possible that we missed correlations that would
have been detected in a larger sample, and it is also possible that
conducting multiple correlations increased the potential for type I
error. Nevertheless, our data provide an important foundation for
future larger‐scale studies.
We included both infants and children (6–36 months) because of
our interest in developing future interventions to begin healthy sleep
habits at an early age. Sleep health recommendations and behavioral
sleep interventions are very similar in this age group, so we did not
expect to see many differences in sleep health characteristics or
bedtime sleep habits between infants and toddlers. However, there
may be differences that could be addressed in a larger study in which
those groups are considered separately.
The use of actigraphy to provide objective data in addition to
self‐report was a strength of this study. However, the results need to
be interpreted cautiously given the limited number of days and
10 | ORDWAY
samples. Despite our concerted efforts to provide reminders and
instruction, we were unable to score 30% of the actigraphs due to
technical failure, nonadherence, or having fewer than 3 nights of
data. Future researchers should carefully consider approaches to
increase adherence to actigraph use with parents of young children
and increase the number of days/nights to at least five for a more
comprehensive assessment of sleep habits.
We selected well known and often used questionnaires for this
study, such as the BISQ, to measure sleep behaviors. However, there
may be other sleep behaviors, including variations in cultural habits
and practices, which are not addressed by this instrument. Future
studies should be conducted to further evaluate the cultural
relevance of sleep measurements.
5 | C O NC LUSION
Our findings and the extant literature suggest the need for further
research and studies of family‐friendly and tailored BSIs that focus
on potentially modifiable behaviors that are relevant to the needs of
families who live with socioeconomic adversity and may also be
culturally diverse. Children from racially and ethnically diverse urban
families had short sleep duration, late and highly variable bedtimes,
and parents had limited knowledge about sleep. Families used
a variety of behaviors that may have both positive and negative
influences on sleep. Future studies are needed to test the sustained
effects of BSIs tailored to the specific needs of these families. These
interventions should address the social, economic, and environmental
contexts in which these families live.
A C K N O W L E D GM E N T S
The authors are grateful to Barbara Caldwell for her advice and
help with research design and to the student research assistants,
community families and advisory committee members who made the
project possible. This study was supported by the National Institutes
of Health (R21NR01690; P20NR014126) Monica Ordway received
support from the National Institute of Nursing Research (K23
5K23NR016277‐03). The project is registered in clinicaltrials.gov
(Clinicaltrials.gov #NCT03045874).
OR CID
Monica R. Ordway http://orcid.org/0000-0002-9765-8962
Nancy S. Redeker http://orcid.org/0000-0001-7817-2708
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How to cite this article: Ordway MR, Sadler LS, Jeon S, et al.
Sleep health in young children living with socioeconomic
adversity. Res Nurs Health. 2020;1–12.
https://doi.org/10.1002/nur.22023