Associations of deep sleep and obstructive sleep apnea with family relationships, life satisfaction, and physical stress experience in children: a caregiver perspective

Abstract

Study Objectives:

Obstructive sleep apnea (OSA) and poor quality of sleep negatively impacts health-related quality of life in adults, but few studies have evaluated the association between sleep disturbance (eg, OSA, inadequate sleep) and health-related quality of life domains (eg, family relations, life satisfaction) in children.

Methods:

Children ages 8–17 years referred to a sleep center for routine polysomnography from April 2022 to August 2022 were approached to participate in the study, and children visiting the department of pediatrics for their wellness visit were recruited for comparisons. Statistical analysis was conducted using R 3.6.0.

Results:

Ninety-nine children were recruited from the sleep clinic, and 23 children were recruited from the primary care clinic. Of these children, 62 were diagnosed with obstructive sleep apnea (31 mild, 12 moderate, 19 severe), and 37 did not meet criteria for a diagnosis. Health-related quality of life domains did not differ across OSA severity levels. Children in general had lower life satisfaction and higher physical stress experience compared to children visiting for their wellness examination (well-child visitors, P = .05 and P = .005, respectively). Children with severe OSA had significantly lower life satisfaction and significantly higher physical stress experience when compared with well-child visitors (P = .008 and P = .009, respectively). Correlation analysis showed that N3 (deep) sleep was positively associated with family relations and life satisfaction, while it was negatively associated with anger.

Conclusions:

Based on caregiver response, N3 sleep is positively associated with family relations and life satisfaction and negatively associated with anger. Severe OSA is associated with lower life satisfaction and higher physical stress experience.

Citation:

Bhushan B, Zee PC, Grandner MA, et al. Associations of deep sleep and obstructive sleep apnea with family relationships, life satisfaction, and physical stress experience in children: a caregiver perspective. J Clin Sleep Med. 2023;19(12):2087–2095.

BRIEF SUMMARY

Current Knowledge/Study Rationale: The study was conducted to evaluate the relationship between sleep disturbances and health-related quality of life in children undergoing routine polysomnography and children visiting for their routine wellness visits at a tertiary care medical center.

Study Impact: Knowledge of associations between obstructive sleep apnea, poor sleep and specific HR-QoL domains will contribute to the most appropriate and effective interventions in children to improve their HR-QoL.

INTRODUCTION

Sleep quality is associated with physical and mental health and overall quality of life (QoL). Sleep-disordered breathing is a common medical condition derived from upper airway obstruction and presents as a spectrum of disorders ranging from snoring to obstructive sleep apnea (OSA). OSA is linked with enlarged tonsils and adenoids, obesity, daytime sleepiness, and elevated cardiometabolic health risks.^1–4 Furthermore, interrupted, insufficient, or poor-quality sleep among children is associated with medical, neurocognitive, and behavioral consequences, such as cardiovascular sequelae, aggression, impulsivity, hyperactivity, mood instability, social withdrawal, and poor school performance,^3,5–9 and therefore exerts impacts on health-related quality of life (HRQoL).^10–12

OSA and sleep quality domains (eg, sleep duration, arousals, deep sleep, and rapid eye movement sleep) have been reported to affect children’s HRQoL in domains related to pain, behavior, and physical health, using both sleep-specific and general questionnaires.^{10,11,13–15} Prior studies have reported the overall association between OSA, specific sleep variables, and sleep-related HRQoL domains.^4,13–19 Scant data are available on HRQoL domains selected in this study, ie, family relations, life satisfaction, physical stress experience, anger, and pain behavior. Most previous studies were focused on children with chronic disease,^10,13,15,20 lacked objective measurement of sleep,²¹ or used different age ranges than ours.^6,22,23 Few studies have explored interdomain relationships.

In this study, we sought to explore associations among OSA severity, sleep quality domains, and psychosocial and physical stress domains in children. We hypothesize that OSA and poor quality of sleep is associated with lower HRQoL and that problems with various HRQoL domains are related to each other.

METHODS

Ethical approval

The study was approved by the Institutional Review Board of Ann & Robert H. Lurie Children’s Hospital of Chicago. Written informed consent was obtained from the participants prior to administrating the questionnaire.

Study population

Patients ages 8–17 years seen at the Department of Sleep Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago for an overnight polysomnography from April to August 2022 were approached to participate in the study. Exclusion criteria included genetic or complex medical history like cardiac concern, organ failure, compromised immune system (n = 6), prior interventions for the treatment of OSA (surgical or the use of positive pressure airway support, n = 7), craniofacial abnormalities (n = 2), or age younger than 8 or older than 17 years (n = 9). Caregivers of patients who met inclusion criteria and consented to participate in the study completed the Patient-Reported Outcome Measure Information System (PROMIS) questionnaire with five HRQoL domains (family relations, life satisfaction, physical stress experience, anger, and pain behavior; see questionnaire in supplemental material) that was administered at the night of polysomnography. Well-child visitors were recruited from the Department of Pediatrics during their routine child health exam visits. The same exclusion criteria were applied to the well-child visitor group in addition to excluding patients with sleep-related symptoms. Polysomnography was not performed for the well-child visitors due to lack of clinical justification for the test. The electronic medical charts were reviewed for demographic data, body mass index (BMI), and polysomnography results (where applicable).

Health-related quality of life assessment

HRQoL was assessed using the PROMIS questionnaire version 2.0. This is a validated tool for the evaluation of patient-reported outcomes in multiple, universal domains by patients ages 8–17 years old and their proxy caregivers (http://www.healthmeasures.net). This type of testing allows an efficient and accurate measure of the domains of interest using only a limited number of questions.^24,25 Using the PROMIS questionnaire, caregivers of patients were asked to complete a questionnaire comprised of 37 questions grouped into five HRQoL domains (family relations, life satisfaction, physical stress experience, anger, and pain behavior). Caregivers were asked to rate the following statements by frequency based on observations of their child in the previous 7 days (physical stress experience, anger, and pain behavior) to 4 weeks (family relations and life satisfaction domains). T-scores were calculated for PROMIS measures where high scores indicate more of the concept measured. In the T-score metric, 50 represents the mean of the relevant population, and 10 represents the standard deviation of the population. Scores 0.5–1.0 standard deviations away from the mean reflected mild symptoms or impairment; scores 2 standard deviations away or more meant severe symptoms or impairment. (https://www.healthmeasures.net/score-and-interpret/interpret-scores/promis).

Polysomnography

Standard overnight polysomnography (Easy 3 version 3.9.34; Cadwell, Kennewick, WA) was performed, using techniques previously reported by our group.^2,16,26 Occurrence of apneas and hypopneas were identified and scored according to accepted American Academy of Sleep Medicine (AASM) pediatric criteria as defined in The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, first edition (2007). Polysomnography was interpreted by a pediatric sleep medicine specialist. An obstructive apnea event was defined as > 90% fall in airflow for 90% or more of the entire respiratory event compared with the pre-event baseline for at least 2 missed breaths or the duration of 2 breaths as determined by baseline breathing pattern. The event was associated with continued increased respiratory effort throughout the entire period of decreased airflow. Apneas were measured from the end of the last normal breath to the beginning of the first breath that achieves the pre-event baseline inspiratory excursion. Hypopneas were defined as discrete respiratory events where there was 30% or greater fall in airflow. Events lasted at least 2 missed breaths or the equivalent duration of 2 missed breaths as determined by baseline breathing pattern. Additionally, hypopneas were scored when these criteria were associated with an arousal, awakening, or greater than or equal to 3% oxygen desaturation. Sleep stages (wake, N1, N2, N3, non-rapid eye movement, and rapid eye movement) and arousals were scored in 30-second sequential epochs commenced at the start of the study. Each epoch was assigned a sleep stage. If two or more stages coexisted during a single epoch, it was assigned with the stage comprising the greatest portion of the epoch. In accordance with standard guidelines for interpretation of disease severity in children, OSA was classified by the apnea–hypopnea index (AHI): mild OSA, AHI 1–4.9 events/h of sleep, moderate OSA, AHI 5–9.99 events/h of sleep, and severe OSA, AHI ≥ 10 events/h of sleep. No OSA was defined as AHI < 1 event/h of sleep.^3,27

Statistical analysis

Descriptive analysis was performed with median and interquartile range based on patient OSA status (no OSA, mild OSA, moderate OSA, severe OSA, and well-child visitors). The Kruskal–Wallis test was used for continuous variables, and the chi-square test or the Fisher exact test were used for categorical variables. The well-child group only provided HRQOL data, so they were not included in the analysis that assessed sleep stage in relation to HRQOL. The T scores for each PROMIS domain (family relations, life satisfaction, physical stress experience, anger, and pain behavior) were calculated by using the guidelines provided on the health measures web page (https://www.healthmeasures.net/score-and-interpret/interpret-scores/promis). HRQoL domains were compared among children with different levels of severity of OSA by using the Kruskal–Wallis tests. Multiple tests were conducted to determine the univariable association between PROMIS domains and other variables of interest. Continuous variables were evaluated with Spearman correlation coefficients, and categorical variables were evaluated with the Wilcoxon rank-sum or Kruskal–Wallis tests. The associations found significant with a two-sided type 1 error rate of 0.15 were analyzed using multiple regression models. Interdomain relationships were assessed using Spearman correlation coefficients and represented in graphs with different colors. The positive coefficients indicated positive relationships, and the negative coefficients indicated negative relationships between domains. Multiple linear regression models included predictors deemed significant in univariable associations (α = 0.15) and considered inclusion of higher order terms. Unless mentioned otherwise, the significance level was two-sided and set at P < .05.

RESULTS

A total of 122 patients were included in the final analysis. There were 62 (50.8%) patients with OSA, 37 (30.3%) patients with no OSA, and 23 (18.9%) patients from the Department of Pediatrics who served as the well-child visitor group. The patients were further categorized by OSA severity as follows: 31 (25.4%) mild OSA, 12 (9.8%) moderate OSA, and 19 (15.6%) severe OSA. Patient demographics are listed in Table 1 by the degree of OSA severity. Sex and BMI percentile were significantly different between the groups (P = .01 and P = .05, respectively). Polysomnography variables are described in Table 2; as expected, the AHI, average oxygen saturation, and number of arousals/h were significantly higher in patients with severe OSA compared to patients with mild or moderate OSA (P < .0001).

Table 1.

Demographic variables of patients undergoing routine polysomnography and control participants.

	Mild OSA (n = 31)	Moderate OSA (n = 12)	Severe OSA (n = 19)	No OSA (n = 37)	Controls (n = 23)	P with Controls	P without Controls
Age (years)	8.0 [6.0, 11.5]	8.5 [6.7, 15.0]	9.0 [7.0, 12.5]	10.0 [7.0, 13.0]	9.0 [6.0, 11.0]	.75	.71
Sex
Female	16 (51.6)	0 (0.0)	9 (47.4)	19 (51.4)	8 (34.8)	.02	.01
Male	15 (48.4)	12 (100.0)	10 (52.6)	18 (48.6)	15 (65.2)
Ethnicity
Hispanic/Latino	12 (38.7)	2 (16.7)	10 (52.6)	8 (21.6)	10 (43.5)	.08	.06
Non-Hispanic/Latino	19 (61.3)	10 (83.3)	9 (47.4)	29 (78.4)	13 (56.5)
BMI percentile	97.6 [78.2, 99.0]	72.6 [53.8, 87.5]	98.5 [80.7, 99.4]	90.1 [56.5, 97.5]	73.80 [35.5, 85.2]	.003	.05

Data are presented as median [interquartile range] or n (%) as applicable. BMI = body mass index, OSA = obstructive sleep apnea.

Table 2.

Polysomnography variables among patients undergoing routine sleep study.

Variables	Mild OSA (n = 31)	Moderate OSA (n = 12)	Severe OSA (n = 19)	No OSA (n = 37)	P
AHI (events/h)	1.90 [1.3, 3.5]	8.4 [6.20 8.6]	18.8 [13.5, 35.8]	0.4 [0.2, 0.7]	<.001
TST (min)	402.0 [372.5, 421.7]	388.0 [319.0, 416.2]	370.0 [356.7, 393.2]	408.0 [366.0, 432.0]	.09
N3 (%)	27.0 [23.5, 35.0]	29.0 [24.0, 34.2]	30.0 [25.5, 32.0]	28.0 [22.0, 34.0]	.93
REM (%)	22.0 [17.0, 24.0]	20.5 [16.0, 24.5]	16.0 [13.5, 20.0]	19.0 [17.0, 23.0]	.06
Sleep efficiency (%)	87.5 [83.2, 93.5]	86.5 [81.0, 93.2]	83.0 [77.5, 89.0]	91.0 [81.0, 96.0]	.21
Avg. SpO2 (%)	98.0 [97.0, 98.0]	97.0 [95.0, 98.0]	96.0 [94.5, 97.0]	98.0 [97.0, 98.0]	<.001
Avg. ECO2 (mmHg)	41.6 [38.7, 43.1]	41.5 [37.0, 43.4]	40.8 [39.3, 44.3]	42.1 [38.9, 44.1]	.93
WASO (min)	33.0 [10.50, 40.7]	40.0 [22.1, 70.7]	47.0 [19.7, 82.0]	22.0 [16.5, 51.0]	.23
Arousals (events/h)	62.0 [55.0, 104.0]	104.5 [80.7, 138.0]	123.5 [87.5, 172.7]	69.0 [55.0, 92.0]	<.001

Data are presented as median [interquartile range]. AHI = apnea-hypopnea index, OSA = obstructive sleep apnea, REM = rapid eye movement, TST = total sleep time, WASO = wake after sleep onset.

Correlation between HRQoL domains and variables of interest

HRQoL domains of interest were analyzed to determine an association with the presence and severity of OSA. (Table 3). Patients referred to the Department of Sleep Medicine for polysomnography had higher physical stress experience and lower life satisfaction as compared to well-child visitors (P = .005 and P = .05, respectively). Correlation analysis (Table 4) demonstrated that age was negatively correlated with family relations (r = −.25, P < .001) and life satisfaction (r = −.27, P < .001). N3 (deep sleep) was positively correlated with both family relations and life satisfaction (r = .28, P = .006 and r = .29, P = .003, respectively) and negatively correlated with anger (r = −.16, P = .05). BMI percentile was negatively correlated with family relations (r = −.2, P = .03). Arousal/h was positively correlated with physical stress experience (r = .11, P = .03). Female sex was correlated with physical stress experience (P = .005), while ethnicity was associated with anger (P = .02). No correlations between AHI, a measure of OSA severity, or rapid eye movement sleep were observed with any HRQoL domain.

Table 3.

T-scores of HRQoL domains included in the study.

HRQoL Domains	Mild OSA (n = 31)	Moderate OSA (n = 12)	Severe OSA (n = 19)	No OSA (n = 37)	Controls (n = 23)	P with Controls	P without Controls
Family relations	63.10 [53.1, 63.1]	56.9 [48.6, 63.1]	57.6 [48.3, 63.1]	62.9 [49.8, 63.1]	63.1 [55.4, 63.1]	.37	.42
Life satisfaction	61.5 [47.7, 61.5]	50.3 [41.9, 56.1]	47.7 [39.6, 52.5]	50.2 [43.7, 61.5]	61.5 [48.0, 61.5]	.05	.13
Physical stress experience	58.1 [53.8, 66.4]	52.1 [41.6, 58.4]	59.9 [49.3, 66.1]	58.6 [49.7, 65.3]	49.0 [41.6, 55.0]	.005	.34
Anger	47.6 [38.9, 53.1]	56.8 [47.6, 69.1]	50.7 [40.4, 56.0]	53.1 [42.4, 59.9]	40.4 [34.2, 52.8]	.08	.21
Pain behavior	42.3 [30.2, 50.5]	37.9 [19.3, 50.2]	42.7 [24.7, 50.4]	41.6 [21.2, 47.5]	40.0 [17.5, 46.3]	.69	.93

Data are presented as median [interquartile range] of the T scores. HRQoL = health-related quality of life, OSA = obstructive sleep apnea.

Table 4.

Correlation analysis between HRQoL domains and variables of interest.

	Family Relation	P	Life Satisfaction	P	Physical Stress Experience	P	Anger	P	Pain Behavior	P
Categorical variables of interest
Sex
Female	63.1 [31.9, 63.1]	0.92	53.9 [27.4, 61.5]	.81	61.2 [41.6, 78.7]	.005	50.7 [29.0, 84.3]	.32	43.1 [16.4, 71.9]	.38
Male	63.1 [23.1, 63.1]		53.3 [28.6, 61.5]		53.5 [41.6, 76.0]		48.6 [29.0, 84.3]		41.6 [16.4, 64.3]
Ethnicity
Hispanic/Latino	63.1 [24.8, 63.1]	0.36	61.5 [36.6, 61.5]	.07	52.7 [41.6, 76.0]	.06	45.2 [29.0, 67.2]	.02	37.8 [16.4, 59.1]	.22
Non-Hispanic/Latino	63.1 [23.1, 63.1]		50.2 [27.4, 61.5]		58.2 [41.6, 78.7]		52.8 [29.0, 84.3]		42.5 [16.4, 71.9]
Continuous variables of interest
Age (years)	–0.25	<0.001	–0.27	<.001	0.19	.07	0.08	.12	0.11	.46
TST (min)	–0.04	0.5	–0.04	.96	–0.02	.65	–0.1	.35	0.05	.81
AHI (events/h)	–0.01	0.8	–0.03	.50	0.06	.23	0.04	.36	0.12	.66
BMI percentile	–0.2	0.03	–0.05	.15	0.18	.21	–0.01	.51	0.1	.98
N3 (%)	0.28	0.006	0.29	.003	–0.06	.46	–0.16	.05	–0.02	.94
REM (%)	–0.08	0.28	–0.03	.68	–0.03	.95	0.03	.52	–0.09	.63
Arousals (events/h)	0	0.8	–0.07	.58	–0.11	.03	0.07	.61	0.02	.54

Values are presented as Spearman correlation and median [interquartile range]. P values from Spearman correlation (continuous variables) and Kruskal–Wallis test (categorical variables). Bold P values indicate statistically significant associations (alpha = 0.05). AHI = apnea-hypopnea index, BMI = body mass index, HRQOL = health-related quality of life, REM = rapid eye movement, TST = total sleep time.

Comparison of OSA severity and HRQoL

There were no significant differences in any HRQoL domains among children with any severity of OSA among themselves and as compared to well-child visitors. Children with severe OSA had significantly lower life satisfaction as compared to well-child visitors (P = .008, Figure 1). Children with severe OSA had significantly higher physical stress experience as compared to well-child visitors (P = .009).

Figure 1. Comparison of HRQoL domains between controls and children with severe OSA and no OSA.

The figure shows the comparisons of HRQoL between controls and children with no OSA and severe OSA. Significant P values are displayed on the graph. Other groups had no significant difference between each other. HRQOL = health-related quality of life, OSA = obstructive sleep apnea.

Multivariate regression analysis

Multiple regression analysis suggested that age was strongly negatively associated to family relations (r = −.84, P = .02) and life satisfaction (r = −.87 P = .01) when controlling for sex and ethnicity. Male sex was found to be negatively associated with physical stress experience (P = .008). BMI and N3 were not associated with PROMIS HRQoL domains after controlling for sex and ethnicity. (Table 5).

Table 5.

Regression models showing the effect of some variables while controlling for others.

Variable	Family Relation	P	Life Satisfaction	P	Physical Stress Experience	P
Sex	–	–	–	–	–	–
Female	–	–	–	–	REF	–
Male	–	–	–	–	–5.4	.008
Ethnicity	–	–	–	–	–	–
Hispanic	–	–	–3.38	.10	3.5	.09
Non-Hispanic	–	–	REF	–	REF	–
Age (years)	–0.84	.02	–0.87	.01	–	–
TST (hours)	–	–	–	–	–	–
AHI (events/h)	–	–	–	–	–	–
BMI	–0.05	.11	–	–	–	–
N3 (%)	0.09	.46	0.13	.32	–	–
REM (%)	–	–	–	–	–	–
Arousals	–	–	–	–	–0.03	.15

Values are presented as estimate and P values. Family relations intercept = 65.28 (P < .001). Life satisfaction intercept = 58.2 (P < .001). Physical stress experience = 60.9 (P < .001). AHI = apnea-hypopnea index, BMI = body mass index, REM = rapid eye movement, TST = total sleep time.

HRQoL interdomains relations

Figure 2 presents the relations among various HRQoL domains of interest. A strong positive correlation was seen between family relations and life satisfaction, while anger was strongly negatively associated with family relations and life satisfaction. A weak positive association was noted between physical stress experience, anger, and pain behavior.

Figure 2. Correlation plot between HRQoL domains included in this study.

The figure shows the correlation between various HRQoL domains that were included in the study. White represents no correlation, red represents negative correlation, and blue represents positive association. The size of the circle represents the strength of the correlation. Small circles represent less correlation and large circles represent large correlation. HRQOL = health-related quality of life.

DISCUSSION

Sleep disturbances like OSA and poor quality of sleep (eg, inadequate sleep duration) are common in children. Unlike adults who may demonstrate daytime somnolence, children often present with cognitive and behavioral symptoms. These may include “externalizing” behaviors, like aggression, impulsivity, hyperactivity, and conduct problems, as well as “internalizing” behaviors like mood instability, low frustration tolerance, social withdrawal, and increased somatic complaints.^3,5,7–9 Hence, the potential effect of sleep disturbances on the child’s QoL exceeds the expected effect from a rather common, generally treatable condition.^7,9–11

Findings from our current study show that patients referred to the sleep medicine clinic for routine polysomnography had higher physical stress experiences and lower life satisfaction than well-child visitors as reported by their caregiver. Children with severe OSA had lower life satisfaction and high physical stress experience when compared with well-child visitors. N3 and BMI were found to be associated with these domains in univariate analysis but did not reach statistical significance in a multivariable analysis. Interestingly, AHI was not associated with any PROMIS domains of interest. Several HRQoL domains demonstrated strong interdomain relations, mostly life satisfaction with family relations and anger.

HRQoL provides a multidimensional view of the holistic impact of an illness on patient well-being and evaluates actionable outcomes for providers. Studies in children with chronic diseases demonstrated psychosocial functioning to be associated with deteriorated HRQoL.²⁸ Former OSA-related HRQoL studies identified a correlation between OSA and poor QoL specifically in pain and physical functioning domains.^10–12,14 However, despite the known effect of OSA on the child and caregiver QoL, the psychosocial effect of pediatric OSA is underrepresented in the literature.

Pooled data from Child Health Questionnaires on the effect of children with OSA compared to healthy children identified significantly higher scores in various domains, including physical functioning, bodily pain, behavior, general health perceptions, parental impact-emotional, parental impact-time, and family activities.¹⁰ These findings were redemonstrated when HRQoL questionnaires of children with OSA were compared to children with juvenile rheumatoid arthritis^10,13,15; Interestingly, children with OSA scored worse than children with juvenile rheumatoid arthritis on the parental emotional domain and family activities domain. Baldassari et al¹⁰ conducted a meta-analysis to assess the QoL in children with OSA. Authors suggested that the high impact of OSA on the child and caregiver’s QoL may be attributed to the significant effect of OSA on the child’s behavior and caregiver anxiety and frustration.

Blackwell et al²⁰ used the PROMIS Global Health questionnaire for caregivers of 1,253 children to evaluate the effect of chronic diseases on life satisfaction. Authors found that although children with chronic diseases had worse general health scores, their life satisfaction scores were comparable to children without chronic illnesses. Indeed, the effect of sleep disturbance in children stretches over the behavioral component and involves both short- and long-term physical, emotional, and social outcomes.^6,22,29,30

In a study by Thumann et al,³¹ authors investigated cross-sectional and longitudinal associations of psychosocial well-being with sleep duration and sleep disturbances. Their HRQoL domains included emotional well-being, self-esteem, and social relationships. Their results suggest that increases in well-being are associated with improvements in both sleep duration and sleep disturbances. However, there was only weak evidence that higher psychosocial well-being at baseline was associated with better sleep 4 years later. In another study, Blackwell et al²¹ assessed the association between children’s (ages 5–9 years) sleep and life satisfaction. Authors reported a positive correlation between a good night’s sleep and higher life satisfaction scores. In their study, the sleep quality was evaluated using the four-item PROMIS Parent-Proxy Sleep Disturbance Short Form 4a, which evaluates sleep onset, continuity, and satisfaction in the past 7 days on a 5-point Likert scale anchored by never and always.

Most previous studies conducted on sleep and HRQoL in children measured the sleep in a self-reported manner (using questionnaire or diary)³² and did not report if any of their participants had OSA.³¹ Moreover, the ages of their participants was different than our study.^20,21,31,32 For example, Shin et al³² conducted the study on undergraduate students (mean age 20.6 ± 1.06 years), administered the Pittsburgh Sleep Quality Index to measure the quality of sleep during past 1 month, and measured the life satisfaction with a single item (“In general, how satisfied are you with your life?”) on a 7-point scale. Ness et al³³ conducted their study on college students by self-reported measurements of the quality of sleep (by using a self-created questionnaire).

Furthermore, in our study, children referred to polysomnography were found to have higher scores in the physical stress experience domain. Although we cannot establish the direction of this association, this finding is consistent with previous studies that found stress to be a potential mediator of sleep quality^21,30 and sleep disturbances to be associated with hypertension in adolescents.¹

Numerous studies evaluated the correlation between HRQoL and family functioning in children with chronic conditions. A meta-analysis by Leeman et al³⁴ demonstrated a significant correlation between family functioning and children’s behaviors, social competence, and HRQoL, dimensions that are affected by sleep disturbances. Ailshire et al³⁵ found that family conflicts are associated with troubled sleep in adults. Other studies indicated the family’s role in supporting children with a chronic disease and the association between HRQoL, health outcomes, and family relations.²⁸ Gordon et al³⁶ conducted a systematic review evaluating the association between sleep and social relationships in healthy populations. The authors found a bidirectional correlation between self-reported and objective measures of sleep quality in children and family relationships.³⁶

In our correlation analysis, AHI, a common measurement for OSA severity and a significant parameter in the decision-making algorithm for treating OSA, was not associated with any of the domains of interest. However, children with severe OSA had comparable life satisfaction to children with no OSA but had significantly lower life satisfaction as compared to well-child visitors. This could possibly be due to higher number of arousals, decreased sleep continuity, and interrupted deep sleep due to frequent apneas.

We also identified interdomain relationships among family relations, life satisfaction, and anger. Bidirectional causation may be proposed between these domains in patients with sleep disturbances. This relationship may represent potential targets for psychosocial interventions and further research.

A few limitations to our study should be considered when interpreting these results. First, our data regarding life satisfaction, family relations, and stress came from the caregivers, rather than the patients. While the questionnaire has been validated for parent-proxy responders, one should not expect a close correlation between the child’s and his caregiver’s responses, as children conceptualize health in a different way than adults. In addition, a recall bias should be considered as caregivers were asked to recall behavior and signs that occurred during past 1–4 weeks prior to administering the questionnaire. Second, our data included a relatively small cohort of patients, which may affect the power of our study to detect differences between the groups. Third, the well-child visitor group was not evaluated for their sleep disturbance by using polysomnography, as the patients had no clinical indications for evaluation. Had this group been evaluated, it is possible that some variability in sleep quality and hence deteriorated HRQoL would have been detected. In addition, caregivers were not evaluated for medical literacy and their mental health, which might affect some of the HRQoL domains of interest.²¹ Lastly, some limitations result from the use of questionnaires rather than collecting objective data on the physical experience domain.

Nevertheless, our study demonstrates that deep sleep is correlated with better family relations and life satisfaction, and severe OSA is correlated with lower life satisfaction and worse physical stress experience. These findings may suggest future longitudinal investigations to examine sleep and HRQoL with medical, surgical, and psychosocial interventions for OSA.

CONCLUSIONS

The current study demonstrates that children with sleep disturbances have lower life satisfaction and worse physical stress experience. Severe OSA was associated with lower life satisfaction and higher physical stress experience. An interesting association between life satisfaction, family relations, anger, and age were also noted.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. The current work was performed at the Ann & Robert H Lurie Children’s Hospital of Chicago, Illinois. The authors report no conflicts of interest.

ABBREVIATIONS

AHI

apnea-hypopnea index

BMI

body mass index

HRQoL

health-related quality of life

OSA

obstructive sleep apnea

PROMIS

Patient-Reported Outcome Measure Information System

QoL

quality of life