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. Author manuscript; available in PMC: 2021 Mar 1.
Published in final edited form as: J Pediatr Nurs. 2020 Jan 13;51:85–91. doi: 10.1016/j.pedn.2019.12.015

Sleep Patterns, Problems and Ecology among Toddlers in Families with a Child Protective Services Maltreatment Referral

Jonika B Hash a, Monica L Oxford b, Teresa M Ward c, Charles B Fleming d, Susan J Spieker b
PMCID: PMC7276301  NIHMSID: NIHMS1549746  PMID: 31945664

Abstract

Purpose:

To describe sleep patterns, problems, and ecology among toddlers (13 to 36 months) from families referred to Child Protective Services (CPS) for maltreatment and to compare sleep duration among a subgroup (24- to 36-month-olds) to previously published population-based data.

Design and methods:

A secondary analysis of a larger longitudinal study was conducted. Participants included 113 parent-toddler dyads recruited out of CPS offices based on having a recent maltreatment referral. Parents reported about their toddler’s sleep at two time points (approximately six months apart).

Results:

At the earlier and later time points, respectively, mean sleep duration was 11.03 and 10.90 h (nighttime), 1.36 and 1.36 h (daytime), and 12.47 and 12.28 h (total 24-h). Of the toddlers, 24% and 17% had two or more nighttime awakenings, 34% and 33% had at least a somewhat hard time falling asleep, and 25% and 26% had difficulty sleeping alone. Mean bedtimes were 8:50pm and 8:58pm. Nighttime sleeping arrangement/location, nap arrangement/location, and method of falling asleep at night varied. Compared to the population-based data, nighttime sleep duration was 43 minutes longer and nap duration was 46 minutes shorter in the CPS sample.

Conclusions:

Symptoms of behavioral sleep problems were common in this sample of toddlers from families referred to CPS for maltreatment. Distribution of sleep, but not total 24-hour sleep, differed significantly between the CPS sample and the population-based data.

Practice Implications:

Nurses caring for toddlers from families involved with CPS can play an integral role promoting sleep health and addressing behavioral sleep problems.

Keywords: sleep, toddlers, Child Protective Services, child maltreatment

Sleep patterns play an important role in early childhood mental health and development. For optimal functioning, it is recommended that toddlers regularly obtain 11 to 14 h of sleep per day, including naps (Hirshkowitz et al., 2015; Paruthi et al., 2016). Obtaining < 10 h of sleep in toddlerhood is associated with an increased risk for later development of behavioral problems (Sivertsen et al., 2015). Missing a usual nap can also negatively impact self-regulation in toddlers (Berger, Miller, Seifer, Cares, & LeBourgeois, 2012; Miller, Seifer, Crossin, & Lebourgeois, 2014).

However, approximately 25% - 30% of toddlers experience sleep problems (Mindell & Owens, 2015). Behavioral sleep problems (e.g., bedtime struggles, difficulty falling asleep independently, frequent and/or prolonged nighttime awakenings), as opposed to physiological sleep problems (e.g., sleep disordered breathing), are the most common types of sleep problems in toddlers (Honaker & Meltzer, 2016; Mindell, Leichman, Puzino, Walters, & Bhullar, 2015). Behavioral sleep problems are associated with self-regulation difficulties (Ward, Gay, Alkon, Anders, & Lee, 2008; Winsper & Wolke, 2014) and can result in insufficient (Plancoulaine et al., 2018) and/or poor-quality sleep. Children’s sleep problems can also negatively impact the family and are associated with poorer parental sleep (Meltzer & Mindell, 2007; Yuwen, Lewis, Walker, & Ward, 2017), greater parental daytime sleepiness (Boergers, Hart, Owens, Streisand, & Spirito, 2007) and poorer parental general health (Martin, Hiscock, Hardy, Davey, & Wake, 2007).

Sleep ecology refers to the contextual factors that shape the amount and/or quality of sleep that children obtain including bedtimes, bedtime routines, parenting practices, and sleeping arrangements (Mindell, Sadeh, Kohyama, & How, 2010; Sadeh, Mindell, Luedtke, & Weigand, 2009; Teng, Bartle, Sadeh, & Mindell, 2012). In young children, longer and/or better-quality sleep is associated with earlier bedtimes (Mindell, Meltzer, Carskadon, & Chervin, 2009) and consistent bedtime routines (Mindell, Li, Sadeh, Kwon, & Goh, 2015). Parenting practices and sleeping arrangements that promote self-soothing and falling asleep independently are also associated with longer and better-quality sleep in young children (Mindell et al., 2010; Touchette et al., 2005).

Maltreatment, including abuse and neglect, is an adversity and toxic stressor (Shonkoff, Boyce, & McEwen, 2009) that could be associated with poor sleep in toddlers. Little is known about sleep among toddlers who have experienced maltreatment. Studies describing and comparing sleep patterns, problems, and ecology among toddlers with and without maltreatment experiences are needed to gain a better understanding of sleep in this population. This is important gap in knowledge, as sleep rapidly develops during the first 3 years of life (Galland, Taylor, Elder, & Herbison, 2012; Iglowstein, Jenni, Molinari, & Largo, 2003), and maltreatment could negatively impact sleep during this critical period.

Prior work among older children (school-age and early adolescence) has shown that those with maltreatment experiences have poorer quality sleep than those without maltreatment experiences (Glod, Teicher, Hartman, & Harakal, 1997; Sadeh et al., 1995). More severe maltreatment has also been associated with greater sleep disturbance among adolescents (McPhie, Weiss, & Wekerle, 2014). Prior work among children ages 3 to 7 years has shown that those in foster care take longer to fall asleep at night compared to those based in the community (Tininenko, Fisher, Bruce, & Pears, 2010) and that experiencing a foster care placement at a younger age is associated with shorter sleep duration (Dubois-Comtois, Cyr, Pennestri, & Godbout, 2016). Among infants and toddlers from families referred to Child Protective Services (CPS) for maltreatment, more adverse experiences have been associated with parent-reported sleep problems (Hash et al., 2019). Findings from the broader trauma literature have additionally indicated that some children, including toddlers, respond to trauma by sleeping more, not less (Klein, Devoe, & Miranda-Julian, 2009; Sadeh, Hen-Gal, & Tikotzky, 2008). It is possible that hypersomnia could function as a coping mechanism in young children experiencing trauma (Klein et al., 2009). Although individual sleep needs vary (Meltzer, 2017), both shorter and longer sleep duration have been associated with more behavior problems in children (James & Hale, 2017; Touchette et al., 2007; Sivertsen et al., 2015). Additional study is needed to better understand sleep patterns, including sleep duration, as well as sleep problems and ecology among toddlers with maltreatment experiences.

This study sought to address these important gaps by describing parent-reported sleep patterns, problems, and ecology among a sample of toddlers (age range 13 to 36 months) from families referred to CPS for maltreatment (denoted as the “CPS sample”) and by comparing sleep duration in this sample to that of previously-published sleep duration data from a population-based sample of toddlers living in the U.S. and Canada (denoted as the “population-based sample”). The specific aims of this study were to: (1) describe sleep patterns (nighttime sleep duration, nap duration, 24-hour sleep duration, daily napping behavior), sleep problems (nighttime awakenings, ease of settling into sleep, difficulty sleeping alone, parental general concerns), and sleep ecology (bedtimes, wake times, bedtime routines, sleeping arrangements and method of falling asleep) among toddlers in the CPS sample; and (2) examine whether sleep duration (nighttime sleep, daytime nap, 24-hour sleep) differed between 24- to 36-month-old toddlers in the CPS sample compared to 24- to 36-month-old toddlers in the population-based sample. Based on prior studies in children who have experienced maltreatment or other trauma (Glod et al., 1997; Klein et al., 2009; Sadeh et al., 2008; Sadeh et al., 1995; Tininenko et al., 2010), we hypothesized that sleep duration in the CPS sample would differ significantly from the population-based sample but did not hypothesize a direction of either more or less.

Methods

Design

A secondary analysis of a larger study of families referred to CPS for maltreatment was conducted. This larger study was a longitudinal, randomized controlled trial testing a parenting intervention among parents and their biological child (baseline child age 10 to 24 months) from families with a recent CPS maltreatment report (see Oxford, Spieker, Lohr, & Fleming, 2016). For this secondary analysis, cross-sectional data in 113 children when they were between the ages 13 to 36 months in this larger study were examined and compared to previously-published cross-sectional data about a population-based sample of 700 U.S.- and Canada-dwelling toddlers (previously published data were from Sadeh and colleagues, 2009).

Participants

The CPS sample.

Participants in the CPS sample included 113 parents and their biological toddler enrolled in the above-mentioned larger study (Oxford, Spieker, Lohr, & Fleming, 2016). Dyads were recruited from five Washington State CPS offices. Inclusion criteria were: (a) a CPS report of alleged maltreatment of a child in the home was recorded at least 2 weeks prior, (b) a biological child in the home was between the ages 10 and 24 months at baseline, (c) the parent was English-speaking and (d) the dyad lived within the study area (Washington State areas of south Skagit, Snohomish, or north King County). A total of 247 dyads were enrolled in the larger study and randomized to either the parenting intervention (n = 124) or a resource and referral control condition (n = 123). All dyads were living together at baseline and none were in a trial return home. The parenting intervention has previously been associated with reduced sleep problems (Hash et al., 2019; Oxford, Fleming, Nelson, Kelly, & Spieker, 2013; Spieker, Oxford, Kelly, Nelson, & Fleming, 2012). Therefore, only dyads assigned to the control condition were included in this secondary analysis. Of the 123 in the control condition, 113 had sleep data on the child. These 113 constituted the final sample for this secondary analysis. The 10 without sleep data were excluded as they were lost to follow-up or were not living with their biological parent when the sleep data were collected. All sleep data were collected at follow-up time points, when children were toddlers between the ages of 13 and 36 months. Human subjects approval was provided by the Washington State Institutional Review Board (IRB). All parents provided written informed consent according to Washington State IRB-approved procedures. Table 1 shows baseline characteristics for the CPS sample.

Table 1.

Baseline Characteristics for the CPS Sample

Characteristic Mean (SD) or n %
Child demographics
 Age, months 16.71 (4.50)
 Gender, female 47 41.6%
 Race
  American Indian/Alaska Native 2 1.8%
  Black/African American 4 3.5%
  White/Caucasian 64 56.6%
  Multiracial 40 35.4%
  Other 3 2.7%
 Hispanic origin 34 30.1%
Parent demographics
 Age 26.96 (6.06)
 Gender, female (mothers) 103 91.2%
 Race
  American Indian/Alaska Native 3 2.7%
  Asian 3 2.7%
  Black/African American 5 4.4%
  White/Caucasian 85 75.2%
  Multiracial 14 12.4%
  Other 3 2.7%
 Hispanic origin 21 18.6%
 Highest level of education
  Less than high school 4 3.5%
  Some or all of high school 67 59.3%
  Some or more college/trade/technical school 42 37.2%
 Obtained high school diploma or GED 83 73.5%
 Employment status
  Full-time 19 16.8%
  Part-time 14 12.4%
  Unemployed/looking 30 26.5%
  Homemaker 30 26.5%
  Student 13 11.5%
  Other (disabled/retired) 7 6.2%
 Marital Status
  Never married 58 51.3%
  Married 34 30.1%
  Separated or divorced 21 18.6%
 Currently living with spouse/partner 57 50.4%
 Receiving food stamps 90 79.6%
 Past 12-month household income, U.S. dollars 24,104.29 (25,601.48)
Allegation type reported for child since birth
 ≥ 1 report of abandonment 1 0.9%
 ≥ 1 report of neglect 90 79.6%
 ≥ 1 report of physical abuse 26 23.0%
 ≥ 1 report of sexual abuse 5 4.4%
Total number of allegations reported for child since birtha
 0 22 19.5%
 1 54 47.8%
 2 19 16.8%
 3 8 7.1%
 4 5 4.4%
 5 4 3.5%
 6 1 0.9%
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Note. N = 113. CPS = Child Protective Services.

a

Cases with 0 allegations indicate that a CPS maltreatment report was made for a sibling of the study child.

The population-based sample.

The population-based sample included 700 U.S.- and Canada-dwelling caregivers and their 24- to 36-month-old toddler from the Sadeh and colleagues (2009) study. Dyads were recruited from a parenting website. Having a CPS referral was not an inclusion criterion in the Sadeh et al. (2009) study. Readers are referred to this study for additional details on participant characteristics. Data from this population-based sample were used as comparisons for data from a subset of same-aged children (toddlers ages 24 to 36 months) in the CPS sample (see Data Analysis section below).

Data Collection Procedures

For the CPS sample, a questionnaire about their toddler’s sleep was administered to the parents by in-home research assistants at approximately 3 months post-baseline (average toddler age 20.68 months, range 13 to 33 months) and again at 9 months post-baseline (average toddler age 27.11 months, range 19 to 36 months). For the population-based sample, parents completed a one-time online questionnaire about their toddler’s sleep (Sadeh et al., 2009).

Measures

Parents in the CPS sample reported about their toddler’s usual sleep over the previous 2 weeks using a questionnaire that was derived from the Brief Infant Sleep Questionnaire (BISQ; Sadeh, 2004). Parents in the population-based sample also reported about their toddler’s usual sleep over the previous 2 weeks using the BISQ (Sadeh, 2004; Sadeh et al., 2009). The BISQ is a valid and reliable tool (Sadeh, 2004) that has been widely used, including among various cultures (Mindell et al., 2010; Mindell, Sadeh, Wiegand, How, & Goh, 2010; Sadeh, Mindell, & Rivera, 2011) and among families with high and low incomes (Tomalski et al., 2013). From the questionnaire administered to the CPS sample, we used five items for sleep patterns, five items for sleep problems, and six items for sleep ecology. The five sleep pattern items were: (a) nighttime sleep duration, (b) nap duration, (c) 24-hour sleep duration, (d) whether toddlers took a daily nap and, (e) if toddlers napped, whether they usually napped at the same time every day. The five sleep problem items were: (a) frequency of nighttime awakenings, (b) needing parental help to fall back to sleep after awakening, (c) ease of falling asleep on own at night, (d) difficulty sleeping alone, and (e) whether parents considered their toddler’s sleep a problem. The six sleep ecology items were: (a) bedtime, (b) waketime, (c) whether toddlers had a usual bedtime routine, (d) nighttime sleeping arrangement/location, (e) nap arrangement/location, and (f) method of falling asleep at night. From the questionnaire administered to the population-based sample, we used three items for sleep patterns: (a) nighttime sleep duration, (b) nap duration, and (c) 24-hour sleep duration (Sadeh et al., 2009).

Data Analysis

Sleep patterns, problems, and ecology in the CPS sample (aim 1).

Descriptive statistics for all of the sleep data including patterns, problems and ecology were computed for both time points in the CPS sample using IBM SPSS Version 19.

Sleep duration patterns in the CPS sample compared to the population-based sample (aim 2).

Two-tailed Welch t’ tests were conducted to examine nighttime sleep duration, nap duration, and total 24-hour sleep duration at the latest time point (9 months post-baseline) among 24- to 36-month-old toddlers in the CPS sample compared to the 24- to 36-month-old toddlers in the population-based sample. We chose to use the latest time point of data about the CPS sample because the largest proportion of children were within the 24- to 36-month-old age range at this time point. We chose to use the Welch t’ test because it did not assume equal variances and because we had unequal sample sizes (Hahs-Vaughn & Lomax, 2012). After obtaining means and standard deviations (which, for the population-based sample, were extracted from the Sadeh and colleagues, 2009, report and, for the CPS sample, were calculated using IBM SPSS Statistics Version 19), we conducted three Welch t’ tests using the formulas given in Hahs-Vaughn and Lomax (2012). To avoid Type I error rate inflation, we applied a Bonferroni correction to adjust the significance level to α = .017 per test.

Exclusion of cases and cases with missing data.

Of the 113 toddlers in the CPS sample who had sleep data for at least one time point, 109 and 102 had sleep data at 3 and 9 months post-baseline, respectively. One child was older than 36 months at 9 months post-baseline and was excluded from analyses of this time point. Some cases in the CPS sample had missing data on some items, which were managed using SPSS default missing data procedures (exclusion of cases on items with missing values). For clarity, we note when cases were excluded due to missing data in the tables below.

Results

Descriptives for Sleep Patterns, Problems, and Ecology in the CPS Sample (Aim 1)

Table 2 shows the descriptives for sleep patterns, problems, and ecology in the CPS sample at 3 months and 9 months post-baseline. Mean nocturnal sleep duration, nap duration, and 24-hour sleep duration were similar at both time points. Of the toddlers, 84% napped daily at 3 months post-baseline and 75% napped daily at 9 months post-baseline. Of the toddlers, 24% had two or more reported nighttime awakenings at 3 months post-baseline and 17% had two or more reported nighttime awakenings at 9 months post-baseline. At both time points, approximately one-third of toddlers were reported to have a somewhat hard or very hard time falling asleep on their own at night, and approximately one-quarter were reported to have difficulty sleeping alone. Of the parents, 23% at both time points considered their toddler to have a small sleep problem and 3 – 4% considered their toddler to have a very serious sleep problem. At both time points, toddlers’ bedtime was just before 9pm and wake time just before 8am. Most toddlers had a usual bedtime routine at both time points (86 – 87%). Toddlers’ sleeping arrangements/locations and methods of falling asleep varied.

Table 2.

Descriptives for Sleep Patterns, Problems, and Ecology in the CPS Sample at 3 and 9 Months Post-Baseline

3 months post-baseline n = 109
 9 months post-baseline n = 101
Sleep parameter M (SD) or n % M (SD) or n %
Sleep patterns
 Nighttime sleep duration (hours) 11.03 (1.25) 10.90 (1.44)
 Nap duration (hours)a 1.36 (0.88) 1.36 (0.99)
 Total 24-hour sleep duration (hours)a 12.47 (1.45) 12.28 (1.67)
 Takes daily nap (% yes) 92 84.4% 76 75.2%
 If naps, takes nap at same time every day (% yes)b 79 86.8% 70 92.1%
Sleep problems
 Frequency of night wakingsc
  0 51 46.8% 62 62.0%
  1 32 29.4% 21 21.0%
  2 16 14.7% 12 12.0%
  3+ 10 9.2% 5 5.0%
 If woke at night, needs help to fall back asleep (% yes)d 39 68.4% 28 75.7%
 Ease of falling asleep on own
  Very easy 42 38.5% 32 31.7%
  Somewhat easy 30 27.5% 36 35.6%
  Somewhat hard 28 25.7% 21 20.8%
  Very hard 9 8.3% 12 11.9%
 Has difficulty sleeping alone (% yes)e 27 25.0% 26 26.3%
 Parent-perceived sleep problemf
  No problem 80 74.1% 74 73.3%
  Small problem 25 23.1% 23 22.8%
  Serious problem 3 2.8% 4 4.0%
Sleep ecology
 Bedtime (hours after noon) 8.84 (1.07) 8.97 (1.14)
 Waketime (hours after noon) 19.87 (1.14) 19.86 (1.28)
 Has a usual bedtime routine (% yes)c 94 86.2% 87 87.0%
 Nighttime sleeping arrangement/locationg
  Crib/bed in separate room 18 25.4% 20 24.7%
  Crib/bed in parent’s room 25 35.2% 21 25.9%
  Crib/bed in sibling’s room 11 15.5% 19 23.5%
  Parent’s/another adult’s bed 12 16.9% 19 23.5%
  Shared bed with sibling in sibling’s room 5 7.0% 1 1.2%
  Playpen/crib in living or other room 0 0.0% 1 1.2%
 Nap arrangement/locationh
  Crib/bed in separate room 18 28.6% 13 18.1%
  Crib/bed in parent’s room 19 30.2% 15 20.8%
  Crib/bed in sibling’s room 9 14.3% 13 18.1%
  Parent’s/another adult’s bed 10 15.9% 13 18.1%
  Shared bed with sibling in parent’s room 1 1.6% 0 0.0%
  Car seat 1 1.6% 1 1.4%
  Daycare 3 4.8% 3 4.2%
  Playpen/crib in living or other room 0 0.0% 2 2.8%
  Couch/floor in living or other room 0 0.0% 11 15.3%
  Anywhere/varies 2 3.2% 1 1.4%
 Method of falling asleepg
  While feeding 8 11.3% 4 4.9%
  Being rocked 4 5.6% 2 2.5%
  In bed alone 35 49.3% 39 48.1%
  In bed near/with parent 20 28.2% 27 33.3%
  Being held 4 5.6% 6 7.4%
  In bed near/with a sibling 0 0.0% 3 3.7%
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Note. CPS = Child Protective Services. % = valid percent.

a

n = 75 at 3 months post-baseline and n = 88 at 9 months post-baseline.

b

n = 91 at 3 months post-baseline and n = 76 at 9 months post-baseline.

c

n = 100 at 9 months post-baseline.

d

n = 57 at 3 months post-baseline and n = 37 at 9 months post-baseline.

e

n = 108 at 3 months post-baseline and n = 99 at 9 months post-baseline.

f

n = 108 at 3 months post-baseline.

g

n = 71 at 3 months post-baseline and n = 81 at 9 months post-baseline.

h

n = 63 at 3 months post-baseline and n = 72 at 9 months post-baseline.

Sleep Duration Patterns in the CPS Sample Compared to the Population-Based Sample (Aim 2)

Table 3 shows sleep duration among 24- to 36-month-olds in the CPS sample compared to 24- to 36-month-olds in the population-based sample. A significant difference was found for nighttime sleep duration (p < .017). On average, nighttime sleep duration was 0.71 h (43 minutes) longer in the CPS sample compared to the population-based sample. Nap duration was also significantly different between the samples (p < .017). On average, nap duration was 0.77 h (46 minutes) shorter in the CPS sample compared to the population-based sample. Total 24-hour sleep duration did not differ significantly between the samples.

Table 3.

Welch t’ Test Results Comparing Sleep Duration Means Between the CPS and Population-Based Samples

Population-based sample n = 700
 CPS sample n = 69
Sleep parameter M (SD) M (SD) t’ df
Nighttime sleep duration 10.00 (1.30) 10.71 (1.50) −3.79 78 *
Nap durationa 1.89 (0.95) 1.12 (0.97) 5.87 68 *
Total 24-hour sleep durationa 11.90 (1.54) 11.82 (1.59) 0.37 68
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Note. CPS = Child Protective Services. Sleep durations are in hours. The population-based sample means and standard deviations are from Sadeh and colleagues (2009).

a

n = 59 for the CPS sample.

*

p < .017 (Bonferroni adjusted alpha level).

Discussion

This study fills an important gap in knowledge about sleep patterns, problems, and ecology among toddlers from families referred to CPS for maltreatment. Key findings showed that nighttime sleep and nap duration significantly differed between toddlers from this sample of families referred to CPS and toddlers from a population-based sample. Compared to the population-based sample, the CPS sample had longer nighttime sleep and shorter daytime sleep, but total 24-hour sleep was similar between the samples. These findings suggest that the distribution of sleep across the 24-hour period, but not total 24-hour sleep itself, differed between the samples. This was surprising. We expected nighttime sleep, daytime sleep, and 24-hour sleep to differ between the samples. We did not anticipate the distribution to differ. These findings could indicate a possible disparity in the napping opportunities available to toddlers from families involved with CPS. Families involved with CPS face high rates of difficult life circumstances including poverty, caregiver depression, and domestic violence (Campbell, Thomas, Cook, & Keenan, 2012). It may be that difficult life circumstances play a role in altering the timing of children’s sleep and sleep schedules, especially naps (Weissbluth, 1995). However, our findings also showed that, overall, the average toddler in the CPS sample obtained the recommended amount of total 24-hour sleep (11 to 14 h per day) for optimal functioning according to the National Sleep Foundation (Hirshkowitz et al., 2015) and the American Academy of Sleep Medicine (Paruthi et al., 2016). Further research is needed to determine whether obtaining less sleep during the day and more at night, but adequate amounts overall within a 24-hour period, has important implications for development and daytime functioning among toddlers from families referred to CPS. Prior literature has shown differing 24-hour distributions of sleep in other samples of children (e.g., Crosby, LeBourgeois, & Harsh, 2005; Thorpe et al., 2015; Ward, Gay, Anders, Alkon, & Lee, 2008), but our findings extend this literature and indicate a need for further research into the 24-hour distribution of sleep among toddlers from families referred to CPS.

Findings from this study also showed that symptoms of behavioral sleep problems were common among this sample of toddlers from families referred to CPS for maltreatment. Symptoms including frequent nighttime awakenings, needing parental assistance to fall asleep, and difficulty sleeping alone were evidenced among toddlers in this study. Many parents also expressed concern that their toddler had a sleep problem at a rate similar to that of prior studies (Sadeh et al., 2009). These findings have important clinical and potential policy implications. Recognizing and screening for behavioral sleep problems is an important component in the nursing care of families with young children and in the early establishment of healthy sleep practices. Public health and community nurses can play a key role in identifying behavioral sleep problems among young children from families referred to CPS for maltreatment. Public health and community nurses can also play a key role in understanding the unique needs of families involved with CPS and in developing strategies to promote sleep health for both the child and the family in ways that are tailored to meet each family’s needs. Future nursing research integrating an understanding of trauma and toxic stress (Cox et al., 2018; Delaney, Burke, DeSocio, Greenberg, & Sharp, 2018; Gross, Beeber, DeSocio, & Brennaman, 2016) can also inform policies promoting sleep health among toddlers who have experienced maltreatment.

There are some limitations of this study that deserve comment. First, how sleep duration was measured differed slightly between the CPS and population-based samples, and this may have had a small impact on the comparability of estimates. The questionnaire given to the CPS sample asked parents to report nap duration only if their toddler took a nap every day whereas, in the population-based sample, no such direction was given (see Sadeh and colleagues, 2009). If children napped on some but not all days of the week, the measurement method used for the CPS sample may have underestimated daytime and total 24-hour sleep duration, as averaged over a 2-week period, relative to the population-based sample. A second limitation is that data from the two samples were collected for different studies. This limited our ability to examine potential factors accounting for differences in sleep duration between the two samples (e.g., factors such as living arrangements or socioeconomic status). A third limitation is that sleep may function differently based on different family experiences including maltreatment and trauma experiences, as well as support services received by families. Our sample included toddlers from families referred to CPS for maltreatment. No children were in out-of-home care or a trial return home at baseline. We did not differentiate between types of maltreatment, whether the maltreatment referral was substantiated, whether the study child was the alleged maltreatment victim or a sibling of the alleged victim, or what support services families received. A fourth limitation is that these data were collected by parent report. Future studies should consider including objective measures of sleep, such as actigraphy, to address this limitation. Finally, information about CPS involvement in the population-based sample was not collected by Sadeh and colleagues (2009). It is possible that some toddlers in the population-based sample may have been from families involved with CPS for maltreatment.

Despite these limitations, this study addresses an important gap in knowledge about sleep in an understudied population. This study is also strengthened by using a measure designed for toddlers (Sadeh, 2004). The parent-reported data providing parents’ perspectives is an additional strength of this study. Parents’ reports are clinically relevant and can provide useful information to nurses caring for children with sleep problems (Mindell & Owens, 2015).

Conclusion

Findings from this study add new knowledge about sleep patterns, problems, and ecology among a sample of toddlers from families referred to CPS for maltreatment. Findings point to a need for further research into possible daytime sleep disparities among toddlers from families involved with CPS for maltreatment. Findings also inform nurses caring for toddlers from families involved with CPS for maltreatment. Public health and community nurses can play an important role in identifying and addressing behavioral sleep problems in these children.

Highlights.

  • Toddlers in a sample of families referred to CPS showed behavioral sleep problems

  • Sleep distribution differed between toddlers in a CPS sample and population data

  • Nurses caring for families referred to CPS can address toddler sleep health

  • Research into sleep and toxic stress is needed for sleep health-promoting policies

Acknowledgements:

we thank the parents and children who participated in this study. We also thank editor David Preston.

This work was supported by the National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant numbers R01 HD061362, U54HD083091); the National Institutes of Health, National Institute of Nursing Research Omics and Symptom Science Training Program at the University of Washington (grant number T32NR016913); the National Institutes of Health, National Institute of Nursing Research, Center for Innovation in Sleep Self-Management (P30NR016585); and the University of Washington Warren G. Magnuson Scholarship Award. Sponsors had no involvement in the design of this study, data collection, data analysis or interpretation, drafting of the manuscript, or findings dissemination. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

CRediT Author Statement

Jonika Hash: Conceptualization, Methodology, Formal Analysis, Data Curation, Writing – Original Draft, Writing – Review & Editing, Visualization, Funding Acquisition. Monica Oxford: Conceptualization, Methodology, Writing – Review & Editing, Supervision, Funding Acquisition. Teresa Ward: Conceptualization, Methodology, Writing – Review & Editing, Supervision, Funding Acquisition. Charles Fleming: Methodology, Formal Analysis, Data Curation, Writing – Review & Editing, Visualization. Susan Spieker: Conceptualization, Methodology, Writing – Review & Editing, Supervision, Funding Acquisition.

Declarations of interest: none.

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