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1 This article was downloaded by: [BaHammam, Ahmed] On: 13 November 2008 Access details: Access Details: [subscription number ] Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK International Journal of Behavioral Medicine Publication details, including instructions for authors and subscription information: Cosleeping and its Correlates in Saudi School-Aged Children Ahmed BaHammam a ; Hatem Alameri a ; Ahmad Hersi a a Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia Online Publication Date: 01 October 2008 To cite this Article BaHammam, Ahmed, Alameri, Hatem and Hersi, Ahmad(2008)'Cosleeping and its Correlates in Saudi School-Aged Children',International Journal of Behavioral Medicine,15:4, To link to this Article: DOI: / URL: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 International Journal of Behavioral Medicine, 15: , 2008 Copyright C Taylor & Francis Group, LLC ISSN: print / online DOI: / Cosleeping and its Correlates in Saudi School-Aged Children Ahmed BaHammam, Hatem Alameri, and Ahmad Hersi Background: There are cross-cultural variations in sleep habits among children. No previous study has assessed the prevalence of cosleeping in school-aged children in Middle Eastern countries. Purpose: To assess the prevalence of, and the factors associated with, cosleeping in Saudi school-aged children. Methods: Questionnaires were distributed according to a specified sampling procedure, and parents were asked to rate each item that described their child s behavior within the previous 6 months. Cosleeping was defined as all-night sharing of a bed or room with a parent. Results: Data were analyzed for 977 children (50.5% boys) with a mean age of 9.5 ± 1.9 years and a range from 5 to 12 years. Cosleeping with parents was reported by 26% (95% CI: %) of the sample. According to a multivariate logistic regression model, a child s school level, enuresis, and nightmares were the only predictors of cosleeping. Conclusion: This study demonstrated that cosleeping is more common among Saudi school-aged children than has been reported for other countries. When assessing children s sleep, the practitioner should give special consideration to the child s needs, and his/her family s cultural background. Key words: cosleeping, school-aged children, culture Introduction Cosleeping with parents is a controversial topic that has not been thoroughly explored in the literature (Owens, 2002). Previous studies addressing cosleeping with parents have focused on infants and preschool children, with limited data being available for schoolaged children. In general, bed sharing in infancy is determined by the mother. However, during childhood, bed sharing is initiated by the child because of a number of factors which, to date, have not been fully elucidated. For example, it has been suggested that bed sharing decreases with advancing age because nocturnal awakenings decrease with age (Jenni, Fuhrer, Iglowstein, Molinari, & Largo, 2005). However, this view was challenged recently by Jenni et al. (2005) who reported a low prevalence of bed sharing during infancy, an increase during early childhood, and a slow decline in prevalence during the school-age years. Bed sharing prevalence rates between 4% and 23% have been reported for school-aged children (Jenni et al., 2005). Also, there are cross-cultural variations in sleep Ahmed BaHammam, FRCP, FCCP, Hatem Alameri, FRCPC, FCCP, Ahmad Hersi, MD, FRCPC, Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia. Correspondence concerning this article should be addressed to Prof. Ahmed BaHammam, Director Sleep Disorders Center, College of Medicine, Department of Medicine, King Saud University, P.O. Box , Riyadh 11324, Saudi Arabia. ashammam2@gmail.com or ashammam2@yahoo.com 336 habits among children. Children s sleeping habits vary not only with age but also with ethnic and sociocultural background (Jenni & O Connor, 2005). Saudi Arabia is culturally different from Western societies. In general, while the practice of cosleeping of infants with their mothers is not discouraged in Saudi Arabia, cosleeping of school-aged children with their parents is not encouraged. The prevalence of cosleeping in school-aged children has not been previously studied in Saudi Arabia or in other Middle Eastern countries that share common ethnic and cultural backgrounds. Therefore, we conducted this study to assess the prevalence of, and factors affecting, cosleeping in Saudi school-aged preadolescent children. Methods Study Subjects This cross-sectional study was conducted in Riyadh, a city with a population of more than four million (Tatweer, 1999). Every public school in Riyadh was assigned a number, and then a random sample of 10 boys schools and 10 girls schools were selected. Further random sampling was used to select classes at each school, with all children in the selected class being included in the study. Elementary schools in Saudi Arabia have students from grades one (age 6 yr) to six (age 12 yr). A pilot sample was selected from the studied population to test the data collection procedures and to assess the

3 COSLEEPING IN SAUDI SCHOOL-AGED CHILDREN legibility, validity, and reliability of the questionnaire. Sixty questionnaires were distributed, after which the necessary modifications were made. Observations obtained using the pilot sample were not included as part of the final sample. A letter addressed to the parents explaining the survey and its procedures, as well as an informed consent form, were sent home with each child. Questionnaires were distributed by trained medical students according to a randomization procedure. Parents were asked to rate each item in terms of how well it described their child s behavior during the previous 6 months. Children were not included in the study if their families reported them as having any of the following problems: chronic neurological diseases, psychiatric diseases (diagnosed by a psychiatrist), or chronic respiratory diseases. Of the 1,500 questionnaires distributed, 1,200 were returned, leading to a response rate of 80%. Two hundred and twenty-three (18.5%) questionnaires were removed because the children had one of the chronic illnesses specified in the study protocol as precluding inclusion in the study. Data were analyzed for 977 children (50.5% boys) with a mean age of 9.5 ± 1.9 years and a range from 6 to 12 years. Among the completed questionnaires, 38.5% were completed by fathers, 47.2% by mothers, and 14.3% by others. Questionnaires As part of a large project that studied sleep in elementary school children, BaHammam, AlFaris, Shaikh, and Bin Saeed (2006) designed a questionnaire to assess bedtime, rise time, sleep habits, sleep problems, home environment, demographic data, and parent s educational level. The questionnaire was based on both experience and the available literature (Andres, Carskadon, Dement, & Harvey, 1978; Epstein, Chillag, & Lavie, 1998). The questionnaire contained two types of question formats, closed questions with multiple choices (31 questions), for example, Does your child have a regular sleep-wake schedule? (yes, no, I do not know), and open-ended questions to be completed with appropriate answers (9 questions). The following sleep problems were assessed: bedtime resistance (how often is it difficult getting your child to go to bed?); sleep-onset delay (does your child have difficulty falling asleep at night?); fear (does your child express any fears or worries before going to bed?); sleep interruption (does your child have difficulty sleeping through the night?); nightmares and sleep terrors based on DSM-VI criteria (APA, 1994), enuresis, sleepwalking, sleep talking, difficulty rising in the morning on weekdays (does your child have difficulty getting out of bed in the morning on weekdays?); daytime fatigue (does your child complain of being tired during the day); sufficient sleep (do you think your child is getting enough sleep?); and snoring. The following problems, bedtime resistance, sleep-onset delay, difficulty rising in the morning on weekdays, and snoring, were considered present if they occurred at least three times a week (BaHammam et al., 2006). The remaining problems were coded as a problem if they occurred at least once per week. Cosleeping was defined as all-night bed or room sharing with a parent. The question was phrased as follows: does your child sleep with you in your bed or room throughout the night? The parent responded using one of the five possible responses, never, less than four times a month, once or twice a week, three or four times a week, and more than four times a week (Yang & Harn, 2002; Cortesi, Giannotti, Sebastiani, & Vagnoni, 2004). In Saudi Arabia, sleep practices use both a bed or sareer above the floor, and a frash, a mattress of cotton or synthetic material on the floor. Even when children sleep on a frash, it is placed near the bed to enable physical contact with parents. We used a similar definition to that described by Yang and Hahn (2002). Children cosleeping one or more times a week were considered to be cosleepers, and those who coslept less than four times a month were considered to be non-cosleepers. Statistical Analyses The data were summarized in terms of the mean and standard deviation (SD) in both the text and tables. Student s t-tests were used to compare the means for continuous data. If the normality test failed, the Mann- Whitney test was used. For categorical data, the chisquare test was used. One-way ANOVA was used for comparing the means of different age groups. The results were considered statistically significant if p <.05. To explore associations between independent factors (i.e., sleeping habits and practices) and cosleeping behaviors, a preliminary analysis used a univariate logistic regression model; one explanatory variable was tested in the model at a time after adjusting for age, sex, and parents occupations and levels of education. Subsequently, variables with significant p-values were evaluated further using a multivariate logistic regression model. SPSS (version 13; Chicago, IL, USA) was used for the analyses. Results The illiteracy level was 11.9% for mothers and 5.6% for fathers. Approximately 65% of mothers and 57% of fathers had completed primary, secondary or high school education. Twenty-three percent of mothers and 37.8% of fathers had completed graduate or postgraduate education. The mother s occupations were distributed as follows: housewives (72.2%), teachers (17.6%), members of the medical profession (4.1%), and administrators (2.4%). 337

4 BAHAMMAM, ALAMERI, AND HERSI Table 1. Characteristics of Cosleeping and Non-Cosleeping Children Non-Cosleeping Cosleeping p Characteristics (n = 715) (n = 262) Value Age 9.68 ± ± Males (%) NS School level 3.6 ± ± Number of siblings 5.2 ± ± Child rank 3.6 ± ± 2.5 NS Have their own NS bedroom (%) Sleep time 21:40 ± 1:10 21:50 ± 1: Wake-up time 05:45 ± 0:50 05:50 ± 0:40 NS Total sleep time 8:27 ± 0:59 8:41 ± 1:20 NS (hr:min) Housewife/working 73/27 69/31 NS mother (%) Educational level (no/low/high) (%) Father 5/57/38 7/56/37 NS Mother 11/66/23 15/62/23 NS Educational levels: No = illiterate; low = scholarly education; high = college or higher education. Cosleeping with parents was indicated by 26% (95% CI: %) of the sample. Of these, 66% reported cosleeping 1 2 times/week, 22% reported cosleeping 3 4times/week, and 12% reported cosleeping >4 times/week. Among cosleepers, 49% were males and 51% were females. Because no statistically significant differences were found between boys and girls, the data were pooled across sex in the analyses. Cosleeping percentage decreased with increasing age (p = 0.036, 95% CI: ), as is indicated by the following summary: younger than 6 years, 40% (95% CI: %); 6 8 years, 34% (95% CI: %); 8 10 years, 25.2% (95% CI: %), years, 19.6% (95% CI: %), and older than 12 years, 19.5% (95% CI: %). Table 1 illustrates the characteristics of cosleeping and noncosleeping children. Table 2 shows sleep habits and behaviors that may affect sleep in cosleepers and non-cosleepers. Fear at bedtime, enuresis, sleep talking, and witnessed apnea were more prevalent in frequent cosleepers (more than four times a week) than in children who coslept less than four times a week. Table 3 shows the independent predictors of cosleeping frequency using univariate and multivariate logistic regression analysis. Lower school level and more frequent nightmares and enuresis remained significant predictors of co-sleeping in a fully adjusted model with child s age, sex, parental level of education and occupation. Discussion This is the first study addressing cosleeping in school-aged children in a Middle Eastern country. Due 338 Table 2. Bedtime, Sleep, and Daytime Behaviors in Cosleeping and Non-Cosleeping Children Non-Cosleeping Cosleeping p Behaviors (%) (n = 715) (%) (n = 262) Value Watching TV after 321 (44.9) 145 (55.4) PM Playing computer 170 (23.8) 94 (35.7) games after 8 PM Resisting going to bed 265 (37.0) 143 (54.7) <0.001 Sleep onset delay 97 (13.6) 57 (21.6) Sleep interruption 32 (4.5) 25 (9.4) Fear at bedtime 48 (6.7) 47 (18.1) <0.001 Sleep terror 16 (2.3) 18 (7.0) Nightmares 29 (4.1) 29 (10.9) Sleepwalking 11 (1.6) 5 (2.0) NS Sleep talking 46 (6.4) 34 (12.9) Snoring 29 (4.0) 21 (8.0) 0.02 Enuresis 24 (3.3) 21 (8.0) Witnessed apnea 9 (1.2) 3 (1.3) NS during sleep Daytime fatigue 90 (12.6) 39 (14.8) NS Note: The percentage is presented in brackets. to the improved economic conditions in Saudi Arabia, many changes have occurred in family lifestyle patterns. Many families are able to own or rent larger family homes containing multiple rooms, which enable parents to sleep separately from their children. Additionally, in contrast to the past, it has become the norm in large Saudi Arabian cities to see young married couples forming a new family away from their extended family. Nevertheless, cosleeping remains quite common among school-aged Saudi children compared to published data in other countries. Because our study is the first in a Middle Eastern country, we were unable to compare our results with data from countries that have comparable childrearing and cultural backgrounds. Recently, Table 3. Independent Predictors of Cosleeping Using Univariate and Multivariate Logistic Regression Analysis Independent Odds p 95% Predictors Ratio Value CI a Univariate model School level (0.7, 0.9) Fear at bedtime 4.3 <0.001 (2.4, 7.5) Nightmares 3.5 <0.001 (1.7, 7.2) Sleep terror (1.6, 9.1) Enuresis (1.5, 6.7) Multivariate model b School level (0.7, 0.9) Nightmares 4.1 <0.001 (1.9, 8.8) Enuresis (1.01, 6.0) a CI = confidence interval. b Watching TV after 8 PM, playing computer games after 8 PM, resisting going to bed, sleep onset delay, sleep interruption, fear at bedtime, nightmares, sleep talking, snoring, school level, enuresis, age, and number of siblings were used as covariates in the univariate model. School level, fear at bedtime, nightmares, sleep terror, and enuresis were used as covariates in the multi-regression model.

5 COSLEEPING IN SAUDI SCHOOL-AGED CHILDREN Cortesi et al. (2004) reported that cosleeping occurred in 5% of Italian school-aged children, which is much lower than the rate of 26% observed in the present study. We found no gender difference in cosleeping habits, consistent with findings from Switzerland (Jenni et al., 2005) and Italy (Cortesi et al., 2004). By contrast, Okami, Weisner, & Olmstead (2002) found that in Euro-American families, girls were about 50% more likely to bed share than were boys. We found that cosleepers had a higher prevalence of sleep problems. This finding is consistent with results from the U.S. (Latz, Wolf, & Lozoff, 1999), Italy (Cortesi et al., 2004), and Switzerland (Jenni et al., 2005), but stands in contrast to results showing no association between cosleeping and sleep problems in Japanese children (Latz et al., 1999). Watching TV at bedtime has been reported to be strongly associated with significantly increased sleep disturbances, particularly bedtime resistance, sleep onset delay, and anxiety concerning sleep (Owens et al., 1999). Therefore, healthcare professionals should be aware of the potential harmful effects of TV watching at bedtime and its impact on children s sleep. The increased prevalence of some sleep problems, such as fear at bedtime and resisting going to bed by cosleepers, may reflect how parents cope with sleep problems rather than be a cause of sleep problems. Coping with such problems could be different for parents from different cultures. On the other hand, the higher prevalence of some sleep problems in cosleepers, such as sleep talking and snoring, may simply reflect the fact that parents are more likely to detect sleep problems when children cosleep with them. Studies of people from different cultural backgrounds have reported different predictors and factors associated with cosleeping, including the child s age, the level of parental education, a lower level of professional training, increased family stress, the parents age, socioeconomic level, and being a single parent (Yang & Hahn, 2002; Cortesi et al., 2004; Sheldon, 2005). In the current study, school level, which reflects age, was a predictor of cosleeping. While the practice of cosleeping is not considered appropriate in many industrialized Western countries, some societies consider cosleeping to be a normal behavior. It seems that there is no consensus among experts about the role and effects of cosleeping. Practicing specialists need to keep this in mind when making judgments about sleep normality. They should always take into account the children s background and the culture when making judgments about children s sleeping practices. Special attention should be paid to coexisting sleep problems in cosleepers. In a recent study that reviewed parenting advice books about children s sleep, 28% of the books endorsed cosleeping, 32% took no position, and 40% opposed it (Ramos & Youngclarke, 2006). Most of these authors recommendations were not evidence-based. In fact, there is no evidence that cosleeping has detrimental effects on either the child s behavioral or emotional development (Okami et al., 2002; Jenni et al., 2005). There are many aspects of this topic that have not been explored, including the effects of cosleeping on parents quality of sleep, parents intimacy and relationship, child-parent attachment, and children s sleep quality. Although the current study had an adequate sample size and equal representation of boys and girls, a number of caveats still need to be addressed. First, although parent-reported data have clear limitations, the validity of self-report and parent-report survey estimates of sleep patterns was demonstrated (Sadeh, 1994; Wolfson et al., 2003). Second, as we did not have information about those who declined to participate (20%), response bias is a potential cause of selection bias. Third, there are many hidden and unmeasured confounders that may influence the practice of cosleeping. These include such factors as family characteristics, marital quality, psychosocial factors, and social class. Nevertheless, at this stage, a basic analysis is all that is needed for researchers to build a solid foundation for future studies, especially since this type of research has not been thoroughly explored in our geographical area. Fourth, since the study was cross-sectional, no conclusions about cause and effect can be made. Additionally, no long-term ramifications of cosleeping behaviors can be drawn. Finally, this study was conducted in a large busy city; therefore, the results cannot be extrapolated to rural and outlying areas of Saudi Arabia. Conclusions Cosleeping is common among Saudi school-aged children. Although the practice of cosleeping is not considered appropriate in many industrialized Western countries, there is no evidence that this practice has detrimental effects on the child s behavioral or emotional development. Hence, professionals should not denounce this practice in general. Special consideration should be paid to the needs of the child, his/her family s cultural background, and any associated sleep problems. References APA (American Psychiatric Association). (1994). Diagnostic and statistical manual of mental disorders, 4th ed. (DSM-VI). Washington, DC: The American Psychiatric Association. Andres, T., Carskadon, M. A., Dement, W. C., & Harvey. K. (1978). Sleep habits of children and the identification of pathologically sleepy children. Child Psychiatry and Human Development, 9, BaHammam, A., AlFaris, E., Shaikh, S., & Bin Saeed, A. (2006). Prevalence of sleep problems and habits in a sample of Saudi primary school children. Annals of Saudi Medicine, 26,

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