The correlation of the sensory profile with sleep disturbances in toddlers

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1 The University of Toledo The University of Toledo Digital Repository Master s and Doctoral Projects The correlation of the sensory profile with sleep disturbances in toddlers La Vonia Roane The University of Toledo Follow this and additional works at: This Scholarly Project is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Master s and Doctoral Projects by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.

2 Running head: SENSORY PROCESSING AND SLEEP IN TODDLERS 1 The Correlation of the Sensory Profile with Sleep Disturbances in Toddlers La Vonia Roane Research Advisor: Alexia E. Metz, Ph.D., OTR/L Occupational Therapy Doctorate Program Department of Rehabilitation Sciences The University of Toledo May 2012 This scholarly project reflects individualized, original research conducted in partial fulfillment of the requirements for the Occupational Therapy Doctorate Program, The University of Toledo.

3 SENSORY PROCESSING AND SLEEP IN TODDLERS 2 Abstract This study examined the relationship of sensory processing patterns to sleep in toddlers. We hypothesized that sensory processing difficulties would correlate to sleep disturbances. This was tested by using a questionnaire of sleep habits, derived from a collection of published sources, and Dunn s Infant/Toddler Sensory Profile (2002). We further hypothesized that the sleep-directed strategies implemented by parents of toddlers without sleep difficulties would be consistent with the children s sensory profiles and conversely, there would be a mismatch between strategies used and sensory processing patterns in some toddlers with sleep difficulties. A convenience sample of fifty-one parents of toddlers ranging between the ages of thirteen to thirty six months participated in the study. The research design was cross-sectional and questionnaire-based. Total hours of sleep averaged 10.8±0.1 hours per day and did not vary with age (R=-.130, r 2 =.02, p>0.05). Using a cut off score of 12 on the ISQ, twelve toddlers showed sleep dysfunction. With the cutoff score of 24 on the sleep profile for children there were thirteen toddlers with sleep dysfunction. The PIBBS strategy most frequently reported to be used Very Often, by 41% of respondents, was the use of a special toy, cloth, or blanket. The Sensory Profile (Dunn, 2002) results distribution reflects the normal distribution associated with the standardization data of the assessment. There were no significant correlations; therefore, we cannot suggest that sleep behaviors and sensory processing are related in a predictable manner. Parents of toddlers with sleep profile for children scores above the cutoff of 24 used significantly more active physical strategies (50±4 compared to 31±4%, p<0.01). Parents of toddlers whose strongest sensory processing pattern was Low Registration or Sensory Sensitivity reported using the strategy of taking the child for a car ride at a higher rate than other respondents (average endorsement was 0.9 ±0.4 and 1±0.1 respectively on the 0-4 scale compared to 0, 0.2±0.4, and 0.1±0.1 for respondents whose toddlers did not have a strongest pattern or had patterns of Sensory Seeking and Sensory Avoiding, respectively). The results suggest that although global sleep patterns do not change with age, sleep-related behaviors and the effort required to settle their children to sleep may become more problematic through toddlerhood.

4 SENSORY PROCESSING AND SLEEP IN TODDLERS 3 Introduction The Occupational Therapy Practice Framework: Domain & Process 2 nd edition defines sleep as an area of occupation consisting of a series of activities resulting in going to sleep and staying asleep, which ensures health and safety (American Occupational Therapy Association, 2008). Sleep is of inherent importance for people of all ages (Ward, Rankin & Lee, 2007). Healthy sleep is essential in everyday functioning. Sleep is connected with emotional, psychosocial, behavioral, and physical responses. Unhealthy sleep patterns can contribute to fatigue irritability, slowed growth, and decreased effectiveness in functioning. Though sleep is important for everyone, it is particularly important for children as it aides with development. Ward, Rankin, and Lee (2007) discussed various factors which may influence children sleep problems including disorders, family structure, and routines. Mindell, Telofski, Weigand, and Kurtz, (2009) demonstrated that of a routine consisting of bath, massage, and quiet activities before bedtime decreased night time awakenings in infants and toddlers. Forquer and Johnson (2005) found that using white noise, sound that covers the entire range of human hearing (20-20,000), decreased night waking in toddlers. In their study, white noise was set at a sound pressure level of 75dB and placed in an area that was inaccessible to the child. The white noise was turned on during all sleep periods, turned on before placing the child in bed and turned off before taking the child out of bed. There were four toddlers included in the study and three of the four toddlers improved during the study and at followup. Two of the toddlers exhibited decreased night awakenings and one exhibited decreased resistance to going to bed. The remaining toddler s night awakenings showed little change throughout the study. This study suggests that audio stimulation at bedtime can decrease night time awakenings and bedtime resistance. Individual responses to sensory stimulation, or sensory processing, may be relevant to sleep behaviors. Current theory of sensory processing (Dunn, 1997) holds that each individual has different thresholds for responding to sensory information, ranging from high to low, and different behavioral strategies for responding to or seeking out sensory stimulation, ranging from active to passive. This creates four sensory processing patterns: sensory seeking, sensory avoiding, sensory sensitivity, and low registration. Sensory processing patterns may have an effect on the way children sleep. For example, children who have sensory seeking

5 SENSORY PROCESSING AND SLEEP IN TODDLERS 4 behavior may need more stimulation at bedtime while children who have sensory sensitivity may need something to help them block out distractions at bedtime. Children may have different levels of tolerance for sensory stimuli and this may contribute to whether or not they have a good night s sleep. This has been addressed in two studies by Engel-Yeger and colleagues. Shani-Adir, Rozenman, Kessel, and Engel-Yeger, (2009) compared the relationship between sensory hypersensitivity and sleep quality in children with atopic dermatitis. They compared results from two questionnaires, the Short Sensory Profile and the Children s Sleep Habits Questionnaire, and found that higher sensory sensitivity was correlated with lower sleeping quality in school-aged children with the skin condition. Shochat, Tzischinsky, and Engel-Yeger, (2009) studied the relationship between sensory hypersensitivity, sleep, and behavioral disorders in typical school aged children. The findings are in support of sensory patterns having an effect on nighttime behaviors. Further research is needed to determine whether the relationship between sensory processing and sleep disturbances occurs earlier in childhood. The current study examined the relationship of sensory processing pattern to sleep in toddlers. It was hypothesized that sensory processing difficulties would correlate to sleep disturbances. This was tested by using a questionnaire of sleep habits, derived from a collection of published sources and Dunn s Infant/Toddler Sensory Profile (2002). We further hypothesized that the sleep-directed strategies implemented by parents of toddlers without sleep difficulties would be consistent with the children s sensory profiles and conversely, there would be a mismatch between strategies used and sensory processing patterns in some toddlers with sleep difficulties. Methods Participants A convenience sample of fifty-one the parents of toddlers ranging between the ages of thirteen to thirty six months was recruited. A collaborating graduate student researcher also enrolled 22 parents of healthy

6 SENSORY PROCESSING AND SLEEP IN TODDLERS 5 infants, ages birth to 12 months. A total of approximately 200 questionnaire packets were distributed; hence, we had an overall return rate of approximately 37%. The parents were recruited from child care centers and parent/family organizations throughout Northwest Ohio. The qualifying criterion for the study was that toddlers were healthy and had not been diagnosed with a major medical condition; this was verbally reported by caregivers. Research Design The research design was cross-sectional and questionnaire based. Instruments The Infant/ Toddler Sensory Profile (Dunn, 2002). This assessment addresses sensory processing, including auditory processing, visual processing, tactile processing, vestibular processing, and oral sensory processing. The items reflect everyday sensory experiences and are ranked on a scale ranging from almost always to almost never. The test re-test reliability is.74 for the quadrants and the coefficient measure of consistency for the 7 to 36 months is to The author of the assessment reports convergent and discriminate validity. The scores of individual participants were normalized through conversion to T scores according to the normative data to allow for comparisons of different age groups. The sleep profile for children. The sleep profile for children that was used in this study was derived from a collection of published sources. Morrell (1999) discussed how sleep dysfunction is likely apparent at the end of the first year; therefore, it is important to have valid and reliable assessment tools available for that time period. The Infant Sleep Questionnaire (ISQ, Morrell, 1999) was established to assess sleep function in children aged months old. In an effort to extend assessment of sleep to younger ages, Sadeh (2004) included infants from birth to 30 months in establishing the psychometric properties of the Brief Infant Sleep Questionnaire (BISQ). The BISQ reliably determines the presence of sleep dysfunction through three criteria; however, it does not provide a score to assess severity of sleep disturbance, measure change in sleep behavior,

7 SENSORY PROCESSING AND SLEEP IN TODDLERS 6 or allow for correlation studies. Finally, the Children s Sleep Habits Questionnaire (CSHQ, Owens, 2000) includes items that assess the impact of sleep deficits such as difficulty waking and daytime sleepiness. The Morrell (1999) Infant Sleep Questionnaire (ISQ) includes criteria for classifying sleep and settling problems. The ISQ was used in infants ranging months and has a cut score of 12 or higher for sleep problems. It was cross tabulated with Richman s criteria to be correct 89.5% of positive cases and 96.7% of negative cases. Mother s classifications using a no problem/mild/moderate/severe system gave similar results. The cut score for maternal perception was 6. The test re-test reliability is.92 at 2-4 weeks. The Sadeh (2004) Brief Infant Sleep Questionnaire (BISQ) was used for infants and toddlers from 0-30 months old in increasing screening for and detecting sleep problems. The test re-test reliability is at 3 weeks. The BISQ was correlated with the actigraph measurements of sleep-onset time and number of night wakings. The BISQ was correlated with sleep logs. Sleep onset was later than reported, number of wakings was more on questionnaire than logs, actigraph showed more waking than reported or recorded. The criterion for having a sleep problem is less than nine hours of sleep, greater than 3 awakenings at night, and greater than one hour of wakefulness at night. Criteria for referral stable from 6 to 30 months. The BISQ documents soothing methods and sleep behaviors The Owens (2000) Child s Sleep Habits Questionnaire (CSHQ) was used for children ages The criteria are used for determining if there is a sleep problem or not. It has a consistency statistics of ~ 0.7 and the criterion determines when there is a sleep problem or not. The clinical sample had higher scores than the community sample. The Morrell (2002) Parental Interactive Bedtime Behavior Scale (PIBBS) is used to identify behaviors used to soothe and settle infant s ages months. It has a Cornbach s alpha of 0.7. The soothing/settling methods are classified in five categories including: active physical comforting, encourage autonomy, settle by movement, passive physical comforting, and social comforting.

8 SENSORY PROCESSING AND SLEEP IN TODDLERS 7 The sleep profile for children. Taken alone, none of these assessments address all of the following: sleep patterns, sleep disturbances, impact of sleep deficit, and parental settling efforts. Yet, administering all of the assessments would result in an abundance of redundancy. Therefore, we developed our sleep profile using these sleep questionnaires and scales. The assessment we have compiled here includes 1) all the items of the ISQ with their original scoring, 2) all the items of the BISQ with new scoring to facilitate combination with the ISQ, and 3) elements of the CSHQ that reflect sleep function and/or impact of sleep deficits (but not those that relate to the underlying causes of sleep dysfunction) with new scoring to facilitate combination with the ISQ. In the PIBBS we eliminated the alcohol and drug questions and retained all the settling methods. We piloted the sleep profile for children with fifteen parents including four occupational therapists. The average time to complete the questionnaire was seven minutes. We made modifications to our questionnaire based on recommendations. We distinguished between settling and falling asleep and modified response categories so the parents could respond in half hour increments. This allowed us to still make calculations on total amount of sleep. The sleep profile for children is presented in Appendix A. The scoring of the sleep profile for children was divided by the different sections. The yes and no questions and the method section are not numerically scored. Responses to the first set of questions indicate the number of days of the week and were scored from zero to seven. Responses to the second set of questions the number minutes in increments of 10 from zero to greater than sixty and were scored zero to six. Responses to the third set of questions indicated how many times per night or day and were scored on a zero to five scale. Questions not included in scores included those regarding number of days a week the child naps and how many naps per day were not scored and those regarding the duration of sleeping problems. Questions were also categorized according to sleep deficit, sleepiness, bedtime, parent role, night awakenings, and naps. The scores from each category were added up with a maximum score of one hundred and fifty four. Hollingshead. The Four Factor Index of Social Status by A.B. Hollingshead (1975) was used to describe the social status of our participant s parents. This Index consists of four factors: education, occupation,

9 SENSORY PROCESSING AND SLEEP IN TODDLERS 8 sex, and marital status. The total scores range from eight to sixty six. Social status categories include: major business and professional (66-55); medium business, minor professional, technical (54-40); skilled craftsmen, clerical, sales workers (39-30); machine operators, semiskilled workers (29-20); and unskilled laborers, menial service workers (19-8). Procedure Sleep profile for children, Infant/ Toddler Sensory Profile, and the Hollingshead along with a cover letter and consent form were distributed to parents by the researchers or by staff at child care facilities that had agreed to assist with recruiting. Participants were encouraged to complete surveys at the point of contact; however, most participants chose to complete the questionnaires at home and return the completed surveys to their child care facility. Researchers were available by phone to answer questions. Researchers answered questions relating to the purpose of the study or the meaning of questions, but did not coach the participants. For participants who completed packets without contact with the researchers, a follow up phone call ensured the opportunity to answer questions and confirm consent. Additionally, we requested contact information in order to inform parents in the case that the results of questionnaires indicated sleep disturbance or sensory processing difficulties. The contact information was stored separately from the questionnaires. We initially planned a pilot intervention study for toddlers who demonstrated both sensory processing difficulties and sleep dysfunction. However, none of the participants who would have qualified for the intervention piece indicated willingness to be contacted for follow up. Data Analysis To assess the sleep profile for children for concurrent validity, we utilized the criteria of the Child Sleep Questionnaire (cut score of twelve or higher) and the Brief Toddler Sleep Questionnaire (of having less than nine hours of sleep total, greater than three night wakings, and greater than one hour of wakefulness at night) to categorize the participants as having typical or problematic sleep. We then compared the sleep profile for children scores of participants in these two groups using unpaired t-tests expecting that if the Sleep Profile for

10 SENSORY PROCESSING AND SLEEP IN TODDLERS 9 Children is valid, scores will be significantly higher in children who met the ISQ and BISQ criteria for sleep disturbances. This was used to assess whether the Sleep Profile for Children can reliably discriminate between children with and without a sleep problem. Validity was further assessed through correlation of derived ISQ scores with Sleep Profile for Children scores where high correlation between these scores would indicate that the Sleep Profile for Children is a valid measure of sleep problems. The internal reliability of the sleep profile for children was assessed using Cronbach s alpha for the whole scale and the subscales of sleep, night wakings, and settling. The use of the ISQ and sleep profile for children to describe areas of sleep dysfunction was done through unpaired t-tests of individual items between respondents above and below cut scores. Responses to the sleep profile for children are reported using descriptive statistics of mean and standard error or percent of respondents. The correlation of responses to toddler age was assessed using Pearson s. Responses to the PIBBS are reported using frequency distribution and average percent of strategies endorsed. Scores for the Sensory Profile quadrants were converted to T-scores according to the normative data provided in the assessment s manual (Dunn, 2002). T-scores between 40 and 60 are comparable to the diagnostic category of Typical Performance. T-scores lower than 40 are comparable to the diagnostic categories of More than Others and Much More than Others. T-scores higher than 60 are comparable to the diagnostic categories of Less than Others. The correlation of sleep profile for children scores and T scores was assessed through Pearson s. The alpha of.05 was adjusted to account for multiplicity of the four quadrants to an alpha of A one-way ANOVA with Bonferroni post-hoc correction was used to assess differences in the use of PIBBS strategies amongst groups according to Sensory Profile results. Results Descriptive Statistics for Participants Fifty one parents of toddlers participated in this study. Of the respondents, 96% were the mothers of the toddlers they reported about with the remaining being fathers. The toddlers ranged in age from 13 months to 31 months at the time of participation. The average age was 22.9±0.9 months. Of the toddlers, 55% were male, the remaining female. Parental descriptive information was determined using the Four Factor Index of Social

11 SENSORY PROCESSING AND SLEEP IN TODDLERS 10 Status (Hollingshead, 1975). There were 16 participants (31%) of participants in the major business and professional category. Twenty two participants (43%) of participants were in the medium business, minor professional and technical category. Ten participants (20%) of participants were in the skilled craftsman, clerical and sales workers category. Two participants (4%) of participants were in the machine operators, semiskilled workers category. One participant (2%) of participants was in the unskilled laborers and menial service workers category. Psychometric Properties of the Sleep Profile for Children Concurrent validity. The average sleep profile for children score for children with ISQ scores below 11 was 13.0±1.0 (n=39). The average sleep profile for children score for children with ISQ scores of 12 or higher was 36.2±3.0 (n=12). The latter was significantly higher (p<0.001, see Figure 1A). There were no cases that met the BISQ criteria for sleep disturbance. ISQ scores and sleep profile for children scores were positively correlated (R 2 =0.699, r=0.836, p<0.01, see Figure 1B) Internal reliability. When including all 15 items of the sleep profile for children in analysis, the Cronbach s alpha was.81 indicating good reliability of the scale as a one dimensional measure of sleep behaviors in toddlers. Removal of any of the individual items did not result in higher Cronbach s scores. The subscales sleep, night waking, and settling had low Cronbach s alpha scores of.68, 0.50, and 0.78, respectively. Discriminant validity. Using a cutoff score of 24 on the sleep profile for children identifies eleven of the twelve of the toddlers with a score above 12 on the ISQ (8% false negative rate) and identifies two toddlers with scores below 12 on the ISQ (5% false positive rate). See Figure 1C. Sleep Behaviors and Maturation The responses to the sleep profile for children offer a picture of sleep behaviors in this population. See Table 1 for the responses to the sleep profile for children. The amount of sleep and sleep consolidation were assessed for correlation with the age of the toddlers. Across measures, sleep patterns did not change with age in this sample. Total hours of sleep averaged 10.8±0.1 hours per day and did not vary with age (R=-.130, r 2 =.02, p>0.05, see Figure 2A). Hours of night time sleep averaged 8.8±0.1 hours and also did not vary with age (R=-

12 SENSORY PROCESSING AND SLEEP IN TODDLERS , r 2 =.02, p>0.05, see Figure 2B). The number of nighttime wakings was 0.8±0.1 and did not significantly correlate with age (R=.199, r 2 =.04, p>0.05, see Figure 3A). Responses indicated that toddlers spent 2±0.1 hours napping, and this similarly did not vary with age (R=.001, r 2 =0, p>0.05, see Figure 2C). The number of naps per day was 1.1±0.1 and also did not significantly correlate with age (R=-.04, r 2 =.001, p>0.05, see Figure 3B). Both ISQ (Morrell, 1999) and sleep profile for children scores were assessed for their correlation with age, see Figure 4. The ISQ score was significantly positively correlated with age (R=.386, r 2 =.15, p<0.01). Similarly, the sleep profile for children scores were significantly positively correlated with age (R=.402, r 2 =0.16, p<0.01). Sleep Disturbance Using a cut off score of 12 on the ISQ (Morrell, 1999), twelve toddlers showed sleep dysfunction. In comparing these twelve toddlers to the 39 with healthy sleep, scores differed in on the following items (with alpha at.003 to account for the 15 items of the sleep profile for children): number of nights the toddler stays up late, number of nights the toddler resists bed, the number of nights it is problematic to get the toddler to sleep, the number of nights the toddler wake up, the number of nights the toddler sleeps in the parents bed, the time it takes the toddler to fall asleep at night, the time the parents spend settling the toddler to bed, the time the parent spends settling the toddler back to sleep upon night waking, the number of time the toddler wakes during the night, the time the toddler spends awake at night, the amount of sleep the toddler gets each night, and the duration that settling, night waking and sleeping in the parents bed has been a problem. See Table 2 for these results. With the cutoff score of 24 on the sleep profile for children there were thirteen toddlers with sleep dysfunction. In comparing them to the 38 toddlers with sleep profile for children scores lower than 24, the items where responses differed included(with an alpha of 0.003): the number of nights the toddler stays up late, the number of nights the toddler resists bedtime, the number of nights there are problems getting the toddler to sleep, the number of nights the toddler wakes up, the number of nights the toddler sleeps in the parents bed, the time it takes the toddler to fall asleep, the amount of time the parent spends settling the toddler, the time amount

13 SENSORY PROCESSING AND SLEEP IN TODDLERS 12 of nighttime sleep and the duration that settling, night waking and sleeping in the parents bed has been a problem. See Table 3 for these results. PIBBS Parents were asked to indicate the frequency with which they use strategies (Morrell, 2002) to settle their toddlers to sleep. Table 4 reports the results per strategy and category of strategies. The strategy most frequently reported to be used Very Often, by 41% of respondents, was the use of a special toy, cloth, or blanket. The next strategy most frequently rated as used Very Often, by 29% o f respondents was reading a story to the child. The third strategy most frequently rated as used Very Often was cuddling, by 25% of respondents. The strategy of pushing the child in a stroller was ranked as Never used by 96% of parents. Of respondents, 84% reported Never using the strategy of taking the child for a car ride, and 69% reported Never using the strategy of lying down with the child in his/her bed. Parents of toddlers with sleep profile for children scores above the cutoff of 24 used significantly more active physical strategies (50±4 compared to 31±4%, p<0.01). Sensory Profile Scores for the Sensory Profile were categorized as Typical, Less than Others, and More than Others according to the normative data provided with the assessment. The number of toddlers in each category for each of the four quadrants of Dunn s model (1997) is reported in Table 5. The distribution reflects the normal distribution associated with the standardization data of the assessment. Sleep Behaviors and Sensory Processing Patterns According to our original plan for data analysis, we assessed the correlation of sleep profile for children scores and Sensory Profile T-scores. Table 6 reports these results. There were no significant correlations. In a post hoc analysis to assess more globally for the potential impact of sensory processing on sleep function, we divided the sample population into those who have scores indicative of Typical Performance (n =7) and those with Sensory Profile scores indicative of dysfunction in any quadrant (T-scores below 40 or above 60, n=15). Using an unpaired t-test, we compared sleep profile for children scores. There was no difference (sleep profile

14 SENSORY PROCESSING AND SLEEP IN TODDLERS 13 scores for children were 18±1.2 for participants with typical Sensory Profile scores and 19±4.0 for participants with Sensory Profile scores indicative of dysfunction, p>0.05). Sensory Profile and PIBBS In order to assess whether parents use of strategies varies with sensory processing patterns, we assigned each participant to their strongest sensory processing pattern by using their lowest T-scores. There were six toddler without one T-score lower than the others. Amongst the others, there were the following numbers of toddlers with their lowest T-score in each quadrant: 6 Low Registration, 16 Sensory Seeking, 26 Sensory Sensitivity, and 17 Sensory Avoiding. A one-way ANOVA with Bonferroni post-hoc correction was used to assess differences in the use of PIBBS strategies amongst these groups. Parents of toddlers whose strongest sensory processing pattern was Low Registration or Sensory Sensitivity reported using the strategy of taking the child for a car ride at a higher rate than other respondents (average endorsement was 0.9 ±0.4 and 1±0.1 respectively on the 0-4 scale compared to 0, 0.2±0.4, and 0.1±0.1 for respondents whose toddlers did not have a strongest pattern or had patterns of Sensory Seeking and Sensory Avoiding, respectively). Discussion The sleep profile for children was useful in measuring sleep behaviors in the toddlers in this study. The sleep profile for children was derived from the ISQ, BISQ, and CSHQ sleep measurements (Morrell, 1999; Sadeh, 2004; and Owens, 2000). The sleep profile for children included all of the items of the ISQ with additional items from the other assessments. We created scoring for the additional items to facilitate the combination. This expanded profile demonstrated concurrent validity when compared to the original ISQ. There is no doubt that this is largely because of the inclusion of all the original items of the ISQ; however, the high correlation between the ISQ scores and the scores of the expanded profile indicates that adding items did not disrupt the integrity of the measure. In keeping, the high internal reliability of the sleep profile for children suggests that the information provided by the new elements is consistent with the measure of the sleep patterns. In addition, the discriminate validity of the sleep profile for children was adequate to support its use to screen for sleep disruption in toddlers while providing clinically useful information the contributing factors. In this

15 SENSORY PROCESSING AND SLEEP IN TODDLERS 14 sample, the sleep profile for children detected areas of difficulty that were qualitatively similar to those detected by the ISQ, specifically that night time settling was particularly troublesome. Both measures showed increasing scores with age (see Figure 4); however, visual inspection of the data might indicate that the sleep profile for children may be more sensitive to sleep disruption in older toddlers. This should be tested in future studies. Sleep patterns (total sleep, night time sleep, napping, and waking at night) did not vary with age and were, on average, not problematic. Using either the ISQ (Morrell, 1999) or the sleep profile for children, parents of participants with sleep dysfunction reported that their toddlers slept approximately half an hour less per night than parents of toddlers without sleep dysfunction (see Tables 2 and 3). This differs from the results of previous studies, sleep patterns were problematic for the experimental groups and on average they slept one hour less than their peers (Minde et al., 2003; Mindell, Telofski, Weigan, & Kurtz, 2009). In our study, scores were positively correlated with age in for both the ISQ and the sleep profile for children. Taken together, this suggests that although global sleep patterns do not change with age, sleep-related behaviors and the effort required to settle their children to sleep may become more problematic through toddlerhood. Putting children to sleep and having them stay asleep may become more problematic with age. It is notable that parents of toddlers with sleep profile for children scores above the sleep profile for children cutoff score of 24 used significantly more active physical strategies for settling their toddlers to sleep. Minde et al. (2003) found that toddlers with sleep dysfunction were unable to soothe themselves back to sleep and woke up on average three times per night; however, the number of night awakenings did not differ from the control group of toddlers. Rather, the control group was able to soothe themselves back to sleep within ten minutes of waking. Using the PIBBS (Morrell, 2002), we assessed the array of strategies that parents employ to settle their toddlers to sleep. The greatest percentage (41%) of parents reported the consistent use of a special cloth or toy as a strategy used most often in the present study, while 27% reported never using this strategy. This differs from the findings of Morrell (2002). Morrell reported the use of a special toy, cloth, blanket showed a reversed bimodal distribution (29% parents always used the strategy and 46% never did). In our study, approximately one quarter of parents reported consistently cuddling (25%) and reading a story (29%). Morrell (2002) found that 53% of parents

16 SENSORY PROCESSING AND SLEEP IN TODDLERS 15 consistently feeding their child, while only 14% of parents in our sample did so. Within our study, the least common strategies were carrying the child around house in arms, using a stroller, and taking the child for a car ride. Use of car rides was also among the least common strategies in the study by Morrell (2002) as were lying down with the children and swaddling. Further research is needed to determine what factors and circumstances influence parents to utilize some strategies over others as well as the effectiveness for the various strategies. The Sensory Profile scores within our sample represent a normal distribution, similar to that described by the author (Dunn, 2002). We hypothesized that sensory processing difficulties in each quadrant of Dunn s sensory processing model (Dunn, 1997) would correlate to sleep disturbances. There were no significant correlations; therefore, we cannot suggest that sleep behaviors and sensory processing are related in a predictable manner. It may be the case that a relationship between sensory processing and sleep difficulties may occur later on in development, as studies by Engle-Yeger et al. (2009) and Shani-Adir et al. (2009) show an association in older children. Another possible explanation for the lack of correlation in our sample is that the participants were typically developing toddlers. Future studies should examine the correlation in children who have been previously diagnosed with sensory processing disorder or sleep dysfunction. Parents of toddlers whose strongest sensory processing pattern was Low Registration or Sensory Sensitivity reported using the strategy of taking the child for a car ride at a higher rate than other respondents. Because the motion and noise associated with riding in a car may cause overstimulation, this may represent a mismatch between the strategy employed by the parents and the sensory processing patterns of the toddlers. The sleep problems of those children may decrease with the appropriate use of a calming strategy. Future studies may explore whether passive strategies may be more appropriate. Limitations Generalization of the results is restricted based on the use of a convenience sample, the return rate, and the restricted geographic location of data collection. Approximately two-hundred questionnaires were handed out in a joint effort to collect a sample of 120 infants and toddlers. We had an overall return rate of 36.5%. It is recommended in future studies to have the participants sit and complete the questionnaires with the researchers

17 SENSORY PROCESSING AND SLEEP IN TODDLERS 16 being present to increase return rate. Future studies would need to include a broader geographic area with a random sample. Another limitation was the small sample size and risk of Type II error, so we cannot assume that there is not a correlation between sensory processing and sleep behaviors. Parental bias may have caused parents to alter their responses on questionnaires based on the fear of their child being labeled atypical in either sensory or sleep function. Lastly, the use of the sleep profile for children was another limitation. Though it demonstrated validity, further testing of the validity and reliability of the instrument is needed. Implications for Occupational Therapy The findings of this study suggest the potential for Occupational Therapy to expand our area of practice to include helping parents with their children s sleep-related behaviors during the toddler years. Occupational therapists may provide intervention strategies that are based on the children s sensory needs, but they may also assess other factors that influence sleep such as daily routines, self regulation, and environmental features. Future research should explore the impact of these factors on sleep and test related interventions. The earlier the problematic sleep is detected, the earlier the intervention can start. We have developed a sleep assessment that addresses a broad array of factors including sleep behaviors (night time wakings, total hours of sleep, total hours of naps, total time to soothe), parent s soothing strategies, and how long the sleep disruption has been a problem. More testing is needed to determine the reliability and validity of the instrument. Such a development would advance evidence based practice in the area of sleep-related intervention.

18 SENSORY PROCESSING AND SLEEP IN TODDLERS 17 Acknowledgements I would like to thank the families of the toddlers who took the time to complete and return our questionnaire to further the growth of the field of Occupational Therapy. I would to thank the individuals who participated in the pilot study portion of our study for taking the time to complete our questionnaire. I would also like to thank Dr. Martin Rice for helping with reviewing of our research results. I would like to especially thank Elise Roth, for being my co-researcher throughout this research experience.

19 SENSORY PROCESSING AND SLEEP IN TODDLERS 18 References Adams, L. A., & Rickert, V. I. (1989). Reducing Bedtime Tantrums: Comparison Between Positive Routines and Graduated Extinction. Pediatrics, 84, American Occupational Therapy Association. (2008).Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, Dunn, W. (1997). The impact of sensory processing abilities on the daily lives of young children and families. A conceptual model. Infants and Young Children. 9(4), Dunn, W. (2001). The Sensations of Everyday Life: Empirical, Theoretical, Pragmatic Considerations The American Journal of Occupational Therapy, 55(6), Dunn, W. (2002). Infant/Toddler Sensory Profile. San Antonio, Tx: Pearson Forquer, L. M., & Johnson, C. M. (2005). Continuous White Noise to Reduce Resistance Going to Sleep and Night Wakings in Toddlers. Child & Family Behavior Therapy, 27, doi: /J019v27n02_01 Hollingshead, A.B. (1975). Four Factor Index of Social Status. A.B. Hollingshead. Department of Sociology. Yale University, New Haven, CT. Minde, K., Popiel, K., Leos, N., Falkner, S., Parker, K., & Handley-Derry, M. (1993). The Evaluation and Treatment of Sleep Disturbances in Young Children. Journal of Child Psychology & Psychiatry & Allied Disciplines, 34(4), Mindell, J. A., Telofski, L. S., Weigand, B., & Kurtz, E. S. (2009). A Nightly Bedtime Routine: Impact on Sleep in Young Children and Maternal Mood. SLEEP 32(5), Morrell, J. M. B. (1999). The Infant Sleep Questionnaire: A New Tool to Assess Infant Sleep Problems for Clinical and Research Purposes. Child & Adolescent Mental Health, 4(1), Morrell, J., & Cortina-Borja, M. (2002). The developmental change in strategies parents employ to settle young children to sleep, and their relationship to infant sleeping problems, as assessed by a new questionnaire: the Parental Interactive Bedtime Behaviour Scale. Infant & Child Development, 11, doi: /icd.251

20 SENSORY PROCESSING AND SLEEP IN TODDLERS 19 Owens, J. A., Spirito, A., & McGuinn, M. (2000). The Children's Sleep Habits Questionnaire (CSHQ): Psychometric Properties of A Survey Instrument for School-Aged Children. SLEEP, 23(8), 1-9. Sadeh, A. (2004). A Brief Screening Questionnaire for Infant Sleep Problems: Validation and Findings for an Internet Sample. Pediatrics, 113(6), e570-e577. Shani-Adir, A., Rozenman, D., Kessel, A., & Engel-Yeger, B. (2009). The Relationship Between Sensory Hypersensitivity and Sleep Quality of Children with Atopic Dermatitis. Pediatric Dermatology, 26(2), doi: /j x Shochat, T., Tzischinsky, O., & Engel-Yeger, B. (2009). Sensory Hypersensitivity as a Contributing Factor in the Relation Between Sleep and Behavioral Disorders in Normal Schoolchildren. Behavioral Sleep Medicine, 7, doi: / Tikotzky, L., De Marcas, G., Har-Toov, J., Dollberg, S., Bar-Haim, Y., & Sadeh, A. V. I. (2009). Sleep and physical growth in infants during the first 6 months. Journal of Sleep Research, 1-8. doi: /j x Wade, C. M., Ortiz, C., & Gorman, B. S. (2007). Two-Session Group Parent Training for Bedtime Noncompliance in Head Start Preschoolers. Child & Family Behavior Therapy, 29, doi: /J019v29n03_03 Ward, T. M., Rankin, S., & Lee, K. A. (2007). Caring for Children With Sleep Problems. Journal of Pediatric Nursing, 22(4), doi: /j.pedn Wright, M., Tancredi, A., Yundt, B., & Larin, H. (2006). Sleep Issues in Children with Physical Disabilities and Their Families. Physical & Occupational Therapy In Pediatrics, 26(3), doi: /j006vn03 05

21 SENSORY PROCESSING AND SLEEP IN TODDLERS 20 Appendix A Sleep Profile for Children Child s date of birth: Today s date: Child s gender: [ˉ] Female [ˉ] Male Your gender: [ˉ] Female [ˉ] Male Your relationship to the child: Please base your answers on what you have noticed over the last MONTH ***Does your child have a regular bedtime? [ˉ] Yes [ˉ] No Please check only one box Indicate how many times per week, 0 or N/A on average How many nights a week does your child stay up later than his/her bedtime? How many nights a week does your child resist going to bed at bedtime? *, ***How many nights are there problems with getting your child to sleep at bedtime? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] *How many nights a week does your child wake up during the night? *, ***How many nights a week does your child sleep in your bed (all or part of the night) because he/she is upset and won t sleep? ***How many mornings a week does your child need to be woken (by a family member or an alarm clock)? ***How many mornings a week does your child have a hard time waking up/getting out of bed? ***How many days a week does your child seem tired/sleepy during daytime activities? How many days a week does your child take a nap during the day? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ]

22 SENSORY PROCESSING AND SLEEP IN TODDLERS 21 Please base your answers on what you have noticed over the last MONTH Does your child have a bedtime routine? [ˉ] Yes [ˉ] No If so, please describe: N/A Less than 10 Please check only one box Indicate how many minutes, on average or more How long is the bedtime routine? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Does your child fall asleep on his/her own? [ˉ] Yes [ˉ] No N/A Less than 10 Please check only one box Indicate how many minutes, on average or more *, ***How long does it take your child to fall asleep at bedtime? How long do you spend with your child settling him/her to sleep at bedtime? *If your child wakes up during the night, how long does it take him/her to go back to sleep? How long does it take your child to settle/go to sleep at nap time? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Please check only one box Indicate how many, on average or more *, **, ***How many times does your child wake up each night and need resettling? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] How many naps does your child take during the day? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ]

23 SENSORY PROCESSING AND SLEEP IN TODDLERS 22 Less than 5 Please check only one box Indicate how many hours, on average More than 9 **How many hours does your child spend sleeping at night? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] If less than 5, please specify the number of hours: 0 or N/A Please check only one box Indicate how many hours, on average or more How many hours does your child spend napping during the day? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] If more than 5, please specify the number of hours: No Please check only one box Indicate your answer Yes, Yes, mild moderate Yes, severe *Do you think your child has sleeping problems? [ˉ] [ˉ] [ˉ] [ˉ] Please check only one box Indicate how many months N/A or more *If settling your child to sleep is a problem, how long has the problem been going on? *If waking up during the night is a problem for your child, how long has the problem been going on? *If there is a problem of your child sleeping in your bed, how long has the problem been going on? [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Do you have any additional comments about your child s sleep behaviors? Note. *Items on the ISQ; ** Items on the BISQ; The BISQ criteria of more than one hour of nighttime wakefulness was calculated using duration of settling at night multiplied by number of night waking; *** Items modified from the CHSQ.

24 SENSORY PROCESSING AND SLEEP IN TODDLERS 23 How often do you use the methods below to settle your child to sleep? Never (0) Rarely (1) Please check only one box Indicate how often Sometimes (2) Often (3) Very often (4) Stroke or pat part of child [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Cuddle or rock child [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Carry child around in your arms [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Push child in stroller [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Take child for a car ride [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Play music or musical toy [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Talk softly to child [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Sing to child [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Read a story to child [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Play with child [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Use of a special toy, cloth, or blanket [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Give bottle/food/drink or nurse [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Leave to cry [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Standing near crib/bed without picking child up [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Settle on sofa/chair with parent [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Lie down with child in his/her bed [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Settle in parent s bed [ˉ] [ˉ] [ˉ] [ˉ] [ˉ] Do you have any additional comments about the ways you help your child sleep?

25 SENSORY PROCESSING AND SLEEP IN TODDLERS 24 The following information is being asked in order for us to accurately describe the group of people who participated in our study. Self Other adult living in the home, such as spouse or committed partner A. Level of school completed, select one A. Level of school completed, select one Less than seventh grade Less than seventh grade Junior high school (9 th grade) Junior high school (9 th grade) Partial high school (10 th or 11 th grade) High school (private, parochial, trade, or public) Partial college (at least one year) or Specialized training Standard college or university Partial high school (10 th or 11 th grade) High school (private, parochial, trade, or public) Partial college (at least one year) or Specialized training Standard college or university Graduate professional training Graduate professional training N/A (i.e. you are single, widowed, divorced) B. If employed, please list current job title: B. If employed, please list current job title:

26 SENSORY PROCESSING AND SLEEP IN TODDLERS 25 Thank You for Your Time!

27 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 26 Table 1 Responses to the Sleep Profile for Children, n=51 Questions Responses Does your child have a regular bedtime? Yes, 82%; No, 16%; No response, 2% How many nights a week does your child stay up later than his/her bedtime? How many nights a week does your child resist going to bed at bedtime? How many nights are there problems with getting your child to sleep at bedtime? How many nights a week does your child wake up during the night? How many nights a week does your child sleep in your bed (all or part of the night) because he/she is upset and won t sleep? How many mornings a week does your child need to be woken (by a family member or an alarm clock)? How many mornings a week does your child have a hard time waking up/getting out of the bed? How many days a week does your child seem tired/sleepy during daytime activities? How many days a week does your child take a nap during the day? 1.8±0.2 times per week 1.6±0.3 times per week 1.4±0.2 times per week 2.2±0.3 times per week 1.3±0.3 times per week 2.0±0.3 times per week 0.8±0.2 times per week 1.1±0.2 times per week 6.7±0.1 times per week Does your child have a bedtime routine? Yes, 82%; No, 16%; No response, 2% How long is the bedtime routine? 2.7±0.3 *

28 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 27 Table 1 continued Questions How long does it take your child to fall asleep at bedtime? How long do you spend with your child settling him/her to sleep at bedtime? If your child wakes up during the night, how long does it take him/her to go back to sleep? How long does it take your child to settle/go to sleep at nap time? How many times does your child wake up each night and need resettling? How many naps does your child take during the day? How many hours does your child spend sleeping at night? How many hours does your child spend napping during the day? Do you think your child has sleeping problems? If settling your child is a problem, how long has the problem been going on? If waking up during the night is a problem for your child, how long has the problem been going on? If there is a problem of your child sleeping in your bed, how long has the problem been going on? Responses 1.1±0.2 * 0.8±0.2 * 0.4±0.2 * 0.7±0.2 * 0.8±0.1 times per night 1.1±0.1 naps per day 8.8±0.1 hours at night 2.0±0.1 hours per day Yes, 22%; No, 78% 0.5±0.1 months 1.0±0.2 months 0.5±0.2 months *NOTE: on a 0-6 scoring scale of increments of 10 minutes from 0 to 60.

29 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 28 Table 2 Significant areas of difference in sleep function using the ISQ cutoff criteria Item Toddlers with healthy sleep Toddlers with sleep dysfunction How many nights a week does your child stay up later than his/her bedtime? How many nights a week does your child resist going to bed at bedtime? How many nights are there problems with getting your child to sleep at bedtime? How many nights a week does your child wake up during the night? How many nights a week does your child sleep in your bed (all or part of the night) because he/she is upset and won t sleep? How long does it take your child to fall asleep at bedtime? How long do you spend with your child settling him/her to sleep at bedtime? If your child wakes up during the night, how long does it take him/her to go back to sleep? How many times does your child wake up each night and need resettling? 1.5±0.2 nights per week 2.9±0.5 nights per week 0.9±0.2 nights per week 3.9±0.6 nights per week 0.8±0.2 nights per week 3.5±0.5 nights per week 1.6±0.3 nights per week 4.3±0.6 nights per week 0.2±0.1 nights per week 4.8±0.9 nights per week 0.8±0.1 * 2.1±0.5 * 0.5±0.2 * 1.8±0.4 * 0.1±0.1 * 1.2±0.7 * 0.5±0.1 times per night 1.5±0.4 times per night

30 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 29 Table 2 continued Item Toddlers with healthy sleep Toddlers with sleep dysfunction How many hours does your child spend sleeping at night? If settling your child is a problem, how long has the problem been going on? If waking up during the night is a problem for your child, how long has the problem been going on? If there is a problem of your child sleeping in your bed, how long has the problem been going on? 8.9±0.0 hours per night 8.3±0.2 hours per night 0.2±0.1 months 1.4±0.4 months 0.6±0.2 months 2.3±0.4 months 0.1±0.1 months 1.8±0.4 months *NOTE: on a 0-6 scoring scale of increments of 10 minutes from 0 to 60.

31 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 30 Table 3 Significant areas of difference in sleep function using the sleep profile for children cutoff criteria Item Toddlers with healthy sleep Toddlers with sleep dysfunction How many nights a week does your child stay up later than his/her bedtime? How many nights a week does your child resist going to bed at bedtime? How many nights are there problems with getting your child to sleep at bedtime? How many nights a week does your child wake up during the night? How many nights a week does your child sleep in your bed (all or part of the night) because he/she is upset and won t sleep? How long does it take your child to fall asleep at bedtime? How long do you spend with your child settling him/her to sleep at bedtime? How many hours does your child spend sleeping at night? If settling your child is a problem, how long has the problem been going on? 1.5±0.2 nights per week 2.8±0.4 nights per week 0.8±0.2 nights per week 3.9±0.6 nights per week 0.6±0.1 nights per week 3.7±0.4 nights per week 1.6±0.3 nights per week 4.2±0.6 nights per week 0.4±0.2 nights per week 3.8±0.9 nights per week 0.7±0.1 * 2.2±0.4 * 0.4±0.1 * 2.0±0.5 * 8.9±0.0 hours 8.4±0.2 hours 0.1±0.1 months 1.5±0.4 months

32 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 31 Table 3 continued Item Toddlers with healthy sleep Toddlers with sleep dysfunction If waking up during the night is a problem for your child, how long has the problem been going on? If there is a problem of your child sleeping in your bed, how long has the problem been going on? 0.5±0.2 months 2.5±0.3 months 0.1±0.1 months 1.7±0.4 months *NOTE: on a 0-6 scoring scale of increments of 10 minutes from 0 to 60.

33 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 32 Table 4 PIBBS results Percent of respondents Never Rarely Sometimes Often Very Often Stroke or pat part of child Cuddle or rock child Carry child around in your arms Give bottle/food/drink or nurse Settle on sofa/chair with parent Settle in parent s bed Average percent of active physical comforting strategies endorsed 35.8±3 Play music or musical toy Use of a special toy, cloth, or blanket Leave to cry Average percent of encourage autonomy strategies endorsed 37.9±3.5 Push child in stroller Take child for a car ride Average percent of settle by movement strategies endorsed 3.7±1.4

34 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 33 Table 4 continued Percent of respondents Never Rarely Sometimes Often Very Often Standing near crib/bed without picking child up Lie down with child in his/her bed Average percent of passive physical comforting strategies endorsed ±2.8 Talk softly to child Sing to child Read a story to child Play with child Average percent of social comforting strategies endorsed Average number of all strategies endorsed 42.6± ±1.6

35 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 34 Table 5 Distribution of Sensory Profile scores Quadrant Less Than Others Typical Performance More Than Others Percent of toddlers Low Registration (includes 4% with the categorization of Much More Than Others) Sensory Seeking Sensory Sensitivity Sensory Avoiding

36 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 35 Table 6 Correlation of SPC scores with Sensory Profile T-scores in each quadrant of Dunn s model Quadrant R 2 R P* Sensory Seeking Low Registration Sensory Sensitivity Sensory Avoiding *Note: p<0.0125

37 Running head: SENSORY PROFILE AND SLEEP DISTURBANCES 36 Figure 1. Concurrent validity of the sleep profile for children. A. B. C. A. Average sleep profile for children average children scores for participants whose Infant Sleep Questionnaire (SPC) scores were below (blue, n=12) and above (red, n=39) the cutoff score of 12. The average sleep profile for children score for children with ISQ scores of 12 or higher was significantly higher using p< B. The sleep profile for children scores were significantly, positively correlated with ISQ scores (R 2 =0.699, r=0.836, p<0.01). C. Using a cutoff score of 24 on the sleep profile for children identifies eleven of the twelve of the toddlers with a score above 12 on the ISQ (8% false negative rate) and identifies two toddlers with scores below 12 on the ISQ (5% false positive rate).