Mediating Effect of Emotional and Behaviors Symptoms on the Relationship Between Parenting Behaviors and Sleep problems in Preschool Children

Abstract

Background

Sleep plays an important role in the growth and development of children, and are affected by many factors. There are few studies on parenting behaviors on preschool children's sleep problems. Understanding the influence of parents on children's sleep and potential factors are helpful to correct rearing strategies in time and better promote children's sleep health.

Methods

A population-based survey was conducted in 109 kindergartens in 11 cities in China. The social security consumption of children was evaluated through a questionnaire filled out by caregivers. Children's sleep problems were assessed by Children's Sleep Habits Questionnaire (CSHQ), the Parent Behavior Inventory (PBI) to evaluate the parenting behavior of preschool children, emotional and behaviors symptoms were assessed by Strengths and Difficulties Questionnaire (SDQ).

Result

Approximately 15.3% of the preschoolers reported sleep problems. The adjusted odds ratios (95% confidence interval) of having elevated total difficulties for sleep problems across the maternal hostile/coercive were 1.00, 1.38 (1.23, 1.54) and 1.86 (1.64, 2.10), respectively (P for trend < 0.001); The paternal hostile/coercive were 1.00, 1.17 (1.05, 1.30) and 1.59 (1.42, 1.79), respectively (P for trend < 0.001). The mediation analysis further revealed partial mediation effects of emotional and behavioral symptoms on the association between parenting behaviors and children sleep.

Conclusions

Parents' hostile/coercive parenting styles increase the risk of children's sleep problems, in which emotional and behavioral problems play a mediating role.

Introduction

Sleep is essential for children's health and growth. Several lines of studies have found that sleep problems in preschool children are common, especially insufficient sleep[1, 2], and more than 40% of Chinese preschoolers do not reach the recommended sleep time[2, 3]. Previous studies have shown that adequate sleep is associated with better attention, behavior, cognitive function, emotional regulation and physical health in children[4–6]. In addition, in a population study of 11,000 children, sleep problems before the age of 5 increased the likelihood of special education at the age of 8[7].Therefore, paying attention to preschool children's sleep and intervention on children's sleep habits can effectively reduce the disease risk of children and their future growth.

Identifying and managing sleep problems in childhood can improve adolescent and adult health[8]. Parent, as guardians of their children, implement positive discipline strategies or limit negative strategies, which are very important to promote positive parent-child interaction. Extending this theoretical framework to the field of sleep, parenting strategies may also play a vital role in promoting healthy sleep habits[9]. Parenting plays an important role in improving children's sleep[10, 11], which can directly or indirectly influence their children's sleep condition through specific parenting style (authoritative, authoritarian, permissive, and uninvolved)[12]. Some studies have shown that parents' mood and parenting pressure can affect children's sleep quality[13–15]. Parental rearing behavior and poor sleep hygiene are also related to sleep difficulties in normally developing children[16]. Despite the extensive literature on parenting strategies on parent-child interaction and behavioral issues, it is uncommon to independently study the association of positive and negative parenting strategies with child sleep problems[9].

A meta-review indicate there is a large and consistent evidence that children sleep problem is related to emotional outcomes[17]. In addition, the interaction between children's emotional and behavioral problems and sleep has also been mentioned in some cohort studies[18–20]. A study of nocturnal awakening in children has found that persistent difficulty in waking up early in life is positively correlated with emotional symptoms, attention-deficit hyperactivity disorder (ADHD), inattention and behavioral problems[21]. And the length of nocturnal sleep and poor sleep quality of Chinese children aged 3 to 6 years old were negatively correlated with their emotional and behavioral problems[22]. Furthermore, parental rearing behaviors and styles also have an important influence on the emotional behavior of preschool children. Negative parenting styles can have adverse consequences for children's emotional and behavioral problems[23–26], correct parenting intervention can reduce the occurrence of emotional and behavioral problems[27]. Combined with the influence of parental rearing styles on children's emotional behavior, this paper also explores the influence of children's emotional behavior on children's sleep quality in the choice of parental rearing strategies.

In the current study, we aimed to investigate the association between parental rearing styles and sleep quality of preschool children, and to explore the mediating role of children's emotion in this association, based on the cross-sectional survey data of 27,200 preschool children in the middle and lower reaches of the Yangtze River in China.

Materials and methods

2.1 Study Design and Population

Data collected in the preschool growth and development status study in the middle and lower reaches of the Yangtze River in 2017, which is a cross-sectional study of 27,200 children (3–6 years old) in kindergartens in Hubei, Anhui and Jiangsu provinces in the middle and lower reaches of the Yangtze River from October to November 2017. This study was aimed to understand the growth and development of preschool children in this area, and to determine the possible risk factors for preschool children's growth and development according to the collected information, so as to formulate and implement comprehensive methods to further improve children's health. Details on the study population and data collection have been described elsewhere[28]. This study follows the principles of informed consent and privacy protection, and informs the parents of the investigated children of the purpose, content and significance of the study. Emphasize the principle of voluntary participation, keep the personal information provided strictly confidential, and sign the informed consent form after obtaining the consent. This study was reviewed by the Biomedical Ethics Committee of Anhui Medical University.

2.2 Study Variables

2.2.1 The Parent Behavior Inventory (PBI)

The PBI to evaluate the parenting behavior of preschool children. PBI is a concise scale used to evaluate the parenting behavior of preschool or lower-grade children[29]. It includes 20 items and was divided into two dimensions: supportive/engaged and hostile/coercive. Each item has six evaluation criteria, including "never", "occasionally", "sometimes", "medium", "often" and "always", with a score of 0–5 respectively. The total score for each dimension was calculated and used to divide the children into three categories (less than or equal to P25, between P25 and P75, greater than P75). In the current study, Cronbach's alpha coefficient for the PBI was 0.799.

2.2.2 The Children's Sleep Habits Questionnaire (CSHQ)

The CSHQ is a parent-reported measurement which widely used to evaluate recent sleep behavior in children[30–32], and has been extensively used to assess Chinese children[33–35].The questionnaire contains a total of 33 scoring items, each of which is scored according to Likert 3. Parents are asked to fill in according to their children's sleep condition in the past week. The higher the score, the more serious it is. The questionnaire discusses children's sleep habits, sleep patterns and sleep problems from eight levels, which can fully reflect the sleep status of children of this age. Generally speaking, CSHQ > 41 will be used as the standard to measure children's sleep abnormality, but this study will adopt the standard that is more suitable for Chinese children. CSHQ scores > 54 have been reported as the most sensitive cutoff for identifying sleep problems that indicates that there are sleep problems and warrant further clinical assessment in China[36]. Cronbach's alpha coefficient for the CSHQ full scale was 0.86.

2.2.3 The strengths and difficulties questionnaire (SDQ)

Children's emotional and behavioral problems were evaluated by using the SDQ [37]. The questionnaire has four difficulties or problems subscales (emotional symptoms, conduct problems, hyperactivity and peer problems) and one strengths subscale (prosocial behavior). The total score of SDQ was the sum of 4 subscales, except for the prosocial behavior, and higher scores indicate more serious problems. SDQ score was divided into normal, suspicious and abnormal according to the classification criteria of Robert Goodman et al[38]. In the current study, Cronbach's alpha coefficient for the SDQ total difficulties scale was 0.842.

2.3 Covariates

Parents and guardians reported their child's date of birth in the questionnaires, for which children's age (3–6 years old) was calculated. Gender, residence, economic status of family, parents' age, parents' education level, night noise, body mass index (BMI), only child, screen time, outdoor activity, exclusive breastfeeding was also included as covariates.

Results

3.1 Sample characteristics

Table 1 shows the association between demographic characteristics and sleep problem in preschoolers. In our survey, approximately 15.3% of the preschoolers reported CSHQ total score > 54, and children with low age group, poor economic status of family, low age group of parents, highly educated parents, night noise, only child, extensive screen time have more sleep problems (P < 0.001 or 0.05). In addition, emotional and behavioral symptoms (SDQ is abnormal) and parents’ higher level hostile/coercive are also more likely to have sleep problems (P < 0.001).  

3.2 Association of parenting behaviors with sleep problems and emotional and behavior symptoms in preschool children

Parenting behaviors takes the low-level group of each dimension as the reference group. In all model, the ORs for the sleep problem increased across the maternal hostile/coercive score and paternal hostile/coercive score.

The adjusted associations between sleep problems (CSHQ total score > 54) and parenting behaviors and emotional symptoms are shown in Table 2. The crude model ORs (95%CI) for sleep problems across the maternal hostile/coercive were 1.00, 1.46 (1.31, 1.63) and 2.21 (1.96, 2.50) (P for trend < 0.001), respectively. After adjusting for confounding factors, the ORs (95%CI) for sleep problems across the maternal hostile/coercive were 1.00, 1.38 (1.23, 1.54) and 1.86 (1.64, 2.10), respectively, suggesting a significant dose-response relationship (P for trend < 0.001). The crude model ORs (95%CI) for sleep problems across the paternal hostile/coercive were 1.00, 1.21 (1.09, 1.84) and 1.83 (1.64, 2.06) (P for trend < 0.001), respectively. After adjusting for multiple confounding factors, the ORs (95%CI) for sleep problems across the paternal hostile/coercive were 1.00, 1.17 (1.05, 1.30) and 1.59(1.42, 1.79), respectively, suggesting a significant dose-response relationship (P for trend < 0.001). The crude model ORs (95%CI) for sleep problems across the SDQ scores were 1.00, 2.35 (2.15, 2.57) and 3.64 (3.33, 3.97) (P for trend < 0.001), respectively. After adjusting for confounding factors, the ORs (95%CI) for sleep problems across the SDQ scores were 1.00, 2.30 (2.10, 2.52) and 3.57 (3.27, 3.90), respectively, suggesting a significant dose-response relationship (P for trend < 0.001). 

 Table 2. Odds ratio of sleep problems by level of parenting behaviors and emotional symptoms

3.3 Association of parenting behaviors with emotional and behaviors symptom in preschool children

Parenting behaviors takes the low-level group of each dimension as the reference group, SDQ scores takes the normal group of each dimension as the reference group. Table 3 shows parenting behavior and childrens’ emotional and behavior symptoms are significantly related (P < 0.001). The model ORs (95%CI) for SDQ scores across the maternal supportive/engaged were 1.00, 0.65 (0.45, 0.57) and 0.51 (0.59, 0.71) (P < 0.001), respectively. The model ORs (95%CI) for SDQ scores across the maternal hostile/coercive were 1.00, 1.64 (1.45, 1.86) and 2.68 (2.34, 3.06) (P < 0.001), respectively. Paternal result is the same as maternal.  

3.4 The relationship between parenting behaviors and children sleep mediated by emotional and behaviors symptoms

In order to further understand the role of children emotional behavior between the parenting behavior and children sleep problem, we performed a mediating effect analysis. In this model, SDQ scores were used as mediating variables, parenting behavior as independent variables and CSHQ score as dependent variables.

Figure 1 shows the model of the relationship between maternal hostile/coercive and sleep problems mediated by SDQ total score. The mediation model was significant (F = 1027.26, p < 0.001), accounting for 16% [0.024/(0.125 + 0.024)] of the mediating effect, where the total effect is equal to the direct effect (0.125) plus the indirect effect (0.024). Both the direct effect of maternal hostile/coercive on SDQ (a = 0.200, SE = 0.004, p < 0.001) and the SDQ on CSHQ (b = 0.118, SE = 0.006, p < 0.001) were significant. Moreover, the direct effect of maternal hostile/coercive on CSHQ (c’ = 0.125, SE = 0.005, p < 0.001) was also significant. Finally, the bootstrapping results proved the significant effect of maternal hostile/coercive on CSHQ score through SDQ score [B = 0.024, bias-corrected and accelerated 5,000 bootstrapping (BCa) 95%CI = 0.020 ~ 0.027] (Table 4). The full model explains 11% of the total variance of maternal hostile/coercive on CSHQ score. These results suggest that emotional and behavioral symptoms partially mediates the relationship between maternal hostile/coercive and sleep problems.

Table 4. Testing of bootstrap the mediation effect of maternal hostile/coercive on CSHQ scores 

Figure 2 shows the model of the relationship between paternal hostile/coercive and sleep problems mediated by SDQ score. The mediation model was significant (F = 827.87, p < 0.001), accounting for 17% [0.024/(0.118 + 0.024)] of the mediating effect, where the total effect is equal to the direct effect (0.118) plus the indirect effect (0.024). Both the direct effect of paternal hostile/coercive on SDQ (a = 0.187, SE = 0.005, p < 0.001) and the SDQ on CSHQ (b = 0.127, SE = 0.006, p < 0.001) were significant. Moreover, the direct effect of paternal hostile/coercive on CSHQ (c’ = 0.118, SE = 0.005, p < 0.001) was also significant. Finally, the bootstrapping results proved the significant effect of paternal hostile/coercive on CSHQ score through SDQ score [B = 0.024, bias-corrected and accelerated 5,000 bootstrapping (BCa) 95%CI = 0.021 ~ 0.027] ( Table 5 ). The full model explains 12% of the total variance of paternal hostile/coercive on CSHQ score. These results suggest that emotional and behavioral symptoms partially mediates the relationship between paternal hostile/coercive and sleep problems.

Table 5. Testing of bootstrap the mediation effect of paternal hostile/coercive on CSHQ score 

Discussion

Based on a multi-center large sample study, we examined the associations between parenting behaviors and sleep problem among preschoolers, and to determine whether emotional and behavioral act as an mediation to affect the sleep status of preschool children. Results showed that parents' higher hostile/coercive level were positively related to children's sleep problem,and emotional behavior emerged as a significant mediator in the association between parenting behaviors and children's sleep problems.

In this large sample of nearly 30,000 preschool children from 11 cities across China, about 15.3% of preschool children were in sleep problems[40]. A study of sleep problems among children in Jiangsu Province of China found that sleep problems in preschool children are very common, ranging from 8.9% who are difficult to maintain sleep to 70.5% who do not want to sleep alone, other sleep problems include difficulty falling asleep (39.4%), nightmares (31.6%), raving (28.0%), sleep deprivation (24.7%) and sleep resistance (23.4%)[41]. In addition, it has been reported in Shijiazhuang of China that the incidence of sleep problems in children is more than 40%[42]. The impact of sleep problems on preschool children in Europe and the United States is 20.0%. The difference in the detection rate of sleep problems may be the result of the interaction between culture and biology[43].

Sleep problems in preschool children are more prominent, and were obviously affected by family environment and other factors. This study found that sleep problems decrease with age, which is similar to previous reports[1, 44]. Among the demographic characteristics of this study, economic status of family, parents’ age, parents’ education level, night noise, only child and screen time ≥ 2h were associated with children sleep problem, which supporting the hypothesis that the family environment and unhealthy lifestyle can affect children’s sleep status.[45, 46]. In addition, Murcia[47] et al have found that breastfeeding for more than 4 months can reduce the risk of prolonged sleep latency in early childhood and preschool children. Therefore, exclusive breastfeeding was introduced into this study, but the relationship between exclusive breastfeeding and children's sleep problems was not observed. We will further explore whether the protective effect of sleep comes from breastfeeding in future studies.

In the current study, we found that parents' hostile/coercive had more significant effects on children's sleep problems than supportive/engaged and parents' hostile/coercive was positively associated with sleep problems in children. The effect of parenting strategies on children's sleep has been reflected in previous studies. For example, the greater the parenting pressure of guardians, the higher the incidence of sleep problems in children[14, 48]. The explanation for the potential mechanism is that neurobiological studies emphasize how stress activates the hypothalamus-pituitary-adrenal (HPA) axis and the secretion of glucocorticoids (such as cortisol), which leads to sleep interruption. Given that there are few studies on the relationship between positive and negative parenting strategies and children's sleep problems[9], the results of this paper can be used as a reference.

Consistent with previous studies, we found an association between parenting behaviors and children's emotional and behavioral problems[13–16]. And in this study, parents' hostile/coercive strategies have a more significant impact on children. In the process of raising children, parents will choose their own attitudes and ways towards their children, and the subjective emotions existing in the process of rearing will exert an imperceptible influence on the children, and then have an impact on the psychological behavior of children[49]. In addition, this study also found that children’s psychological and behavioral problems are also related to their sleep problems[50]. A number of studies have shown the effects of emotional and behavioral problems on children's sleep, consistent with the results of this study [19–21].Therefore, combining the relationship between the three, we speculate that children’s emotional and behavioral problems may be the mediating factors in the relationship between parenting behaviors and children’s sleep problems. By using the mediating effect model, we found that emotional behavior problems do play a mediation role in the associations between negative rearing styles and children sleep problem. Indicating parents' negative rearing strategies will cause certain psychological pressure to children, thus affecting their sleep.

The strengths of this study include its wide geographical coverage and large sample size, which imparted good representation. Furthermore, we fully considered potential covariates, especially emotional behaviors. However, this study also has some limitations. First, the data concerning sleep problem and emotional behaviors symptom was retrospective and reported by a caregiver, which might have been subject to recall biases. Furthermore, behavioral problems were not confirmed by clinical diagnosis but relied on a screening scales of the SDQ. The total scores on the SDQ do not correspond with a clinical diagnosis of behavioral problems but rather indicate the level of psychological symptoms and ASD that may be clinically relevant. Second, although we adjusted for potential confounding factors, we may not have measured all aspects of these factors. Thirdly, in the questionnaire, we lack information about children's pre-bedtime activities and electronic exposure, resulting in some potential influencing factors not taken into account. Finally, although the mediating effect model can explore the internal mechanism of variable associations, cross-sectional data limit the strength and direction of inferences about variable causal associations. Potential causal associations need to be further verified through longitudinal studies.

Conclusion

Parenting behavior will affect the sleep quality of preschool children, especially hostile/coercive rearing strategies, and emotional behavior factors play a role in it. In addition, sleep problems and quality of preschool children are more likely to be affected by family and environmental factors.

Declarations

Ethics approval and consent to participate: All experimental protocols were approved by the Ethics Committee of Anhui Medical University. Also, all methods in this study were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects and/or their legal guardian(s) of participants below 16 years.

 Consent for publication: Not applicable.

 Availability of Data and Materials: The data used and analyzed during the current study are available from the corresponding author on reasonable request.

 Competing Interests: The authors declare no conflicts of interest.

 Funding: The study is funded by the National Natural Science Foundation of China (No. 81573168).

 Author Contributions: PD: investigation, statistical analysis and draft the manuscript; MLG: involved in statistical analysis, draft and review manuscript; XYW: investigation and statistical analysis; SMT: study design, involved in statistical analysis. FBT: obtained the funding and designed the study, recruited the participants, edited and revised the manuscript. All the authors who contributed to the manuscript gave their approval for its submission. The work presented here has not been published previously and is not being considered for publication elsewhere. The author(s) read and approved the final manuscript. All authors have read and approved the manuscript. 

 Acknowledgments: Thanks to all participants who involved in the study for their inputs. We frankly thank all participants and the schools involved in the survey, as well as other staff members on the scene.

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