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An
Pediatr
(Barc).
2018;
89(4)
:230---237
www.analesdepediatria.org
ORIGINAL
ARTICLE
Adaptation
and
study
of
the
measurement
properties
of
a
sleep
questionnaire
for
infants
and
pre-school
children

,

Pia
Cassanello
a
,
Ana
Díez-Izquierdo
a
,
b
,
Nuria
Gorina
a
,
b
,
Nuria
Matilla-Santander
b
,
Jose
M.
Martínez-Sanchez
b
,
Albert
Balaguer
a
,
b
,
a
Hospital
Universitari
General
de
Catalunya,
Sant
Cugat
del
Vallès,
Barcelona,
Spain
b
Universitat
Internacional
de
Catalunya,
Sant
Cugat
del
Vallès,
Barcelona,
Spain
Received
14
September
2017;
accepted
7
December
2017
Available
online
6
September
2018
KEYWORDS
Child;
Pre-school;
Infant;
Sleep/physiology;
Sleep
wake
disorders/diagnosis;
Surveys
and
questionnaires;
Validation
studies
Abstract
Introduction:
Although
sleep
disturbances
in
infants
and
toddlers
are
common,
there
is
no
suit-
able
validated
tool
in
Spanish
to
evaluate
sleep
disorders.
The
Brief
Infant
Sleep
Questionnaire
(BISQ)
is
a
well-established
multidimensional
questionnaire
widely
used
internationally.
Objectives:
To
adapt
the
BISQ
questionnaire
to
Spanish
and
analyse
its
reliability
and
validity.
To
explore
its
feasibility,
both
in
the
clinical
context,
and
in
epidemiological
research.
Methods:
Participants
were
parents
of
children
between
3
and
30
months
of
age.
The
adapta-
tion
to
Spanish
(BISQ-E)
was
achieved
by
using
both
back
translation
and
consensus,
following
the
international
guidelines.Reliability
was
determined
by
means
of
test---retest
and
measure-
ment
of
agreement
(Kappa
value)
between
2
forms
of
administration
of
the
questionnaire
(self-administration
and
clinical
interview).
Construct
validity
was
established
by
analysing
its
correlation
with
a
sleep
diary.
Results:
A
total
of
87
families/children
participated.
The
test---retest
reliability
undertaken
in
60
subjects
was
r
=
0.848
(
P
<
.001).
The
kappa
value
was
0.939
(95%
CI:
0.858---1.00,
P
<
.001).The
agreement
between
BISQ-E
and
the
sleep
diary
was
analysed
in
27
families/children,
with
statistically
significant
values
being
obtained
for
the
following
variables:
bedtime
(
r
=
0.731),
hours
of
night
sleep
(
r
=
0.726),
hours
of
daytime
sleep
(
r
=
0.867),
and
number
of
nocturnal
awakenings
(
r
=
0.888)
(
P
<
.001).

Please
cite
this
article
as:
Cassanello
P,
Díez-Izquierdo
A,
Gorina
N,
Matilla-Santander
N,
Martínez-Sanchez
JM,
Balaguer
A.
Adaptación
y
estudio
de
propiedades
métricas
de
un
cuestionario
de
valoración
del
sue
̃
no
para
lactantes
y
preescolares.
An
Pediatr
(Barc).
2018;89:230---237.

Previous
presentation
:
Parts
of
this
study
were
presented
as
an
oral
communication
at
the
65th
Congress
of
Sociedad
Espa
̃
nola
de
Pediatría;
June
1---3,
2017;
Santiago
de
Compostela,
Spain.
Corresponding
author.
E-mail
address:
abalaguer@uic.es
(A.
Balaguer).
2341-2879/©
2017
Asociaci
́
on
Espa
̃
nola
de
Pediatr
́
ıa.
Published
by
Elsevier
Espa
̃
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(
http://creativecommons.org/licenses/by-nc-nd/4.0/
).
Adaptation
and
study
of
the
measurement
properties
of
a
sleep
questionnaire
231
Conclusions:
The
Spanish
adaptation
of
the
BISQ
shows
overall
adequate
validity
and
reliability
for
the
evaluation
of
sleep
in
infants
and
pre-school
children.
Its
use
as
a
clinical
tool,
or
for
clinical-epidemiological
research
studies,
is
feasible.
©
2017
Asociaci
́
on
Espa
̃
nola
de
Pediatr
́
ıa.
Published
by
Elsevier
Espa
̃
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY-NC-ND
license
(
http://creativecommons.org/licenses/by-nc-nd/
4.0/
).
PALABRAS
CLAVE
Ni
̃
no;
Preescolar;
Lactante;
Sue
̃
no/fisiología;
Trastornos
del
sue
̃
no/diagnóstico;
Encuestas
y
cuestionarios;
Estudios
de
validación
Adaptación
y
estudio
de
propiedades
métricas
de
un
cuestionario
de
valoración
del
sue
̃
no
para
lactantes
y
preescolares
Resumen
Introducción:
Aunque
las
alteraciones
del
sue
̃
no
en
lactantes
y
preescolares
son
comunes,
no
se
dispone
de
un
instrumento
en
espa
̃
nol
adecuadamente
validado
para
su
estudio.
El
Brief
Infant
Sleep
Questionnaire
(BISQ)
es
un
cuestionario
multidimensional
bien
establecido
con
este
fin
en
el
ámbito
internacional.
Objetivos:
Adaptar
el
BISQ
al
espa
̃
nol
y
analizar
su
fiabilidad
y
validez.
Explorar
su
viabilidad
en
el
contexto
asistencial
y
de
investigación.
Participantes
y
métodos:
Se
incluyeron
ni
̃
nos
de
3
a
30
meses
de
edad.
La
adaptación
al
espa
̃
nol
(BISQ-E)
se
efectuó
mediante
técnica
bilingüe
de
retrotraducción
y
consenso,
siguiendo
las
recomendaciones
internacionales.
Se
evaluó
la
fiabilidad
mediante
análisis
de
los
resultados
del
test---retest
del
BISQ-E
y
de
la
concordancia
de
las
respuestas
a
2
formas
de
administración
(autoadministración
y
entrevista
clínica).
La
validez
de
constructo
se
estableció
analizando
su
correlación
con
un
diario
de
sue
̃
no.
Resultados:
Participaron
un
total
de
87
familias/ni
̃
nos.
La
correlación
global
test---retest
en
60
sujetos
fue
de
r
=
0,848
(p
<
0,001).
El
índice
de
kappa
entre
las
2
formas
de
administración
fue
de
0,939
(IC
95%:
0,858---1,00;
p
<
0,001).La
correlación
BISQ-E-diario
de
sue
̃
no
se
analizó
en
27
familias/ni
̃
nos
y
fue
estadísticamente
significativa
para
las
variables
estudiadas:
hora
de
acostarse
(r
=
0,731),
horas
de
sue
̃
no
nocturno
(r
=
0,726),
horas
de
sue
̃
no
diurno
r
=
0,867)
y
número
de
despertares
nocturnos
(r
=
0,888)
(p
<
0,001).
Conclusiones:
La
adaptación
espa
̃
nola
del
BISQ
presenta
unas
características
de
validez
y
fia-
bilidad
adecuadas
para
la
evaluación
del
sue
̃
no
en
lactantes
y
preescolares.
Su
utilización
como
instrumento
clínico
o
para
estudios
de
investigación
clínico-epidemiológica
resulta
factible.
©
2017
Asociaci
́
on
Espa
̃
nola
de
Pediatr
́
ıa.
Publicado
por
Elsevier
Espa
̃
na,
S.L.U.
Este
es
un
art
́
ıculo
Open
Access
bajo
la
licencia
CC
BY-NC-ND
(
http://creativecommons.org/licenses/by-
nc-nd/4.0/
).
Introduction
Sleep
disturbances
in
children
are
among
the
most
frequent
reasons
for
consultation
in
paediatric
clinical
practice.
1,2
Previous
studies
report
that
between
25%
and
46%
of
the
paediatric
population
may
experience
some
type
of
sleep
disturbance
during
childhood
or
adolescence.
3,4
The
preva-
lence
reported
in
the
literature
for
children
aged
less
than
3
years
ranges
between
11%
and
40%.
5,6
Many
sleep
distur-
bances
are
behavioural
in
nature
(difficulty
falling
asleep,
difficulty
staying
asleep
or
poor
sleep
hygiene),
7
so
their
prevention
and
management
should
start
as
early
as
possible
and
should
be
pursued
from
the
field
of
primary
care.
Current
sleep
recommendations
and
guidelines
are
mainly
based
on
expert
opinion
and
consensus,
as
there
is
little
experimental
evidence
in
this
field.
2,8
Notwithstand-
ing,
the
available
literature
evinces
a
growing
interest
in
the
essential
link
between
sleep
and
adequate
physical,
cognitive
and
psychosocial
development,
including
its
impact
on
family
dynamics.
9---11
The
sleep-onset
time
and
the
total
duration
of
sleep
in
the
first
years
of
life
are
considered
predictors
for
features
of
anxiety
(separation
anxiety,
introversion)
12,13
and
have
been
associated
with
an
adequate
acquisition
of
healthy
eating
habits
14
and
increased
inactivity
and
obesity
in
toddlers.
15
In
light
of
their
importance,
routine
screening
of
sleep
disturbances
would
be
helpful
for
their
early
detec-
tion,
which
would
allow
appropriate
intervention
and
thus
improvement
of
psychosocial
and
cognitive
outcomes
in
the
paediatric
population.
16
The
multidimensional
nature
of
sleep
poses
challenges
to
its
evaluation.
Polysomnography
and
actigraphy
contribute
relevant
data,
11,17
but
their
usefulness
is
limited
due
to
their
low
feasibility
in
large-scale
population-based
studies.
Fur-
thermore,
they
offer
little
towards
the
assessment
of
some
behavioural
factors
that
play
important
roles
in
sleep.
1
This
is
why
it
is
important
to
develop
questionnaires
that
can
assess
subjective
variables
such
as
the
restorative
quality
of
sleep
and
the
potential
impact
on
the
family.
The
Brief
Infant
Sleep
Questionnaire
(BISQ)
is
one
of
the
most
widely
used
questionnaires
currently
available
for
the
assessment
of
sleep
in
early
childhood
(
Table
1
).
18
It
was
232
P.
Cassanello
et
al.
Table
1
Instruments
to
assess
sleep
in
infancy
and
early
childhood.
Instrument
(acronym)
Author,
year
Age
Dimensions
assessed
Items
Assessment
period
Infant
Sleep
Questionnaire
(ISQ)
Morrell,
1999
12---18
months
Tool
to
screen
for
difficulty
falling
asleep
and
duration
of
night-time
sleep
10
1
month
Maternal
Cognitions
about
Infant
Sleep
Questionnaire
(MCISQ)
Morrell,
1999
12.9---16.8
months
Sleep
habits,
parent
attitudes
towards
difficulties
falling
and
staying
asleep,
demographic
variables
20
Not
specified
Obstructive
Sleep
Apnea
(OSA)
Franco,
2000
6
months---12
years
Breathing
pattern
during
sleep,
mood,
daytime
sleepiness,
parental
anxiety
18
4
weeks
Sleep
and
Settle
Questionnaire
(SSQ)
Matthey,
2001
6
weeks---6
months
Instrument
to
assess
difficulties
falling
asleep,
duration
of
night-time
sleep
and
daytime
behaviour
34
1
week
Parental
Interactive
Bedtime
Behaviour
Scale
(PIBBS)
Morrell,
2002
12---19
months
Method
to
help
child
fall
asleep
22
Not
specified
Brief
Infant
Sleep
Questionnaire
(BISQ)
Sadeh,
2004
0---30
months
Instrument
to
assess
duration
of
sleep,
duration
of
sleep
by
circadian
rhythm
and
night-time
awakenings
13
2
weeks
Tayside
Children’s
Sleep
Questionnaire
(TCSQ)
McGreavey,
2005
1 --- 5
years
Instrument
for
screening
difficulties
falling
and
staying
asleep
10
3
months
Children’s
Sleep
Status
Questionnaire
(CSSQ)
Xiao,
2009
0 --- 5
years
Bedtime
routines,
sleep
patterns,
sleep
disorders,
sleep
habits,
demographic
characteristics
47
1
month
Adaptation
and
study
of
the
measurement
properties
of
a
sleep
questionnaire
233
designed
to
be
administered
to
parents
of
children
aged
3---30
months
of
age.
This
questionnaire
stands
out
because
it
is
a
robust
instrument
of
proven
reliability
and
validity,
easy
to
use
and
brief
(14
items),
and
thus
could
be
used
as
a
screening
tool.
1,7,16,19
The
BISQ
has
been
widely
used
in
countries
such
as
the
United
States
and
China.
20---23
In
addition
to
the
English
version,
it
has
been
translated
to
Portuguese,
24
Turkish,
25
Chinese
21
and
Nepalese.
26
The
Spanish
primary
care
clinical
practice
guideline
on
sleep
disorders
in
children
and
adolescents
proposes
this
instrument
as
the
preferred
choice
for
screening
of
sleeping
disorders
in
early
childhood.
27
To
date,
there
is
no
version
translated
to
Spanish
and
adapted
to
the
Spanish
population
with
an
appropriate
methodology,
including
assessment
of
its
psychometric
prop-
erties.
Our
hypothesis
was
that
it
would
be
possible
to
develop
a
Spanish
version
of
the
BISQ
that
would
retain
its
good
psychometric
properties.
Consequently,
the
aim
of
our
study
was
to
translate
and
adapt
the
original
versions
and
analyse
the
reliability
and
validity
of
the
new
questionnaire
in
Spanish.
Patients
and
methods
The
BISQ
comprises
14
items:
4
on
the
demographic
char-
acteristics
of
the
child
and
10
on
sleep
habits.
There
are
4
multiple-choice
single-answer
questions
and
6
open-ended
questions
about
the
timing
and
duration
of
sleep.
To
adapt
these
items,
we
followed
the
general
recommendations
of
the
International
Test
Commission
guidelines
for
test
trans-
lation
and
adaptation
28
as
well
as
specific
recommendations
for
adapting
health-related
quality
of
life
(HRQoL)
assess-
ment
tools.
29,30
First
phase:
transcultural
translation
and
adaptation
to
the
Spanish
population
After
obtaining
permission
from
the
author
of
the
original
BISQ,
18
we
followed
a
process
of
forward-backward
bilingual
translation
and
adaptation
by
consensus.
Thus,
3
members
of
the
research
team
produced
3
translations
to
Spanish
of
the
original
instrument,
independently
and
blinded
to
each
other’s
work.
This
was
followed
by
the
collaborative
devel-
opment
of
a
single
integrated
version,
reaching
a
consensus
on
the
wording
of
each
item
on
the
scale.
This
prelimi-
nary
version
was
submitted
to
a
native
English
speaker
that
was
not
acquainted
with
the
original
English
version
and
produced
a
backward
translation.
After
analysing
these
ver-
sions
in
a
consensus
meeting,
additional
changes
were
made.
Finally,
we
performed
a
pilot
test
of
the
translation
in
5
fam-
ilies,
which
resulted
in
subtle
adaptations
and
the
definitive
version
of
the
Spanish
BISQ
(BISQ-E)
(
Appendix
A
).
Second
phase:
validation
of
the
questionnaire
To
determine
whether
the
psychometric
properties
of
the
translated
questionnaire
were
acceptable,
we
assessed
its
reliability
and
validity.
To
assess
its
reliability,
we
analysed
two
components:
(A)
interobserver
reliability
and
(B)
intraobserver
reliability.
A)
We
measured
the
agreement
of
the
answers
obtained
with
the
BISQ-E
when
it
was
self-administered
compared
to
when
it
was
administered
by
an
interviewer.
We
selected
an
item
of
the
questionnaire
that
was
impor-
tant
in
the
interpretation
of
results
18
(
Do
you
consider
your
child’s
sleep
habits
a
problem?
)
and
compounded
the
two
affirmative
answer
choices
into
a
single
one
to
turn
the
answer
into
a
dichotomous
variable
(yes/no).
A
total
of
60
families
completed
the
BISQ-E
before
their
appointment
in
the
referral
hospital
where
the
question-
naire
was
validated.
Later
on,
a
member
of
the
research
team
asked
the
aforementioned
question
(administration
by
interviewer)
to
assess
the
degree
of
agreement
of
the
two
answers
obtained
for
this
item.
We
estimate
that
approxi-
mately
20---30
min
passed
between
the
two
interventions.
B)
We
performed
correlation
analysis
to
assess
test---retest
reliability,
for
which
we
administered
the
BISQ-E
to
a
group
of
27
families
at
2
time
points:
during
the
first
contact
of
the
families
with
the
research
team
(T1),
and
after
a
period
of
at
least
1
week
from
the
first
test
(T2).
To
analyse
construct
validity,
we
compared
the
results
of
the
BISQ-E
questionnaire
with
the
records
of
a
sleep
diary.
The
diary
was
formatted
as
a
table
and
was
used
to
collect
different
variables
related
to
sleep-wake
cycle
pat-
terns
for
7---14
days:
bedtime,
sleep-onset
time,
night-time
awakenings
(number
and
duration),
time
of
final
awaken-
ing
and
hours
of
daytime
sleep.
The
sleep
diary
is
a
valid
and
independent
instrument
to
assess
sleep
patterns
in
chil-
dren
and
is
considered
the
gold
standard
for
subjective
sleep
assessment.
31
To
compare
the
two
measures,
we
asked
the
27
families
that
had
completed
the
BISQ-E
to
fill
out
the
sleep
diary
for
7
consecutive
days
(diary
adapted
from
Richman
32
).
Study
population
and
participants
To
assess
reliability,
we
included
60
child/family
by
consec-
utive
sampling.
For
the
assessment
of
validity,
we
selected
a
convenience
sample
of
27
individuals.
Overall,
the
study
included
87
healthy
children
aged
3---30
months
(60
in
the
assessment
of
reliability
and
27
in
the
assessment
of
validity)
included
in
the
outpatient
caseload
of
the
depart-
ment
of
paediatrics
of
the
Hospital
Universitario
General
de
Catalunya.
The
inclusion
criteria
were
to
have
an
age
in
the
established
range
and
consent
from
the
parents
or
legal
tutors
to
participate
in
the
study.
The
exclusion
criteria
were
presence
of
a
language
barrier
and
refusal
to
participate.
The
field
work
took
place
between
October
2016
and
April
2017.
Statistical
analysis
To
assess
interobserver
agreement,
we
analysed
the
concordance
between
the
2
modes
of
administration
(self-administered
and
administration
by
interviewer)
by
calculating
the
kappa
statistic
for
the
dichotomous
answer
variable.
To
assess
validity,
we
calculated
the
Pearson
234
P.
Cassanello
et
al.
Table
2
Test---retest
correlation
coefficients
for
the
original
BISQ
18
and
the
BISQ-E.
Original
BISQ
BISQ-E
Test---retest
Test---retest
Sleep-onset
time
r
=
0.95
(
P
<
.001)
r
=
0.735
(
P
<
.001)
Hours
of
night-time
sleep
r
=
0.82
(
P
<
.001)
r
=
0.881
(
P
<
.001)
Hours
of
daytime
sleep
r
=
0.89
(
P
<
.001)
r
=
0.900
(
P
<
.001)
Number
of
awakenings
r
=
0.88
(
P
<
.001)
r
=
0.876
(
P
<
.001)
r
=
Pearson
correlation
coefficient.
correlation
coefficient
for
the
comparison
of
BISQ-E
varia-
bles
and
the
records
of
the
sleep
diary.
We
calculated
the
sample
size
assuming
a
correlation
of
.35
for
an
̨
level
of
.05
and
a
ˇ
level
of
.20.
Although
the
assumed
correlation
was
lower
than
the
correlation
reported
in
previous
studies,
18
we
chose
to
use
a
conservative
esti-
mate
to
maximise
the
sample
size
and
guarantee
statistical
power.
Ethical
considerations
Parents
received
oral
and
written
information
and
signed
an
informed
consent
form.
The
study
adhered
to
the
basic
prin-
ciples
of
the
Declaration
of
Helsinki,
the
Council
of
Europe
Convention
of
Human
Rights
and
Biomedicine,
the
Universal
Declaration
on
the
Human
Rights
of
the
UNESCO
and
Spanish
law
on
biomedical
research.
Results
Once
the
BISQ-E
questionnaire
was
developed
through
the
adaptation
process
described
above,
which
included
the
adjustment
of
the
time
frame
considered
‘‘night-time’’
based
on
Spanish
cultural
norms
and
the
geographical
time
zone,
we
studied
its
psychometric
properties
by
assessing
its
validity
and
reliability.
Eighty-seven
families
with
children
aged
3---30
months
that
resided
in
the
autonomous
community
of
Catalonia
par-
ticipated
in
the
study.
The
mean
age
of
the
children
was
17.95
months
(SD,
9.04),
59%
were
male,
and
62%
were
sin-
gle
or
first-born
children.
In
addition,
65%
were
enrolled
in
child
care.
The
mean
age
was
similar
in
parents
and
mothers
(36
years),
and
58%
of
parents
had
a
university
education.
Of
all
the
families
that
agreed
to
participate,
only
one
withdrew
from
the
study.
Assessment
of
reliability
A)
In
the
group
of
60
families,
we
analysed
the
interob-
server
reliability
of
the
BISQ-E
by
comparing
the
answers
obtained
with
the
2
different
methods
of
administration
(self-administration
versus
interview).
We
found
a
high
level
of
agreement,
with
a
high
kappa
value
of
0.93
(95%
CI,
0.85---1.00;
P
<
.001).
B)
We
measured
the
test---retest
reliability
of
the
BISQ-E
administered
twice
in
the
same
subjects
to
assess
its
con-
sistency
over
time.
To
do
so,
we
measured
the
Pearson
correlation
for
the
sleep
scores
obtained
in
2
different
times
that
the
BISQ-E
was
administered
to
each
subject,
T1
and
T2.
The
mean
time
elapsed
between
the
2
time
points
in
the
test---retest
assessment
(T1---T2)
was
10
days
(range,
8---22
days).
We
found
a
strong
correlation
in
the
different
variables
analysed
in
the
test---retest
reliability
assessment:
bed-
time
(
r
=
0.735),
hours
of
night-time
sleep
(
r
=
0.881),
hours
of
daytime
sleep
(
r
=
0.900)
and
number
of
awakenings
(
r
=
0.876).
All
the
correlations
were
statistically
significant,
with
P
-values
of
less
than
.001;
we
found
a
high
consis-
tency
between
the
2
time
points
in
the
overall
questionnaire
(
r
=
0.848)
and
all
the
subscale
scores.
Table
2
presents
these
results
and
compares
them
to
the
results
of
the
validation
study
of
the
original
questionnaire.
18
Assessment
of
validity
We
administered
the
BISQ-E
to
the
27
families
selected
by
nonprobability
sampling.
Subsequently,
the
same
families
filled
out
the
sleep
diary
for
7
consecutive
nights.
We
found
a
high
and
statistically
significant
correlation
between
the
two
measures
for
the
variables
bedtime
during
weekdays
(Mon-
day
through
Friday)
(
r
=
0.731),
hours
of
night-time
sleep
(between
8
pm
and
7
am
)
(
r
=
0.726),
hours
of
daytime
sleep
(between
7
am
and
8
pm
)
(
r
=
0.867)
and
number
of
night-time
awakenings
(
r
=
0.888).
We
also
found
a
moderate
correla-
tion
for
the
variable
bedtime
on
weekend
days
(
r
=
0.692),
which
was
also
statistically
significant.
Discussion
We
chose
the
BISQ
as
the
measure
to
be
validated
after
care-
ful
consideration.
To
make
this
decision,
we
performed
an
exhaustive
review
of
the
relevant
literature.
Among
many
other
studies,
we
identified
4
recent
systematic
reviews
on
the
methods
used
to
assess
sleep
in
the
paediatric
age
group.
1,16,19,33
The
BISQ
stood
out
in
the
comparative
analysis
of
the
psychometric
properties
of
these
instruments.
1,16,19
Table
1
describes
the
different
instruments
designed
to
assess
sleep
mainly
in
early
childhood
that
we
considered
for
our
study.
One
of
the
main
advantages
of
the
BISQ
is
that
it
con-
tributes
to
the
adequate
assessment
of
different
aspects
of
sleep
with
a
multidimensional
approach
by
the
use
of
a
single
and
brief
instrument.
The
different
measures
that
are
obtained
with
the
use
of
the
BISQ
are:
time
of
sleep
onset
(hours),
duration
of
night-time
sleep
(hours),
dura-
tion
of
daytime
sleep
(hours),
total
sleep
duration
(hours),
night-time
awakenings
(number),
duration
of
night-time
Adaptation
and
study
of
the
measurement
properties
of
a
sleep
questionnaire
235
awakenings
(hours).
The
author
of
the
questionnaire
18
estab-
lished
3
criteria
to
identify
children
with
inadequate
sleep
patterns:
a
sustained
pattern
of
more
than
3
night-time
awakenings,
1
hour
of
wakefulness
during
the
night-time
period,
or
total
duration
of
sleep
of
less
than
9
h
in
24
h.
According
to
Sadeh,
these
indicators
remain
stable
in
chil-
dren
between
ages
6
and
30
months.
18
However,
given
the
variability
of
sleep
patterns
at
these
ages
and
the
semi-
qualitative
character
of
their
assessment,
the
questionnaire
cannot
be
used
to
diagnose
a
sleep
disorder.
Rather,
it
helps
identify
early
and
by
simple
means
those
children
that
could
benefit
from
improvement
of
sleep
habits
or
require
further
follow-up.
The
BISQ
has
been
used
widely
to
assess
the
quality
of
sleep
in
the
healthy
paediatric
population,
and
it
has
also
been
used
to
study
sleep
patterns
in
specific
situations.
For
instance,
it
has
been
used
to
assess
sleep
in
breastfed
infants
compared
to
formula-fed
infants,
34
in
infants
with
Williams
syndrome,
35
children
that
snore
36
and
preterm
infants.
21
It
has
also
been
used
to
assess
sleep
in
relation
to
obesity
15
and
the
use
of
new
information
technologies,
22
in
studies
on
postpartum
depression
37
or
in
relation
to
diseases
such
as
atopic
dermatitis.
38
In
Spain,
it
has
been
used
in
a
cross-
sectional
study
that
compared
the
populations
of
Asturias
and
Castilla
y
León.
39
In
the
validity
analysis,
the
new
BISQ-E
version
exhib-
ited
a
strong
correlation
with
a
detailed
and
much
more
labour-intensive
method,
the
sleep
diary.
This
suggests
that
the
BISQ-E
provides
adequate
measures
of
the
dimensions
assessed
by
the
sleep
diary.
Furthermore,
when
it
came
to
reliability,
we
found
high
test---retest
correlations
with
values
that
were
similar
to
those
obtained
for
the
original
questionnaire
by
its
author
18
(
Table
2
).
Similarly,
we
found
an
excellent
agreement
between
the
results
obtained
when
the
BISQ-E
was
self-administered
and
the
results
obtained
when
it
was
administered
by
an
interviewer
(questions
asked
by
a
clinician).
In
the
sample
of
60
families
analysed
in
our
study,
the
parents,
accompanied
by
their
children,
were
able
to
fill
out
the
questionnaire
in
the
waiting
room
of
the
department
of
paediatrics
in
approximately
8---10
min,
a
fact
that
further
reinforces
that
the
BISQ-E
could
be
an
excellent
screening
tool
in
this
population.
Among
the
possible
limitations
of
the
study,
we
ought
to
mention
the
relatively
small
sample
size
of
our
study,
although
it
did
suffice
to
obtain
statistically
significant
values
in
the
analysis
of
psychometric
properties.
Fur-
thermore,
the
fact
that
all
the
families
to
which
we
administered
the
questionnaire
were
managed
in
a
single
centre
could
restrict
the
generalisation
of
our
results
to
other
populations.
However,
since
we
used
the
question-
naire
to
assess
children
with
no
detectable
disease
and
of
the
ages
for
which
the
questionnaire
was
designed,
we
think
that
this
will
probably
not
be
a
relevant
factor
in
the
results
that
may
be
obtained
in
other
populations.
On
the
other
hand,
our
reliability
analysis
had
sufficient
power
to
estimate
correlations,
since
the
correlation
we
assumed
in
the
sample
size
calculation
was
much
lower
(0.35)
than
the
correlations
found
in
the
study
(all
of
which
were
greater
than
0.5).
Similarly,
the
analysis
of
validity
also
found
strong
correlations
(all
greater
than
0.7),
so
our
convenience
sample
had
statistical
power
for
the
assumed
estimate.
On
the
other
hand,
the
retrospective
assessment
of
sleep
involves
a
risk
of
recall
bias.
However,
this
limi-
tation
is
intrinsic
to
any
type
of
questionnaire,
and
the
BISQ-E
has
the
advantage
of
being
simpler
to
implement
compared
to
other
sleep
assessment
methods
that
are
prospective
and
more
objective,
which
makes
it
particu-
larly
suitable
for
screening
at
the
population
level.
Given
that
the
evidence
in
the
literature
demonstrates
that
col-
lection
of
information
from
parents
is
an
effective
method
to
detect
behavioural
and
sleep
problems
in
children,
1,19
we
consider
the
subjective
assessments
of
families
highly
relevant.
In
conclusion,
the
results
of
our
study
allow
us
to
assert
that
the
BISQ-E
is
a
valid
and
reliable
instrument
for
the
assessment
of
sleep
in
Spanish
children.
This
questionnaire
can
be
useful
for
screening
of
sleep
disorders
in
clinical
practice
and
in
epidemiological
research.
Conflicts
of
interest
The
authors
have
no
conflicts
of
interest
to
declare.
236
P.
Cassanello
et
al.
Appendix
A.
Cultural
adaptation
of
the
Brief
Infant
Sleep
Questionnaire
to
Spanish
(BISQ-E)
Adaptation
and
study
of
the
measurement
properties
of
a
sleep
questionnaire
237
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