Clinical ReviewPediatric sleep questionnaires as diagnostic or epidemiological tools: A review of currently available instruments
Introduction
The great popularity with questionnaires is that they provide a “quick fix” for research methodology. No single method has been so abused.1
The last several decades have taught us that a long list of potentially misleading conclusions can be drawn when practitioners in the field of pediatrics continue to overlook sleep in their professional activities. There is a pervasive lack of awareness to the relatively frequent presence of sleep problems in children, which in turn can manifest in a myriad of clinical presentations that may be easily misconstrued as other pediatric conditions and mistreated accordingly. In other words: questions about sleep should always be included!
A systematic screening for sleep issues might assist in early identification of academic, behavioral, health and quality of life problems, which if treated will result in a better learning, happier, and healthier child. In the field of pediatric sleep research, a trend toward implementation of large-scale sleep surveys has surfaced. Unfortunately, only a fraction of the manuscripts seems to report on reliability or validity, and rarely, if at all, will describe endorsement rates. Surprisingly, even the survey itself is missing in a large number of those studies. Notwithstanding, is any sleep question asked a ‘good’ question to ask? In other words, are surveys merely straightforward question-answer scenarios? How valid and comparable are the results from such surveys? Survey instruments are increasingly being created, adapted or translated with little scrutiny regarding their psychometric qualities, their structure, reliability and validity, and therefore, substantial doubts and concerns should emerge regarding their findings. Another consequence of the lack of psychometric validity is that direct comparison(s) of pediatric sleep problems, their prevalence, as well as the understanding of their impact on every day functioning is also substantially hampered. Likewise, the treatment of sleep disorders in children should benefit from well-designed, psychometrically sound tools. The field of pediatric sleep can only continue to grow and exert its impact on other fields if researchers and clinicians thoroughly investigate and report the psychometric properties of the tool(s) they develop and use. In this manuscript, we have tabulated ‘all’ existing subjective tools within the field of pediatric sleep medicine, and have attempted to describe their psychometric qualities. As a preamble to this review, we described in greater detail in the preceding paper the 11 methodological steps needed to develop and evaluate a sleep assessment tool, and inherent potential pitfalls were also discussed in greater detail.2 The methodological steps should include: 1. Purpose; 2. Research Question; 3. Response Format; 4. Generation of Items; 5. Pilot; 6. Item-analyses and non-response analyses; 7. Structure; 8. Reliability; 9. Validity; 10. Confirmatory analyses; and 11. Standardization and norms development. These psychometric approaches should be implemented using appropriate manuals and scholarly manuscripts on this topic, because inappropriate tools and lack of rigor inevitably lead to poor quality data, misleading conclusions, and inaccurate recommendations.
The dynamic and accelerated expansion of pediatric sleep science has inevitably led to development and utilization of numerous survey instruments that have enabled important discoveries and overall advancement of the discipline. As we now reach a more mature stage in our field, we believe that time has arrived to critically examine the constructs of existing instruments, and delineate not only the specific questions being sought, but also evaluate the steps taken to validate their implementation. An extensive list of published and unpublished instruments used to investigate or evaluate sleep issues in children was therefore collected and assessed based on our 11 step-by-step guide as outlined in the preceding paper.2
Section snippets
Procedure
The MeSH search terms combined were “Sleep” AND (“infant*” OR “child*” OR “adolescent*”) AND (questionnaire*, instrument*, scale*, checklist*, assessment*, log*, diary*, record*, report*, interview*, test*, measure*), and implemented in the following search engines: PubMed, PsycINFO, Child Development and Adolescent Studies, Health and Psychosocial Instruments, Mental Measurements Yearbook, CINAHL, Scopus (also Web crawling), ClinicalTrials.gov, Dissertations and Theses, Google Scholar (Web
Results
This comprehensive review led to tabulation of the subjective tools in which psychometric properties as described in the preceding paper were evaluated. Next, tools for which no psychometric properties were evaluated were divided into those that are reported or published, those that are part of established tools, and those that are unpublished or used in clinical practice. As a rule, we focused on the original tool unless translations, modifications etc. were found to contribute clinical
Short history
The potentially first ‘diagnostic’ sleep questions, historically and not surprisingly, were embedded in daytime ‘psychopathology’ tools, such as Achenbach’s Child Behaviour Checklist (CBCL)3 and Sines Missouri Children’s Picture Series (MCPS),4 Conners’5 and the Louisville Behavior Checklist,6, 7 all of which were developed in the 1970s. As such, ‘a’ connection between mental health and sleep was made, although their interrelation remained unspecified. Prior to these tools, questions on sleep
Tools in which psychometric properties were evaluated
57 Tools were found to have been psychometrically evaluated to some extent (Table 1, and tabulated in detail in Supplementary Tables 1–3). Tools are ranked chronologically on the lowest age boundary (an alphabetical list for easy reference can be found at the end of this manuscript) being an important criteria upon deciding which tool to use.
Approximately half of the tools (52.6%) are printed together with the paper or are accessible online. The majority of the reported tools(43) were published
Diaries, logs and other tools
Instruments were grouped according to self-report13 or parental report.16 29 diaries and logs are described in Supplementary Table 4. The literature search revealed that these terms are used interchangeably, and that a clear distinction was not made from the often concomitantly applied actigraphy and its parameter report. Even in these tools, heterogeneity is remarkably apparent in the wording, the order, the lay-out, the number of questions, when to fill-out and in the time-frame, or even
Tools in which psychometric properties were not evaluated
This list is not exhaustive since an overwhelming amount of papers implement a certain ‘subjective tool’. The contrast of these unevaluated tools with the limited number of tools that are actually psychometrically evaluated should prompt caution in their use based on the assumption that they are a priori valid. The 70 instruments were ranked based upon the lower age boundary (an alphabetical list can be found at the end of this manuscript). These include not only questionnaires, but also
Sleep questions in other existing tools
Contact with publishers yielded limited results with most instruments probably having just a few items or the publisher being unaware of any ‘sleep items’ (Supplementary Table 6). Therefore the list tabulated, again chronologically on lower age boundary, is based upon 21 instruments to which we had access. In contrast to the sleep instruments, it becomes apparent that these daytime tools are mostly created in 70–90s. Only a handful of sleep items appear in each of the instruments, and their
Unpublished tools
This list probably represents only a minority of the tools available, and was created primarily through the willingness of colleagues in the field to share their tool (Supplementary Table 7). 28 instruments are listed. We would like to draw special attention to instruments in development or in press: RLS rating scale [nr. 3], RLS/PLMD pediatric screening questionnaire [nr. 4], sleep paralysis [nr. 5], dream habits [nr. 7], treatment evaluation inventory [nr. 11], hospitalized children’s sleep
Synopsis
“Begin at the beginning”, the King said gravely, “and then go on till you come to the end; then stop” – Alice’s adventures in Wonderland
From this review it is clear that much remains to be done, even if in recent years the psychometric evaluation of tools created and applied within the field of pediatric sleep medicine is growing. Sleep-related breathing and sleepiness disorder questionnaires are probably leading this trend.
The Brouillette’s30 questionnaire assessing sleep-related breathing
Conclusions
In 1981, the textbook ‘The Mismeasure of Man” symbolized the previous hazards of measuring intelligence as a single quantity and its possible adverse consequences (e.g., Goddard’s belief in intelligence testing). This review was written solely to allow critical reflection upon the risk of ‘the mismeasure of sleep’, and thus promote and enhance collaborative studies on measurement of pediatric sleep. This interesting journey in the world of pediatric sleep tools revealed that efforts have been
Conflict of interest
The authors have no conflict of interest to declare pertaining to this manuscript.
Acknowledgments
We would like to express our gratitude to Drs. Oliviero Bruni and Avi Sadeh for distributing our request via their pediatric sleep listservers. The following individuals not only expressed their enthusiasm towards the review, but each added to its value by providing tools or contact persons or references (alphabetically): Thomas M. Achenbach, Rosana Cardoso Alves, Jessica M. Bennett, Sarah Biggs, Luigia Brunetti, Oliviero Bruni, Sandra Carvalho Bos, Ronald Chervin, Martin Delatycki, Pernilla
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