Sleep problems as a mediator of the association between parental education levels, perceived family economy and poor mental health in children

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Abstract

Objective

The aim of this study was to investigate the association between familial socioeconomic status (SES) and children's sleep problems, and the role of sleep problems as a mediator between familial SES and childhood mental health problems.

Methods

Participants were 5781 11–13 year old children from the Bergen Child Study. Data were collected on family economy, parental education, and children's difficulties initiating and/or maintaining sleep (DIMS), time in bed (TIB) and self-reported mental health problems using the Strengths and Difficulties Questionnaire (SDQ).

Results

Sleep problems were significantly more common in children from lower SES families. Children from families with poor and average perceived family economy had significantly higher odds of reporting DIMS compared to children from families with very good economy (ORs = 3.5 and 1.7, respectively). The odds were reduced by 12–36% adjusting for poor parental health and single parenting, but remained significant. Children from families with a poor economy had increased odds of a short TIB, both in the crude model (OR = 1.9) and adjusted for parental characteristics (OR = 2.2). Maternal education level was significantly associated with short TIB. Path analysis was conducted to investigate the potential mediating role of DIMS in the relationship between SES and mental health. The significant direct association between perceived family economy and SDQ total problems score was partially mediated by a significant indirect effect of sleep problems.

Conclusion

Sleep problems are common among children from families with a lower SES and may be a potential mechanism through which low SES is translated into mental health problems.

Introduction

Sleep problems are common during childhood and adolescence [1] and are related to learning, memory and school performance [2] as well as emotional and behavioral difficulties [3], possibly acting through hormonal, neuronal and psychological pathways [4]. Sleep problems are known to be more common in adults with lower socioeconomic status (SES) [5]. In studies of children, however, some find an association between low familial SES and childhood sleep problems [6], [7], while others have failed to confirm this association [8], [9].

In one of the studies that explored sleep and SES in children, 309 mothers completed a questionnaire about sleep problems in their school aged children [6]. It was found that children in the lowest social classes had higher rates of sleep problems, such as daytime drowsiness and awakenings during the night, than children from higher social classes [6]. In a study including both subjective and objective sleep measures, it was found that high parental SES was related to higher sleep efficiency and longer sleep duration measured with actigraphy, and fewer parent reported sleep problems on the Children's Sleep Habits Questionnaire [7]. Further evidence for a SES-sleep association was found in a study where high SES was associated with lower levels of self-reported sleep problems on the sleep habits survey and longer sleep duration in 166 8–9 year olds [10]. There have also been studies that have found a lack of, or only a minor, association between SES and sleep problems. Guerin et al. [8] did not find parental SES to be related to sleep problems measured by sleep logs in 95 10 years old children, and in a study of 472 4–12 year olds, SES was not found to be associated with insomnia [9]. In a separate publication from the same sample referred to earlier [10], SES was found to be unrelated to measures of sleep duration, sleep efficiency and wake after sleep onset derived from actigraphy [11]. There is also one study suggesting a reverse association between SES and sleep duration. Zhang et al. [12] found that children aged 6–12 from families with a higher SES spent a shorter time in bed than children with lower SES. This association is in contrasts with previous findings, and the authors suggest that it may either be due to high SES-parents having higher academic expectations for their children, thereby curtailing their TIB, or that the children's TIB is directly influenced by parental sleep/wake patterns.

Although several of the studies reviewed suggest that lower family SES is associated with more childhood sleep problems, comparisons and conclusions across studies are difficult because of the wide age ranges, small samples as well as methodological differences between the studies. Furthermore, SES has not been the main objective in most of these studies, and hence the relation has often not been analyzed nor discussed in detail, and there has typically been a lack of control of possible confounding variables. Several pathways have been proposed to account for the adverse influence of poor SES on children's sleep. Different characteristics that relate to SES, for example family structure and parental health, may account for some of the association between SES and sleep [13], [14]. Child features, such as high body mass index should be controlled for, as it is associated with both SES and sleep problems [15].

Studies of sleep and SES have mostly investigated their direct relationship, but sleep problems may also be a pathway through which low SES is associated with mental health problems. Children who grow up in families with a lower SES have increased risks of developing emotional and behavioral problems [16], [17], and the magnitude of these problems vary as a function of socioeconomic deprivation, a pattern referred to as a social gradient [18], [19]. In societies, such as the Nordic countries, where welfare is high, social gradients still appear [20]. This was confirmed in a previous study using the same sample as the current, where poorer family economy and lower parental education levels were associated with increased symptoms of conduct-, emotional-, hyperactivity-/inattention- and peer problems in children [21]. Knowing that SES is related to both sleep and emotional and behavioral problems, and that sleep problems is a known predictor of emotional and behavioral problems, it is plausible that sleep problems may act as a mediator of the association between SES and poor health [22]. This hypothesis was supported in a study of adults, where higher income was related to better sleep quality which in turn was associated with lower psychological distress, even after controlling for age, gender, ethnicity and prior health status [23]. No studies have assessed whether these mechanisms operate similarly in children.

In sum, several studies suggest that childhood sleep problems are more common in families with a lower SES. However, we do not know if there exists a social gradient in sleep problems in populations that are generally healthy and where the majority may be described as having a relatively high SES. This has been observed for emotional and behavioral problems. Furthermore, findings suggest that sleep problems may mediate the association between SES and mental health problems, but to our knowledge, this hypothesis has not been tested in large community samples of school-aged children. Based on these results, the aims of the current study were to (1) assess the frequency of sleep problems across different indicators of SES, (2) to investigate the confounding effect of particular family and demographic factors associated with socioeconomic status, and (3) to assess the role of sleep problems as a mediating factor of the association between SES and poor mental health in childhood. We hypothesized that sleep problems would be more common among those with lower SES, that some of the association between SES and sleep problems would be explained by family and demographic factors, and that the association between SES and mental health problems would be mediated by sleep problems.

Section snippets

Participants

Data stem from the second wave of the Bergen Child Study (BCS), carried out in 2006. The BCS is a population-based study of children in all public and private schools in the municipality of Bergen, Norway. Bergen is the second largest city in Norway, and the total population is around 230,000. Ethnic diversity is small, with about 6.4% of the population being immigrants (out of which 4.4% had non-western origin) [24].

In 2002, a target population of 9430 primary school children (7–9 years) was

Demographic and clinical characteristics

There were slightly fewer boys (47.8%) than girls in our sample with approximately equal numbers of children from each school grade sampled (34.7% 5th grade, 34.8% 6th grade, 30.5% 7th grade). The majority of the participants (68.1%) described their perceived family economy as good or very good, compared to 29% as average and 2.8% as poor. More than 50% reported a high education level, compared to 8% reporting basic education level.

Younger children spent more time in bed than older children

Discussion

In the current population based study, DIMS was more frequent among children from families with a poorer economy, whereas short TIB was more common in children from families with a lower SES. This was true across all SES indicators. The association between poorer family economy and DIMS was somewhat attenuated by family factors, but such factors had minor influence on the association between family economy and maternal education levels and TIB. Furthermore, it was found that DIMS partially

Limitations

The results from the study and their interpretations should be considered in the context of several potential limitations. The primary limitation is the use of a cross-sectional sample which precludes insight into the causality between SES, sleep problems and mental health problems. Although the BCS is a longitudinal study, information about SES was not gathered during the first wave of the study. We were therefore presently limited to using data from the second wave in the current analyses.

Conclusion

The results from the current study suggest that children from families with a poor economy and where mothers have lower education levels experience most sleep problems, and that such problems are associated with mental health problems in those families. Clinicians that are working with children from families with a lower SES should be particularly sensitive to potential sleep problems and provide targeted intervention for the sleep problems and evaluate the family environment for potential

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