Abstract and Keywords
The overarching purpose of The Oxford Handbook is to both inform readers about the current state of our science in infant, child, and adolescent sleep and behavior, and to inspire additional, innovative contributions. These contributions will come from current members, and ideally also from behavioral scientists in related disciplines who are interested in dedicating energy to this remarkable field. The goal in this concluding chapter is to share a compilation of the chapter authors’ collective view on the most urgent future directions in infant, child and adolescent sleep. Represented here are eight cross-cutting goals that were identified by 25% or more of the chapter authors as imperative to advancing the field: increase research using longitudinal and/or experimental designs; more in-depth focus on individual differences; more systems and family-oriented research; more thorough validation of instrumentation and equipment; innovative behavioral interventions; more integration of environmental contributions; and greater sleep education.
It has been a privilege to work on this volume with Amy Wolfson and all of our contributing authors, whose passionate dedication to our field is evident through the care and thoughtful approach in their chapters. By design, each chapter stands alone as a comprehensive state-of-the-science review of each author’s area of expertise within infant, child, and adolescent sleep and behavior. To compliment the depth within each chapter, we have worked to ensure that extensive cross-referencing gives our readers the opportunity to follow themes across chapters. Thus, it is our hope that a significant and lasting contribution of this volume will be a pathway through converging topical areas that will facilitate insight into the field.
I have valued the opportunity that reviewing our authors’ collective work has given me to update and refine my understanding of several areas distinct from my own laboratory’s primary research focus. An additional and unexpected benefit has been that through Oxford’s formalized Future Directions section for each chapter we were able to capture each author’s perspective on where our science needs to go from here. Independently, our authors’ Future Directions follow closely from the work they presented in their chapter. Cumulatively they show a pattern that sets an agenda for the field. This where-now and where-to synergy played perfectly into our aim of using this volume not only as a platform to describe the state of the field, but additionally to inspire novel, innovative contributions. Our specific hope is that both long-time contributors and behavioral scientists relatively new to child and adolescent sleep will both find through these chapters that there are tremendous questions remaining, and that their contributions are critical to answering them.
My goal in this concluding chapter is to share with you the results of my compilation and analyses (p. 612) of our authors’ collective view on the most urgent future directions in child and adolescent sleep. Here I have represented each of eight cross-cutting Future Direction themes that were identified by 25% or more of our authors.
The need for longitudinal studies, identified by more than half of our authors, was the most frequently cited priority area. Of note, these authors point not simply to normative, descriptive work (which is certainly needed), but also to the importance of establishing sleep duration needs across the child and adolescent age span, how these needs change over time, developmental trajectories in both macro and micro structure of sleep, and the long-term behavioral and biomedical consequences of early sleep disorders. In other words, knowing how much infants, children, and adolescents sleep is not enough; we need to know what sleep duration, consolidation, and timing are optimal and how these change across development.
Two ends of the age spectrum are worth highlighting. The earliest period of development, prenatal, is generally underrepresented in sleep science and thus excluded almost entirely from this volume. However, new technologies such as high-resolution ultrasound are increasingly used to identify human prenatal physiologic state and development. Importantly, fetal observation can inform us about both the current status of the maternal-fetal system and predict infant outcomes (Salisbury, Fallone & Lester, 2005; Salisbury, Ponder, Padbury & Lester, 2009). In addition, exciting behavioral neuroscience approaches are increasingly applied by investigators using animal models to examine sleep behaviors, as well as waking behaviors that are facilitated by sleep, even during prenatal development (Tiriac, Uitermarkt, Fanning, Sokoloff, & Blumberg, 2012).
The latter end of our age span—adolescence—is equally important. At the intersection between “child” and “adult,” work on adolescents and emerging adults continues to emphasize the uniqueness of this developmental period. Specifically, chapters by Mary Carskadon, Shelly Hershner, and Pamela Thatcher and their colleagues highlight the changes that occur during this period to the circadian system of adolescents,, the high-stakes risks to which this exposes them, and the challenges in their treatment, respectively. Amy Wolfson (2007) has long been an advocate for policy changes to benefit adolescents (and, as a consequence, the rest of us) and made a point of encouraging authors to address how sleep issues pertain to adolescents within the chapters as often as possible.
Closely related to longitudinal work is the need, identified by about a quarter of our authors, for increased empirical evaluation of individual differences within infant, child, and adolescent sleep. This differential psychology approach can yield rich insight into how—and sometimes why—different people have different trajectories or responses. Traditionally seen as error variance, unique responses can instead inspire novel insight into human behavior. It is important to study individual differences from the perspective of normal development, but it is also important when examining risk factors for disorders, protective factors that promote resilience, and factors that may be used to predict responsivity or resistance to behavioral and other treatments. This approach has been infrequently applied to pediatric and adolescent sleep; its ability to reveal interesting truths is exemplified by St James-Roberts and Plewis (1996) in their study describing changes in and relations between infant sleep, feeding, and crying behaviors during the first 40 weeks after birth.
Family Systems, General Systems, and Biopsychosocial Approaches
Nearly half of our authors note that more work reflecting a dynamic systems approach is needed. One example of this is the increasing use of multimodal assessment strategies. Mothers have one perspective on their child’s sleep, but the profile becomes much more revealing when both parents report independently, in conjunction with the school or daycare teacher and, for older children and adolescents, their self-report (for example, see Beebe, Ris, Kramer, Long, & Amin, 2010). Another example is that little work has currently been done to address the sleep of postpartum fathers or the impact of sleep disturbance on their contributions to the workplace or family; their potential role for mitigating the impact of sleep disturbance on postpartum mothers is almost entirely unexplored. More work is clearly needed to balance a culturally sensitive and practical approach to co-sleeping when considering infant sleep interventions—both of which are often-controversial issues in our field (see Chapter 37 on interventions by Melisa Moore and Jodi Mindell and Chapter 12 on co-sleeping by Melissa Burnham). A truly biopsychosocial approach that uses a systems approach to include (p. 613) simultaneous assessment of biological, behavioral, and environmental influences on pathology is as important now as when it was originally conceptualized nearly 40 years ago (Engel, 1977).This doesn’t make such work any less challenging.
Valid, Standardized Subjective and Objective Assessment Measures
Over one-third of the authors emphasized the urgency of demand for improvement of both objective and subjective assessments we use for screening, assessing, estimating, and measuring sleep behaviors. Since polysomnography became established as the gold standard for identification of sleep states, the field has seen a surge of technologies and approaches to measuring and collecting parent and self-report of child and adolescent sleep. The chapters by Karen Spruyt on survey validation (Chapter 18) and by Rosemary Horne and Sarah Biggs on actigraphy (Chapter 16) indicate how far we have come—and how far we still have to go.
I want to particularly emphasize that the quality of our science depends on the quality of these measurement techniques, so it is in the interest of all sleep researchers that we insist on tools with the strongest validity for use with our infant, child, and adolescent populations—both normative and disordered. This is particularly true for methods such as actigraphy that are now in wide use and, due to decreasing costs, likely to become even more frequently used. However, pediatric and adolescent sensitivity and especially specificity are generally very low with these devices, and we currently have no professional standards (Meltzer, Montgomery-Downs, Insana, & Walsh, 2012). This issue is compounded when parent report and child self-report measures are then validated against actigraphy. Researchers and clinicians should insist on the highest standards for their recording equipment and refuse to accept or support anything inferior.
Intervention Efficacy and Novel Therapies
One-third of our authors also highlighted that interventions—and specifically behavioral interventions—should undergo rigorous evaluation for efficacy among pediatric and adolescent populations. In addition, they point out that novel, innovative therapies are needed. As described by Charles Super and Sara Harkness in their chapter on Culture and Children’s Sleep, and by Melissa Burnham in her chapter on Co-Sleeping and Self-Soothing during Infancy, it is essential that interventions be developed from a perspective of genuine sensitivity to the family’s situation, resources, and history—both developmentally and culturally.
A quarter of our authors noted the need to account for the environment in our science. This point is quite important to me professionally because my training background and way of thinking are in developmental psychobiology; within this field, the need to consider nonobvious influences on the developing system is critical (Miller, 1997). That the context in which sleep takes place influences the sleeper should no longer be nonobvious—but our authors point out that there are much deeper potentials for investigation within “environment.” Profoundly important is the broader environment; a marked weakness in our field currently is our lack of understanding of the influences of poverty and social class on sleep duration, quality, and timing. On another level of environment, several authors specifically mentioned epigenetics, the study of how history and environment influence our genome, an impact that can be transmitted across generations (Meaney, 2010; Roth, 2012). A Medline search for the concurrence of the terms “epigenetic” and “sleep” (on November 28, 2012) revealed that 55 such papers have been published to date, none of which are on young humans or animal models. Investigators with the resources to incorporate developmental sleep into their epigenetic research programs, developmental sleep researchers who can address epigenetics, or (best yet) collaborations between the two, will be well-positioned for discovery and innovation.
More than one quarter of the chapters discussed the need for more studies that use experimental designs or randomized control trials to establish the mechanisms of action—particularly underlying treatment effects. I suspect that more authors would likely have identified this as prominent gap in our science were it not so challenging to implement this type of study in child and adolescent populations. Obvious ethical concerns aside, the logistics of experimental manipulation and accounting for a multitude of influences (see section on systems approach above) can seem insurmountable. Collaboration and formation of multisite studies is one way to overcome this, which has been done successfully over the past decade by top investigators studying the efficacy of adenotonsillectomy, the current front-line treatment for childhood obstructive sleep apnea (Redline, Amin, Beebe, Chervin, (p. 614) Garetz, Giordani, et al., 2011). To my knowledge, at this time no such large-scale collaboration on evaluating behavioral therapy of any kind in pediatric and adolescent sleep has been initiated.
Finally, 20% of our authors indicated a greater need for education about infant, child, and adolescent sleep. They specify that the target audiences include parents, children and adolescents, health care providers, and school personnel. To these I will add that legislators also need us to teach them more about sleep and its importance among their youngest constituents. There have been several successful approaches to prevention and education; these are well-described in Chapter 21, Role of Schools in Identification, Treatment, and Prevention of Children’s Sleep Problems by Joseph Buckhalt, and in the chapter Preventative Intervention: Curricula and Programs by Reut Gruber and colleagues.
Sleep is well-loved by the media. As sleep scientists we are well poised to take advantage of the public’s general fascination with (and, if our generally anti-sleep culture and rampant mythology about sleep is any index, a perseverating ignorance about) our field. Sleep science is fun, sleep facts are cool, and sleep is linked to danger in the form of disorders that cause morbidity and mortality as well as increased risk behaviors. Sleep is also something that every person does. In short, our field includes all of the prerequisites to “arouse and fulfill”—the not-so-secret method for effective science communication (Olson, 2009). It is incumbent upon sleep scientists to ensure that the message of the good work we are doing is represented—and represented accurately—to those who need to hear it: the public, health care providers, parents, schools, policy makers. I suggest we find a poster child for pediatric sleep; someone as effective at “getting the message out” about infant, child, and adolescent sleep as Arianna Huffington has been for women’s sleep (Huffington, 2011). Such a voice is desperately needed to counter the anti-sleep culture that is endemic in—as a popular example—advertisement campaigns aimed at selling caffeine-laden drinks to adolescents.
Addressing these priority areas is necessary toward advancing our basic behavioral science, as well as translating that science into improved interventions to advance sleep health care. Of note, these priority areas reflect each of the four areas of translational research depicted in the 2003 United States National Institutes of Health roadmap, designed to set the research agenda for the future (Zerhouni, 2003) and that has been incorporated as a way of thinking among researchers around the world (Woolf, 2008). These priorities identified by our chapter authors also reflect current national health care agendas around the world. As an example, three of the four target Sleep Health priorities outlined in the United States objectives for Healthy People 2020 are directly relevant to pediatric and adolescent sleep: evaluation for obstructive sleep apnea (including pediatric patients); vehicular crashes due to drowsy driving (particularly relevant to adolescents); and sufficient sleep among 9th through 12th graders (Healthy People 2020).
As my co-editor, Amy Wolfson, aptly described at the beginning of this handbook, we hope that psychologists and other behavioral scientists who are drawn to this volume will continue to work in sleep and become greater contributors to this fascinating field. There are many ways to get involved with sleep research. Collaborating is great; although I also like to tell, or even warn, colleagues that I don’t collaborate…I infiltrate. Sleep researchers are a remarkably friendly group of researchers and clinicians, perhaps owing in some part to the relative newness of our field. There are national and regional sleep societies too numerous to list here—and every year new groups are formed. Attending a nearby conference or joining a professional society is an excellent way to start. There is also an ever-growing list of high-quality peer reviewed journals with editorial boards that are remarkably receptive to receiving submissions from those outside the mainstream sleep field who have incorporated sleep into their research programs. Those looking for information about adult sleep are also referred to our “sister book”: The Oxford Handbook of Sleep and Sleep Disorders. Our volume was developed to complement the success of Morin and Espie (Eds.) volume, and the interested reader will find there a compendium of the state-of-the-science of adulthood and aging (2012).
In closing, a brief message to trainees in our field. The Sleep Research Society (based in the United States) invests the majority of its revenue in a “Trainee Day” pre-meeting preceding the annual meeting of the Associated Professional Sleep Societies; in 2012 they hosted the 17th annual pre-meeting for undergraduate, graduate, postdoctoral, and medical trainees. While working on this chapter it surprised me to realize that I began attending this conference prior to the first Trainee Day. Two of the most important lessons (p. 615) I learned were at these training days, both from then-editors-in-chief of the top-tier journal in our field, SLEEP, the official journal of the Associated Professional Sleep Societies. The messages were: (1) do not do “me too” research that reiterates the work of others and (2) do publish your work in journals other than those focused on an exclusively sleep-science readership. In other words, do exciting, risky research and then tell everyone about it—not just your friends.
Currently, pediatric sleep is a field in which important discoveries are rapidly reshaping how we think about sleep development and disorders, their antecedents and consequences. There is tremendous opportunity in the field now, and we have an urgent need for others to lend their time, energy, and expertise toward answering key developmental questions in the field. Above all, it was with the goal of energizing our field by introducing it to others that we began thinking about this volume. It is our hope that this collection of chapters by some of the world’s experts will serve as a vehicle for this purpose.
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