The Relationship Between Caretaking Experiences in Childhood and Sleep Disturbances in Adulthood

| May 19, 2010 | 0 Comments

by Randy A. Sansone, MD; Howard C. Edwards, MD; and Jeremy S. Forbis, PhD
Dr. Sansone is a Professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio. Dr. Edwards is a resident in the Department of Internal Medicine at Kettering Medical Center in Kettering, Ohio. Dr. Forbis is an Assistant Professor in the Department of Sociology at the University of Dayton in Dayton, Ohio.

Psychiatry (Edgemont) 2010;7(5):33–36

Funding: There was no funding for the development and writing of this article.

Financial disclosure: The authors have no conflicts of interest relevant to the content of this article.

Key words: caretaking, childhood experiences, Pittsburg Sleep Quality Index, sleep, sleep disturbances

Abstract

Studies on the relationship between childhood experiences with parents and sleep disturbances in adulthood are relatively few in number. Excluding studies on posttraumatic stress disorder, available studies on this relationship in adult participants is scant. In this study, we examined three caretaking variables (i.e., the number of different caretakers in childhood, whether caretakers were the biological parents or not, and the perceived quality of caretaking) and their relationship to self-reported sleep quality over the past month. Contrary to our expectations, only one of the childhood caretaking variables demonstrated a relationship with quality of sleep in adulthood—the perceived quality of caretaking. Lower ratings of parental caretaking quality were associated with poorer overall sleep quality. We discuss the potential implications of this finding.

Introduction

There is growing evidence that parents play a pivotal role in the sleep experience of their progeny. While empirical data are relatively meager, we initially review a sampling of available findings from childhood to adulthood (i.e., an across-the-lifespan perspective).

Beginning with infants, Armitage et al[1] found that maternal depression correlated with sleep disturbances in babies.

In toddlers, several studies have linked parental behavior with sleep problems. For example, in an Australian study, Hall et al[2] found that a conflicted and lax parenting style predicted higher scores for children on a sleep-problem scale. In a United States study, Warren et al[3] found that maternal depressive symptoms were associated with an increased frequency of awakenings in their toddlers. In another Australian study, Johnson and McMahon[4] concluded that low parental “hardiness” significantly predicted sleep problems in toddlers.

In addition to studies in toddlers, there are also several studies among preschool and latency-age children. For example, in a Canadian study, researchers concluded that the mothers of sleep-disordered children were unanimously insecure with respect to attachment.[5] Gregory et al[6] concluded among preschoolers that family disorganization and maternal depression contributed to sleep problems in children. In Chinese elementary school children, Lianqi et al[7] found associations between parenting styles and sleep problems in offspring. In another Chinese study of latency-age children, investigators determined that parental psychopathology was associated with several types of sleep problems.[8]

As for adolescent populations, Brand et al[9] examined Swiss students and found that adverse parenting styles were associated with low sleep quality and increased daytime sleepiness. In a United Kingdom study, Gregory et al[10] examined 18-year-olds and concluded that family conflict between the ages of 7 and 15 predicted insomnia at age 18.

As for studies in adults, we elected to bypass the formal literature on posttraumatic stress disorder (PTSD) and trauma because of the well-known and evident impact on sleep problems in the perpetrated. As a result, we were only able to locate one study of parental dysfunction during childhood and sleep difficulties in adulthood. In this Swiss study, Bader et al[11] confirmed a relationship between adverse experiences in childhood, particularly severe maltreatment in childhood and adolescence (which clearly borders on the trauma literature), and insomnia in adulthood. In this study, 46 percent of participants with insomnia reported moderate-to-severe adverse experiences in childhood.

While studies in infants are confounded by the chicken-or-the-egg dilemma (i.e., do sleep disturbances in infants drive maternal depression, or does maternal depression drive sleep disturbances in infants), the predominant theme of the preceding literature is that impaired and/or dysfunctional parenting has the potential to culminate in sleep disturbances in progeny. However, outside of the trauma literature (i.e., studies of participants with formal diagnoses of PTSD), very little research has been undertaken in this area. In addition, in the only related study outside of overt trauma that we could locate (i.e., the Bader et al[11] study), participants were Swiss and the sleep assessments consisted of polysomnographic assessment and determination of nighttime body movements, making the data challenging to generalize to other populations and/or to reproduce. In the following study of adults in a primary care setting, we examined three caretaking variables during childhood that we believed might be associated with poor sleep quality in adulthood (i.e., number of caretakers, biologically versus nonbiologically related caretakers, ratings of caretaking quality) and self-reported sleep quality over the past month.

Method

Participants. Participants were men and women, ages 18 years or older, who were being seen in an outpatient internal medicine clinic that is predominantly staffed by resident physicians. This clinic is located in the suburbs of a mid-sized, midwestern city. The sample was one of convenience (i.e., participants were recruited as time allowed). Exclusion criteria were medical (i.e., severe pain), cognitive (e.g., dementia), intellectual, or psychiatric (e.g., psychotic) illness that would preclude the successful completion of a survey booklet.

During the study period (January 2009–September 2009), 149 patients were approached; 116 agreed to participate, for a response rate of 78 percent. Only 76 respondents completed all materials and were included in our analyses. Of these, 74.6 percent were women and 25.4 percent men, ranging in age from 18 to 70 years (M=41.6, SD=13.8). Most participants were Caucasian (84%); six participants were African American, two were Hispanic, and two were Native American. With regard to educational attainment, all but 6.6 percent had at least graduated high school, whereas 26.6 percent had earned a college degree. One participant did not provide any demographic information.

Procedure. During assigned clinic times, one of the investigators (HCE) recruited participants from his clinical caseload according to the preceding inclusion/exclusion criteria, which were informally assessed. Following an explanation of the project, including risks and benefits, participants were asked to complete a six-page survey.

The cover page of the survey booklet contained the elements of informed consent, and completion of the booklet was assumed to be implied consent. In the survey booklet, we initially inquired about demographic information. We then explored participants’ childhood caretaking experiences. Specifically, we asked 1) “How many different caretakers did you have while growing up?” with response options of 1 to 10+; 2) “Who was/were your primary caretakers or parents when you were growing up?”, which was coded as biological parents or not; and 3) “How would you rate the overall quality of care you received as a child?” with response options of “excellent,” “good,” fair,” “not very good,” and “poor.”

Finally, we assessed subjective sleep quality with the Pittsburgh Sleep Quality Index (PSQI).[12] The PSQI is a 19-item, self-report questionnaire that explores subjective sleep quality over the past month. The last item relates to impressions of a bed partner and was deleted for this study, leaving a total of 18 items. There are seven component scores (i.e., subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, daytime dysfunction), which may be coalesced into one global score, with higher global scores indicating poorer sleep quality. A Global PSQI score of greater than five is considered to be a sensitive and specific measure of poor sleep quality.

Results

The average number of caretakers per participant was 2.32. Biological parents were identified as caretakers by 93 percent of participants. The mean response to the perception of parental caretaking quality was 3.16 (SD=0.99) on the five-item response scale (three participants did not fully complete the demographic information).

The responses of participants to the queries regarding sleep quality are shown in (Table 1). Of the 76 respondents, 12 (15.8%) scored in the top quartile of the global PSQI score, indicating severe sleep difficulties. For the entire sample, of the seven different sleep quality components, habitual sleep efficiency was the most commonly self-rated component score of extreme difficulty (36.8%), whereas only nine (11.8%) respondents indicated extreme difficulty with regard to daytime dysfunction.

We next performed Spearman’s Rho correlations between the Global PSQI score, as well as the seven component scores, and our caretaking variables. Results indicated that the number of caretakers was not statistically significantly related to sleep difficulties. Respondents with biological caretakers showed a statistically significantly negative correlation with subject sleep difficulty as well as habitual sleep deficiency. In other words, respondents raised by their parents were less likely to report sleeping difficulty and were more likely to be asleep while in bed. The third caretaking variable, percieved quality of caretaking, was the largest single factor in determining sleep quality over the past month, with statistically significant correlations with the Global PSQI score, subjective sleep quality, and daytime dysfunction.

We next performed a logistic regression analysis of perceived quality of caretaking on poor sleep quality (PSQI score >5). We controlled for demographic indicators, including weight, male, white, marital status, and education. Results indicated that perceptions of caretaking quality remained statistically significantly related to being a poor sleeper (coefficient=-1.151, z=-2.21) (Table 2). In other words, despite these other controls, respondents were less likely to experience poor sleep quality when caretaking quality was perceived as positive.

Discussion

Only one of our hypotheses evidenced a relationship with poor sleep quality in adulthood—participants’ ratings of parental caretaking quality. We strongly suspect that this finding parallels with the findings of Bader et al[11] who completed the only other study of adults that we could find in the empirical non-PTSD literature. These investigators determined that adverse childhood experiences were associated with sleep disturbances in adulthood as evidenced by polysomnographic recordings and assessment of nocturnal movements. Poor parental caretaking may be linked with adverse experiences in childhood. Therefore, our findings may mirror each other despite an entirely different methodology. In addition, a relationship between problematic parenting in childhood and current sleep disturbances has been clearly demonstrated in studies of adolescents as well.[9,10]

We were genuinely surprised to find that the number of caretakers, and whether these caretakers were biological parents or not, demonstrated no negative influences on sleep quality in adulthood. This leads us to believe that being cared for in the sense of being protected against excessive childhood adversity is the most salient feature in the relationship between caretaking in childhood and sleep disturbances in adulthood. Whether this important finding with regard to sleep generalizes to other outcomes of adverse childhood experiences remains to be determined. For example, adverse experiences in childhood are also generally associated with higher levels of psychopathology in adulthood. Is this latter relationship also independent of the number of caretakers and/or whether caretakers are the biological parents or not? Is caring and protection the ultimate defining line between nondysfunction and dysfunction in adulthood? Only further research will clarify these relationships.

From a clinical perspective, our findings, in conjunction with the findings of others, suggest that current poor sleep quality may be related to perceived poor quality parenting in childhood. Given these findings, this line of inquiry (i.e., having had adverse parental rearing experiences, having had adverse experiences in childhood) seems relevant in the assessment of patients presenting with sleep difficulties, whether in primary care settings or specialty clinics (e.g., psychiatry, sleep disorders).

This study has a number of potential limitations. First, we used a sample of convenience, which heightens the risk of sampling bias (Type II error). However, we believe that this was a minimal potential influence given the nature of the study variables and the use of an internal medicine resident recruiter. Second, all data were self report in nature and subject to the vicissitudes of this type of methodology. Third, the sample size was fairly small. However, this is one of the few studies to examine caretaking relationships in childhood and their relationship to sleep quality in adulthood. According to our findings, the number of caretakers and whether they are the biological parents or not do not demonstrate an association with current sleep quality; however, lower quality ratings of caretakers is associated with poorer sleep quality in adulthood. In summary, negative experiences in childhood seem to have sleep effects that emerge in adulthood.

References
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Category: Anxiety Disorders, Neurology, Original Research, Past Articles, Psychiatry, Sleep Disorders

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