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Abstract

Introduction

Pediatric sleep concerns are common in primary care. Sleep problems are associated with increased problems with social-emotional development and behavior. Early sleep assessment could be a critical component of behavior screening programs within integrated pediatric primary care programs.

Practice Change Implemented

This program development initiative to design an early screening program was implemented in an integrated suburban primary care clinic in the Mid-Western United States. The proportion of early sleep concerns among children <2 years of age were and documented among patients referred to Integrated Behavioral Health (IBH) who presented with elevated scores on the Externalizing scale of the Child Behavior Checklist (CBCL).

Aim and Theory of Change

The aim of the current study was to determine if future early behavioral screening initiatives should focus on sleep among children under age two.  It was predicted that early sleep problems would be predictive of later elevated Externalizing behavior scores on the CBCL. 

Population and Stakeholders

The target population included pediatric primary care patients referred to the IBH program by their primary care provider for behavioral health problems. The sample included 50 patients with an average age of 8.2 (SD=3.6) with 33% of patient identifying as female. The majority of patients were Caucasian (75.5%).

Timeline

Data collection began in October 2018 and was recorded for one year.

Highlights

It was found that 63% of patients with elevated Externalizing scores also had a history of sleep problems before age two, with 8% percent reporting delayed sleep onset, 24% reporting frequent night awakenings, and 4% reporting both issues as problematic.  A linear regression was conducted to predict whether the presence of sleep problems prior to age two predicted elevation in CBCL Externalizing scores.  Approximately 5% of the variance in Externalizing scores was accounted for by early sleep concerns (F(1,47) = 2.45, p=.12).  This approached significance, however given the small sample size, there was likely insufficient power to detect a significant effect. 

Sustainability

Identifying risk factors is an important step in the development of early behavioral screening programs.  Systematic sleep assessment in primary care could be a feasible way to identify children at risk for future behavior concerns.

Transferability

Sleep assessment within primary care health maintenance exams could guide the development of screening and prevention programs.

Conclusions

More data are needed to determine the value of including sleep in early screening initiatives. Further research should be conducted in order to gauge the correlation between sleep concerns reported prior to age 2 and subsequent IBH referrals for externalizing behaviors.

Discussion

Although more than half of the sample referred to integrated behavioral health services, had early sleep problems prior to age two, this was not significantly predictive of CBCL Externalizing scores. More data should be collected to determine the role of sleep in the development of later problem behavior.

Lessons Learned

As a next step it would be important to focus on how to monitor and screen for sleep concerns in primary care and utilize early intervention for sleep concerns in primary care.