Schwerpunkt Somnologie 2016 · 20:275–280 DOI 10.1007/s11818-016-0085-1 Received: 21 April 2016 Accepted: 24 August 2016 Published online: 16 September 2016 © Springer-Verlag Berlin Heidelberg 2016 Isabel Bihlmaier1 1 2 · Angelika A. Schlarb2 Faculty of Science, Clinical Psychology and Psychotherapy, University of Tuebingen, Tuebingen, Germany Faculty for Psychology und Sports, Clinical Psychology and Psychotherapy for Children and Adolescents, Bielefeld University, Bielefeld, Germany Self-efficacy and sleep problems A pilot study comparing sleep-disordered and healthy school-age children Introduction Self-efficacy is defined as the extent or strength of one’s belief in one’s own ability to reach personal goals and to manage tasks [3, 4, 5]. The expectation of one’s efficacy is hypothesized to influence task effort, task persistence and relevant coping behavior. Moreover, general self-efficacy is positively associated with self-esteem and optimism and negatively associated with depression and anxiety [12]. The majority of previous studies refer to findings in adults whereas only few studies investigated the concept and correlates of self-efficacy in children. Results of the latter confirm findings in adults: in children and adolescents, perceived selfefficacy is linked to depression and anxiety, as well as academic performance and behavioral problems [5]. Self-efficacy therefore seems to be associated with various domains of cognitive, behavioral and in general psychological functioning in children. In addition, previous studies concerning university students show a link between self-efficacy and sleep behavior: students suffering from insomnia symptoms and impaired sleep quality report lower self-efficacy than those without insomnia [22]. Another study compares students suffering from frequent nightmares to those without. Suffering from nightmares is associated with lower sleep qualityand lowerself-efficacyscores [20]. This relationship between self-efficacy and sleep behavior in adolescents is not yet adequately proven for children. Based on these data, the present pilot study investigates the relationship between perceived general self-efficacy (GSE) and sleep behavior in schoolage children. To our knowledge, there are no comparable studies. In contrast to well-established instruments to measure GSE in adults, e. g., the General Self-Efficacy Scale [25], few comparable instruments for children are available. Based on previous studies with young children and concerning the fact that children are not yet able to rate metadata adequately, GSE was therefore rated in parental report [13]. We hypothesized that 4 there is a difference in GSE between sleep-disturbed and healthy children, 4 GSE and sleep are interrelated, and 4 sleep problems serve as a predictor of perceived GSE. It is important to note that we did not assess the specific domain of sleep-related self-efficacy but general self-efficacy concerning tasks and demands in life. Participants and methods Procedures and participants For comparison of general self-efficacy (GSE), we recruited parents of sleepdisturbed children (chronic insomnia of childhood) and parents of healthy school-age children. GSE ratings of sleep-disturbed children were collected in families interested in a sleep treatment. Parents of healthy school-age children were recruited via pediatricians, homepage information, etc. All parents were informed about the goal, procedure, content, and any other relevant aspect of the study prior to participation. They were informed about the right to refuse participation or to withdraw consent to participate at any time without reprisal. Participation was absolutely voluntary. Prior to participation parents had to give their written consent for participation and afterwards were given the full questionnaires. Parents of both groups filled in the same questionnaires concerning demographic information, GSE and sleep behavior of the child. In the sleep-disordered sample, an additional structured interview for sleep disorders in children and clinical interview confirmed that children suffered from chronic insomnia according to criteria of the third edition of the International Classification of Sleep Disorder (ICSD3 [2]). Families with children suffering from other sleep disorders such as obstructive sleep apnea syndrome (OSAS) or parasomnias and children with a diagnosed psychiatric disorder were not included in the study but were informed about further diagnostic and treatment opportunities. For the healthy sample, only children without any sleep and/or psychiatric disorder diagnosis in the parents’ report were included. Children of the two groups were matched concerning age (between 5 and 10 years) and gender resulting in two samples with n = 54 children (mean age = 7.5 years), respectively. The study was conducted according to standard ethical guidelines as defined by the Declaration of Helsinki and approved by the ethics committee of the department of medicine of the University of Tuebingen. Somnologie 4 · 2016 275 Schwerpunkt Table 1 Meanvalues andtests ofdifferences ingeneral self-efficacy andsleep behaviorbetween sleep-disturbed and healthy school-age children Mann–Whitney U-test Healthy Insomnia children childrena n = 54 n = 54 Measure M (SD) M (SD) Parent-reported General Self-Efficacy (GSE) 24.75 (4.10) 30.17 (4.04) z = –5.47, p < 0.001 CSHQ sleep parameters Bedtime Resistance 10.58 (2.93) 7.02 (1.57) z = –6.60, p < 0.001 Sleep Onset Delay 2.21 (0.87) 1.31 (0.58) z = –5.28, p < 0.001 Sleep Duration 5.89 (1.94) 3.81 (1.29) z = –5.48, p < 0.001 Sleep Anxiety 7.73 (2.30) 4.85 (1.25) z = –6.33, p < 0.001 Night Waking 5.60 (1.20) 3.53 (1.16) z = –5.51, p < 0.001 Parasomnias 9.65 (2.22) 7.93 (1.93) z = –4.48, p < 0.001 Sleep Disordered Breathing 3.38 (0.80) 3.17 (0.84) z = –1.67, p = 0.094 Daytime Sleepiness 13.90 (3.43) 14.93 (2.45) z = –1.74, p = 0.082 Total Sleep Disturbance Score 55.09 (5.78) 44.22 (5.33) z = –7.32, p < 0.001 CSHQ-DE Parent-reported sleep parameters in the Children Sleep Habits Questionnaire (CSHQ-DE [21]) a Children suffering from chronic insomnia according to ICSD-3 Table 2 Correlation matrix for sleep parameters and general self-efficacy ratings (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (1) Age ... – – – – – – – – – – – (2) Gender 0.04 ... – – – – – – – – – – (3) CSHQ Bedtime Resistance –0.04 –0.01 ... – – – – – – – – – (4) CSHQ Sleep Onset Delay 0.23* 0.03 0.25* ... – – – – – – – – (5) CSHQ Sleep Duration 0.29** 0.05 0.24* 0.62** ... – – – – – – – ... – – – – – – 0.20* 0.67*** ... – – – – – ... – – – – 0.23* 0.36*** ... – – – –0.26** –0.29** –0.13 0.02 ... – – 0.06 0.66*** 0.61*** 0.63*** 0.62*** 0.61*** 0.53*** 0.32** 0.25* ... – (6) QSHQ Sleep –0.16 –0.01 0.07*** 0.24* 0.19 Anxiety (7) CSHQ Night Waking –0.17 –0.07 0.60*** 0.15 * (8) CSQH Parasomnias –0.08 0.20 0.19 0.32 (9) CSHQ Sleep Disordered Breathing –0.05 0.17 0.01 0.05 ** 0.16 0.35 0.13 0.17 (10) CSHQ Day- 0.51*** –0.05 –0.16 0.26** 0.18 time Sleepiness (11) CSHQ Total Sleep Disturbance Score 0.16 (12) Parent-re- 0.11 ported General Self-Efficacy *** 0.42 *** 0.04 –0.28** –0.30** –0.24* –0.35***–0.38***–0.25* –0.14 0.17 –0.37***... Correlation coefficients of non-parametric Spearman’s rank correlation (rs) * p < 0.05, **p < 0.01, ***p < 0.001 276 (12) Somnologie 4 · 2016 Instruments General Self-Efficacy Scale To measure perceived GSE of the child, we used the General Self-Efficacy (GSE) Scale [25]; a 10-item psychometric scale to assess optimistic self-beliefs to cope with different tasks and demands in life. The belief that one’s action is responsible for successful outcomes is measured on a 4-point scale (“not at all true”, “hardly true”, “moderately true”, “exactly true”) with a sum score ranging between 10 and 40. In validation studies, psychometric properties of the GSE were proved to be adequate with Cronbach’s alpha between 0.76 and 0.90 [24]. The scale is designed for the general adult population, including adolescents. In a representative investigation (N = 2019, age range between 19 and 95 years), norm values for the German version of the GSE were conducted: mean GSE corresponded to a sum score of 29.40 (standard deviation [SD] = 5.4) [9]. In a sample of N = 3494 German high-school students (12 to 17 years) mean GSE was found to be 29.60 (SD = 4.0) [26]. The authors state that subjects below the age of 12 should not be tested. Therefore, we generated a parentversionofthe GSE (see . Table 4). Validation studies for this parent version are not yet available. Structured interview for sleep disorders in children and clinical interview Inthe sleep-disordered sample, the child’s sleep disorder was assessed in the parents’ report using a structured clinical interview based on diagnostic criteria of the ICSD-3 [2]. Children were diagnosed with chronic insomnia, if they had problems initiating and maintaining sleep for at least 3 months with sleep-onset latencies of more than 20 min on five or more nights per week. To ensure that no mental disorder caused insomnia, a structured clinical interview of mental disorders according to ICD-10 [29] was conducted. Children’s Sleep Habit Questionnaire Sleep behavior of children was assessed in parents report using the German version of the Children’s Sleep Habit Question- Abstract · Zusammenfassung naire (CSHQ) [14], the CSHQ-DE [21]. With eight subscales (Sleep Anxiety, Bedtime Resistance, Night Waking, Sleep Duration, Sleep Onset Delay, Daytime Sleepiness, Sleep-Disordered Breathing, Parasomnias) and a Total Sleep Disturbance Score (TSDS) both behaviorally and medically based sleep problems in school-age children are covered. Internal consistency for a clinical sample (α = 0.78) and test/retest reliability (range 0.62–0.79) were acceptable [14]. Mean TDSD of the community sample was 56.2 (SD = 8.9) and for the clinical sample 68.4 (SD = 13.7); as determined by the intersect point of sensitivity and specificity, a value of 41 was determined as most sensitive and specific cut-off score. In a validation study, internal consistency (α = 0.68) and test/retest reliability (r = 0.76) of the CSHQ-DE also proved to be adequate [21]. Statistical analysis The Statistical Package for the Social Sciences SPSS 21.0 for Windows was used for analysis. Tests were two-tailed and the α-level was 5 %. Depending on criteria for parametric testing corresponding tests were carried out. We investigated differences within and between groups using t-tests or Mann-WhitneyU-tests. Spearman’s rank correlations were conducted to determine interrelation between GSE and sleep behavior. Finally, a stepwise multivariate regression model controlling for age and gender was computed to test the hypothesis that sleep behavior predicted GSE ratings. The Total Sleep Disturbance Score (TSDS) of the CSHQ was not included in the multiple regression model, because as a sum score it is highly intercorrelated with the subscales scores. This would affect calculations regarding individual predictors. The predictive value of the TSDS was determined by computing a single linear regression model also controlling for age and gender. Results The full sample consisted of 108 children between 5 and 10 years; 54 sleepdisordered children with chronic insom- Somnologie 2016 · 20:275–280 DOI 10.1007/s11818-016-0085-1 © Springer-Verlag Berlin Heidelberg 2016 I. Bihlmaier · A. A. Schlarb Self-efficacy and sleep problems. A pilot study comparing sleepdisordered and healthy school-age children Abstract The present pilot study investigates the relationship between general self-efficacy (GSE) and sleep behavior in school-age children (between 5 and 10 years). Children with chronic insomnia (n = 54) had significantly lower GSE scores (p < 0.001) compared to a sample of healthy school-age children (n = 54) matched concerning age (M = 7.5 years) and gender (59.3 % boys, 40.7 % girls). In general, higher sleep disturbance scores were associated with lower GSE (rs = –0.37, p < 0.001). The highest negative correlations with GSE were found for frequent night wakings (rs = –0.38, p < 0.001), sleep anxiety (rs = –0.35, p < 0.001), and sleep onset delay (rs = –0.30, p < 0.01). In a multiple stepwise regression model, frequency of night wakings (ß = –0.33, p < 0.01) and sleep onset delay (ß = –0.26, p < 0.01) predicted GSE scores of children; sleep parameters accounted for 20 % of the variance in GSE scores. All in all, the present findings provide evidence for an association between GSE and sleep behavior, which are in line with previous results in other age groups and concerning other psychological constructs, e. g., depression and anxiety. Future studies should further investigate this topic in order to improve effective intervention programs for children. Keywords General self-efficacy · Chronic insomnia · School-age children · Projections and predictions · Coping behavior Selbstwirksamkeitserwartung und Schlafprobleme. Pilotstudie zum Vergleich von schlafgestörten und gesunden Kindern im Grundschulalter Zusammenfassung Die vorliegende Pilotstudie untersucht den Zusammenhang zwischen der allgemeinen Selbstwirksamkeitserwartung (SWE) und dem Schlafverhalten bei Kindern im Grundschulalter (zwischen 5 und 10 Jahren). Kinder mit chronischer Insomnie (n = 54) zeigten im Vergleich zu einer hinsichtlich Alter (M = 7,5 Jahre) und Geschlechtsverteilung (59,3 % Jungen, 40,7 % Mädchen) übereinstimmenden Gruppe von gesunden Grundschulkindern (n = 54) signifikant geringere SWE-Werte (p < 0,001). Höhere Schlafstörungswerte gingen mit einer geringeren SWE einher (rs = –0,37; p < 0,001). Die stärksten negativen Korrelationen mit der SWE zeigten sich für häufiges nächtliches Erwachen (rs = –0,38; p < 0,001), schlafbezogene Ängste (rs = –0,35, p < 0,001) und Einschlafverzögerungen (rs = –0,30; p < 0,01). In einem multiplen schrittweisen Regressionsmodell ließen sich die SWE-Werte der Kinder aus der Häufigkeit nächtlichen nia and 54 healthy school-age children who were matched concerning age (M = 7.5 years, SD = 1.8) and gender (59.3 % boys, 40.7 % girls). There were no gender differences with respect to sleep and general self-efficacy (GSE) except for para- Erwachens (β = –0,33; p < 0,01) und dem Ausmaß an Einschlafverzögerungen (β = –0,26; p < 0,01) vorhersagen. Die Schlafparameter klärten dabei 20 % der Varianz der SWE-Werte auf. Die vorliegenden Ergebnisse stimmen mit bisherigen Befunden für andere Altersgruppen und andere psychologische Konstrukte (z. B. Depressionen und Ängste) überein und deuten insgesamt auf einen Zusammenhang zwischen der SWE und dem Schlafverhalten hin. Weiterführende Studien sollten diesen Zusammenhang näher untersuchen, nicht zuletzt, um effektive Interventionsprogramme für Kinder zu verbessern. Schlüsselwörter Allgemeine Selbstwirksamkeitserwartung · Chronische Insomnie · Grundschulkinder · Prognose und Vorhersage · Bewältigungsverhalten somnias, z = –2.0, p < 0.05, with boys having higher parent ratings for parasomnias than girls. Somnologie 4 · 2016 277 Schwerpunkt Table 3 Step 1 Step 2 Stepwise multiple regression model to predict general self-efficacy B SE B ß p Constant 31.99 1.20 – – CSHQ Night Wakings –0.93 0.25 –0.36 < 0.001 Constant 34.10 1.40 – – CSHQ Night Wakings –0.84 0.24 –0.33 < 0.01 CSHQ Sleep Onset Delay –1.46 0.54 –0.26 < 0.01 R2 = 0.13 for Step 1, R2 = 0.20 for Step 2 Table 4 Items of the original version of the General Self-Efficacy Scale together with items of the adapted parent version used in the present worka Item General Self-Efficacy Scale Parent version (Schwarzer and Jerusalem [25]) of the General Self-Efficacy Scale 1 I can always manage to solve difficult problems if I try hard enough My child can always manage to solve difficult problems if he/she tries hard enough 2 If someone opposes me, I can find the means and ways to get what I want If someone opposes my child, he/she can find the means and ways to get what it wants 3 It is easy for me to stick to my aims and accomplish my goals It is easy for my child to stick to his/her aims and accomplish his/her goals 4 I am confident that I could deal efficiently with unexpected events I am confident that my child could deal efficiently with unexpected events 5 Thanks to my resourcefulness, I know how to handle unforeseen situations Thanks to his/her resourcefulness, my child knows how to handle unforeseen situations 6 I can solve most problems if I invest the necessary effort My child can solve most problems if he/she invests the necessary effort 7 I can remain calm when facing difficulties because I can rely on my coping abilities My child can remain calm when facing difficulties because he/she can rely on its coping abilities 8 When I am confronted with a problem, I can usually find several solutions When my child is confronted with a problem, he/she can usually find several solutions 9 If I am in trouble, I can usually think of a solution If my child is in trouble, he/she can usually think of a solution 10 I can usually handle whatever comes my way My child can usually handle whatever comes his/her way a GSE items used in the present work were translated into German Comparison of sleep parameters and general self-efficacy Children in the two samples differed significantly concerning parent-reported GSE, as well as most of the sleep parameters except for CSHQ subscales Sleep Disordered Breathing and Daytime Sleepiness. The latter were only marginally different. Mean values and comparisons between the two groups are presented in . Table 1. in . Table 2. There was no association between GSE and age or gender of the child. Furthermore, GSE was negatively associated with nearly all sleep-related CSHQ subscales. The strongest negative associations with GSE were found for Night Wakings and Sleep Anxiety, followed by Sleep Onset Delay. Sleep Disordered Breathing and Daytime Sleepiness were notcorrelated significantlywith GSE (see . Table 2). Prediction of general self-efficacy Interrelations between general self-efficacy and sleep parameters Interrelations between GSE and sleep parameters in the full sample are depicted 278 Somnologie 4 · 2016 According to a stepwise multiple regression model controlling for age and gender (. Table 3) CSHQ subscales Night Wakings and Sleep Onset Delay predicted GSE of children in parent’s reports. Night Wakings and Sleep Onset Delay explained 19.6 % of the variance in GSE ratings of children. As mentioned above, Total Sleep Disturbance Score (TSDS) of the CSHQ was not included in the model but was used as single predictor in a regression model. The TSDS also appeared as significant predictor (p < 0.001) explaining 14.8 % of the variance in GSE ratings. Discussion The present pilot study investigates the relationship between general self-efficacy (GSE) and sleep behavior in school-age children with a mean age of 7.5 years. Confirming our hypotheses and previous findings concerning other variables of psychological functioning, there was a difference in GSE between sleep-disturbed and healthy school-age children. According to parents report, healthy children with better sleep behavior had significantly higher GSE ratings compared to children with chronic insomnia. With a value of 30.17, GSE of healthy children was similar to mean GSE (M = 29.60) of a sample of German high-school students (12–17 years) [26], whereas GSE of sleep-disordered children was considerably lower (M = 24.75). Moreover, GSE was interrelated with various sleep parameters in parent’s reports. In general, higher GSE ratings were associated with lower CSHQ problem scores (Bedtime Resistance, Sleep Onset Delay, Sleep Duration, Sleep Anxiety, Night Wakings, Parasomnias, and Total Sleep Disturbance Score) and therefore with better sleep behavior. These results are partially in line with those found in other age groups, e.g., university students [23, 22]. The correlation between GSE and sleep-related anxiety found in the present study can be compared with similar results on a relationship between selfefficacy and anxiety. In children, a link between GSE and social anxiety was detected [16]. Moreover, self-efficacy was shown to be associated with specific mathematics anxiety in school [8, 10, 11]. The relation between self-efficacy and anxiety was also found for ado- lescents [13] and adults [12]. Because anxiety is also strongly connected to sleep behavior in children [1, 7, 22], future studies should investigate the relationship of these constructs, as well as possible moderating effects. All in all, the present results are in line with previous research concerning the connection between self-efficacy, sleep, and anxiety. When sleep parameters were added in a multiple stepwise regression model controlling for age and gender, Night Wakings and Sleep Onset Delay served as predictors for GSE. Together, they explained 20 % of the variance in GSE ratings of parents. In a single linear regression model, the Total Sleep Disturbance Score also predicted GSE ratings and explained 15 % of the variance in parent ratings. As regression models indicate a correlative relationship between sleep and GSE ratings, future longitudinal studies are needed to give evidence for a causal relation between these factors. Moreover, the relation between sleep and GSE ratings found in the present study does not imply direction of this relationship. On the one hand, low GSE could represent a risk factor for the development of sleep problems, while on the other hand, impaired sleep—especially prolonged sleep onset delay and frequent night wakings—could cause lower GSE. Shorter sleep duration and poorer sleep quality were already identified as riskfactors for low self-esteem and depression [15, 17], as well as pain [6]. Equally, a bidirectional association between sleep and self-efficacy could be hypothesized. The relationship between sleep and GSE could also be influenced by other factors, e. g., psychological characteristics of the child or its parents and parenting style. Future studies should therefore include more questionnaires on other constructs to explore possible moderator and/or mediator variables that could affect the direction and/or strength of the relation between sleep behavior and GSE. Yet, the present study points towards a link between GSE and sleep behavior which includes important implications for the treatment of sleep problems in children. Intervention programs could, for example, also address self-efficacy in the treatment of sleep problems and sleep distur- bances. The treatment program KiSS [19] for school-age children with chronic insomnia tries to include these considerations: the stuffed leopard Kalimba serves as a coping and master model, which encourages the child to implement newly learned strategies and therefore could enhance self-efficacy of the child. Future (longitudinal) studies in children should address the question whether improvements in sleep behavior and enhanced self-efficacy are related. The present pilot study provides preliminary insights into the complex relationship between GSE and sleep behavior in children. Limitations As previoiusly mentioned, the present findings on a relationship between sleep behavior and GSE indicate a correlative relation allowing no causal conclusions. Moreover, the relationship between sleep behavior and GSE could be moderated or mediated by other factors (e. g., anxiety, self-esteem, sociodemographic variables and/or educational level of children and/or parents). Therefore, future studies should include further questionnaires to examine possible influencing factors. It is also important to consider that sleep behavior and GSE of children were assessed by parents and not by self-report and therefore could be biased by the estimation of parents. Parents of sleepdisturbed children often experience the disability of the child to (re-)initiate sleep and therefore might estimate sleep-related self-efficacy of the child as low. When sleep problems persist, this tendency could extend and generalize concerning the perception of other abilities of the child in everyday life. Therefore, future studies should include self-report instruments to compare estimation of parents and self-report of children to quantify a possible bias and to prove the validity of parent’s reports. As indicated by former studies, maternal self-efficacy influenced parenting practices and behavioral competences [18, 27]. Moreover, decreasing parenting self-efficacy was associated with perceptions of infant negative characteristics. Importantly, crosslagged path analysis on the direction of effect showed that parenting self-efficacy predicted characteristics of infant negative temperament [28]. Therefore, future studies should (1) measure GSE of parents to test whether there is a connection between the latter and parent-reported GSE of the child, and (2) investigate this connection and the possible influence on other parent and child variables (e. g., sleep problems) over time (e. g., before and after treatment of insomnia). Conclusion The present pilot study provides preliminary exploratory insights into the relationship between general self-efficacy (GSE) and sleep behavior in school-age children. Sleep-disturbed children indicated significantly lower GSE in parent’s reports compared to healthy school-age children. Besides other variables of psychological functioning (e.g., depression, anxiety and school performance), GSE also seems to be linked to sleep behavior of children. Future longitudinal studies should investigate the direction of relation (whether low GSE is the cause or consequence of sleep problems in children), possible mediating/moderating variables and treatment perspectives concerning sleep behavior and GSE. Corresponding address I. Bihlmaier Faculty of Science, Clinical Psychology and Psychotherapy, University of Tuebingen Schleichstr. 4, 72076 Tuebingen, Germany Isabel.bihlmaier@ uni-tuebingen.de Compliance with ethical guidelines Conflict of interest. I. Bihlmaier and A.A. Schlarb declare that they have no competing interests. This article does not contain any studies with human participants or animals performed by any of the authors. Somnologie 4 · 2016 279 Fachnachrichten Schwerpunkt References 1. Alfano CA, Ginsburg GS, Kingery JN (2007) Sleeprelated problems among children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 46(2):224–232 2. 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