PEDIATRICS
Bed Sharing, Sleep Habits, and Sleep Problems Among Chinese School-Aged
Children
Xianchen Liu MD, PhD1; Lianqi Liu MD2; Ruzhan Wang MD2
1Department
of Family and Human Development and Program for Prevention Research, Arizona State University, Tempe, AZ, USA; 2Shandong
Mental Health Center, Jinan, People’s Republic of China
Study Objectives: This study examined the association between bed
sharing, sleep habits, and sleep problems among Chinese school-aged
children.
Design and Setting: A questionnaire survey of school-aged children was
undertaken in Jinan city, People’s Republic of China, in 2001.
Participants: A total of 517 elementary-school children (mean age, 10.5
years; 47.4% boys) participated in the survey.
Measurements: The parents completed the Chinese version of the
Children’s Sleep Habits Questionnaire and a number of questions that
asked about bed sharing and characteristics of the family and child.
Results: The prevalence of regular bed sharing in Chinese school-aged
children was as high as 18.2%. The rate of bed sharing did not differ
between boys and girls but significantly decreased with age from 55.8%
in 7-year-olds to 7.2% in 11- to 13-year-olds. Multivariate logistic regression analysis showed that younger age, poor physical health of the child,
and crowded housing were associated with an increased likelihood for the
child’s bed sharing with parents. Bedtime and total sleep duration did not
significantly differ between children who shared beds and those who slept
alone. Children who shared beds with their parents were reported to have
more sleep anxiety and daytime sleepiness than children who slept alone.
Bed sharing was not associated with parasomnias and breathing problems during sleep.
Conclusions: Regular bed sharing in Chinese school-aged children was
very common and significantly decreased with age. Crowded housing and
poor physical health of the child increased the likelihood for children and
parents to share beds. Bed sharing may exert influences on sleep quality
rather than sleep quantity.
Key Words: Child; bed sharing; sleep patterns; sleep duration; sleep
problems
Citation: Liu X; Liu L; Wang R. Bed sharing, sleep habits, and sleep problems among Chinese school-aged children. SLEEP 2003;26(7):839-44.
INTRODUCTION
and independence.17 However, in many Asian countries, childrearing
practices emphasize the development of interdependence and family
closeness, and child-parent bed sharing up to school age is accepted by
many families.18 There is evidence that bed sharing is more prevalent in
Asian countries than in Western countries. For example, it has been
reported that more Japanese than American children share beds with
their parents 3 or more times per week.19 A recent report of trends in
infant bed sharing in the United States between 1993 and 2000 indicated that infant bed sharing was strongly associated with race or ethnicity,
with the highest prevalence being found in Blacks (27.9%), followed by
Asians (20.9%), and the lowest prevalence among White families
(7.2%). 16 In a study of 427 Korean children aged 12 to 84 months, Yang
and Hahn reported a bed-sharing rate as high as 45.0%, and they found
that traditional cultural values, child’s age, and maternal attitude toward
bed sharing were the main determinants of bed sharing in Korean families.18
Bed-sharing practices also are influenced by family environments,
with a higher prevalence of bed sharing among lower socioeconomic
and higher stress families.20-22 In an earlier study of bed sharing in urban
families with young children in the United States, Lozoff and colleagues
found that bed sharing was associated with a lower level of parental education, less professional training, and increased family stress among
White families but not among Black families.21 In the United States
national trend study of infant bed sharing between 1993 and 2000,
results indicated that bed sharing in families with household incomes
less than $20,000 was 1.5 times more likely to occur than in those families with an income of more than $20,000.16 A recent study of bed sharing in an inner-city population showed that single marital status of the
mother, household crowding, and household moves since the birth of the
infant were significantly associated with bed sharing.20 Due to lack of
data, it is unclear if these family characteristics are associated with child
bed sharing among Chinese families.
In China, childrearing practices and beliefs are very similar to those
held in other Asian countries such as Korea and Japan. Bed sharing of
DURING THE PAST 2 DECADES, SLEEP PRACTICES AND SLEEP
PROBLEMS IN CHILDREN HAVE RECEIVED MORE ATTENTION
FROM PARENTS AND MEDICAL PROFESSIONALS BECAUSE
SLEEP PROBLEMS IN CHILDREN ARE NOW RECOGNIZED TO
BE VERY COMMON (estimated prevalence 10% - 45%),1-6 often persist over several years,7-9 and can exert adverse effects on cognitive,
behavior, emotional, and even physical development.1 Sleep practices
and sleep behaviors in children are associated not only with a large number of biologic and psychologic factors, but also with cultural, social,
and family factors.1,4,10,11 However, most epidemiologic studies of sleep
practices and sleep problems have been of Western children.11-14
Because of the great cultural and socioeconomic differences between
China and Western countries, results from Western children may not be
generalizable to Chinese children. This study represents the first investigation of bed sharing (cosleeping) and sleep problems in a sample of
children from Mainland China. We will use “bed sharing” to mean a
child sleeping in the same bed with 1 or 2 parents.
Bed sharing between young children (particularly infants) and parents
varies across cultures and ethnicities.15,16 In most Western countries,
people generally believe that a child should sleep separately from his or
her parents as soon as possible to foster the development of autonomy
Disclosure Statement
This study was supported in part by the Shandong Medical Research
Foundation, People’s Republic of China, and the Multi-Investigator Proposal
Development Grant Program, Arizona State University.
Submitted for publication February 2003
Accepted for publication June 2003
Address correspondence to: Xianchen Liu, MD, PhD, Program for Prevention
Research, Arizona State University, PO Box 876005, Tempe, AZ 85287;
Tel: 480-727-6145; Fax: 480-965-5430; E-mail: [email protected].
SLEEP, Vol. 26, No. 7, 2003
839
Sleep Problems Among Chinese School-Aged Children—Liu et al
young children with parents is also accepted by Chinese culture. Among
families of China, all-night bed sharing during infancy and early childhood years is normative, decreases as the child’s age increases, and
seems unusual during puberty. However, Mainland China as a developing country differs greatly from Japan and South Korea in socioeconomic status (SES), which may have a unique contribution to bed-sharing practices among Chinese families. For example, compared with
Japan and South Korean, urban residents of China have few choices of
housing, and living space is very crowded due to financial restrictions
and rapid population growth. Most urban families with young children
are residing in an apartment, possibly with only 1 bedroom, which may
prevent the child from having her or his own room or bed and may
increase the likelihood of bed sharing with parents. In addition, almost
all of the families in urban China have only 1 child due to the 1-child
family-planning policy. Only children are more likely to be spoiled or
over protected and are egocentric, less cooperative, timid, and unadjusted.23 These characteristics may increase the likelihood of children sharing a bed with their parents.
Several cross-sectional studies have investigated the association
between bed sharing and sleep problems in young children under 4 years
of age, and their results are inconsistent. In a study of children aged 6 to
48 months in Cleveland, Lozoff et al reported an increase in disruptive
sleep problems among bed-sharing White children but not among Black
children. 21 Schachter and colleagues reported increased sleep problems
among bed sharing Hispanic American children in New York,24 and
Madansky and Edelbrock reported increased sleep problems in bed sharing children in Massachusetts for both Whites and non-Whites.22 A
recent study by Lozoff and colleagues found that the association
between bed sharing and problematic sleep behaviors differed across
ethnicity (White vs Black) and SES (lower SES vs higher SES).11 For
example, night awakenings in bed-sharing children were approximately
2 times as frequent as in non–bed-sharing children, and the difference
was marked for lower-SES White families. However, bedtime protests
were more prevalent among bed-sharing than non–bed-sharing children
in higher-SES Black families.11 To our knowledge, only 1 longitudinal
study has investigated the long-term effects of parent-child bed sharing
in infancy and early childhood on sleep problems and cognitive and
emotional consequences.25 In the only longitudinal study over a period
of 18 years, Okami and colleagues followed 205 children and did not
observe any associations between bed sharing in infancy (35% at age 5
months) and early childhood (7% at aged 3 years and 4% at aged 5 and
6 years) and sleep problems and psychologic consequences at ages 6 and
18 years. 25 However, the small sample number of cosleepers, the different definitions of bed sharing and sleeping problems, and the different
target populations in most previous studies may contribute to the conflicting results.
Compared with studies in infants and toddlers,11,13,21,22,24 little research
has described bed sharing in community samples of school-aged chil-
dren and adolescents. One study of children up to age 7 years in South
Korea reported that rates for all-night bed sharing and room sharing were
45.0% and 43.3%, respectively.18 Another study of part-night bed sharing in a group of White upper-middle-class families of 2- to 10-year-old
children found that 63% were reported to sleep with their parents part of
the night when the child awoke frightened or ill.26 In 1 study of adolescents, Simonds and Parraga reported that 2% to 4% of the sample had
bed sharing with family members at least once per 6 months.27 There
have been no reports on all-night bed sharing and its association with
sleep problems in school-aged children. We report here a school-based
cross-sectional study of Chinese children with a standardized sleep questionnaire. Specific purposes of this study were 1) to describe child-parent bed-sharing practices in Chinese children, 2) to identify differences
in bed sharing in relation to age and sex, 3) to examine the correlates of
child-parent bed sharing in Chinese children, and 4) to examine the
hypothesis that bed sharing is associated with an increased risk for sleep
problems.
METHODS
Subjects and Procedure
This study was conducted in the fall of 2001, in Jinan, the capital city
of Shandong Province located in the eastern part of Mainland China. We
recruited participants from 3 elementary schools in 1 representative
school district of Jinan. We explained the aims of the survey to school
principals and teachers and obtained their permission to carry out the
survey. It is the standard practice in China to obtain consent from the
principals of targeted schools first, since schools in China act in loco parentis.28 After receiving permission from the target schools, we randomly
selected 1 class from each grade for each school and identified 565 children as potential participants. The sampled children were asked to take
a questionnaire to their parents with a letter explaining the project and
requesting that the parents complete the questionnaire. The parents were
also told that participation in the survey was voluntary. The study was
approved by the research committee at Shandong Mental Health Center.
Of the 565 identified children, 517 (92%) returned completed questionnaires. This sample consisted of 47% boys, and mean age was 11.0
years (SD = 1.9, range 7-13). In 68% of the children, the informant was
the mother, in 30% the father, and in 2% the grandparents. Sample characteristics are summarized in Table 1.
Measures
We used the Children’s Sleep Habits Questionnaire (CSHQ)29 to
assess the children’s sleep habits and sleep disturbances as reported by
parents. The CSHQ, developed by Owen et al, consists of 33 sleep-disturbance items and 3 items asking information about bedtime, morning
waking time, and daily total sleep duration.29 Parents are asked to recall
the child’s sleep behaviors over a “typical” recent week. Items are rated
Table 1—Demographic characteristics of study sample (N = 517)
Variables
Boys
Mean age (SD)
Father’s education
Middle school or less
High school
Some university
University
Mother’s education
Middle school or less
High school
Some university
University
House size (square meters per person)
10 or less
11 - 15
16 - 20
Over 20
SLEEP, Vol. 26, No. 7, 2003
Table 2—Mean bedtime, wake-up time, and sleep duration among
Chinese children (N = 517)
%
47.0
11.0 (1.9)
Age (year)
11.0
32.0
22.0
35.0
7
8
9
10
11
12
13
Total
Sex effects (F)
Age effects (F)
Sex × Age (F)
19.0
39.0
24.0
18.0
15.1
19.7
27.1
38.1
Bedtime
(SD in minutes)
Wake-up time
(SD in minutes)
Sleep duration
(Hours)
20:58 (30.6)
20:56 (30.0)
21:08 (34.2)
21:02 (30.6)
21:01 (32.4)
21:14 (36.6)
21:10 (75.0)
21:06 (44.4)
0.00
5.78*
0.01
06:31 (16.8)
06:36 (18.0)
06:31 (18.0)
06:23 (18.0)
06:19 (16.2)
06:18 (22.2)
06:22 (21.0)
06:24 (19.8)
0.03
36.61***Y
0.00
9.29 (0.67)
9.53 (0.75)
9.07 (0.67)
9.27 (0.86)
9.21 (0.67)
8.89 (0.72)
8.98 (0.71)
9.13 (0.74)
0.16
19.63***Y
0.15
YYounger
children woke up later and slept longer.
*P<.05; ***P<.001
840
Sleep Problems Among Chinese School-Aged Children—Liu et al
Family Demographics and Child Developmental Characteristics
on a 3-point scale: usually if the sleep behavior occurred 5 to 7 times per
week, sometimes for 2 to 4 times per week, and rarely for 0 to 1 time per
week. The 33 sleep-disturbance items were conceptually grouped into 8
subscales: Bedtime resistance, Sleep onset delay, Sleep duration, Sleep
anxiety, Night wakings, Parasomnias, Sleep-disordered breathing, and
Daytime sleepiness.29 The CSHQ has been used for a number of studies
of sleep behavior in Western children.14,29,30 We developed a Chinese
version of the CSHQ by translation and back translation. Cronbach’s
alphas using data from these children were 0.80 for the entire scale, and
0.49 to 0.72 for subscales. The psychometric properties of the Chinese
CSHQ with this sample are comparable to those found in American children for most of the subscales.29
A structured family demographic and child development questionnaire was devised for the parents to elicit hypothesized correlates of bed
sharing. The family demographic questions asked information about
family economic status, the size of the home (square meters per person),
parental education level, occupation, the state of the relationship
between the parents (good/fair/poor/ separation/divorce), perceived
health status (good/fair/poor), and the style of disciplining the child
(authoritarian/permissive/between above). The characteristics related to
the child included the child’s sex, age, school grade, the parent’s perception of the child’s physical health (good/fair/poor), and the childmother or child-father relationships (good/fair/poor).
Bed Sharing
Statistical Analysis
Although sleeping on the floor is a typical practice in Korea and
Japan,18,19 the use of beds is universal in urban and most rural areas of
China. We defined bed sharing to mean parents and children regularly
sleeping together in a bed for the whole night. Parents were asked to
choose 1 of 3 statements to indicate the child’s regular nightly sleeping
practice: 1. Share a bed with parent(s) (bed sharing); 2. Share a room
with parent(s) but different bed (room sharing); and 3. Sleep alone in a
different room.
We performed analyses of covariance (ANCOVAs) with sex as a
between-subjects factor and age (in years) as a covariate to assess the
effects of age and sex on sleep patterns (bedtime and wake-up time),
sleep duration, and individual sleep problems as measured by the CSHQ.
Type III sums of squares were used for main and interaction effects,
whereby each significant effect was tested after controlling for all other
effects.
We performed a series of logistic regression analyses to examine significant correlates of regular bed sharing. All variables were initially
examined in univariate models. The final multivariate logistic regression
model included all variables retaining significance after a forward likelihood-ratio stepwise elimination procedure. Statistical tests of the
regression estimates or odds ratios (OR) were based on Wald statistics.
The ORs and their 95% confidence intervals (CIs) were presented to
show the association.
Finally, we performed ANCOVAs with bed sharing as a between-subjects factor and age (in years), sex, physical health, and house size as
covariates to examine the effects of bed sharing on sleep patterns, sleep
duration, and sleep problems as measured by the CSHQ after controlling
for all other effects.
All analyses were performed using the Statistical Program for Social
Sciences (SPSS), Version 11.5 for Windows. All statistical significance
was set at P< .05.
Table 3—Frequencies of sleep behavior and sleep problems in Chinese
children (N = 517)
Frequency (%)
ANCOVA
Sometimes Often Sex Age
Sex×Age
22.6
11.8
5.8
10.4
4.4
12.2
12.0
12.2
8.3
9.5
6.2
9.1
1.2
13.9
11.6
8.9
0.08
0.01
0.02
0.54
1.24
1.96
0.09
0.29
6.83**O
2.40
35.14***Y
30.56***Y
2.59
2.46
14.27***Y
0.84
0.09
0.00
0.04
0.34
1.23
1.63
0.01
0.59
8.3
15.5
5.8
25.0
1.7
18.4
2.9
17.6
1.39
0.00
0.02
0.18
15.32***Y
0.06
8.57**Y
0.44
1.30
0.00
0.10
0.62
RESULTS
9.3
9.7
2.38
0.62
1.43
Sleep-disordered breathing
Snores loudly
Holds breath or stops breathing
Snorts and gasps
8.7
4.8
7.4
2.9
0.8
4.8
1.14
0.01
1.76
4.11*
4.49*
0.56
0.88
0.01
1.28
Parasomnia
Wets the bed
Talks in sleep
Restless
Sleepwalks
Grinds teeth
Awakens screaming or sweating
Nightmares
5.8
13.3
17.0
4.8
13.3
5.0
6.8
1.0
6.2
16.2
1.2
5.8
1.0
2.3
0.12
0.72
0.07
0.00
0.48
1.68
1.95
10.32***Y
0.07
3.52
1.76
4.79*
3.02
0.00
0.11
0.79
0.15
0.02
0.71
1.34
1.46
Table 2 presents mean bedtime, wake-up time, and sleep duration in
517 Chinese school-aged children. As Table 2 indicates, average bedtime
and wake-up time were 9:06 PM (SD=44.4 minutes) and 6:24 AM
(SD=19.8 minutes), respectively, with no difference between boys and
girls. As age increased, however, children stayed up later (P=.02) and
woke up earlier (P<.001). Average sleep duration was 9.13 hours, significantly decreasing with age (F = 19.63, P<.001), but the same in boys
and girls. Sex-by-age interactions were not observed for bedtime, wakeup time, or sleep duration.
20.5
19.0
23.4
15.5
15.9
36.0
7.0
23.4
7.9
6.8
2.22
1.48
1.73
0.14
0.02
4.17*
0.00
2.50
0.09
2.39
2.63
0.96
1.14
0.10
0.04
7.0
4.3
1.49
0.01
1.22
14.1
22.4
0.00
2.57
0.10
Bedtime resistance & anxiety
Does not go to bed at same time
Cannot fall asleep in 20 minurtes
Falls asleep in another’s bed
Needs a parent in room to sleep
Struggles at bedtime
Afraid to sleep in the dark
Afraid of sleeping alone
Trouble sleeping away from home
Night wakings & sleep duration
Moves to another’s bed at night
Awakes once during night
Awakes more than once
Does not sleep the right amount
Does not sleep same amount
each night
Daytime sleepiness
Needs awakening by others
in the morning
Wakes up in a bad mood
Hard time getting out of bed
Takes a long time to be alert
Seems tired during the day
Seems very sleepy or falls asleep
while watching TV
Seems very sleepy or falls asleep
while riding in car, bus, or bicycle
Sleep Patterns and Sleep Duration
Frequency of Sleep Problems
Table 3 shows the frequencies of individual sleep problems and sex
and age effects on sleep problems. Daytime sleepiness was the most
prevalent problem: 36% children needed to be awakened by others in the
morning, 23% had difficulty getting out of bed, and more than 22%
seemed very sleepy while riding in a car or bus. Night wakings, sleep
movements (restlessness), and being afraid to sleep in the dark or alone
also were common. Breath holding, bed-wetting, and waking up screaming or sweating were less common compared with other sleep problems.
The frequencies of all of the sleep problems listed in Table 3 were similar in boys and girls. The ANCOVA showed that 11 sleep problems were
significantly associated with age. Six problems significantly decreased
with age: falling asleep in another’s bed (F=35.14, P<.001), needing par-
YMore
problems in younger children; OMore problems in older children; ANCOVA, analyses of covariance; *P<.05; ** P<.01; *** P<.001
SLEEP, Vol. 26, No. 7, 2003
841
Sleep Problems Among Chinese School-Aged Children—Liu et al
ent in the room to sleep (F=30.56, P<.001), being afraid to sleep alone
(F=14.27, P<.001), moving to another’s bed at night (F=15.32, P<.001),
awakening more than once (F=8.57, P<.01), and bed-wetting (F=10.32,
P<.001). Only problems with not going to bed at the same time
increased with age (F=6.83, P<.01). Four problems were significantly
related to age but without linear associations: snoring loudly (F=4.11,
P<.05), breath holding (F=4.49, P<.05), grinding teeth (F=4.79, P<.05),
and needing awaking in the morning (F=4.17, P<.05).
Regular Bed Sharing and Correlates
In these children, 63.4% slept alone in their own room, 18.4% slept
alone but in the parents’ room, and 18.2% shared a bed with their parent
or parents for the whole night. Regular bed sharing declined significantly with age, from as high as 55.8% at age 7 to 7.1% at age 13 (χ2=86.77,
df=6, P<.001). Figure 1 shows the decline in frequencies of bed sharing
for boys and girls, respectively.
A series of univariate logistic regression models were performed to
examine the significant correlates of regular bed sharing in Chinese children. All family and child variables as described in the methods section
were individually entered into the model with regular bed sharing (yes
or no) as the dependent variable. There were no statistical associations
between bed sharing and most of the family and child variables such as
parental education levels, the style of disciplining the child, perceived
family economic status, child sex, and child-parent relationships. As
shown in Table 4, 4 variables were found to be significantly associated
with increased likelihood for bed sharing: younger age, poor physical
health, poor parental relationships, and crowded housing. Multivariate
logistic regression analysis was performed to adjust for potentially confounding effects of other factors. In the multivariate model, 3 factors
remained significant: younger age of the child (OR=13.57 for age 7,
OR=9.27 for age 8, OR=2.44 for age 9, and OR=2.91 for age 10), poor
physical health of the child (OR=2.34), and crowded housing
(OR=2.98).
Figure—Prevalence (%) of regular bed sharing in relation to age and sex. Blank rectangular bars and filled rectangular bars present prevalence for boys and girls, respectively.
Table 4—Bed sharing and correlates in Chinese children (N = 517)
Variables
%
Crude
Bed sharing OR
95% CI
Associations of Bed Sharing and Room Sharing with Sleep
Adjusteda
OR
95% CI
The associations of regular bed sharing and bed sharing with sleep
patterns and sleep problems were examined by ANCOVA with age, sex,
physical health, and house size as covariates. Table 5 shows the means
Sex
Boys
15.1
1.00
1.00
and SD of bedtime, wake-up time, sleep duration, and sleep problems as
Girls
21.0
1.49 0.95-2.35
1.53 0.91-2.57
measured by the CSHQ for bed-sharing children, room-sharing children,
Age (year)
and children who slept alone, respectively.
7
55.8
16.27 7.98-31.13*** 13.57 6.46-28.50***
8
39.6
8.45 4.05-17.64*** 9.27 4.31-19.91***
As shown in Table 5, we found significant differences among the 3
9
18.4
2.91 1.39-6.09**
2.44 1.12-5.31*
groups of children in wake-up time (F=4.41, P<.05), sleep anxiety
10
19.0
3.03 1.40-6060**
2.91 1.31-6.49**
(F=14.49, P<.001), and daytime sleepiness (F=3.14, P<.05). Tukey
11-13
7.2
1.00
1.00
posthoc tests were performed to detect significant differences between
Physical health
Good
14.9
1.00
1.00
the 2 groups. Results showed that bed-sharing children woke up in the
Fair
17.3
1.20 0.71-2.00
0.99 0.55-1.80
morning significantly later than did room-sharing children (P<.05) and
Poor
32.8
2.79 1.40-5.56**
2.34 1.06-5.14*
sleeping-alone children (P<.05), but room-sharing children and sleepParental relationship
Good
17.4
1.00
1.00
ing-alone children had no significant differences in wake-up time
Conflicts/divorce
57.1
6.33 1.39-28.80*
4.96 0.89-27.53
(P<.05). Children who slept alone were less likely to have reported sleep
Crowded housing
anxiety than bed-sharing (P<.05) and room-sharing children (P<.05),
15.7
1.00
1.00
≥ 11m2/ person
while bed-sharing children were more likely to have reported daytime
< 11m2/ person
32.1
2.53 1.47-4.34***
2.98 1.59-5.57***
sleepiness than were room-sharing (P<.05) and sleeping-alone children
aAdjusted for all others in the table in multivariate logistic regression model; OR, odds
(P<.05).
No significant differences among the 3 groups of children were
ration; CI, confidence interval; * P<.05; ** P<.01; *** P<.001
observed in bedtime, total sleep duration, delay
in sleep onset, parasomnias, or breathing probTable 5—Sleep time and sleep problems among 3 groups of children: bed sharing, room sharinga,
lems during sleep (Table 5).
b
and sleeping alone
Bedtime
Wake-up time
Sleep duration
Sleep onset delay
Sleep anxiety
Parasomnias
Sleep-disordered breathing
Daytime sleepiness
DISCUSSION
Bed sharing
(N = 94)
Mean
SD
Room sharing
(N = 95)
Mean
SD
Sleeping alone
(N = 328)
Mean
SD
ANCOVAc
20.95
6.54
9.19
1.22
6.16
8.71
3.46
11.16
21.09
6.41
9.12
1.40
5.81
8.29
3.38
9.99
21.13
6.36
9.11
1.30
4.97
8.24
3.36
10.05
0.73
4.41*
0.69
0.61
14.49***
0.44
0.02
3.14*
1.29
0.30
0.77
0.55
2.21
2.39
0.95
3.62
0.54
0.32
0.68
0.69
2.19
1.91
0.94
3.16
0.55
0.33
0.75
0.64
1.48
1.95
0.89
3.18
aSharing a room with parents but separate bed; bSleeping in own room; cCovariates: age, sex, physical health, and house size.
* P<.05; *** P<.001; ANCOVA, analyses of covariance
SLEEP, Vol. 26, No. 7, 2003
842
Although there are several studies of bed
sharing in young Asian children,18,19 this is the
first investigation to report the prevalence of
bed sharing and sleep patterns and problems in
Chinese school-aged children. The major findings of the current study are 1) the prevalence
of routine bed sharing in Chinese school-aged
children was as high as 18%, and another 18%
of the sample shared a room with parents; 2) the
prevalence of routine bed sharing declined sig-
Sleep Problems Among Chinese School-Aged Children—Liu et al
practices, child development factors, and household living conditions.
Chinese parents often initiate bed sharing for their convenience during
the breastfeeding period and because of their beliefs that bed sharing
benefits young children. As the child’s age increases, bed sharing among
Chinese families also decreases. For preschoolers, bed sharing is normative among Chinese families. For school-aged children, children are
often separated from their parents’ beds, and bed sharing seems atypical.
Bed sharing is considered unusual for adolescents. Bed sharing in urban
families of China is maintained later, even up to puberty, for most cases,
possibly due to a lack of living space and, for some cases, possibly due
to child’s anxiety, resistance to separation, illness, or need for security.
Prospective research is needed to examine how cultural factors contribute to bed sharing and how cultural beliefs and child factors and
household conditions exert interactive effects on bed-sharing practices
in China.
The association between bed sharing and the child’s sleep quality and
quantity has not been consistent in previous studies of infants and
preschool children. No studies have investigated the association with
elementary-school children. Our results showed that sleep anxiety in
room-sharing and bed-sharing children was more common than in children sleeping alone. Compared with room-sharing and sleeping-alone
children, bed-sharing children were more likely to have increased daytime sleepiness. However, room sharing and bed sharing were not significantly associated with bedtime, sleep-onset delay, sleep duration, and
most other sleep problems such as parasomnias and breathing problems
during sleep. These results suggest that bed sharing may have potential
effects on the child’s sleep quality, but room sharing has little effect on
the child’s sleep. However, this speculation should be further prospectively investigated because bed sharing may arise from, or may be a
solution to, the child’s sleep problems. 21,26,32
There are several limitations to the current study. First, bed sharing
was derived from a 3-choice question and was limited to routine sleeping practices. We did not obtain information on the frequency of occasional all-night and part-night bed-sharing practices, which are often
reported in Western countries. Second, we did not collect data on
parental beliefs and attitudes toward and reasons for bed sharing. Third,
the child’s sleep was assessed by reports from the parent rather than
objective instruments. Fourth, parents were the only informants of the
child’s bed sharing and sleep problems. The association between bed
sharing and sleep anxiety and daytime sleepiness may be due to shared
variance of information. However, this could not explain why most of
the other sleep problems were not associated with bed sharing. Ideally, a
combination of parental and child reports would provide a better picture
of the child’s sleep behaviors because children report more sleep problems than do their parents.14 In addition, the present findings were cross
sectional and retrospective. We could not conclude that there were causal
relationships between bed sharing and sleep anxiety and daytime sleepiness. For example, the association between bed sharing and sleep anxiety has 3 possible explanations: bed sharing causes sleep anxiety; sleep
anxiety increases the likelihood of bed sharing; and the association may
be caused by a third confounding factor (eg, child’s physical diseases).
Finally, the sample was drawn from 3 elementary schools in a large
urban city of Mainland China. In our sample, 35% of fathers and 18% of
mothers graduated from a college; the level of the parents’ education in
this sample was higher than that of the general population of urban
China. The higher level of the parents’ education indicates better SES
and possibly better living conditions, which are associated with a
decreased likelihood for bed sharing and sleep problems.33 Thus, the
prevalence of bed sharing and sleep problems may be underestimated in
this study. Further studies are needed to establish whether or not these
findings can be generalized to all urban children of China.
Despite the limitations of the study, this is the first attempt to examine routine bed sharing, sleep habits, and sleep problems in Chinese
school-aged children. Results indicate that regular bed sharing in
Chinese school-aged children was very common and significantly
decreased with age. Crowded housing and poor physical health of the
nificantly with age; 3) younger age, crowded housing, and poor physical
health of the children were associated with increased likelihood for bed
sharing; and 4) bed-sharing children did not differ significantly in bedtime, total sleep duration, parasomnias, and breathing problems during
sleep from those children who slept alone, but bed-sharing children were
reported to have more sleep anxiety and daytime sleepiness than were
children who slept alone.
As expected, routine bed sharing in Chinese school-aged children is
very prevalent, with 56% in 7-year-olds and 7% in 11- to 13-year-olds.
Although bed sharing is an accepted practice in many Asian countries,
we do not know if these Chinese numbers would apply throughout Asia.
However, this rate is expected to be markedly higher than that found in
Western children. A recent United States national survey conducted
between 1993 and 2000 indicated that only 9.2% of infants usually share
a bed with their parents.16 In Western countries, most child-health professionals emphasize the hazards of bed sharing, such as impeding the
development of autonomy and independence, fostering dependence on
parents, being sexually aroused, increasing risk for sleep problems, and
interfering with parents’ sexuality and intimacy.18,31,32 In contrast, Asian
childrearing practices stress the development of interdependence, conformity, and family closeness.18 In a study of bed sharing in Korean children, for example, Yang and Hahn found that 73.5% of mothers
approved of bed sharing between 3 and 6 years of age. The main reasons
for bed sharing were “to look after the child while sleeping” and “child
too young to sleep alone.” 18 Thus, cultural beliefs and childrearing practices may account for a large proportion of bed sharing among Chinese
children.
In addition to cultural beliefs and attitudes in childrearing practices,
researchers have shown that a number of family demographic and childdevelopment factors such as single or married status of the mother,
crowded housing, and child health problems affect the decision to share
the bed with the child.11,16,20 In order to examine what family and child
characteristics contribute to bed-sharing practices in Chinese families,
we performed a series of logistic regression analyses. Results indicated
that younger age of the child, crowded housing, and poor physical health
of the child were significantly associated with increased odds for bed
sharing in this sample of children, after adjusting for other factors in the
multivariate model. Younger age was the strongest predictor after controlling for all other variables (see Table 3). The finding that younger
children are more likely to share a bed with their parents is consistent
with Yang and Hahn’s study of Korean children,18 possibly due to the
Asian mothers’ belief that children are too young to sleep alone and bed
sharing is a part of the fabric of the close-knit relationships of family
members. Crowded housing was the second strongest predictor of bed
sharing. This finding is consistent with those observed in Asian children18 and Western children.20 In urban residences of China, crowded
housing is very common and many families with young children may
have only 1 bedroom. In this sample, more than 60% of families owned
a living space less than 20 square meters per person, and 35% had less
than 15 square meters. Crowded housing limits children having their
own room and even a separate bed at home, and parents have to share
beds with their children. The association between poor health of the
child and bed sharing may be explained by the child’s need for assistance
and security during the night.
Another potential factor that may contribute to higher rates of bed
sharing among Chinese families should not be ignored: the only child in
the family. Almost all of the families in urban China have only 1 child
due to family-planning policy. An only child is frequently regarded as “a
little emperor” or “a little sun,” namely a spoiled or overprotected child.
Only children in China are described as over dependent, egocentric, less
cooperative, timid, and unadjusted.23 These characteristics may increase
the likelihood of children sharing beds with their parents. However, this
hypothesis cannot be examined in the current study because almost all of
the children in the sample (98%) are only children.
In summary, bed sharing in Chinese families is not determined by 1
single factor but by multiple factors such as cultural belief, childrearing
SLEEP, Vol. 26, No. 7, 2003
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Sleep Problems Among Chinese School-Aged Children—Liu et al
child increased the likelihood for children to share a bed with their parents. Bed sharing was associated with increased sleep anxiety and daytime sleepiness, suggesting that bed sharing may exert influences on
sleep quality. Two directions for further study of bed-sharing practices
among Chinese families and the association between bed sharing and
children’s sleep are recommended. Further research is needed to investigate what cultural factors (childrearing beliefs, attitudes, and practices)
contribute to bed sharing among Chinese families. Prospective research,
with multiple informants and possibly objective measures, is also needed to understand the causal relationship between bed sharing and sleep
problems and the long-term effects of bed sharing on cognitive, behavioral, and emotional development of children.
27. Simons JF, Parraga H. Prevalence of sleep disorders and sleep behaviors in children and
adolescents. J Am Acad Child Psychiatry 1982;21:383-8.
28. Liu XC, Zhou HB. Sleep duration, insomnia, and behavioral problems among Chinese
adolescents. Psychiatry Res 2002;111:75-85.
29. Owens JA, Spirito A, McGuinn M. The Children’s Sleep Habit Questionnaire (CSHQ):
psychometric properties of a survey instrument for school-aged children. Sleep
2000;23:1043-51.
30. Honomichl RD, Goodlin-Jones BL, Burham M, Gaylor E, Anders TF. Sleep patterns of
children with pervasive developmental disorders. J Autism Dev Disord 2002; 32:553-61.
31. Stein MT, Colarusso CA, McKenna JJ, Powers NG. Cosleeping (bedsharing) among
infants and toddlers. J Dev Behav Pediatr 1997;408-12.
32. Rath FH, Okum ME. Parents and children sleeping together: Cosleeping prevalence and
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33. Liu XC, Sun ZX, Uchiyama M, Shibui K, Kim K, Okawa M. Prevalence and correlates
of sleep problems in Chinese schoolchildren. Sleep 2000;23:1053-62.
ACKNOWLEDGEMENTS
The authors thank Dr. Judith A. Owens, Brown University School of
Medicine, for permission to develop the Chinese version of the
Children’s Sleep Habits Questionnaire, and all the children and parents
for participation in the study. In addition, the authors would like to
acknowledge Dr. Walter Rogan, Epidemiology Branch, National
Institute of Environmental Health Sciences, for reviewing and commenting on an earlier draft of this article.
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