Research Article| Volume 7, ISSUE 2, P143-152, April 2021

Socioeconomic disadvantage and sleep in early childhood: Real-world data from a mobile health application

Published:March 04, 2021DOI:



      To examine whether increased socioeconomic disadvantage, indexed using a measure of community distress, was associated with variation in caregiver-reported early childhood sleep patterns and problems in a large US sample using a mobile health application (app).




      Data were collected using the free, publicly available Johnson's Bedtime© baby sleep app.


      A total of 14,980 caregivers (85.1% mothers) of children ages 6-35.9 months (M = 13.88 months; 52.6% boys) participated in this study.


      Caregivers reported on child sleep using the Brief Infant Sleep Questionnaire-Revised. Socioeconomic disadvantage was indexed by zip code using the Distressed Communities Index (DCI), which combines seven US census indicators of socioeconomic disadvantage. DCI scores range from prosperous (lowest quintile) to distressed (highest quintile).


      Socioeconomic disadvantage was significantly associated with later bedtimes, longer sleep onset latency, and shorter nighttime and 24-hour (total) sleep duration, with children living in distressed communities showing the poorest sleep. However, caregivers living in distressed communities reported a significantly lower prevalence of overall child sleep problems (43% vs 58% in prosperous communities), and more confidence in managing child sleep (42% vs 34% in prosperous communities).


      Children living in the most distressed communities have the poorest reported sleep patterns and bedtime behaviors; however, their caregivers are less likely to report problematic child sleep. These findings highlight the need for community-level sleep health promotion interventions, as well as further investigation of caregiver perceptions about child sleep and sleep health promotion among families living in socioeconomically disadvantaged contexts.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Sleep Health: Journal of the National Sleep Foundation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Black MM
        • Walker SP
        • Fernald LC
        • et al.
        Early childhood development coming of age: science through the life course.
        Lancet. 2017; 389: 77-90
        • Byars KC
        • Yolton K
        • Rausch J
        • Lanphear B
        • Beebe DW.
        Prevalence, patterns, and persistence of sleep problems in the first 3 years of life.
        Pediatrics. 2012; 129: e276-e284
        • Kocevska D
        • Rijlaarsdam J
        • Ghassabian A
        • et al.
        Early childhood sleep patterns and cognitive development at age 6 years: the Generation R Study.
        J Pediatr Psychol. 2017; 42: 260-268
        • Sivertsen B
        • Harvey AG
        • Reichborn-Kjennerud T
        • Torgersen L
        • Ystrom E
        • Hysing M.
        Later emotional and behavioral problems associated with sleep problems in toddlers: a longitudinal study.
        JAMA Pediatr. 2015; 169: 575-582
        • Alamian A
        • Wang L
        • Hall AM
        • Pitts M
        • Ikekwere J.
        Infant sleep problems and childhood overweight: effects of three definitions of sleep problems.
        Prev Med Rep. 2016; 4: 463-468
        • Mindell J
        • Sadeh A
        • Kohyama J
        • How TH.
        Parental behaviors and sleep outcomes in infants and toddlers: a cross-cultural comparison.
        Sleep Med. 2010; 11: 393-399
        • Sadeh A
        • Tikotzky L
        • Scher A.
        Parenting and infant sleep.
        Sleep Med Rev. 2010; 14: 89-96
        • Teti DM
        • Crosby B.
        Maternal depressive symptoms, dysfunctional cognitions, and infant night waking: the role of maternal nighttime behavior.
        Child Dev. 2012; 83: 939-953
        • Tikotzky L
        • Shaashua L.
        Infant sleep and early parental sleep-related cognitions predict sleep in pre-school children.
        Sleep Med. 2012; 13: 185-192
        • Smith JP
        • Hardy ST
        • Hale LE
        • Gazmararian JA.
        Racial disparities and sleep among preschool aged children: a systematic review.
        Sleep Health. 2019; 5: 49-57
        • El-Sheikh M
        • Bagley EJ
        • Keiley M
        • Elmore-Staton L
        • Chen E
        • Buckhalt JA
        Economic adversity and children's sleep problems: multiple indicators and moderation of effects.
        Health Psychol. 2013; 32: 849
        • Hale L
        • Berger LM
        • LeBourgeois MK
        • Brooks-Gunn J.
        Social and demographic predictors of preschoolers’ bedtime routines.
        J Dev Behav Pediatr. 2009; 30: 394
        • Jarrin DC
        • McGrath JJ
        • Quon EC.
        Objective and subjective socioeconomic gradients exist for sleep in children and adolescents.
        Health Psychol. 2014; 33: 301
        • Peña M-M
        • Rifas-Shiman SL
        • Gillman MW
        • Redline S
        • Taveras EM.
        Racial/ethnic and socio-contextual correlates of chronic sleep curtailment in childhood.
        Sleep. 2016; 39: 1653-1661
        • Williamson AA
        • Mindell JA.
        Cumulative socio-demographic risk factors and sleep outcomes in early childhood.
        Sleep. 2020; 43: zsz233
        • Nagy E
        • Moore S
        • Gruber R
        • Paquet C
        • Arora N
        • Dubé L.
        Parental social capital and children's sleep disturbances.
        Sleep Health. 2016; 2: 330-334
        • Johnson DA
        • Billings ME
        • Hale L.
        Environmental determinants of insufficient sleep and sleep disorders: implications for population health.
        Curr Epidemiol Rep. 2018; 5: 61-69
        • Rudolph KE
        • Shev A
        • Paksarian D
        • et al.
        Environmental noise and sleep and mental health outcomes in a nationally representative sample of urban US adolescents.
        Environ Epidemiol. 2019; 3: e056
        • Bottino CJ
        • Rifas-Shiman SL
        • Kleinman KP
        • et al.
        The association of urbanicity with infant sleep duration.
        Health Place. 2012; 18: 1000-1005
        • Troxel WM
        • Shih RA
        • Ewing B
        • Tucker JS
        • Nugroho A
        • D'Amico EJ
        Examination of neighborhood disadvantage and sleep in a multi-ethnic cohort of adolescents.
        Health Place. 2017; 45: 39-45
        • Bagley EJ
        • Kelly RJ
        • Buckhalt JA
        • El-Sheikh M.
        What keeps low-SES children from sleeping well: the role of presleep worries and sleep environment.
        Sleep Med. 2015; 16: 496-502
        • Sheehan C
        • Powers D
        • Margerison-Zilko C
        • McDevitt T
        • Cubbin C.
        Historical neighborhood poverty trajectries and child sleep.
        Sleep Health. 2018; 4: 127-134
        • Grimes M
        • Camerota M
        • Propper CB.
        Neighborhood deprivation predicts infant sleep quality.
        Sleep Health. 2019; 5: 148-151
        • Graham C
        • Reither EN
        • Ciciurkaite G
        • Dev DA
        • Fargo J.
        Does context matter? A multilevel analysis of neighborhood disadvantage and children’s sleep health.
        Sleep Health. 2020; 6 ([Online ahead of print]): 578-586
        • MacKinnon AL
        • Tomfohr-Madsen L
        • Tough S.
        Neighborhood socio-economic factors and associations with infant sleep health.
        Behav Sleep Med. 2020; ([Online ahead of print]): 1-13
        • Milan S
        • Snow S
        • Belay S.
        The context of preschool children's sleep: racial/ethnic differences in sleep locations, routines, and concerns.
        J Fam Psychol. 2007; 21: 20
        • Meltzer LJ
        • Johnson C
        • Crosette J
        • Ramos M
        • Mindell JA.
        Prevalence of diagnosed sleep disorders in pediatric primary care practices.
        Pediatrics. 2010; 125: e1410-e1418
        • Caldwell B
        • Ordway M
        • Sadler L
        • Redeker N.
        Parent perspectives on sleep and sleep habits among young children living with economic adversity.
        J Pediatr Health Care. 2020; 34: 10-22
        • Williamson A
        • Milaniak I
        • Watson B
        • et al.
        Early childhood sleep intervention in urban primary care: caregiver and clinician perspectives.
        J Pediatr Psychol. 2020; 54: 933-945
        • Sadeh A
        • Mindell JA
        • Rivera L.
        My child has a sleep problem”: a cross-cultural comparison of parental definitions.
        Sleep Med. 2011; 12: 478-482
        • American Academy of Sleep Medicine
        International Classification of Sleep Disorders—Third Edition (ICSD-3).
        AASM Resource Library, 2014
        • Williamson AA
        • Mindell JA
        • Hiscock H
        • Quach J.
        Longitudinal sleep problem trajectories are associated with multiple impairments in child well-being.
        J Child Psychol Psychiatr. 2020; 61 ([Online ahead of print]): 1092-1103
        • Jackson CL
        • Walker JR
        • Brown MK
        • Das R
        • Jones NL.
        A workshop report on the causes and consequences of sleep health disparities.
        Sleep. 2020; 43: zsaa037
        • Leichman ES
        • Gould R
        • Williamson A
        • Walters R
        • Mindell J.
        Effectiveness of an mHealth intervention for infant sleep disturbances.
        Behav Ther. 2020; 51: 548-558
        • Mindell JA
        • Gould R
        • Tikotzky L
        • Leichman ES
        • Walters R.
        Norm-referenced scoring system for the Brief Infant Sleep Questionnaire—Revised (BISQ-R).
        Sleep Med. 2019; 63: 106-114
        • Mindell JA
        • Du Mond CE
        • Sadeh A
        • Telofski LS
        • Kulkarni N
        • Gunn E
        Long-term efficacy of an internet-based intervention for infant and toddler sleep disturbances: one year follow-up.
        J Clin Sleep Med. 2011; 7: 507-511
        • Kushnir J
        • Sadeh A.
        Correspondence between reported and actigraphic sleep measures in preschool children: the role of a clinical context.
        J Clin Sleep Med. 2013; 9: 1147-1151
        • Sadeh A.
        A brief screening questionnaire for infant sleep problems: validation and findings for an Internet sample.
        Pediatrics. 2004; 113: e570-e577
        • Quach J
        • Hiscock H
        • Ukoumunne OC
        • Wake M.
        A brief sleep intervention improves outcomes in the school entry year: a randomized controlled trial.
        Pediatrics. 2011; 128: 692-701
      1. Economic Innovation Group. From great recession to great reshuffling: Charting a decade of change across American communities. Findings from the 2018 Distressed Communities Index.Available at: Accessed September 2, 2020.

        • Weeks WB
        • Ouayogodé MH
        • Weinstein JN.
        Association between a measure of community economic distress and Medicare patients’ health care utilization, quality, outcomes, and costs.
        J Gen Intern Med. 2018; 33: 1433-1435
        • Mindell JA
        • Leichman ES
        • Walters RM.
        Sleep location and parent-perceived sleep outcomes in older infants.
        Sleep Med. 2017; 39: 1-7
        • Gruber R
        • Cassoff J
        • Frenette S
        • Wiebe S
        • Carrier J.
        Impact of sleep extension and restriction on children's emotional lability and impulsivity.
        Pediatrics. 2012; 130: e1155-e1161
        • Berger RH
        • Miller AL
        • Seifer R
        • Cares SR
        • LeBourgeois MK.
        Acute sleep restriction effects on emotion responses in 30-to 36-month-old children.
        J Sleep Res. 2012; 21: 235-246
        • Miller AL
        • Seifer R
        • Crossin R
        • Lebourgeois MK.
        Toddler's self-regulation strategies in a challenge context are nap-dependent.
        J Sleep Res. 2015; 24: 279-287
        • Evans GW
        • Kim P.
        Multiple risk exposure as a potential explanatory mechanism for the socioeconomic status–health gradient.
        Ann NY Acad Sci. 2010; 1186: 174-189
        • McDowall PS
        • Galland BC
        • Campbell AJ
        • Elder DE.
        Parent knowledge of children's sleep: a systematic review.
        Sleep Med Rev. 2017; 31: 39-47
        • Bathory E
        • Tomopoulos S
        • Rothman R
        • et al.
        Infant sleep and parent health literacy.
        Acad Pediatr. 2016; 16: 550-557
        • Zambrano DN
        • Mindell JA
        • Reyes NR
        • Hart CN
        • Herring SJ.
        “It's not all about my baby's sleep”: a qualitative study of factors influencing low-income African American mothers’ sleep quality.
        Behav Sleep Med. 2016; 14: 489-500
        • Pennestri M-H
        • Laganière C
        • Bouvette-Turcot A-A
        • et al.
        Uninterrupted infant sleep, development, and maternal mood.
        Pediatrics. 2018; 142: e20174330
        • Johnson DA
        • Jackson CL
        • Williams NJ
        • Alcántara C.
        Are sleep patterns influenced by race/ethnicity—a marker of relative advantage or disadvantage? Evidence to date.
        Nat Sci Sleep. 2019; 11: 79
        • Schwichtenberg A
        • Abel E
        • Keys E
        • Honaker SM
        Diversity in pediatric behavioral sleep intervention studies.
        Sleep Med Rev. 2019; 47: 103-111
        • Pew Research Center
        Mobile Fact Sheet.
        Pew Research Center: Internet, Science & Tech, 2019 (Available at:) (Accessed September 2, 2020)
        • Franzoni C
        • Sauermann H.
        Crowd science: the organization of scientific research in open collaborative projects.
        Res Pol. 2014; 43: 1-20
        • Davis DW
        • Logsdon MC
        • Vogt K
        • et al.
        Parent education is changing: a review of smartphone apps.
        Am J Matern Child. 2017; 42: 248-256
        • Cushing CC
        • Fedele DA
        • Brannon EE
        • Kichline T
        Parents’ perspectives on the theoretical domains framework elements needed in a pediatric health behavior app: a crowdsourced social validity study.
        JMIR mHealth uHealth. 2018; 6: e192
        • McCloskey ML
        • Thompson DA
        • Chamberlin B
        • Clark L
        • Johnson SL
        • Bellows LL
        Mobile device use among rural, low-income families and the feasibility of an app to encourage preschoolers’ physical activity: qualitative study.
        JMIR Pediatr Parent. 2018; 1: e10858