Sleep Quality, Emotion Regulation and Parenting Stress in Children with Congenital Heart Disease

Simona De Stasio, Francesca Boldrini, Benedetta Ragni, Francesca Bevilacqua, Silvia Bucci, Rosaria Giampaolo, Valeria Messina, Simonetta Gentile


The aim of this study is to evaluate parental perceptions of parent-infant bedtime interactions and quality of sleep, after hospital discharge, in a group of children diagnosed at birth with congenital heart disease (CHD), as compared with the perceptions of parents in a control group of children who were healthy at birth. More specifically, we evaluated the associations between parental stress, parental perceptions of infant emotion regulation, and infants’ bedtime and sleep routines in each of the two groups. Fifty Italian intact two-parent families (23 boys) of toddlers ageing from 11 to 36 months (M= 23.42, SD=7.10) were recruited. 20 families of CHD children group were recruited from the Department of Cardiology at the Bambino Gesù Children’s Hospital in Rome, Italy; 30 families of the healthy children group were recruited from two childcare units. Parents completed Emotion Regulation Checklist (Shields & Cicchetti, 1997), Parent-Child Sleep Interaction Scale (PSIS; Alfano et al., 2013), Parent-Stress Index-Short Form (PSI-SF; Abidin, 1990) and ad-hoc semi-structured interview on child’s sleep quality. The independent-samples t-test evidenced that parents of healthy children reported significantly higher scores on children's emotion regulation compared with the CHD group Specifically CHD children and healthy children's emotion regulation reported both by mothers (respectively CHD children’s mothers: M= 26.11, SD= 2.9; healthy children’s mothers: M= 28.85, SD= 2.71; t(37) = 3.10, p= .004) and fathers (respectively CHD children’s fathers: M=25.76, SD= 2.79; healthy children’s fathers: M= 27.37, SD= 2.02; t(31)= 2.71, p= .010). Main correlational findings showed in the CHD children’s group that parenting stress total scores were positive related to difficult parent-infant bedtime interactions both for mothers (r=.58, p < .01) and fathers (r= .70, p < .01). Results show significant differences in emotion regulation between the two groups. The results of this research will show to the clinicians the aspects of parent-infant bedtime interactions to be addressed in parents of children with CHD.


Sleep; Parent-infant bedtime interactions; Parenting stress; Toddlers; Congenital heart disease.

Full Text:



Abidin, R. R. (1990). Parenting stress index-short form. Pediatric Psychology Press Charlottesville, VA.

Aite, L., Bevilacqua, F., Zaccara, A., La Sala, E., Gentile, S., & Bagolan, P. (2016). Seeing their children in pain: Symptoms of posttraumatic stress disorder in mothers of children with an anomaly requiring surgery at birth. American Journal of Perinatology, 33(08), 770–775.

Alfano, C. A., Smith, V. C., Reynolds, K. C., Reddy, R., & Dougherty, L. R. (2013). The parent-child sleep interactions scale (PSIS) for preschoolers: Factor structure and initial psychometric properties. Journal of Clinical Sleep Medicine, 9(11), 1153–1160.

Armstrong, K. L., Quinn, R. A., & Dadds, M. R. (1994). The sleep patterns of normal children. Medical Journal of Australia, 161(3), 202–205.

Barbeau, D. Y., & Weiss, M. D. (2017). Sleep Disturbances in Newborns. Children, 4(10), 90.

Barker, B., Iles, J. E., & Ramchandani, P. G. (2017). Fathers, fathering and child psychopathology. Current Opinion in Psychology, 15, 87–92.

Bell, B. G., & Belsky, J. (2008). Parents, parenting, and children’s sleep problems: Exploring reciprocal effects. British Journal of Developmental Psychology, 26(4), 579–593.

Bernier, A., Tétreault, É., Bélanger, M.-E., & Carrier, J. (2017). Paternal involvement and child sleep. International Journal of Behavioral Development, 41(6), 714–722.

Bevilacqua, F., Palatta, S., Mirante, N., Cuttini, M., Seganti, G., Dotta, A., & Piersigilli, F. (2013). Birth of a child with congenital heart disease: emotional reactions of mothers and fathers according to time of diagnosis. The Journal of Maternal-Fetal & Neonatal Medicine, 26(12), 1249–1253.

Brosig, C. L., Whitstone, B. N., Frommelt, M. A., Frisbee, S. J., & Leuthner, S. R. (2007). Psychological distress in parents of children with severe congenital heart disease: the impact of prenatal versus postnatal diagnosis. Journal of Perinatology, 27(11), 687.

Caris, E. C., Dempster, N., Wernovsky, G., Butz, C., Neely, T., Allen, R., … Texter, K. (2016). Anxiety scores in caregivers of children with hypoplastic left heart syndrome. Congenital Heart Disease, 11(6), 727–732.

Cole, P. M., Michel, M. K., & Teti, L. O. (1994). The development of emotion regulation and dysregulation: A clinical perspective. Monographs of the Society for Research in Child Development, 59(2‐3), 73–102.

De Stasio, S., Ragni, B., Boldrini, F., Bevilacqua, F., & Gentile, S. (2018). Parental stress and bedtime routines. ANTHROPOLOGICAL RESEARCHES AND STUDIES, 8, 75–84.

De Stasio, S., Coletti, M. F., Boldrini, F., Bevilacqua, F., Dotta, A., & Gentile, S. (2018). Parenting stress in mothers of infants with congenital heart disease and of preterm infants at one year of age. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 15(1), 3–11.

Doherty, N., McCusker, C. G., Molloy, B., Mulholland, C., Rooney, N., Craig, B., … Casey, F. (2009). Predictors of psychological functioning in mothers and fathers of infants born with severe congenital heart disease. Journal of Reproductive and Infant Psychology, 27(4), 390–400.

El-Sheikh, M., & Buckhalt, J. A. (2005). Vagal regulation and emotional intensity predict children’s sleep problems. Developmental Psychobiology, 46(4), 307–317.

Galland, B. C., Taylor, B. J., Elder, D. E., & Herbison, P. (2012). Normal sleep patterns in infants and children: A systematic review of observational studies. Sleep Medicine Reviews, 16(3), 213–222.

Gatta, M., Miscioscia, M., Svanellini, L., Brianda, M. E., Guerra, G., Battistella, P. A., & Simonelli, A. (2017). Triadic interactions in families with preterm children: a comparative study with children born at term. Neuropsychiatric Disease and Treatment, 13, 2375.

Gögenur, I., Wildschiøtz, G., & Rosenberg, J. (2008). Circadian distribution of sleep phases after major abdominal surgery. British Journal of Anaesthesia, 100(1), 45–49.

Goldberg, W. A., Lucas-Thompson, R. G., Germo, G. R., Keller, M. A., Davis, E. P., & Sandman, C. A. (2013). Eye of the beholder? Maternal mental health and the quality of infant sleep. Social Science and Medicine, 79(1), 101–108.

Grunau, R. E., Whitfield, M. F., Petrie-Thomas, J., Synnes, A. R., Cepeda, I. L., Keidar, A., … Johannesen, D. (2009). Neonatal pain, parenting stress and interaction, in relation to cognitive and motor development at 8 and 18 months in preterm infants. Pain, 143(1–2), 138–146.

Hartman, D. M., & Medoff-Cooper, B. (2012). Transition to home after neonatal surgery for congenital heart disease. MCN. The American Journal of Maternal Child Nursing, 37(2), 95.

Hughes, A., Gallagher, S., & Hannigan, A. (2015). A cluster analysis for reported sleeping patterns of 9-month old infants and the association with maternal health: results from a population based cohort study. Matern Child Health J, 19(8), 1881–1889.

Jack, P. (2004). Children born with cyanotic congenital heart disease: effects on the family. JOURNAL OF NEONATAL NURSING-LONDON-, 10, 191–196.

Kaugars, A., Shields, C., & Brosig, C. (2018). Stress and quality of life among parents of children with congenital heart disease referred for psychological services. Congenital Heart Disease, 13(1), 72–78.

Keenan, K. (2000). Emotion dysregulation as a risk factor for child psychopathology. Clinical Psychology: Science and Practice, 7(4), 418-434.

Kim‐Spoon, J., Cicchetti, D., & Rogosch, F. A. (2013). A longitudinal study of emotion regulation, emotion lability‐negativity, and internalizing symptomatology in maltreated and nonmaltreated children. Child Development, 84(2), 512–527.

Krasuski, R. A., & Bashore, T. M. (2016). Congenital Heart Disease Epidemiology in the United States: Blindly Feeling for the Charging Elephant. Circulation, 134(2), 110–113.

Lee, S., Yoo, J.-S., & Yoo, I.-Y. (2007). Parenting stress in mothers of children with congenital heart disease. Asian Nursing Research, 1(2), 116–124.

Linden, M. A., Cepeda, I. L., Synnes, A., & Grunau, R. E. (2015). Stress in parents of children born very preterm is predicted by child externalising behaviour and parent coping at age 7 years. Archives of Disease in Childhood, 100(6), 554–558.

Matthey, S. (2001). The sleep and settle questionnaire for parents of infants: psychometric properties. Journal of Paediatrics and Child Health, 37(5), 470–475.

McCusker, C. G., Doherty, N. N., Molloy, B., Rooney, N., Mulholland, C., Sands, A., … Casey, F. (2012). A randomized controlled trial of interventions to promote adjustment in children with congenital heart disease entering school and their families. Journal of Pediatric Psychology, 37(10), 1089–1103.

Meltzer, L. J., & Mindell, J. A. (2007). Relationship between child sleep disturbances and maternal sleep, mood, and parenting stress: a pilot study. Journal of Family Psychology, 21(1), 67.

Miller, A. C., Gordon, R. M., Daniele, R. J., & Diller, L. (1992). Stress, appraisal, and coping in mothers of disabled and nondisabled children. Journal of Pediatric Psychology, 17(5), 587–605.

Millikovsky-Ayalon, M., Atzaba-Poria, N., & Meiri, G. (2015). The role of the father in child sleep disturbance: Child, parent, and parent-child relationship. Infant Mental Health Journal, 36(1), 114–127.

Mindell, J. A., Telofski, L. S., Wiegand, B., & Kurtz, E. S. (2009). A nightly bedtime routine: impact on sleep in young children and maternal mood. Sleep, 32(5), 599–606.

Mindell, J. a, Kuhn, B., Lewin, D. S., Meltzer, L. J., & Sadeh, A. (2006). Behavioral treatment of bedtime problems and night wakings in infants and young children - An American Academy of Sleep Medicine review. Sleep, 29(10), 1263–1276.

Molina, P., Sala, M. N., Zappulla, C., Bonfigliuoli, C., Cavioni, V., Zanetti, M. A., … Cicchetti, D. (2014). The Emotion Regulation Checklist - Italian translation. Validation of parent and teacher versions. European Journal of Developmental Psychology, 11(5), 624–634.

Morrell, J., & Steele, H. (2003). The role of attachment security, temperament, maternal perception, and care-giving behavior in persistent infant sleeping problems. Infant Mental Health Journal, 24(5), 447–468.

Mulkey, S. B., Yap, V. L., Bai, S., Ramakrishnaiah, R. H., Glasier, C. M., Bornemeier, R. A., … Bhutta, A. T. (2015). Amplitude-Integrated EEG in Newborns With Critical Congenital Heart Disease Predicts Preoperative Brain Magnetic Resonance Imaging Findings. Pediatric Neurology, 52(6), 599–605.

Palmstierna, P., Sepa, A., & Ludvigsson, J. (2008). Parent perceptions of child sleep: a study of 10 000 Swedish children. Acta Paediatrica, 97(12), 1631–1639.

Sadeh, A., Tikotzky, L., & Scher, A. (2010). Parenting and infant sleep. Sleep Medicine Reviews, 14(2), 89–96.

Settineri, S., Frisone, F., Alibrandi, A., & Merlo, E. M. (2019). Italian adaptation of the Mannheim Dream Questionnaire (MADRE): Age, Gender and Dream Recall effects. International Journal of Dream Research, 12(1), 119-129.

Shields, A., & Cicchetti, D. (1997). Emotion regulation among school-age children: The development and validation of a new criterion Q-sort scale. Developmental Psychology, 33(6), 906–916.

Sinai, D., & Tikotzky, L. (2012). Infant sleep, parental sleep and parenting stress in families of mothers on maternity leave and in families of working mothers. Infant Behavior and Development, 35(2), 179–186.

Smith, V. C., Leppert, K. A., Alfano, C. A., & Dougherty, L. R. (2014). Construct validity of the Parent-Child Sleep Interactions Scale (PSIS): Associations with parenting, family stress, and maternal and child psychopathology. Sleep Medicine, 15(8), 942–951.

So, K., Buckley, P., Adamson, T. M., & Horne, R. S. C. (2005). Actigraphy Correctly Predicts Sleep Behavior in Infants Who Are Younger than Six Months, When Compared with Polysomnography. Pediatric Research, 58(4), 761–765.

Sorondo, B. M., & Reeb-Sutherland, B. C. (2015). Associations between infant temperament, maternal stress, and infants’ sleep across the first year of life. Infant Behavior and Development, 39, 131-135.

Soulvie, M. A., Desai, P. P., White, C. P., & Sullivan, B. N. (2012). Psychological distress experienced by parents of young children with congenital heart defects: A comprehensive review of literature. Journal of Social Service Research, 38(4), 484–502.

Spence, K., Swinsburg, D., Griggs, J., & Johnston, L. (2011). Infant well‐being following neonatal cardiac surgery. Journal of Clinical Nursing, 20(17‐18), 2623–2632.

Spruyt, K., Aitken, R. J., So, K., Charlton, M., Adamson, T. M., & Horne, R. S. C. (2008). Relationship between sleep/wake patterns, temperament and overall development in term infants over the first year of life. Early Human Development, 84(5), 289–296.

Staples, A. D. and Bates, J. E. Children’s sleep deficits and cognitive and behavioral adjustment. In: M. El-Sheikh (Ed.) Sleep and Development: Familial and Socio-Cultural Considerations. Oxford University Press, New York, NY, 2011: 133–164.

ter Horst, H. J., Mud, M., Roofthooft, M. T. R., & Bos, A. F. (2010). Amplitude integrated electroencephalographic activity in infants with congenital heart disease before surgery. Early Human Development, 86(12), 759–764.

Teti, D. M., Crosby, B., Mcdaniel, B. T., Shimizu, M., & Whitesell, C. J. (2015). X. marital and emotional adjustment in mothers and infant sleep arrangements during the first six months. Monographs of the Society for Research in Child Development, 80(1), 160–176.

Tikotzky, L, Sadeh, A., & Glickman-Gavrieli, T. (2011). Infant sleep and paternal involvement in infant caregiving during the first 6 months of life. J Pediatr Psychol, 36(1), 36–46.

Tikotzky, L, Sadeh, A., Volkovich, E., Manber, R., Meiri, G., & Shahar, G. (2015). VII. Infant sleep development from 3 to 6 months postpartum: Links with maternal sleep and paternal involvement. Monographs of the Society for Research in Child Development, 80(1), 107–124.

Tikotzky, Liat, Sadeh, A., Volkovich, E., Manber, R., Meiri, G., & Shahar, G. (2015). VII. Infant sleep development from 3 to 6 months postpartum: Links with maternal sleep and paternal involvement. Monographs of the Society for Research in Child Development, 80(1), 107–124.

Torowicz, D., Irving, S. Y., Hanlon, A. L., Sumpter, D. F., & Medoff-Cooper, B. (2010). Infant temperament and parent stress in 3 month old infants following surgery for complex congenital heart disease. Journal of Developmental and Behavioral Pediatrics: JDBP, 31(3), 202.

Troxel, W. M., Trentacosta, C. J., Forbes, E. E., & Campbell, S. B. (2013). Negative emotionality moderates associations among attachment, toddler sleep, and later problem behaviors. Journal of Family Psychology, 27(1), 127–136.

Upham, M., & Medoff-Cooper, B. (2005). What are the responses & needs of mothers of infants diagnosed with congenital heart disease? MCN: The American Journal of Maternal/Child Nursing, 30(1), 24–29.

Uzark, K., & Jones, K. (2003). Parenting stress and children with heart disease. Journal of Pediatric Health Care, 17(4), 163–168.

van der Bom, T., Luijendijk, P., Bouma, B. J., Koolbergen, D. R., de Groot, J. R., & Mulder, B. J. M. (2011). Treatment of congenital heart disease: risk-reducing measures in young adults. Future Cardiology, 7(2), 227–240.

Weinberg, M. K., & Tronick, E. Z. (1994). Beyond the Face: An Empirical Study of Infant Affective Configurations of Facial, Vocal, Gestural, and Regulatory Behaviors. Child Development, 65(5), 1503–1515.

Werner, H., Latal, B., Valsangiacomo Buechel, E., Beck, I., & Landolt, M. A. (2014). The impact of an infant’s severe congenital heart disease on the family: a prospective cohort study. Congenital Heart Disease, 9(3), 203–210.

Zaidman-Zait, A., & Hall, W. A. (2015). Children’s night waking among toddlers: Relationships with mothers’ and fathers’ parenting approaches and children’s behavioural difficulties. Journal of Advanced Nursing, 71(7), 1639–1649.

Zero to Three. ( 2005). Diagnostic classification: 0–3R: Diagnostic classification of mental health and developmental disorders of infancy and early childhood: revised edition (revised edn). Washington, DC: Zero To Three Press.



  • There are currently no refbacks.