Journal of Pediatric Nursing (2016) xx, xxx–xxx

The Development and Psychometric Properties

of the Children's Sleep Assessment Questionnaire
in Taiwan
Hsiao-Ling Chuang RN, MS Candidate a,b,c , Ching-Pyng Kuo RN, PhD b,c ,
Cheng-Ching Liu RN, PhD d , Chia-Ying Li RN, BS c , Wen-Chun Liao RN, PhD b,e,⁎
a
Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
b
School of Nursing, Chung Shan Medical University, Taichung, Taiwan
c
Department of Nursing, Chung Shan Medical University Hospital, Taichung, Taiwan
d
College of Nursing, Michigan State University
e
School of Nursing, China Medical University, Taichung, Taiwan

Received 4 December 2015; revised 28 June 2016; accepted 20 July 2016

Key words:
Purpose: To develop and examine the validity and reliability of the Children's Sleep Assessment
Children's sleep
Questionnaire (CSAQ) for school-aged children in Taiwan.
assessment questionnaire;
Design and Methods: We used a cross-sectional study design with stratified random sampling. Pairs of
School-aged child;
children and parents were recruited from a school-based sample of third- and fourth-grade students,
Sleep problems
enrolling 362 child and parent pairs. The content validity, construct validity, convergent validity,
internal consistency, and inter-rater reliability of the CSAQ were assessed.
Results: The CSAQ comprised three parts: sleep hygiene, sleep quality, and sleep disturbance. Sleep
hygiene showed a moderate intra-class correlation coefficient (0.37–0.66) between children and parents.
Results of exploratory factor analysis suggested a four-factor structure model for sleep quality with
64.9% of variance and a two-factor structure for sleep disturbance with 57.7% of variance. These two
models also demonstrated good fit with the confirmatory factor analysis.
Conclusions: The CSAQ is a valid and reliable instrument for assessing sleep problems in school-aged children.
Practice Implications: Both clinicians and researchers can use the CSAQ to screen or elucidate the children’
sleep problems.
© 2016 Elsevier Inc. All rights reserved.

SLEEP PLAYS A pivotal role in the health and well-being
of children. Insufficient sleep can impede metabolic function
and lead to obesity in school-aged children (Cespedes et al.,
2014; Spruyt, Molfese, & Gozal, 2011). Moreover, insufficient
sleep can result in excessive daytime sleepiness, impaired
attention, and impaired concentration, as well as problems with
learning (Kopasz et al., 2010), behavioral and emotional
regulation (Hansen, Skirbekk, Oerbeck, Wentzel-Larsen, &
⁎ Corresponding author: Wen-Chun Liao, RN., PhD.
E-mail address: wcl@csmu.edu.tw.
Kristensen, 2014; Pesonen et al., 2010), cognitive performance
(Ferri et al., 2010; Gruber et al., 2010; Wang, Wang, et al.,
2013; Wang, Xu, et al., 2013), and school performance (Li et
al., 2013). Therefore, children's sleep affects not just physical
growth but also behavior, cognitive function, and school
performance.
Unfortunately, sleep problems are common among
school-aged children in various cultures. The incidence of
sleep problems ranges from 23.8% to 43.0% among Chinese
(Li et al., 2013; Wang, Wang, et al., 2013; Wang, Xu, et al.,
2013), Finnish (Simola et al., 2012), and American

http://dx.doi.org/10.1016/j.pedn.2016.07.008
0882-5963/© 2016 Elsevier Inc. All rights reserved.
2 H.-L. Chuang et al.
school-aged children (Surani et al., 2015). Recent studies
have also revealed that daytime sleepiness occurs in over
62% of school-aged children (Li et al., 2013). This high
prevalence indicates that sleep problems are an important
modern social issue for child health.
Polysomnography is the gold standard of objective sleep
biophysiological changes (Marcus et al., 1992; Uliel,
Tauman, Greenfeld, & Sivan, 2004). Actigraphy is also an
objective measure of rest/activity cycles (Waldon et al.,
2016). However, they both fail to qualify the subjective
experience of sleep quality or sleep hygiene, such as
difficulty waking in the morning or daytime sleepiness.
Moreover, needed sleep hours are different in different
people. Thus, the individual's objective sleep quantity may
be good, but subjective experience may be bad. If we obtain
both objective and subjective data to assess sleep, we will not
only know the sleep biophysiological changes or rest/activity
cycles but also know the individual's subjective perception.
Thus, both objective quantity and subjective quality are
important for sleep assessment. A self-report measure to
assess children's subjective experience of sleep problems is
therefore needed.
Sleep problems in children are multifaceted, covering
multiple domains. The best predictor for sleep change, such
as reduced sleep length and circadian shift, is age
(Iglowstein, Hajnal, Molinari, Largo, & Jenni, 2006). The
most marked reduction in sleep duration occurs when
children attend primary school. Since bedtimes become
increasingly delayed, yet morning rising times remain fixed
(Li et al., 2013). In Chinese society, children's academic
performance is emphasized, which often requires extra
classes after school. Children spend more time on their
studies, adversely affecting their sleep–wake habits and
sleep duration (Li et al., 2014). These differences suggest
that sleep problems are driven not only by biological
processes but are also influenced by social and cultural
factors (Li et al., 2010). Thus, sleep assessment, reflecting
sleep's multidimensional nature, is necessary for
school-aged children.
Based on existing literature (Meltzer et al., 2013; Orgilés,
Owens, Espada, Piqueras, & Carballo, 2013; Yolton et al.,
2010), a multidimensional children's sleep assessment tool
should include three components: sleep hygiene, sleep
quality, and sleep disturbance. Sleep hygiene refers to
lifestyle and environmental factors that affect an individual's
sleep quality (Meltzer et al., 2013; Yolton et al., 2010). Sleep
quality refers to quantitative sleep patterns, night waking,
waking in the morning, and daytime sleepiness (Drake et al.,
2003; Meltzer et al., 2013). Sleep disturbances refer to
behaviors that occur only during sleep, such as snoring or
sleepwalking (Meltzer et al., 2013). Currently, no multidi-
mensional questionnaire on sleep assessment exists for
school-aged children in Taiwan.
Secondary, parents may be unaware of certain aspects of
children's sleep hygiene (e.g., exposure to second-hand
smoke or daytime caffeinated beverage consumption).
Children reported more caffeine consumption than parents
did (Meltzer et al., 2013). Additionally, approximately 40%
of parents are not aware of children's difficulties in
sleep-onset latency, night waking, or poor sleep quality
(Meltzer et al., 2013). Therefore, sleep hygiene and quality
reported by children may be more accurate than parental
reports. By contrast, status of sleep disturbances is best
reported by the parent as an observer (Meltzer et al., 2013).
For example, snorers may not know they are snoring during
sleeping. Thus, assessments that rely solely on parent- or
child-reported questionnaires may result in incomplete
information. Both perspectives are necessary for a complete
picture. However, currently available multidimensional
assessment tools on children's sleep rely exclusively on
either parent- or child-reported questionnaires. Only few
measures include both parents' and children's reports
(Lewandowski, Toliver-Sokol, & Palermo, 2011; Spruyt &
Gozal, 2011). To our knowledge, the Children's Sleep Habits
Questionnaire (CSHQ) (Owens, Spirito, & McGuinn, 2000)
is the most commonly used tool in child sleep science in
Chinese societies. However, CSHQ is a parent-reported
measure and does not examine children's sleep hygiene.
Because of the need for a comprehensive self-report
measure of Taiwanese school-aged children's sleep, we
developed the Children's Sleep Assessment Questionnaire
(CSAQ). The CSAQ includes three components – sleep
hygiene, sleep quality, and sleep disturbance – with reports
from both parents and children. We proposed that the
CSAQ will provide a holistic picture of children's sleep.
The purpose of this study was to describe the development
of the CSAQ and examine the CSAQ's reliability and
validity in measuring sleep problems in Taiwanese school-
aged children.
Methods
Developing Initial Items
The CSAQ focuses on children's sleep problems. The
initial scale and items were developed on the basis of
previous literature (Meltzer et al., 2013; Orgilés et al., 2013;
Owens et al., 2000; Yolton et al., 2010) and the researchers'
clinical experience. The questionnaire comprised three parts,
chosen for their ability to identify sleep problems or
insufficient sleep. Part one, “sleep hygiene” concerns social
and cultural factors, such as lifestyle and environmental sleep
factors that influence children's sleep quality. Thus, sleep
hygiene includes indices of diet, exercise, electronics use,
sleep routine, and the environment. Part two, “sleep quality”
includes bedtimes, wake times, sleep latency, night waking
frequency in varying situations, difficulty waking in the
morning, and daytime sleepiness in different situations (in
school, during short car rides, while doing homework, and
while watching television). Part 3, “sleep disturbance”
includes parasomnias and sleep-disordered breathing. The
original scale comprised three parts with a total of 44 items:
16 items for sleep hygiene, 20 items for sleep quality, and 8
items for sleep disturbances. Literature showed that sleep
Children’s Sleep Assessment Questionnaire
hygiene and quality reported by children were more accurate
than parental reports, and sleep disturbance reported by
parents were more accurate than children's reports (Meltzer
et al., 2013). Therefore, this study designed that parts one
and two were reported by children, while part three was
reported by parents. Moreover, parents also completed all the
CSAQ items because parental information was used to assess
children's and parents' inter-rater reliability.
A four-point Likert scale indicated frequency of occur-
rence: 0 = “never” to the given situation, 1 = “less than once
a week,” 2 = “one to three times a week,” and 3 = “four to
seven times a week.” We used the summation for each part.
Item 4, item 5, and item 9 were reverse items. Higher scores
indicate poorer sleep hygiene, poorer sleep quality, or more
sleep disturbances, respectively.
Content Validity
An expert panel examined the original items' content validity
index (CVI) (Lynn, 1986). Panel experts (one elementary school
teacher, one clinician specializing in children's sleep problems,
one pediatrician, and two experienced researchers specializing
in child care) rated each CSAQ item based on relevance, clarity,
and simplicity using the following scale: 1 (not relevant), 2
(somewhat relevant), 3 (relevant), or 4 (very relevant). Only
items scored 3 and 4 were considered relevant and thus used to
calculate CVI. Results from panel experts yielded CVIs of 0.97
and 0.80–one each for the scale (S-CVI) and items (I-CVIs),
respectively. These values fulfilled the requisite criteria
(S-CVI≥0.90 and I-CVI ≥0.78) (Polit, Beck, & Owen, 2007).
No items were deleted from the instrument, and minor revisions
regarding items' clarity or wording were suggested. Revisions
were incorporated into the instrument, and the revised items
were used in subsequent reliability and validity testing.
Establishing Psychometric Properties
After developing initial items and performing the content
validity test, we conducted a cross-sectional survey for
CSAQ item analysis and psychometric testing. We used item
analysis to exclude items with a standard deviation of 1.5, as
well as item–total correlations less than 0.30 or greater than
0.70 (Chiou, 2010). We then tested the final scale's
psychometric properties, including construct and convergent
validities, internal consistency, and intra-class correlation
coefficient (ICC). The Pittsburgh Sleep Quality Index (PSQI)
and the Epworth Sleepiness Scale (ESS) were used to test
CSAQ's convergent validity.
Design, Sample, and Data Collection
A cross-sectional design was used in this study. Children
were recruited by stratified random sampling. Three
administrative areas in Taichung were selected from the
eight districts of Xitun, Beitun, Nantun, West District, North
District, Central District, East District, and South District
(Figure 1). Considering time and money, one elementary
school (of 11) was selected from each administrative area. A
3
total of three city-funded schools were included in this study
and each had six grades with 700–800 students at each
school. School 1, located outside the city center, has been
established for 15 years. School 2, located in a new
city-center community, has been established for 16 years.
School 3, located in an old city-center community, has been
established for 55 years. Moreover, the socioeconomic status
of the students' parents was similar among the three schools.
After receiving permission from school administrators, the
first author gave instructions to all the 3rd- and 4th-grade
classes. The investigator explained the research purpose, its
process, and all scales to the children. Further, a formal letter of
consent was sent to children and their parents, who were
required to provide signed informed consent along with their
returned questionnaires. Parents signed a consent form while
their corresponding children signed an assent form. Each child
received a box of 12 colored pencils to thank them for their
time, none for parents. Furthermore, children or parents who
wanted to withdraw from the study could do so at any time by
calling the researchers. Participants had to fulfill the following
criteria: (a) able to read Chinese, (b) child aged N8 years, and
(c) parent completing the questionnaire had to be the child's
primary caregiver. Figure 1 displays a flowchart of the
recruiting process. All third- and fourth-grade classes from
participating elementary schools were recruited, and all
children and their parents were asked to complete the
questionnaire including the CSAQ and demographic data.
The children also complete the Pittsburgh Sleep Quality Index
(PSQI) and the Epworth Sleepiness Scale (ESS) to assess
convergent validity between the CSAQ and the PSQI, and
between the CSAQ and the ESS. Based on the suggestion from
the literature (Costello & Osborne, 2005), five to ten subjects
per item were used for sample size estimation in this study.
This study was approved by the Institutional Review Board
(CSMUH, no. CS11213). Each child and parent participant
provided informed consent for the study. All were informed
that participating in this study would not harm or discomfort
them in any way. They were also informed that everyone
would receive individual report about the assessment results as
part of the benefit for their participation. To ensure data
confidentiality, all data were encoded, used only for this study,
and not disclosed to other parties. The study was conducted
within the parameters of the Helsinki agreement.
Measures
The questionnaire includes demographic data, CSAQ,
Pittsburgh Sleep Quality Index (PSQI) and Epworth
Sleepiness Scale (ESS). Demographic data includes the age
of child and parent, sex and grade of child, and education and
marital status of the parent.
Pittsburgh Sleep Quality Index (PSQI)
The PSQI, used to measure sleep quality during the
previous month, is a self-administered questionnaire. It
contains 19 questions yielding seven subscores, covering
4 H.-L. Chuang et al.

Eight administrative areas

Three administrative areas selected

Three of 11 elementary schools selected from three administrative areas

559 3rd-and 4th-Grade students

188 refused to participate in the study

371 completed

9 primary caregivers excluded because they

were not the students’ parents

362 Successful questionnaires

290 Mothers 72 Fathers

Figure 1 Flowchart of 3rd- and 4th-grade children and their parents as participants in each stage of the Children's Sleep Assessment
Questionnaire study in Taiwan.

subjective sleep quality, sleep latency, sleep duration, sleep
efficiency, sleep disturbance, hypnotic medication use, and
daytime dysfunction. Each component is scored 0–3,
yielding a global PSQI score of 0–21, with higher scores
indicating lower sleep quality. The PSQI's reliability and
validity study showed acceptable internal consistency
(Cronbach's α = 0.83) and test–retest reliability with a
coefficient of 0.85 (Buysse, Reynolds, Monk, Berman, &
Kupfer, 1989). A modified Chinese version of the PSQI
(CPSQI) was used to assess school-aged children's sleep
quality in Taiwan (Tan, 2004; Wu, 2009). Here, we used the
modified CPSQI for CSAQ's convergent validity.
Epworth Sleepiness Scale (ESS)
The ESS is a widely used scale that evaluates the degree
of daytime sleepiness. Responders are instructed to rate, on a
scale of 0–3 (never =0, slight =1, moderate =2, and high =3),
the likelihood of falling asleep in eight different situations
(Johns, 1991). The Chinese version of the ESS (CESS) was
translated and validated by Chen et al. (2002). The scale
showed acceptable internal consistency (Cronbach's α =
0.81) and test–retest reliability with a coefficient of 0.74 in
individuals who experienced symptoms of sleep-disordered
breathing (Chen et al., 2002). A modified CESS was used to
assess excessive daytime sleepiness of Chinese children. The
scale showed acceptable internal consistency (Cronbach's
α = 0.85) (Chan et al., 2009). Here, the modified CESS was
also used to assess CSAQ's convergent validity.
Data Analysis
The CSAQ was developed and tested for item analysis,
validity, and reliability. Item descriptive statistics and
corrected item–total correlations were performed for item
selection (n = 362 pairs of children and parents). Items must
meet a minimum criterion of an all-item mean+ 1.5 standard
deviation (Chiou, 2010). We considered those items with
item–total correlations of less than 0.30 not to contribute
sufficiently to measuring the concept and considered those
with item–total correlations greater than 0.70 as possibly
redundant (Chiou, 2010). Thus, we deleted items with item–
total correlations of less than 0.30 and greater than 0.70.
After performing item analysis, revised items were subse-
quently tested for validity and reliability. Because there were
multiple indicators for sleep hygiene that may be unrelated
(e.g., frequency that child drinks soda may not relate to
frequency of exercising), calculating internal consistency for
sleep hygiene was not appropriate and was omitted. IBM SPSS
statistics version 20.0 (IBM Corporation, 2011) was used to
analyze the data. The p level of significance was less than.05.
Validity testing
Exploratory factor analysis (EFA) was conducted using
principal component analysis to examine the CSAQ's
construct validity of sleep quality and sleep disturbance.
Confirmatory factorial analysis (CFA) was conducted to
validate the structure obtained in the EFA. The x2/df ratio,
root mean residual (RMR), root mean square error of
Children’s Sleep Assessment Questionnaire 5

Table 1 Item Analysis and Exploratory Factor Analysis for the CSAQ
Items Missing Mean (SD) Correlation a Factor
rates (%) loadings
Sleep hygiene
Diet index
Frequency of fast food consumption 0.0 0.57 (0.70) − −
Frequency of sweetened food consumption 0.0 1.44 (0.92) − −
Frequency of caffeinated beverage consumption 0.0 1.18 (1.00) − −
Exercise index
Frequency of sports per week 0.0 0.78 (0.75) − −
Exercise for more than 30 minutes each time 0.5 1.14 (0.98) − −
Strenuous exercise in the hours before sleep 0.3 0.32 (0.70) − −
Electronic use index
Watching TV or playing computer games within 4 hours of sleeping 0.0 1.95 (1.00) − −
Watching TV or playing computer games for more than 2 hours per day 0.8 1.18 (1.10) − −
Sleep routine index
Goes to bed at the same time every night 0.8 1.01 (1.09) − −
Goes to bed after 10 pm 0.8 1.64 (1.16) − −
Keeps a blanket or toy while sleeping 0.0 1.15 (1.33) − −
Environment index
Exposure to second-hand smoke 0.0 0.75 (1.07) − −
Sound present during sleep 0.3 1.00 (0.92) − −
Light present during sleep 0.0 0.84 (0.72) − −
Alteration of the setting would result in insufficient sleep 0.0 0.67 (0.71) − −
Room-sharing 0.0 2.23 (1.21) − −
Sleep quality
Night waking
Wakes at night 0.0 1.58 (1.02) .44 .90
Goes to the toilet at night 0.0 1.13 (0.98) .33 .78
Alarmed by nightmares 0.0 0.57 (0.80) .48 .73
Discomfort (e.g., cough and stuffy nose) during sleep 0.0 0.73 (0.93) .50 .69
Wakes because it is too cold or too hot 0.0 0.72 (0.92) .36 .68
Daytime sleepiness
Daytime sleepiness 0.0 0.83 (1.04) .52 .92
Sleepiness in class 0.0 0.22 (0.57) .30 .83
Sleepiness while doing homework 0.0 0.30 (0.65) .40 .76
Sleepiness while watching TV 0.0 0.24 (0.65) .43 .74
Sleepiness while riding in a car or on a motorcycle 0.0 0.58 (0.91) .50 .59
Quantitative sleep pattern
Sleep-onset latency 0.0 0.71 (0.76) .31 .95
Sleep efficiency 0.0 0.49 (0.74) .33 .94
Waking in the morning
Wakes in a bad mood 0.0 0.84 (1.02) .34 .85
Has difficulty getting out of bed 0.0 1.60 (1.09) .35 .84
Seems tired in the morning 0.3 1.80 (1.13) .37 .50
Sleep disturbances
Parasomnias
Talking during sleep 0.0 0.69 (0.75) .43 .69
Nightmares or screaming 0.0 0.20 (0.47) .33 .64
Struggles at bedtime 0.0 1.28 (1.05) .43 .67
Night waking 0.0 0.66 (0.79) .48 .70
Sleep breathing-related disorder
Snoring 0.0 0.81 (0.95) .38 .88
Stuffy nose or mouth breathing 0.0 0.93 (0.98) .51 .81
Note. CSAQ, Children's Sleep Assessment Questionnaire; SD, standard deviation.
a
Corrected item–total correlation.
6 H.-L. Chuang et al.
approximation (RMSEA), goodness-of-fit index (GFI), and
comparative fit index (CFI) were conducted. Moreover, partici-
pants were randomly split into two groups. EFA was performed on
Group 1 (n = 181), and CFA on Group 2 (n = 181).
Convergent validity was further evaluated by the Pearson
correlation examining association among the three parts of
the CSAQ, CPSQI, and CESS (n = 362), based on the
hypothesis that CPSQI and CESS scores should correlate
positively with the CSAQ's three parts.
Reliability Testing
Cronbach's α coefficients were used to measure internal
consistency for CSAQ sleep quality and sleep disturbance
(n = 362). Inter-rater reliability was assessed for sleep
hygiene and sleep quality using the ICC between children
and parents (n = 362).
Results
Participants
Of the 559 pairs of children and parents (father or mother)
invited to participate, 371 (66.4%) pairs completed the study.
A further nine pairs were excluded because primary caregivers
were not parents, but grandparents, aunts, or nursemaids.
Finally, 362 pairs of children and parents completed the
questionnaire and 188 participants refused to do so (Figure 1).
Among the 188 who refused, parents claimed they were too
busy to complete the questionnaire and children responded
with no interest in sleep problems at all.
Of the 362 participating children, 172 were boys and 190
were girls, with an average age of 9.9 years (SD = 0.82,
range = 8.0–12.0). More than half the children were
fourth-graders (62.7%). Of the parents, 290 were mothers
(average age 39 years), and 72 were fathers (average age 43
years). Most parents were educated through senior high
school (46.5% mothers, 31.9% fathers) or college (42.9%
mothers, 46.8% fathers), and most were married (88.1%
mothers, 85.4% fathers).
Item Analysis
Descriptive statistical analysis and item–total correlations
of retained items are presented in Table 1. All item–scale
correlations fulfilled the prerequisite criterion of all-item
mean + 1.5 standard deviation. Otherwise, correlations
ranged from 0.30 to 0.52, indicating adequate performance.
However, from the original scale of the remaining items,
seven (nos. 28, 30, 32, 33, 37, 38, and 40) were eliminated
because of their low item–total correlation. The revised scale
included 37 items: 16 items for sleep hygiene, 15 items for
sleep quality, and 6 items for sleep disturbances. This revised
scale was used in the subsequent reliability and validity test.
Factor Analysis
EFA was conducted to examine the CSAQ's construct
validity for sleep quality (Figure 2A) and sleep disturbance
(Figure 2B). Results of the Kaiser–Meyer–Olkin index (0.74
and 0.73, respectively) and Bartlett's Test of Sphericity
(χ2 = 1601.96 and χ2 = 310.120; all p b 0.000) demon-
strated adequacy to conduct EFA. Criteria of factor with
eigenvalues N1 were used to select factors. Items with a
factor loading of b0.40 were excluded from the scale (Chiou,
2010). No items were deleted from this instrument. Table 1
shows the factor loadings' results.
Four factors were extracted, and they explained 64.9% of
variance in sleep quality. The first factor includes 5 items and
describes night-waking frequency in different situations,
including going to the toilet, having a nightmare, being
uncomfortable, or anything else defined as night waking.
The daytime sleepiness factor with 5 items and describes
frequency of sleepiness in different situations during the day,
such as in school classrooms, during short car rides, and
while doing homework or watching television. The third
factor, quantitative sleep pattern, refers to sleep-onset latency
and efficiency, consist of 2 items. The fourth factor, waking
in the morning, refers to difficulties in waking, consist of 3
items. Two factors were extracted and explained 57.7% of
variance in sleep disturbance. The first factor described
parasomnias with four items. The second factor referred to
sleep-disordered breathing and comprised two items.
CFA was computed to validate the factorial structure
obtained in the EFA. Model fit was considered acceptable if
the x2/df ratio ranged from 1.0 to 3.0, if both the GFI and CFI
were greater than 0.90, if RMR was less than 0.05, and the
RMSEA was less than 0.08 (Li, 2006). Results (Figure 2A)
demonstrated good fit for the model of sleep quality with the
data (x2/df = 1.81; RMR = 0.04; RMSEA =0.06; GFI =
0.91; CFI = 0.94). In addition, results (Figure 2B) also
demonstrated good fit for the model of sleep disturbance
with the data (x2/df = 1.53; RMR = 0.03; RMSEA =0.05;
GFI = 0.98; CFI = 0.98).
Convergent Validity
Convergent validity was determined using correlation
among the three parts of the CSAQ, the CPSQI, and the
CESS (Table 2). The three parts of CSAQ including Sleep
hygiene, sleep quality, and sleep disturbance, had low to
moderate correlation with both the CPSQI (r = 0.20–0.41)
and the CESS (r = 0.15–0.42), respectively. All correlation
coefficients are statistically significant (p b 0.05).
Internal Consistency
Cronbach's α for sleep quality and for sleep disturbance
were 0.80 and 0.68, respectively (Table 2). Removal of one
or more weakly correlated items did not significantly
improve the alpha value.
Inter-Rater Reliability
ICC results between children and parents for CSAQ sleep
hygiene and sleep quality are presented in Table 2. Moderate
agreement between children's and parents' reports was found
for diet, exercise, electronics use, sleep routine, and
Children’s Sleep Assessment Questionnaire 7

A .85
.92 .85
.58
.76
.56 .32
.58
.24
.51
.26
.34
.85
.92
.34
.58
.03
.65 .42
.53
.21 .28
.84
.01 .70

.38
.37 .62
1.41
1.19
.21
.22
.47
.80 .64
.73 .58

B .25
.06

.29
.54
.39
.16
.49
.24
.67

.61 .37

.50
.71

Figure 2 Path diagram for confirmatory factor analysis model with standardized values A, CFA model for Sleep quality of 3rd- and
4th-grade children in Taiwan Note. Model fit indices: x2/df = 1.81; RMR = 0.04; RMSEA =0.06; GFI = 0.91; CFI = 0.94). The numbers on
the double-headed arrow refer to the correlation between latent variables (nightwaking, sleepiness, quamtitativesleep, and morningwaking);
the numbers on the direction arrow refer to the standardized regression weights between the latent variables and the items; the numbers on the
right side of item boxes refer to the squared multiple correlations of the items. B, CFA model for sleep disturbance of 3rd- and 4th-grade
children in Taiwan Note. Model fit indices: x2/df = 1.53; RMR = 0.03; RMSEA =0.05; GFI = 0.98; CFI = 0.98. The numbers on the
double-headed arrow refer to the correlation between latent variables (parasomnias and breathing); the numbers on the direction arrow refer to
the standardized regression weights between latent variables and items; the numbers on the right side of item boxes refer to the squared
multiple correlations of the items.

environmental indices (0.37–0.66). A similar result was
obtained for sleep quality (ICC = 0.41).
Discussion
Here, we report psychometric properties of a
sleep-screening questionnaire designed primarily to assess
children's sleep hygiene, sleep quality, and sleep disturbance
in a community setting. Based on these results, the CSAQ was
found to be a reliable and valid measure of children's sleep,
with acceptable content validity, construct validity, convergent
validity, internal consistency, and inter-rater reliability.
Results from content validity according to panel experts
yielded a high CVI. In addition, missing rates of all items ranged
from 0.3% to 0.8% (Table 1). We did not find any reported
difficulties for children and parents in completing this measure.
Thus, we can recommend that the CSAQ is easy to use both for
children and parents, and that children can provide information
regarding their own sleep hygiene and sleep quality.
Results of EFA suggest a four-factor structure for sleep
quality and a two-factor structure for sleep disturbance. All
items are significantly loaded to their corresponding factor as
designed. No item is cross-loaded to difference factors.
Furthermore, the factor structure of sleep quality obtained in
8 H.-L. Chuang et al.

Table 2 Convergent Validity Test, Internal Consistency, and comparable subscales in the CSHQ (0.36–0.65) (Owens
ICCs for the CSAQ et al., 2000), the most popular scale in Chinese society.
Score CPQSI a CESS a α b ICC ICCs between children and parents were moderately
range correlated for sleep hygiene indices (0.37–0.66) and sleep
quality overall (0.38–0.78), comparable with those of the
Sleep hygiene 0–48 .22*** .23*** −
Children's Report of Sleep Patterns (ICCs =0.39–0.71)
Diet index 0–9 − − − 0.40
Exercise index 0–9 − − − 0.40 (Meltzer et al., 2013). Because literature showed poor
Electronic use index 0–6 − − − 0.37 agreement (ICCs =0.05) between children and parents on the
Sleep routine index 0–9 − − − 0.49 parasomnias subscale (Meltzer et al., 2013), we did not
Environment index 0–15 − − − 0.66 examine ICCs between children and parents for sleep
Sleep quality 0–45 .41*** .42*** .80 0.41 disturbance of parasomnias and sleep-disordered breathing
Night waking 0–15 .81 0.38 subscales. However, another study showed moderate
Daytime sleepiness 0–15 .82 0.45 agreement (ICC = 0.36–0.51) between children and parents
Quantitative sleep for both subscales (Owens et al., 2000). Therefore, we
0–6 .90 0.78
pattern suggested that future study may be needed to examine ICCs
Waking in the morning 0–9 .66 0.42
between children and parents for sleep disturbance in
Sleep disturbances 0–18 .20*** .15* .68 -
the CSAQ.
Parasomnias 0–12 .61 -
Sleep breathing-related This study has several strengths. First, although this study
0–9 .64 - only included 3rd & 4th graders, the children's age ranges
disorder
from 8–12 years old. Thus, it supports accuracy of
Note. CSAQ = Children's Sleep Assessment Questionnaire; CPSQI =
Chinese version of the Pittsburgh Sleep Quality Index; CESS = Chinese information provided by children aged 8–12 years regarding
version of the Epworth Sleepiness Scale; ICC = Intra-class correlation their own sleep hygiene and quality. Second, the CSAQ is
coefficient between children and parents. the only multidimensional measure for examining
*p b .05; **p b .01; ***p ≤ .001. sleep-related problems reported by children aged 8–12
a
Refer to Pearson correlation coefficient.
b years in Taiwan. Furthermore, CSAQ use was more likely to
Refer to the internal consistency of sleep quality and disturbance
modules. result in documentation of additional sleep-related informa-
tion, including sleep hygiene, insufficient sleep, and sleep
disturbance. Such information may be important in identi-
fying potential intervention to prevent children's future sleep
the EFA demonstrated good fit with the CFA. A similar problems. For example, discussing the importance of
result was also found in that the factor structure of sleep bedtime routines with children and parents, and providing
disturbance obtained in the EFA demonstrated good fit with basic information regarding good sleep hygiene may help
the CFA. Construct validity of sleep quality and disturbance parents to identify workable strategies for children. Finally, a
were supported. Thus, we suggest four subscales for sleep single-reporter sleep scale may fail to uncover all relevant
quality and two subscales for sleep disturbance. clinical information necessary to identify sleep problems.
The CSAQ had low-to-moderate positive correlation with The multi-reporter (child and parent) CSAQ can provide
both the CPSQI and CESS (r = 0.15–0.42). Previous studies comprehensive information that may otherwise be missed.
showed that poor sleepers reported poor sleep hygiene This study's limitations must be considered when
(Meltzer et al., 2013; Yolton et al., 2010), whereas this study evaluating the scale's suitability. First, no specific observa-
showed that children with poor sleep hygiene had poor tion period was included in participant instructions, which
nighttime sleep quality and more daytime sleepiness. A asked only for frequency of sleep behaviors over one week.
similar result was also found in this study that children with This may have resulted in relative over-reporting of transient
more sleep disturbances had poor nighttime sleep quality and sleep problems, indicating a need to establish a timeline for
more daytime sleepiness. In the CSAQ, sleep quality also assessing habitual sleep. Second, the CSAQ should be
had moderate positive correlation with both nighttime sleep compared to objective measures of sleep problems, such as
quality and daytime sleepiness. The CSAQ demonstrated actigraphy or polysomnography, to assess its validity against
acceptable convergent validity. those measures. Notably, the CSAQ was designed as a
The CSAQ's reliability was demonstrated through screening rather than a diagnostic instrument, with utility in
acceptable internal consistency for sleep quality and sleep both clinical and research settings. A cutoff point would be
disturbance. Internal consistency coefficients of sleep quality useful for clinicians and researchers to make a diagnosis
and sleep disturbance were near (0.68) or above (0.90) a during clinical interviews. In future, a diverse sample from
required criterion of (0.70). However, a Cronbach's α value community-based and clinical settings will be needed to
between 0.6 and 0.7 is acceptable for a preliminarily establish a cutoff score. Finally, we assessed only third- and
developed scale (Chiou, 2010). For a community-based fourth-graders from selected schools in Taichung, and this
population, performances of the total scale and subscales of may limit the findings' generalizability to other school-aged
sleep quality and sleep disturbance were greater than children and populations. More studies are needed to assess
Children’s Sleep Assessment Questionnaire
the questionnaire's generalizability to other grades and
children from other populations, including different cities
and rural areas.
Practice Implications
The CSAQ is a multidimensional measure that can provide
comprehensive information to clinicians and researchers. In
particular, CSAQ is a multi-reporter measure that can provide
additional information which may not be captured if relying
solely on children or parents. Further, an increasing score on
the CSAQ would alert clinicians or parents to provide
additional screening for underlying sleep problems.
Conclusion
The results of the study suggest that the CSAQ is a
reliable and valid instrument for evaluating sleep problems in
school-aged children, with acceptable content validity,
construct validity, convergent validity, internal consistency,
and inter-rater reliability. Additional studies should address
the use of the CSAQ in other populations to provide further
evidence of its use in a variety of settings.
Acknowledgments
No funding was secured for this study.
Appendix A. Supplementary Data
Supplementary data to this article can be found online at
http://dx.doi.org/10.1016/j.pedn.2016.07.008.
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