A shared-management web-based intervention for sleep deficiency in school-age children with juvenile idiopathic arthritis and their parents: feasibility and acceptability study.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Clin Sleep Med . 2025 Jun 1;21(6):1007–1021. doi: 10.5664/jcsm.11610 A shared-management web-based intervention for sleep deficiency in school-age children with juvenile idiopathic arthritis and their parents: feasibility and acceptability study Shumenghui Zhai 1 , Tonya M Palermo 2, 3 , Susan Shenoi 4, 5 , George Demiris 6 , Waylon Howard 3 , Julie Kientz 7 , Weichao Yuwen 8 , Teresa M Ward 3, 9, ✉ Author information Article notes Copyright and License information 1 School of Nursing, Pacific Lutheran University, Seattle, Washington 2 Department of Anesthesia and Pain, University of Washington School of Medicine, Seattle, Washington 3 Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington 4 Division of Pediatric Rheumatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington 5 Clinical Translational Research Center, Seattle Children’s Hospital and Research Institute, Seattle, Washington 6 Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania 7 Department of Human Centered Design Engineering, University of Washington, Seattle, Washington 8 University of Washington School of Nursing and Healthcare Leadership, Tacoma, Washington 9 Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington ✉ Address correspondence to: Teresa M. Ward, PhD, RN, FAAN, Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA 98101; and Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98145; Email: teresa.ward@seattlechildrens.org Received 2024 Aug 28; Revised 2025 Feb 5; Accepted 2025 Feb 6; Collection date 2025 Jun 1. © 2025 American Academy of Sleep Medicine PMC Copyright notice PMCID: PMC12134579  PMID: 40051205 Abstract Study Objectives: We aimed to describe the feasibility, acceptability, and preliminary efficacy of a pilot randomized controlled trial of a sleep health intervention (SLEEPSMART) for children with juvenile idiopathic arthritis and their parents. Methods: Fifty children, 8–13 years of age, with juvenile idiopathic arthritis and sleep deficiency and their parents participated in the study. Participants were randomized to either the SLEEPSMART intervention or the control group (usual care). The SLEEPSMART intervention lasted 7 weeks and included weekly educational modules, quizzes, assignments, goal setting, and an online sleep coach. Children wore actigraphy and completed sleep diaries and surveys at baseline, immediately postintervention, and 1 month postintervention. Feasibility was measured by the percentage of eligible, enrolled, and retained child–parent dyads; engagement was measured when dyads completed the modules; and usefulness and acceptability were measured with the Treatment Evaluation Inventory and qualitative exit interviews. Results: Of the 50 child–parent dyads enrolled, 88% completed the baseline assessment. Seventy-five percent of children and 89% of parents reported high acceptance; 89% of parents and 80% of children recommend SLEEPSMART. Compared to children in the control group, those who received the SLEEPSMART intervention had significant improvements in actigraphy total sleep time and sleep efficiency and Patient-Reported Outcomes Measurement Information System sleep disturbance scores immediately postintervention and at 1-month follow-up and in their dysfunctional beliefs and attitudes about sleep and sleep efficacy scores 1 month postintervention. Parents in the SLEEPSMART group had significant improvements in the Patient-Reported Outcomes Measurement Information System sleep-related impairment and dysfunctional beliefs and attitudes about sleep scores immediately postintervention and at 1-month follow-up and in their self-efficacy scores 1 month postintervention in comparison to parents in the control group. Conclusions: SLEEPSMART was feasible, acceptable, and improved objective and self-report sleep and self-efficacy outcomes in children with juvenile idiopathic arthritis and their parents. Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Sleep Shared-Management Intervention for Children with Juvenile Idiopathic Arthritis; URL: https://clinicaltrials.gov/study/NCT04066205 ; Identifier: NCT04066205 Citation: Zhai S, Palermo TM, Shenoi S, et al. A shared-management web-based intervention for sleep deficiency in school-age children with juvenile idiopathic arthritis and their parents: feasibility and acceptability study. J Clin Sleep Med. 2025;21(6):1007–1021. Keywords: actigraphy, RCT intervention, technology, JIA, school-age children, child–parent dyads, shared management, self-efficacy, beliefs and attitudes about sleep, transdiagnostic sleep and circadian intervention BRIEF SUMMARY Current Knowledge/Study Rationale: Although sleep deficiency is recognized as a critical outcome for pediatric pain management, sleep has been rarely targeted in nonpharmaceutical intervention studies. Few sleep interventions have focused on school-age children with chronic health conditions; most of the interventions focus on young children or adolescents. Study Impact: Sleep is modifiable and a missing piece in rheumatology care. Developing technology-based interventions that integrate children and parents into the design and development of sleep interventions has high potential to mitigate current clinical and family barriers including lack of clinician time to assess and manage sleep, long referral waiting times, lack of health care access, missed work, and school. Since the COVID pandemic, digitally deployed supportive care has rapidly evolved and accelerated in research and practice settings. INTRODUCTION Sleep deficiency, including inadequate amount and/or poor sleep quality, is highly comorbid in children with juvenile idiopathic arthritis (JIA), affecting an estimated 30%. 1 Sleep deficiency in JIA is associated with increased arthritic symptoms, fatigue and pain, anxiety, poorer health-related quality of life, and higher health care utilization. 1 – 3 Despite prior studies reporting sleep deficiency in JIA, sleep behaviors are not routinely assessed in pediatric rheumatology or in primary care. 4 Many pediatric providers have limited knowledge and training in behavioral sleep and lack confidence to manage behavioral sleep problems. 4 Moreover, limited time during pediatric clinical visits, low provider reimbursement rates, limited access to pediatric sleep centers, and high caseloads are additional barriers to assess and treat sleep deficiency in children. 4 Cognitive behavioral therapy for insomnia (CBT-I) is the first-line therapy for behavioral sleep problems in children. 5 CBT-I often requires in-person sessions, is costly, time-intensive, and requires parents and children to miss work and school. Providing accessible and tailored interventions that leverage technology to improve sleep in school-age children and their parents is important to mitigate the current barriers in clinical care for families. Zhu et al 6 conducted a systematic review on the effectiveness of technology-based interventions to improve sleep in 6-to-12-year-old children and reported improvements for sleep duration and sleep efficiency (SE). Most of the technology-based interventions target parents, and less is known about which technology components are most effective to improve sleep. 6 The current study sought to fill this gap by including school-age children and parents in the design and development of the sleep intervention. We also explored shared-management behaviors including self-efficacy and motivation that could be targeted to engage children and parents as partners to improve sleep. 7 – 9 Shared management reflects the shared responsibility for parents and children to comanage children’s sleep health and establish healthy behaviors. It assumes that with parents’ ongoing support, the child’s responsibility for their own health management increases along with developmental progression and health-related experiences. 8 , 9 Given the complexity of sleep behaviors and JIA in school-age children, strategies that encourage the child–parent dyads to engage in problem-solving and compromise around barriers to boost parents’ and children’s self-efficacy (eg, confidence) may improve sleep outcomes. We developed a behavioral web-based intervention, Sleep Shared-Management Intervention (SLEEPSMART), with input from children with JIA and their parents that provides children with JIA and their parents the knowledge, motivation, and skills for setting and achieving goals, problem-solving, and working through setbacks to improve their child’s sleep. 10 The purpose of this pilot randomized controlled trial was to (1) describe the feasibility and acceptability of SLEEPSMART and (2) examine the preliminary efficacy of SLEEPSMART on primary outcomes (actigraphy total sleep time [TST], SE, Patient-Reported Outcomes Measurement Information System [PROMIS] sleep disturbance, and PROMIS sleep-related impairment) and secondary outcomes (dysfunctional beliefs and attitudes about sleep and self-efficacy) in children with JIA and their parents. METHODS Design A parallel-arm pilot randomized controlled trial design was used to describe the feasibility, acceptability, and preliminary efficacy of a behavioral web-based SLEEPSMART intervention. Children and their parents were first screened for eligibility. Eligible participants were randomly assigned to receive SLEEPSMART or usual care. The University Committee for Protection of Human Subjects approved the study protocol. SLEEPSMART is registered at ClinicalTrials.gov. A description of the design and development of SLEEPSMART is provided elsewhere. 10 Participants From July 2019 through December 2021, children with JIA and their parents were recruited from a large urban pediatric hospital. A list of names and addresses of children who met the study eligibility criteria was obtained from an electronic medical review by the clinical research assistant. Potential participants were mailed a letter with the study website and the clinical research assistant’s contact information. Interested participants were directed to the SLEEPSMART study website that described the study. Inclusion criteria for children included (1) JIA diagnosis and (2) 8–13 years of age. Exclusion criteria for children included (1) diagnosed with a obstructive sleep apnea, (2) positive screen on the sleep-related breathing disorder subscale of the Pediatric Sleep Questionnaire 11 for obstructive sleep apnea because treatment of obstructive sleep apnea is beyond the scope of this intervention, (3) developmental delay, (4) currently taking a sleep medication (eg, melatonin), and (5) currently participating in psychological therapy and/or participated in psychological therapy the prior 3 months. Parent eligibility criteria included (1) ≥ 18 years of age, (2) access to a computer or web-based device to complete the surveys, and (3) resides with the child more than 50% of the time. Exclusion criteria for parents included diagnosed with a chronic illness that would interfere with the ability to complete study procedures. For families in which the child routinely spent the night in more than 1 home, a primary study parent was selected based on being a primary caregiver who resided with the child more than 50% of the time. Procedures Screening Parents and children completed eligibility screening surveys online through the SLEEPSMART website. Parents were notified if they and their child were eligible for the study through the scoring of an automated survey. Those who met eligibility criteria were contacted by a research staff member for consent and assent from the child. Figure 1 shows the study protocol. Figure 1. Study protocol. Open in a new tab Enrollment After consent and assent were obtained, the baseline data collection (T1) was obtained for each parent–child dyad through a Research Electronic Data Capture (REDCap) link that included questionnaires and a daily electronic sleep diary. Children were also given an Actiwatch to wear on their nondominant wrist for 10 consecutive days for each of the 3 time points: (1) baseline (T1), (2) immediately after the SLEEPSMART intervention (T2), and (3) at 1-month follow-up after SLEEPSMART (T3). At the end of 10 days, the Actiwatch was returned and study staff reviewed the electronic sleep diaries and scored the actigraphy data. Participants were provided with gift card incentives after each time point. Figure 2 shows the Consolidated Standards of Reporting Trials (CONSORT) SLEEPSMART flow chart. In brief, 63 dyads were screened for this study, and 13 were excluded, resulting in a final sample of 50 dyads. Of the 50 dyads enrolled in the study, 6 dropped out, 24 dyads received access to the SLEEPSMART program, and 20 dyads received usual standard care. Of the 24 dyads who received the SLEEPSMART intervention, 2 were studied in the school year prior to COVID (March 13, 2020), 19 were studied in the school year during COVID, and 3 were studied in the summer (June 15–September 9) during COVID. Of the 20 dyads who received usual care, none were studied prior to COVID, 18 were studied in the school year during COVID, and 2 were studied in the summer during COVID. Figure 2. Consolidated Standards of Reporting Trials (CONSORT) flowchart. Open in a new tab Intervention protocol During the T1 assessment, children and parents were given written and verbal feedback over Zoom from a sleep coach about their child’s baseline actigraphy data (TST, wake after sleep onset, SE, variability in bedtimes and waketimes) and self-reported sleep data (PROMIS Sleep Disturbance, PROMIS Sleep Impairment, Dysfunctional Beliefs About Sleep, Adolescents Sleep Wake Scale). Based on this assessment and the clinical judgment of the sleep coach, the sleep coach recommended 1 of the SLEEPSMART modules tailored to meet the individual child’s need: (1) learning a wind-down and wake-up routine, (2) reducing time in bed, (3) reducing sleep-related worry, (4) negotiating sleep in the environment, (5) correcting unhelpful sleep-related beliefs, and (6) sleep maintenance and relapse prevention. The modules were delivered (as opposed to sequential) to meet each dyad’s needs given the variability in children’s sleep problems. For example, children who lack a sleep routine started with a different module than those who ruminate at bedtime. Sleep maintenance and relapse prevention was the last module that all parent–child dyads completed. At the end of each week, children and parents uploaded the weekly activities and goals via the REDCap link and set up a meeting with the sleep coach to review by phone call or Zoom. Each parent–child dyad received the above modules over 7 weeks. Seven weeks was chosen because some child–parent dyads may need additional time to complete a module, reach their goals, and complete weekly assignments. Follow-up assessments occurred immediately after the intervention (T2) and at 1-month follow-up after SLEEPSMART (T3) and included actigraphy, sleep diaries, and questionnaires. In addition, at the T3 follow-up, children and their parents participated in a semistructured exit interview to assess the acceptability of the intervention and identify what worked well, areas for improvement, and other suggestions. The exit interviews were conducted by a research assistant with prior experience in conducting qualitative interviews. Intervention SLEEPSMART development SLEEPSMART was developed by a team including children with JIA, parents, a biomedical informatician, computer scientist, a pediatric rheumatologist, and a pediatric nurse and a psychologist with expertise in behavioral sleep problems and CBT-I and human-centered design (HCD) approaches. HCD is a collaborative approach that brings stakeholders and teams together to cocreate health interventions, services, or products that prioritize and address stakeholders’ needs. 12 Applying participatory design, HCD emphasizes stakeholders’ active engagement to improve intervention utility, uptake, sustainability, and effectiveness. 12 , 13 During the SLEEPSMART developmental phase, the content team met weekly to develop and review intervention materials, multimedia elements, the structure of the program, and paper-based prototypes. Three in-person participatory design sessions were conducted among children with JIA and their parents to further tailor intervention content to meet their needs. Based on the initial development, paper prototypes, participatory design session results, and user flows, a high-fidelity prototype of SLEEPSMART was developed. 10 SLEEPSMART modules and content SLEEPSMART is a web-based intervention that was theoretically guided by Bandura’s Social Cognitive Theory, 14 parent–child shared management, 8 , 9 and sleep principles of CBT-I. 15 SLEEPSMART adapted and modified components from the Transdiagnostic Sleep and Circadian Dysfunction intervention for youth that included 4 cross-cutting components (sleep complaint, education, behavior change and motivation, and goal-setting) that were integrated into each module: (1) learning a wind-down and wake-up routine, (2) reducing time in bed, (3) reducing sleep-related worry, (4) negotiating sleep in the environment, (5) correcting unhelpful sleep-related beliefs, and (6) sleep maintenance and relapse prevention. 15 The SLEEPSMART program was built on a responsive web platform that was accessible with web-enabled devices (laptop, smartphone, tablet). REDCap, a secure, web-based software platform designed to support data capture and management, was used for data collection. Participants in the intervention group received access to SLEEPSMART and an online sleep coach each week. To access SLEEPSMART, REDCap generated personalized weblinks that were emailed to parents. The child and parent were encouraged to access SLEEPSMART together. Each week, in consultation with the sleep coach, a different module would be provided to the participants based on their goals. REDCap would generate an automated reminder and a link to complete the weekly activities within 7 days. Daily reminders were sent to the parents if the activities were not completed by day 4. The intervention was designed to be interactive for children and their parents by having them partner to identify sleep needs and goals, anticipate barriers and solve problems, monitor their progress, and provide positive reinforcement for behavioral changes. Each of the learning modules consisted of an online presentation, a brief quiz, a tailored weekly activity focused on reinforcing goal setting and skills practice, and resources for the child and parent (eg, handouts, links to sleep organizations, videos). Each module was designed to take 20–30 minutes to complete. A trained sleep coach with a background in psychology and prior clinical experience in managing sleep problems with CBT-I and motivational interviewing met with the child and parent on a weekly basis via phone call or Zoom to review the goals, solve problems and provide strategies, and/or address setbacks. For example, if a goal was to increase the child’s sleep duration but the child did not have an established wind-down routine, the sleep coach would recommend starting with the wind-down routine module to increase sleep opportunity. The child and parent would partner together to develop a bedtime wind-down routine, including a consistent time to start and end the routine and activities to incorporate into the routine prior to bed (eg, read quietly with a dim light, parent and child read together, deep breathing, or listening to relaxing music). The sleep coach followed a standardized manual, and given this was a pilot study, the SLEEPSMART intervention included 1 sleep coach. Sample educational modules and weekly activities are shown in Figure 3 . Figure 3. SLEEPSMART online educational modules and activities ( https://www.sleepsmartstudy.org/ ). Open in a new tab Randomization Following completion of baseline assessments (T1), parent–child dyads were randomized to 1 of 2 treatment groups (treatment [SLEEPSMART] or usual care). A 4:1 block randomization scheme was generated by a statistician using an online program to derive randomization assignments. By the nature of the pilot feasibility and efficacy trial design, the participants were not blinded to the intervention. Study staff involved with the participant recruitment were not involved in the intervention or outcome assessment procedures. Usual care Participants in the usual care group received standard rheumatology care, including medications, regular follow-ups with pediatric rheumatologists, and, for some, physical therapy to maintain joint mobility and strength. Measures Feasibility and acceptability outcomes Feasibility: The number of eligible child–parent dyads, enrollment, retention, and participant attrition rate were calculated as the intervention feasibility. The percentage of completing at least 1 module in the SLEEPSMART program was considered treatment engagement, and the percentage of completing 5 or more modules was considered adherence. Treatment evaluation inventory form (TEF, parent and child): At T3, parents and children completed an 11-item TEF together that measures the overall acceptability of the program, including the content, structure and format, procedure, and how likely parents and children would recommend it to others. 16 Survey items were rated on a 5-point scale (1 = strongly disagree to 5 = strongly agree); higher scores indicate higher satisfaction and acceptability of the intervention. “Moderate” satisfaction and treatment acceptability is indicated by a score of 3 for each item. The TEF instrument demonstrates good internal consistency with Cronbach’s α = 0.85; 16 in this study, internal consistency was 0.9 for children and 0.9 for parents. Qualitative interview: To assess acceptability, semistructured exit interviews were conducted by phone or Zoom with a subset of parent–child dyads (n = 12) at the end of the program by a research assistant. Each of the exit interviews was audio-recorded and lasted 30 minutes. The interviews consisted of open-ended questions on what dyads liked about the SLEEPSMART intervention, what they would like to change, and general feedback and suggestions. Preliminary intervention efficacy and management behaviors The below measures were obtained for each data assessment (T1, T2, and T3). Actigraphy: Children wore an Actiwatch on their nondominant wrist and completed electronic sleep diaries for 10 consecutive days (Actiwatch Spectrum; Philips Respironics, Murrysville, Pennsylvania). They were instructed to press the event marker when they attempted to fall asleep, when they woke up in the morning, at the beginning and end of naps, and when the watch was removed (eg, swimming, showering). After the Actiwatch was returned, the data were downloaded and scored using the Actiware software (Actiware Version 6.1, Philips). Activity counts were scored using a weighted algorithm in the medium threshold (40 activity counts per epoch) at 1-minute intervals. This algorithm has a high sensitivity to detect sleep and low specificity to detect wake compared to polysomnography in children with and without chronic conditions. 17 Two separate coders coded 25 of the same records; when the interrater reliability reached over 90%, the 2 coders continued coding all other records. Interrater reliability was assessed with 2 members who individually scored actigraphy data (> 0.90). Variables derived from actigraphy included (1) sleep onset was defined as the first 3 consecutive minutes scored as sleep after the diary reported bedtime; sleep offset was defined as the last 5 consecutive minutes of sleep before the diary reported wake time; 18 , 19 (2) TST was defined as the minutes scored as sleep during the sleep period; (3) wake after sleep onset was defined as the minutes scored as wake during the sleep period; and (4) SE was defined as the ratio of TST/time in bed, computed as a percentage where 100% is the most efficient sleep. Sleep diaries: An electronic daily sleep diary was used with actigraphy. Children completed the electronic sleep diary every morning and every night at bedtime; parents assisted the child as needed. Variables derived from the sleep diary included the following: (1) bedtime was defined as the time children recorded in the sleep diary as “falling asleep"; (2) wake time was defined as the time children recorded in the sleep diary as “waking up”; (3) sleep duration was defined as the total amount of time spent asleep between bedtime and wake time; and (4) sleep quality was reported as 0 = “extremely poor sleep” to 10 = “extremely good sleep” (higher numbers indicate better sleep quality); (e) pain on average, was reported as 0 = “no pain” to 10 = “pain as bad as you can imagine” (higher numbers indicate greater pain). In addition, evening activities, medications, illnesses, and any unusual events that may have affected their sleep (eg, parent out of town, worry about a test) were recorded. PROMIS sleep disturbance: Parents and children each completed an 8-item questionnaire that assessed their perceptions of sleep quality, depth, and restoration within the past 7 days. 20 Items were rated on a 5-point Likert scale (1 = not at all/very poor, 3 = somewhat/fair, 5 = very much/very good). Raw scores were converted to standardized T-scores using the online Health Measure Scoring Services program ( https://www.assessmentcenter.net/ac_scoringservice ); higher scores indicate more significant sleep disturbances. Prior studies report Cronbach’s α > 0.9 among children 8–17 years old, 20 – 22 and in this study the Cronbach’s α was 0.72 for children and 0.80 for parents. PROMIS sleep-related impairment: Parents and children each completed a 4-item questionnaire that assessed sleepiness, tiredness, and functional impairments associated with sleep problems during waking hours over the past 7 days. 20 Items were rated on a 5-point Likert scale (1 = never, 3 = sometimes, 5 = always). Similar to the above PROMIS instrument, raw scores were converted to standardized T-scores; higher scores indicate more significant sleep-related impairment. Prior studies report Cronbach’s α > 0.97 among children 8–17 years old, 20 – 22 and in this study the Cronbach’s α was 0.90 for children and 0.90 for parents. Dysfunctional Beliefs and Attitudes about Sleep (DBAS-C10): A 10-item child-report measure that assessed their beliefs, attitudes, and misconceptions about sleep. 23 Items were rated on a 5-point Likert scale (1 = strongly disagree, 3 = neutral, 5 = strongly agree). DBAS consists of 3 subscales: (1) beliefs about immediate negative consequences (4 items), (2) beliefs about long-term negative consequences (4 items), and (3) need to control insomnia (2 items). A total score was computed by averaging the scores of all items; higher scores indicate more dysfunctional beliefs and attitudes about sleep. In prior studies, the Cronbach’s α internal was adequate, 23 , 24 and in this study the Cronbach’s α was 0.80. Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16): A 16-item parent-report measure that assessed their sleep-related attitudes and beliefs (eg, consequences of insomnia, worry about sleep, sleep expectations, and medication). 25 This scale has 4 subscales: (1) perceived consequences of insomnia, (2) worry/helplessness about insomnia, (3) sleep expectations, and (4) medication. Items were rated on a scale of 0 (strongly disagree) to 10 (strongly agree). A total score was computed by averaging the scores for all the items; higher scores indicate more dysfunctional beliefs and attitudes about sleep. In prior studies, internal consistency was adequate (Cronbach’s α > 0.77), 25 , 26 and in this study the Cronbach’s α was 0.90 among parents. Self-efficacy managing sleep: A 9-item parent-reported measure that assessed their confidence in managing their child’s sleep. We adapted the self-efficacy to manage chronic disease scale. 27 , 28 Items were rated using a visual analog scale, ranging from 1 = not at all confident to 10 = totally confident. A mean score was calculated; higher scores indicate higher self‐efficacy. In this study, the Cronbach’s α was 0.80. Child self-efficacy scale: A 7-item child-report measure that assessed their confidence to manage their sleep. We adapted items from the pediatric pain self-efficacy scale. 29 , 30 Items were scored on a 5-point Likert scale (1 = very sure, 2 = pretty sure, 3 = in the middle, 4 = pretty unsure, 5 = very unsure); lower scores indicate higher self-efficacy. This scale has established reliability with Cronbach’s α > 0.90 in children 9–18 years old, 29 , 30 and in this study the Cronbach’s α was 0.91. Demographics The measures below were obtained 1 time and used to describe the sample and baseline symptom characteristics. Demographics: Child and parent demographics (age, sex, race) were completed by the parents. Adolescent Sleep Wake Scale: The Adolescent Sleep Wake Scale is a 28-item child-reported measure of sleep quality and behaviors over the past month. 31 The Adolescent Sleep Wake Scale includes 5 domains (going to bed, falling asleep, maintaining sleep, reinitiating sleep, and returning to wakefulness) and items are scored on a 6-point Likert scale (1 = always to 6 = never). Higher scores indicate better sleep quality. Prior studies show good internal consistency (Cronbach’s α > 0.70) in children and adolescents, 31 , 32 and in this study the Cronbach’s α was 0.76. Pediatric Quality of Life Inventory Multidimensional Fatigue Scale: This is an 18-item child-reported measure of fatigue over the past month. 33 Items are rated on a 5-point Likert scale (0 = never a problem, 4 = almost always a problem). Raw scores were reverse-scored on a 0–100 scale; lower scores indicate more fatigue. This scale has established reliability (Cronbach’s α 0.70–0.93) among children and adolescents, 34 , 35 and in this study the Cronbach’s α was 0.75 for the children. PROMIS pediatric global health: This is a 7-item child-reported measure of physical, mental, and social health in children and adolescents ages 8–18 years. 36 Similar to the above PROMIS instrument, raw scores were converted to standardized T-scores. A higher T-score indicates better overall health. Prior studies report good internal consistency (Cronbach’s α > 0.8), 37 , 38 and in this study the Cronbach’s α was 0.78. Analytic strategy Deidentified data were exported from REDCap and Philips Actiware. Descriptive statistics were used to compute participant baseline characteristics between the groups (SLEEPSMART and usual care) using the two-sample t test for continuous measures and the chi-square test for categorical measures. The percentage of participants rated TEF items as “agree” or “strongly agree,” and thematic analyses of semistructured exit interviews were considered intervention acceptability . The qualitative interviews were conducted at the end of the study and audio-recorded and transcribed verbatim in English. Data were analyzed thematically using inductive coding, a coding approach that allows researchers to read and interpret raw textual data to develop themes without pre-defined themes. 39 Inductive coding included 5 phases: 40 (1) unitizing data; (2) open coding and identification of initial categories; (3) naming and defining initial categories; (4) developing a codebook; and (5) coding all data. The qualitative software ATLAS.ti 9 was used for data management and analysis. Of the 50 child–parent dyads, none of the dyads was studied during holidays and/or school breaks (eg, spring break) because of the effects of travel and time zone changes on sleep, as well as the potential adjustments in sleep routines. Additionally, none of the participants started the study at the end of the summer then transitioned to school year or started the study at the end of the school year and transitioned to the summer. We analyzed differences in primary (actigraphy TST, SE, PROMIS sleep disturbance, PROMIS sleep-related impairment) and secondary (DBAS, self-efficacy) outcomes between these groups and found no significant differences. To examine the SLEEPSMART intervention effects on children’s sleep outcomes and parent and child self-efficacy, we used Cohen’s d to evaluate the magnitude of difference between T1, T2, and T3, and the effect sizes were classified as small ( d = 0.2), medium ( d = 0.5), and large ( d ≥ 0.8). 41 Children who dropped out between T1, T2, and T3 were included in the analyses according to the intention-to-treat principle. 42 RESULTS Participant characteristics Table 1 summarizes the baseline sample and symptom characteristics between the control and SLEEPSMART groups. There were no significant group differences found for the baseline and symptom characteristics. The mean age of the children was 10.3 ± 1.7 years, and the majority (72%) were female. The mean age of parents was 41.8 ± 5.7 years, and all the parents were mothers. Table 1. Baseline demographic and symptom characteristics by group. Variables SLEEPSMART (n = 24) Control Group (n = 20) P Child outcomes Age, years 10.1 (1.7) 10.5 (1.8) .37 Sex, n (%) Female 18 (72%) 18 (90%) Race, n (%) Hispanic/Latino 3 (12.5%) 4 (16.6%) Biracial 2 (8.3%) 2 (8.3%) White 17 (70.8%) 13 (54.2%) Other 2 (8.3%) 1 (4.1%) Ethnicity, n (%) Hispanic 4 (16.6%) 6 (25%) Non-Hispanic White 20 (83%) 14 (58.3%) Actigraphy TIB, min 631.4 (95.8) 617.6 (50.2) .58 TST, min 464.0 (46.7) 483.2 (25.1) .12 WASO, min 71.4 (22.6) 60.8 (22.7) .14 SE, % 74 (.08) 78 (.05) .07 PROMIS Sleep Disturbances 62.0 (5.4) 62.2 (7.3) .93 PROMIS Sleep Impairment 57.4 (8.9) 56.2 (9.6) .65 DBAS 29.1 (6.3) 27.2 (6.7) .33 ASWS 2.1 (.4) 2.1 (.4) .94 Self-efficacy 2.5 (.8) 2.4 (.8) .68 PedsQL Multidimensional Fatigue 63.7 (10.1) 68.2 (11.6) .17 PROMIS Global Health Pain Interference 52.7 (8.0) 53.3 (7.7) .82 Parent outcomes Age, years 40.7 (5.4) 43.2 (6.0) .15 Sex, n (%) Female 24 (100%) 20 (100%) PROMIS Sleep Disturbances 51.6 (3.7) 52.6 (3.5) .41 PROMIS Sleep Impairment 54.9 (8.1) 53.3 (7.1) .44 Self-efficacy 5.8 (1.9) 6.5 (1.6) .19 Open in a new tab Values are presented as mean (standard deviation) unless otherwise indicated. ASWS = Adolescent Sleep Wake Scale, DBAS = Dysfunctional Beliefs About Sleep, PROMIS = Patient-Reported Outcomes Measurement Information System, SE = sleep efficiency, TIB = time in bed, TST = total sleep time, WASO = wake after sleep onset. Feasibility and acceptability Sixty-three parents completed the online eligibility screening, and 56 (89%) of the dyads were eligible. Of the 7 dyads who were not eligible, 6 were due to children participating in psychological therapy. Of the 56 eligible dyads, 50 dyads enrolled in the study, and 44 completed baseline measures (88% participation rate). Of the 24 dyads assigned to the SLEEPSMART intervention group, 19 (80%) completed all 6 intervention modules and study surveys at T1, T2, and T3; 21 (88%) completed at least 1 of the modules; and 3 (12.5%) completed 4 modules. Of the dyads who completed the 6 modules, the mean time spent on all the modules was 7.1 ± 2.2 weeks. The sleep coach provided coaching sessions to 22 dyads and the mean duration for each of the sessions was 24.3 minutes. Seventy-five percent of children and 89% of parents reported high acceptance (agree and strongly agree on the TEF) with SLEEPSMART, and 89% of parents and 80% of children would recommend SLEEPSMART to others. Of the 20 dyads assigned to the control group, 17 (85%) completed study surveys at T1, T2, and T3. The findings from the qualitative interview suggest that the intervention was highly feasible, acceptable, and useful to dyads. Table 2 shows themes, subthemes, and direct quotes from participants’ exit interviews. Three themes emerged that include satisfaction, usefulness, and improvement. Dyads were satisfied with the flexibility of online self-paced learning, the trustworthy educational content, and the research team’s responsiveness. Dyads reported that SLEEPSMART was useful to empower children to take more responsibility and to reconnect with parents to achieve the same goals. Recommended improvements included a dashboard that housed the videos, weekly assignments, and sleep diary in one place for each week, reducing the number of surveys, and making intervention modules more interactive (eg, gamified). Table 2. Themes and subthemes from exit interview. Theme 1 Satisfaction Dyads were positive with SLEEPSMART flow, structure, content, and functions Subtheme 1 Subtheme 2 Subtheme 3 The flexibility of online learning Intervention content and structure Research team response Dyads appreciated the flexibility of online learning for SLEEPSMART Dyads were satisfied with reliable and abundant intervention knowledge Dyads found the research team was highly responsive, informative, and accessible “The web-based program is convenient access anywhere to avoid COVID exposure.” (child) “You can replay the modules if you wanted to review a section or did not understand.” (child) “I could help my child with any questions he had.” (parent) “We can do the program with child and parent together.” (parent) “I love the knowledge learned from SLEEPSMART modules and quizzes to reinforce.” (child) “I liked the mini quizzes afterward [after each module]. And just like you know, it was nice to get practical.” (child) “Research assistants’ timely response and sleep coach’s regularly check-in to help us back on track.” (parent) Theme 2 Usefulness SLEEPSMART is valuable for participants and worth their time to use Subtheme 1 Subtheme 2 Empowering children Parent–child shared- management SLEEPSMART activated/motivated children to take control to improve their sleep Dyads like how SLEEPSMART reconnected them together for the same goal “[The program] empowers children to control their sleep by learning new strategies and useful tips on healthy sleep.” (parent) “It gave the kind of handle the power or the control of it to the kids where they realized that they could make changes. Instead of just mom saying OK, this is your new bedtime. It is more I think I need to do that. It was a little different, kind of, put them in making some decisions for themselves.” (parent) “You saw actual changes start to happen pretty quick. … it didn’t take a really long time for something to start shifting it. It was fairly quick that she could start to see some changes.” (parent) “It gave us a common language to discuss sleep issues. It also provided an expert voice to common parenting issues around bedtime avoidance behaviors.” (parent) “Reinforcing the importance of communication between parent and child and child self-talk is so important for us to reconnect with each other.” (parent) Theme 3 Improvement Suggestions for future SLEEPSMART refinement Subtheme 1 Subtheme 2 Subtheme 3 System Surveys Intervention modules Organize the tasks more structured in 1 dashboard, with tools to check out daily tasks and track the progress; more coaching. Reduce the burden of too many surveys and provide more explanations for survey Divide the videos into smaller sections, visualize and gamify the knowledge to make them more storytelling and playful, interact more with real person guides, and develop an actual rewarding system. “I think having everything in one place would be helpful. Instead of having to click in different parts in the email for the surveys and then the modules would separate.” (parent) “Maybe like an in-person appointment just to have like face to face. A conversation about it and that might be helpful. ” (child) “Shorter surveys and fewer questions for younger kids.” (parent) “Started that section parent questionnaire section with just a little paragraph that said that like we’re asking about your sleep to see how your child’s disease or how your child sleep impacts your sleep, that would have been kind of helpful.” (parent) “I kind of wish that they had been broken up a little bit more just because it was sometimes it’s hard to get have her stay with me as far as what we’re doing so.” (parent) “They’re very sophisticated parts like some of the concepts are quite sophisticated. So I guess actually I’m breaking into two parts. The learning part. Yeah, like more storytelling, more playfulness. for younger kids, I think there might have to be some other way of thinking, like how do you ask that question in a playful way.” (parent) “A sticker after finishing one module, and other physical rewards after completing the quizzes to motivate children.” (child) Open in a new tab Preliminary efficacy on sleep and management behaviors Table 3 and Table 4 show the means, standard deviations, and effect sizes for child and parent outcomes at each time point for the SLEEPSMART intervention and control group. In comparison to the control group of children, those who received the SLEEPSMART intervention had significant improvements in actigraphy TST ( d = .66 at T2; d =.49 at T3) and SE ( d = .88 at T2; d =.8 at T3), and the PROMIS sleep disturbance score decreased immediately postintervention and at 1-month follow-up ( d = −.62 at T2; d = −.82 at T3). In children who received the SLEEPSMART intervention, TST increased from 464.02 minutes per night at baseline to 508.58 minutes per night immediately postintervention and remained at 506.75 minutes 1 month postintervention. Similarly, SE increased from 74% at baseline to 84% immediately postintervention and at 1 month postintervention for children who received the SLEEPSMART intervention. In comparison to children in the control group, those who received the SLEEPSMART intervention also had significant differences (reduction) in the PROMIS sleep-related impairment score from baseline (T = 57.42) to immediately postintervention (T = 52.82) and 1 month postintervention (T = 51.81). Children who received the SLEEPSMART intervention also had significant differences in DBAS score and self-reported sleep self-efficacy score at 1 month postintervention (see Table 3 ). Children in the control group had no significant changes in their PROMIS sleep disturbance, PROMIS sleep-related impairment, DBAS, or self-efficacy scores (see Table 4 ). Table 3. Change in outcome variables for SLEEPSMART by time point. Outcomes T1 Baseline Mean (SD) T2 Immediately Postintervention Δ from Baseline (95% CI) d (95% CI) T3 1-Month postintervention Δ from Baseline (95% CI) d (95% CI) Child Actigraphy TST, minutes 464.02 (46.7) 31.34 (9.89, 52.79) 0.66 (0.18, 1.13) 26.48 (0.47, 52.49) 0.49 (0.01, 0.96) Actigraphy SE, % 0.74 (0.08) 0.08 (0.04, 0.12) 0.88 (0.37, 1.38) 0.08 (0.03, 0.13) 0.8 (0.27, 1.31) PROMIS Sleep Disturbances 62.01 (5.47) −2.74 (−5.32, −0.17) −0.51 (−0.99, −0.03) −4.02 (−6.38, −1.66) −0.82 (−1.34, −0.29) PROMIS Sleep-related Impairment 57.42 (8.92) −4.14 (−7.45, −0.82) −0.62 (−1.12, −0.11) −4.07 (−8.61, 0.48) −0.43 (−0.9, 0.04) DBAS 29.07 (6.34) −1.53 (−4.52, 1.47) −0.25 (−0.7, 0.21) −5.47 (−8.57, −2.38) −0.85 (−1.37, −0.32) Self-efficacy 2.53 (0.78) −0.35 (−0.7, 0.01) −0.47 (−0.94, 0.01) −0.32 (−0.6, −0.03) −0.54 (−1.01, −0.05) Parent PROMIS Sleep Disturbances 51.64 (3.70) −0.64 (−1.46, 1.29) −0.16 (−2.61, 0.30) −0.53 (−2.79, 1.74) −0.33 (−0.79, 0.14) PROMIS Sleep-related Impairment 54.93 (8.07) −4.50 (−9.04, −0.04) −0.48 (−0.95, 0.00) −2.91 (−5.76, −0.06) −0.49 (−0.96, −0.01) DBAS 4.22 (1.24) −0.61 (−1.17, −0.48) −0.52 (−1.00, 0.04) −0.89 (−1.39, −0.39) −0.86 (−1.38, −0.32) Self-efficacy 5.78 (1.95) 0.78 (−0.09, 1.61) 0.43 (−0.44, 0.90) 1.21 (0.47, 1.95) 0.78 (0.26, 1.29) Open in a new tab Effect size magnitude: 0.20 = small, 0.50 = moderate, ≥ 0.80 = large. ASWS = Adolescent Sleep Wake Scale, CI = confidence interval, DBAS = Dysfunctional Beliefs and Attitudes about Sleep, PROMIS = Patient-Reported Outcomes Measurement Information System, SE = sleep efficiency, TST = total sleep time. Table 4. Change in outcome variables for controls by time point. Outcomes T1 Baseline Mean (SD) T2 Immediately Postintervention Δ from Baseline (95% CI) d (95% CI) T3 1 Month postintervention Δ from Baseline (95% CI) d (95% CI) Child Actigraphy TST, minutes 483.24 (25.08) 1.13 (−10.93, 13.19) 0.05 (−0.43, 0.52) 6.25 (−11.79, 24.3) 0.18 (−0.3, 0.65) Actigraphy SE, % 0.79 (0.05) 0.01 (−0.01, 0.03) 0.16 (−0.32, 0.63) 0.03 (0, 0.05) 0.61 (0.09, 1.13) PROMIS Sleep Disturbances 62.18 (7.23) −3.5 (−7.28, 0.28) −0.48 (−0.97, 0.03) −3.33 (−7.59, 0.93) −0.4 (−0.89, 0.1) PROMIS Sleep-related Impairment 56.17 (9.65) −0.64 (−3.74, 2.45) −0.11 (−0.58, 0.37) −2.52 (−5.39, 0.36) −0.45 (−0.94, 0.06) DBAS 27.2 (6.71) −1.41 (−3.35, 0.53) −0.37 (−0.86, 0.12) −1.59 (−4.7, 1.52) −0.26 (−0.74, 0.23) Self-efficacy 2.43 (0.82) −0.01 (−0.42, 0.4) −0.01 (−0.49, 0.46) −0.13 (−0.54, 0.28) −0.16 (−0.63, 0.32) Parent PROMIS Sleep Disturbances 52.55 (3.47) −0.81 (−3.25, 1.64) −0.18 (−0.67, 0.32) −0.45 (−3.32, 2.42) −0.08 (−0.87, 0.14) PROMIS Sleep-related Impairment 53.29 (7.13) −1.71 (−7.27, 3.85) −0.16 (−0.66, 0.33) −4.29 (−10.45, 1.88) −0.37 (−0.87, 0.14) DBAS 4.42 (1.49) −1.24 (−2.23, −0.24) −0.64 (−1.15, −0.11) −1.54 (−2.69, −0.39) −0.69 (−1.21, −0.15) Self-efficacy 6.54 (1.63) 0.06 (−0.54, 0.66) 0.05 (−0.42, 0.53) 0.63 (−0.33, 1.58) 0.34 (−0.16, 0.82) Open in a new tab Effect size magnitude: 0.20 = small, 0.50 = moderate, ≥ 0.80 = large. ASWS = Adolescent Sleep Wake Scale, CI = confidence interval, DBAS = Dysfunctional Beliefs and Attitudes about Sleep, PROMIS = Patient-Reported Outcomes Measurement Information System, SD = standard deviation, SE = sleep efficiency, TST = total sleep time. Among the parents who received the SLEEPSMART intervention significant improvements were found for the PROMIS sleep-related impairment and DBAS scores from baseline to immediately postintervention ( d = −.48, d = −.52 at T2, respectively) and at 1-month follow-up ( d = −.49, d = −.86 at T3, respectively; see Table 3 ). Similarly, significant improvements were also found for the PROMIS sleep disturbance and self-efficacy scores in managing their child’s sleep from baseline to 1 month postintervention ( d =.33, d =.78 at T3, respectively) for parents who received the SLEEPSMART intervention. Among the control group of parents, the DBAS score significantly improved from baseline to immediately postintervention ( d = −.64 at T2) and at 1-month follow-up ( d = −.69 at T3; see Table 4 ). Figure 4 shows the changes in children’s actigraphy TST, SE, self-reported DBAS, and self-efficacy scores and parents’ self-efficacy and DBAS scores over time. Figure 4. Change from baseline in children and parents’ outcomes. Open in a new tab This figure shows the changes in child and parent outcomes from baseline (T1) to 1 month postintervention (T3). Children in the SLEEPSMART group had significant differences in actigraphy total sleep time and sleep efficiency immediately post intervention and at 1-month follow-up. Children’s self-report of Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scores and sleep efficacy in managing their sleep also significantly improved from baseline to 1 month postintervention. Parents in the SLEEPSMART group had significant improvement in their DBAS scores immediately postintervention and at 1-month follow-up in comparison to parents in the control group. Among parents in the SLEEPSMART group, but not the control group, parent self-efficacy scores in managing their children’s sleep also significantly improved 1 month postintervention. DISCUSSION The primary goal of this study was to evaluate the feasibility, acceptability, and preliminary efficacy of a web-based SLEEPSMART intervention for children with JIA and their parents. Findings indicate that the SLEEPSMART intervention was acceptable, feasible, and improved actigraphy TST, SE, and self-reported sleep disturbances, daytime impairments, and self-efficacy outcomes for children and parents. The exit interview findings indicated that SLEEPSMART was highly acceptable, with 89% of parents and 75% of children reporting overall acceptance, and 89% of parents and 80% of children would recommend SLEEPSMART to others. Parent–child dyads appreciated the flexibility of online learning and were satisfied with the content, resources, and highly responsive and accessible research team. They also appreciated that SLEEPSMART provided an opportunity for children to take more control in managing their sleep and reconnect with parents to work toward the same goal. Parents and children provided valuable feedback to improve SLEEPSMART by consolidating tasks into 1 dashboard, reducing the number of surveys, and incorporating games and a reward system into the intervention. Of the digital health interventions developed for children with JIA, several have focused on pain symptom monitoring with an mHealth application, 43 , 44 physical activity, 45 , 46 and self-management skills with online CBT programs. 47 , 48 Most behavioral intervention research in JIA has focused on pain and physical activity with limited attention to sleep, despite its importance as a critical outcome for pediatric pain management, and it is rarely targeted in nonpharmaceutical intervention studies. 49 Given the prevalence of sleep problems in JIA, and its interrelationships with pain, fatigue, and physical activity, future intervention research in JIA should incorporate sleep. Drawing upon parent–child shared management, 8 , 9 SLEEPSMART partnered with parent–child dyads as a team to improve sleep. Including parents and children in the co-design and development of SLEEPSMART empowered parent–child dyads as active participants in their health and provided an opportunity to better understand parent–child dyad technological needs and valuable insights into how real-world participants interact with the planned intervention. Our findings support preliminary efficacy for the SLEEPSMART intervention because significant improvements were observed in children’s TST and SE as measured by actigraphy, as were positive changes in children’s PROMIS sleep disturbance, DBAS, and self-efficacy scores from baseline to 1-month postintervention. Similarly, parents in the SLEEPSMART intervention also had positive improvements in PROMIS sleep-related impairment, DBAS, and self-efficacy scores from baseline to 1 month postintervention. Unexpectedly, parents in the control group also had significant improvements in their DBAS score from baseline to the 1-month follow-up period. This finding may be attributed to control parents being more cognizant of their beliefs and attitudes toward sleep while participating in our sleep study. Parent and child self-efficacy was a key target of behavioral change with the goal of empowering children and their parents to actively engage to set and monitor their child’s sleep goals, work with a weekly sleep coach to debrief and troubleshoot, and modify their beliefs and expectations about sleep. For example, the sleep coach partnered with parents to promote self-efficacy with positive reinforcement to facilitate change (eg, I can be patient and consistent in responding when my child wants to use technology before bed, and I can get my child on board with this plan) which empowered parents to follow through in changing their behavior. Less attention has been given to engaging both parents and children in the co-design of sleep interventions and taking active roles to improve children’s sleep. To our knowledge, only 1 other small pilot randomized controlled trial included shared-management skills to improve sleep in children with asthma and their parents, 50 and a limitation of this study included the lack of information about how much time parent–child dyads spent on the weekly modules and activities. Nonetheless, further studies are needed because parents play critical roles in shaping children’s sleep and JIA health management skills. HCD approaches and integrating children and parents into the intervention design was pivotal to understanding their needs and enhancing their experience and motivation to engage. Our goal is to revise and implement SLEEPSMART on waiting lists for pediatric sleep centers and/or primary care centers where it could act as an initial form of evaluation and assistance with behavioral sleep concerns. SLEEPSMART may mitigate long waiting lists and assist in allowing for referral of more complex/severe sleep concerns to a sleep specialist. Strengths and limitations Strengths of this study include use of objective measures of sleep, use of PROMIS measures, integration of children and parents in the design and development of the intervention using HCD approaches and shared-management, use of an online sleep coach with expertise in CBT-I and motivational interviewing, inclusion of modifiable measures (eg, self-efficacy, DBAS, sleep), the ability to track user activity, and not studying dyads during school breaks (eg, spring break), holidays, or transitions at the start of and/or end of the school year. As with any study, this pilot study has some limitations. First, this is a single-site pilot trial, which may limit the generalizability of findings. However, the strengths of this single-site study are established relationships with the clinic to ensure project completion and preliminary data for future scale-up initiatives. Second, our sample was predominantly middle-class, reflective of the JIA children cared for at the clinic we recruited from. SLEEPSMART will be revised to incorporate participant feedback and tested in children with JIA from diverse geographic locations to ensure a representative JIA population. Third, our follow-up period was limited to 1 month postintervention, and some children and parents may have needed a longer time to see the effects of SLEEPSMART, and it is unknown whether the positive effects of the intervention would remain 1 year postintervention. Additionally, it is difficult to determine the degree to which improved outcomes in sleep were due to SLEEPSMART intervention only vs a combination of SLEEPSMART and the ability to meet with a sleep coach each week. Fourth, the control group was usual care. We plan to revise SLEEPSMART based on participant feedback and to test the SLEEPSMART intervention in comparison to an attention control group. Fifth, participants were not blinded to intervention conditions, which is a potential source of bias. Although most of the children were studied during the school year, 5 children (2 controls) were studied in the summer, which limited the statistical analysis to evaluate how the variation in the time of year could affect the findings. Similar to our prior studies, we did not try to control for the time of year because in our prior studies we did not find seasonal differences in sleep. This is likely due to the high prevalence of sleep deficiency in children (> 30%) regardless of season. We intentionally center families’ schedules and what works best for them. Finally, some of the participants were recruited during the COVID pandemic, and stay-at-home guidance may have altered sleep routines and patterns for some children and parents. CONCLUSIONS Sleep deficiency is a critical outcome for pediatric pain management. 49 Sleep is a modifiable behavior and a missing piece in pediatric rheumatology care. Less attention has been given to engaging both parents and children as active participants in the co-development and design of sleep health interventions. Parents play critical roles in shaping children’s health management skills. This pilot randomized controlled trial addressed current gaps in the literature and will inform a larger multisite trial in a diverse population of children with JIA. DISCLOSURE STATEMENT All authors have seen and approved the manuscript. Work for this study was performed at the University of Washington and Seattle Children’s Hospital. This study was supported by National Institutes of Health/National Institute of Nursing Research grant NR016585. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the US Government. The authors report no conflicts of interest. ACKNOWLEDGMENTS The authors thank the children and caregivers who participated in this study and Ching Hung, Christine Hussain, Maeve Rogers Edstrom, and Dahee Wi and the Department of Rheumatology staff and clinicians at Seattle Children’s Hospital for assistance with recruitment and data collection. They also thank Dr. Allison Harvey and her team for sharing the Transdiagnostic Sleep and Circadian materials with us. ABBREVIATIONS CBT-I cognitive behavioral therapy for insomnia DBAS Dysfunctional Beliefs and Attitudes about Sleep HCD human-centered design JIA juvenile idiopathic arthritis PROMIS Patient-Reported Outcomes Measurement Information System REDCap Research Electronic Data Capture SE sleep efficiency TEF treatment evaluation form TST total sleep time REFERENCES 1. 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