# Intimate partner psychological violence and children's sleep difficulties up to 5 years of age: an ELFE birth cohort

Marion Bailhache, Sabine Plancoulaine, Fabienne El-Khoury, Olivier Leproux, Eloi Chazelas, Ramchandar Gomajee, Judith van der Waerden, Marie-aline Charles, Maria Melchior

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Marion Bailhache, Sabine Plancoulaine, Fabienne El-Khoury, Olivier Leproux, Eloi Chazelas, et al. "Intimate partner psychological violence and children's sleep difficulties up to 5 years of age: an ELFE birth cohort." European Journal of Public Health, 2025, 10.1093/eurpub/ckaf037. hal-05049956

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# Intimate partner psychological violence and children's sleep difficulties up to five years of age: an ELFE birth cohort

Marion Bailhache¹,², Sabine Plancoulaine³,⁴, Fabienne El-Khoury², Olivier Leproux², Eloi Chazelas², Ramchandar Gomajee², Judith Van Der Waerden², Marie Aline Charles⁵,⁶, Maria Melchior²

**Affiliations:**

¹CHU de Bordeaux, Pole de pediatrie, Place Amélie Raba Léon, F-33000 Bordeaux, France

²Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), Equipe Sociale Santé Mentale et Addictions (ESSMA), 75571 Paris Cedex 12, France

³Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), 75004, Paris, France.

⁴Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon (CRNL), U1028 UMR5292, F-69500, Bron, France

⁵Université de Paris, INSERM, INRAE Centre for Research in Epidemiology and Statistics Paris, France

⁶Ined Inserm EFS joint unit ELFE, France

**Address correspondence to:** Marion Bailhache, Hôpital des Enfants – Urgences Pédiatriques, Place Amélie Raba Léon 33 076 Bordeaux Cedex, France, marion.lerouge-bailhache@chu-bordeaux.fr, tel + 33 5 56 79 59 12, fax + 33 5 56 79 48 66

**Acknowledgments:** We thank the scientific coordinators (MA Charles, B Geay, H Léridon, C Bois, M-N Dufourg, JL Lanoé, X Thierry, C Zaros), IT and data managers, statisticians (A Rakotonirina, R Kugel, R Borges-Panhino, M Cheminat, H Juillard), administrative and family communication staff, study technicians (C Guevel, M Zoubiri, L Gravier, I, Milan, R Popa) of the Elfe coordination team as well as the families that gave time for the study. Special thanks to Inès Khati for data cleaning and preliminary analysis.

**Data Availability statement** data of the study are protected under the protection of health data regulation set by the French National Commission on Informatics and Liberty (Commission Nationale de l'Informatique et des Libertés, CNIL). Deidentified individual participant data (including data dictionaries) will be made available, in addition to study protocols, the statistical analysis plan, and the informed consent form. The data will be made available upon publication to researchers who provide a methodologically sound proposal for use in achieving the goals of the approved proposal. Proposals should be submitted to the authors.

**Authors Contribution**

MB: Conceptualization, Formal analysis, Part of funding acquisition, Methodology, interpretation of data, Writing, Original draft, Review.

SP: Methodology, interpretation of data, review.

FE, OL, EC, RG: Formal analysis, Methodology, Interpretation of data and Review

JVDW: interpretation of data, review.

MAC: Data curation, interpretation of data, review.

MM: Supervision, conceptualization, Methodology, interpretation of data, review.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

**Word count:** 3499
# Abstract

## Background

To examine the association between Intimate Partner Psychological Violence (P-IPV) from before pregnancy to two years after the child's birth and child's sleep patterns, i.e., sleep onset difficulty (SOD), nighttime awakenings (NA), and nighttime sleep duration (NSD) between two and five years of child's age.

## Methods

Data come from the population-based French birth ELFE cohort launched in 2011. P-IPV was assessed before and during pregnancy, at two months and two years post-partum. Child's sleep patterns were measured at two, three and five years of age. Group-based trajectory modelling was used to identify trajectories of P-IPV and each child's sleep patterns. Associations between P-IPV and child's sleep trajectories were assessed by weighted multivariate logistic regressions.

## Results

Five P-IPV trajectories were identified: Minimal (64%), Prenatal (14%), Decreasing (9%), Increasing (8%) and persistent (5%). Two trajectories of SOD (few 65%, many 35%), three trajectories of NA (few 49%, decreasing 24%, many 23%), and three trajectories of NSD (short 21%, medium 56%, long 23%) were identified. 9513, 9512 and 9499 children were included in comparative analyses respectively focused on SOD, NA, and NSD. Increasing and persistent P-IPV trajectories were both associated with the trajectory of many SOD (OR=1.53 95%CI[1.24-1.91], and OR=1.71 95%CI[1.31-2.22], respectively), and the trajectory of many NA (OR=1.66 95%CI[1.29-2.13], OR=1.95 95%CI[1.42-2.69], respectively). Associations between persistent P-IPV and decreasing and many NA were significant among girls (OR=1.76 95%CI[1.12-2.75]; OR=2.27 95%CI[1.39-3.71], respectively), but not among boys.

## Conclusions

Family interventions in response to IPV should pay particular attention to sleep patterns of children exposed to IPV.

Word count: 250

**Key words:** intimate partner violence; child; sleep

## Abbreviations:

Intimate Partner Psychological Violence (P-IPV)

Confident Interval (CI)

Interquartile Range (IQR)

Nighttime awakenings (NA)

Nighttime Sleep Duration (NSD)

Sleep Onset Difficulty (SOD)
Introduction

Intimate Partner Violence (IPV) is a serious global public health problem. Nearly one third of women aged 15-49 years, have experienced IPV [1]. About 10.6% of men experienced contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime, according to nationally representative data collected in the United States in 2015 [2]. Children exposed to IPV is a co-victim and have important negative short-and long-term consequences for their mental and physical health, such as under-immunization or internalizing and externalizing behaviour problems in the short term, and more risk-taking behaviours or substance abuse in adulthood [3,4]. In a meta-analysis conducted in the United Kingdom, IPV exposure was the most prevalent forms of child maltreatment, estimated around 11.90% [5]. Among different types of IPV, Intimate Partner Psychological Violence (P-IPV) is the most common [6]. Among women, the prevalence rate of P-IPV was estimated around 27% [6]. Psychological violence very often accompanies the other types of violence. In the study conducted by Barbier et al, physical or sexual IPW were isolated in less than one percent of cases [7].

Poor sleep quality is a precursor to further negative health outcomes, as poor mental health and poor academic performance [8,9]. Healthy sleep is often characterized by sufficient duration, good quality, and the absence of sleep disturbances such as difficulty in initiating or maintaining sleep [9]. Among the long-term consequences of sleep disruptions are metabolic disorders, including obesity and type 2 diabetes mellitus [9].

While several studies explored the association between IPV exposure during childhood and subsequent sleep disruptions [10–12], few studies focused on sleep problems before adulthood. Among these studies, adolescence was the most commonly studied period, and very few were conducted in childhood [10–14]. More difficulty falling asleep, more difficulty staying asleep, shorter sleep duration and more often irregular bedtimes were reported among adolescents exposed to IPV during childhood [10–12]. Earlier in childhood, Smith et al showed no association between P-IPV exposure between three and five years of age and sleep problems at five years of age [13]. However, the sample of participants in this study included only women who experienced additional social adversity, and the sample size was limited (n=194). Similarly, in the study of Gustafsson et al including 185 children, no association was found between inter-parental verbal aggression exposure at 30 months and developmental trajectories of sleep problems between 24 to 36 months [14]. In contrast, physical-IPV was associated with more sleep problems [14].

The objective of the current study was to explore, in a large population-based birth cohort, P-IPV trajectories from pre-pregnancy to two years after birth, and child sleep problems between two and five years of age.

Considered child sleep problems were nighttime awakenings (NA), sleep onset difficulty (SOD), and nighttime
sleep duration (NSD) between two and five years of child's age. It was hypothesized that persistent P-IPV during pregnancy and early childhood would be associated with more adverse child sleep trajectories, i.e. more SOD, more NA, and shorter NSD.

## Methods

### Study design and participants

Data were drawn from the French population-based ELFE cohort study (French Longitudinal Study since Childhood) [15]. A total of 320 randomly selected maternity units in metropolitan France participated in 2011.

Inclusion criteria were infants born at ≥33 weeks of gestation, who were singletons or twins, for whom the family did not plan to leave metropolitan France within three years and informed consent from the mother with information to the father of his right to oppose. Infants born to mothers younger than 18 years old, who did not read French, Arabic, Turkish or English were excluded. Due to the specificity of their sleep and the correlation between their data, twins were excluded from the present study.

### Outcome

Parents were asked to report on their children's sleep characteristics at two, three, and five years of age in phone interviews. Bedtime and wake time were assessed for weekdays and weekend days. A daily average nightly sleep duration was estimated (NSD). Parents reported whether their child wakes up during the night and, if so, the number of nights this had happened in the past week. A categorical variable was created for NA from never, one to two nights per week, to more than two nights per week. SOD was also collected with the question: "When you put your child to bed, does he/she have difficulty falling asleep? For example, does he/she cry or fuss for more than 30 minutes?" The response was never, sometimes, or often.

### Main exposure

Parental conflicts were collected from both parents 1) for the period before pregnancy, during pregnancy, and the first two months of child's life, at the 2-month telephone interview, and 2) during the 2-years telephone interview. Parents were asked to rate the frequency of arguments with their partner on a 4-point scale from "never", "rarely", "sometimes" and "often". If they reported arguing often or sometimes, they were asked to rate whether insults or hurtful comments were frequent ("Has your partner ever insulted you or said hurtful things to you?"). The responses of both parents were combined. The maximum response was chosen if their responses differed. Thus, a variable with a 4-point scale was created for each period: "no insults or hurtful comments or never or rarely arguments", "rarely", "sometimes" and "frequent insults or hurtful comments during arguments". Single parents were grouped in the "no insults or hurtful comments or no or rare arguments" category.
Covariates

Known risk factors of IPV and variables that have been known to be associated with children’s sleep disorders
were identified in the scientific literature [16–18]. The variables measured in the cohort were thus selected. A
directed acyclic graph was used to identify covariates in adjusted models (Supplementary Figure 1).

Sociodemographic, parental and child characteristics were collected at two months: grand-parental birthplace,
parental age, parental educational level, monthly household income in euros per consumption unit, parental
employment, parental desire of pregnancy, whether the parents lived together or not, and the number of siblings.
Maternal alcohol consumption during pregnancy was assessed in a face-to-face interview at the maternity ward.
The child’s biological sex, prematurity and low birth weight (defined as birth weight below the 10th percentile for
gestational age) were collected in children’s medical health records. We used standardized French intrauterine
growth curves to determine intrauterine growth restriction [19]. Parental smoking status and the main day-care
arrangement were collected by phone interview at one years of age.

When the child was two years old, the following information was collected through telephone interviews with
the mother and the father: the parent's perception of grandparental support during the child's second years, the
frequency of the child's presence during arguments between parent and his/her partner, ranging on a 4-point
scale from “never” to “often”. The responses with the highest frequency were selected if parents reported
different frequencies. The mental health of both parents was assessed though the 6-item Kessler Psychological
Distress Scale. This scale is a self-report questionnaire screening global psychological distress during the
previous 30 days, range between 0 to 24. A score equal or greater than 13 indicates the probability of serious
mental illness. The scale has been validated around the world, and a French version showed good performances
[20–22]. The child risk of autism was assessed by the Revised-Modified Check List Autism for Toddler (M-
CHAT). The parents completed the 20-item questionnaire from which the child was classified into three
categories of risk: few, moderate and high risk. The sensibility of the test was around 83% and the specificity
95% [23]. The questionnaire bas been validated in French [24]. Parents reported the average time their child
spent on each of five screens – TV, smartphone, video game console, tablet and computer- during a typical
weekday and weekend day The average daily screen use over the week was the sum of reported screen time
weighted by the times on weekdays and weekends ([weekdays*5] + (weekend*2))/7 [25]. Finally, sleep routine
were collected through several questions to the mother: the parent or caregiver who put the child to bed, the
parent or caregiver who gets up at night when the child wakes up, the child falls asleep in own bed or not, and
the child ends sleep in parent's bed or not when the child wakes up at night.
## Statistical analyses

We performed group-based trajectory modelling using the latrend package in R to identify different longitudinal trajectories of P-IPV from before pregnancy up to the child's two years of age, and different longitudinal trajectories of average NSD, SOD, and NA between two and five years of child's age (26). Group-based trajectory modelling handles missing values, however children with no information or with only one point of measurement were excluded from these analyses. The Bayesian information criterion, the Weighted Mean Absolute Error and the logLik were used to select the best-fitting models. We performed the selections via a manual elbow method, using the plotMetric function because of the consistent improvements of these criteria for an increasing number of clusters leading to an overestimation.

A specific weight was calculated for each participating child to deal with selection and attrition biases. Weights were calculated to take into account the sampling plan, initial non-response and attrition during follow-up.

National statistical data and the 2010 French National Perinatal study [27] to make ELFE participants nationally representative on the following variables: age, region, marital status, migration status, level of education and primiparity were used [28].

Missing data on covariables were imputed using multiple imputation models by chained equations utilizing classification and regression trees assuming missing data at random [29]. The imputed datasets were used in weighted multivariate logistic regressions to compare the different trajectories of average nighttime sleep duration, difficulty falling asleep, and nighttime awakenings relative to the trajectories of P-IPV. Combined variables with information from both parents were created for pregnancy intention and parental education due to collinearity between information from the mother and father. Similarly, mother's age was chosen to represent parental age. According to the DAG, minimally adjusted models (including household income, mother's age, parental education level, parental unwanted pregnancy and immigrant status), and fully adjusted models (including in addition: number of siblings, child's biological sex, prematurity, low birth weight, risk of autism, alcohol use during pregnancy, main day-care arrangement, parental tobacco use, sleeping routine, parental mental health, parental employment, child's presence during arguments) were performed (Supplementary Figure 1). Interactions between the child's biological sex and P-IPV exposure were explored. Sensitivity analyses were performed with complete case data.

## Ethics
The ELFE study has been approved by the authorities in accordance with the Declaration of Helsinki. (Comité de Protection des Personnes (CPP in 2011 no. IDFIX-11-024); Comité National Informatique et Libertés (CNIL no. 910504, no. 913074, no. 915770); and CNIS (no. 2011X716AU, no. 2013X719AU, no. 2016X718AU)).

## Results

At birth, 18329 children were included in the ELFE cohort. Finally, 9513 children followed for 5 years were included in the comparative analyses for SOD trajectories, 9512 for NA trajectories, and 9499 for NSD trajectories (Supplementary Figure 2).

### P-IPV and sleep trajectories

Five trajectories of P-IPV were identified (Figure 1): A Minimal (64%), B Prenatal (14%), C Decreasing, P-IPV decreases after the child's birth (9%), D Increasing (8%), P-IPV increases at two years of the child, and E Persistent (5%), always P-IPV.

We identified two trajectories of SOD (Figure 2): few difficulties falling asleep (65%) and frequent difficulties falling asleep (35%); Three trajectories of NA: few night awakenings (49%), decreasing night awakenings (24%) and many persistent night awakenings (23%); Three trajectories of NSD: short (21%), medium (56%) and long (23%).

### Description of the study population

Table 1 describes the characteristics of participating children and their families overall and according to the different sleep trajectories. The average daily duration of screen use at two years of age was longer among children on the trajectory with more SOD (Median M= 0.36 h interquartile range IQR[0.11, 0.71] than with few SOD (M=0.30h IQR[0.10, 0.60]). Similarly, the duration of screen use was more important among children with trajectories with more NA (M=0.36h IQR[0.10, 0.70] for decreasing and M=0.36h IQR[0.13, 0.69] persistent many) than with few NA (M=0.29h IQR[0.08, 0.57]). When screens were used longer, sleep time was shorter: short (M=0.36h IQR[0.14, 0.71]), medium (M=0.31h IQR[0.10, 0.64]) and long sleep duration trajectories (M=0.29h IQR[0.08, 0.61]). The mean daily duration of screen use at two years of child's age was longer in the persistent (M=0.36h IQR[0.13, 0.71]), decreasing (M=0.36h IQR[0.12, 0.71]), and increasing (M=0.39h [0.14, 0.71]) P-IPV trajectories, than in the minimal (M=0.29h IQR[0.10, 0.59]) and prenatal (M=0.29h IQR[0.11, 0.64]) P-IPV trajectories. Similarly, children were less likely to fall asleep in their own bed at two years in these P-IPV trajectories (Supplementary table 1).

### Association between sleep trajectories and P-IPV trajectories
Table 2 shows the results of multivariate analyses. P-IPV trajectories were associated with the trajectory of SOD, particularly increasing (Odds Ratio OR 1.53 95%Confident Interval CI[1.24-1.91]) and persistent trajectories (OR 1.71 95%CI[1.31-2.22]). Children who were in the increasing and persistent P-IPV exposure group had a higher risk of being in the many persistent NA trajectory (OR=1.66 95%CI[1.29-2.13], and OR=1.95, 95%CI[1.42, 2.69], respectively). Increasing P-IPV exposure at two years of age was associated with the decreasing trajectory of SOD (OR 1.49, 95%CI[1.15-1.91]).

*Interactions between child's biological sex and P-IPV trajectories*

Interaction tests between the child's biological sex and P-IPV trajectories were not statistically significant in fully adjusted and bivariate statistical models for SOD and NSD. Associations between P-IPV exposure and SOD and NSD were statistically similar between boys and girls. Interaction tests between the child's biological sex and P-IPV trajectories were statistically significant for NA. Associations between persistent P-IPV and NA were statistically significant among girls (decreasing vs few NA OR-1.76 95%CI[1.12-2.75]; many vs few NA OR=2.27 95%CI[1.39-3.71], respectively), but not among boys (Table 2).

**Discussion**

The present study examined the association between early P-IPV exposure and children's sleep patterns in a large population-based birth cohort. Very few studies focus on the first years of life. We observed that persistent P-IPV up to two years of age was associated with greater SOD and staying asleep. Children with persistent P-IPV exposure also had shorter NSD, but the association did not persist after adjustment for potential variables on the causal pathway. To a lesser extent, the same was observed for SOD and prenatal and decreasing P-IPV trajectories. The effect of P-IPV appears to be more important for girls than for boys, concerning NA, which is partly consistent with previous studies among adolescents [11].

These results are not consistent with previous studies in the childhood [13,14], but are in line with studies conducted during adolescence [10–12]. There could be several explanations to this. First, in the study of Smith et al, P-IPV exposure was measured between the ages three and five years, and different trajectories over time were not examined. Children were classified as exposed or not exposed without distinguishing variations in exposure over time. Second, in the same study, sleep problems were assessed with one question at five years old (problems with sleep pattern or habits) [13]. In the current study, we showed that different characteristics of children's sleep were not associated in the same way with P-IPV exposure, and in particular we found less association with NSD. Additionally, parental perception of the child's sleep problems could be different according to many complex
factors including culture and parental beliefs and cognitions [30]. In the second study, the sample size was
probably too small (n=185) to show a significant difference between groups [14].

The possible explanations of the effects of P-IPV exposure on children’s sleep are many and complex, as
suggested by several models including the transactional model of Sadeh and Anders [30,31]. In this model,
children need to develop self-regulation skills to soothe themselves and fall asleep independently of their
parents. However cultural, environmental and family factors influence intrinsic child and parental factors, which
in turn influence the parent-child interaction, strongly linked to the child’s sleep patterns [31]. In this context, P-
IPV would increase the victim parent’s separation anxiety, with an over-sensitivity to the child's distress signal
and more guilt and sadness when separated from her child during sleep. This anxiety could affect parental
nighttime involvement and thus the child’s ability to self-regulate and soothe. Similarly, parental emotional
availability and positive feelings could be less important for parents experiencing P-IPV, particularly through the
effect on parental mental health. Furthermore, going to sleep represents a separation between the child and
his/her attachment figure. Noonan et al showed that IPV exposure during childhood is associated with less secure
child-parent attachment for the child [32]. Children exposed to P-IPV could have more sleep disturbances
through this mechanism. Regarding the intrinsic child factor, several studies have already shown that children
exposed to P-IPV have more emotional problems than those who are not exposed [13,33,34]. The relationship
between sleep and emotional and behavioural functioning is strong and probably bidirectional [35]. Children
exposed to P-IPV could have more emotional problems, which could affect their development of self-regulation
skills.

It is difficult to explain why girls are more likely to wake up at night when they are exposed to P-IPV, while boys
are not. A systematic review of the prevalence of nightmares in children found that the prevalence of nightmares
was higher in girls than boys [36]. Nightmares could be responsible for night awakening. The consequences of
exposure to intimate partner violence could be also differ depending on the child's biological sex. Women are
more often the victims of intimate partner violence, and daughters could be more likely to identify with their
mothers, which could have a greater impact on their sleep patterns. Finally, a recent study shows that women are
more empathetic than men, which could also be an explanation of why parental conflicts have more of an impact
on girls [37].
The current study has several strengths. We used data from a large nationwide sample. The prospective and longitudinal design is particularly well-suited to better understand possible causal pathways between exposure to violence and children's sleep patterns. In addition, we collected information about potential confounding factors. The current study also has some limitations. First, only P-IPV was measured in our study. P-IPV is the most common form of IPV and is present in the vast majority of other forms of IPV [7]. However, the simultaneous presence of multiple forms of violence increases the severity of the situation. The combined effects of multiple violence types are therefore not considered in our study. When P-IPV is persistent over time, the prevalence of other forms, such as physical violence, could be more important and responsible for the significant impact on the child. Second, the child's sleep characteristics were reported by their parents. Parents' perceptions of SOD or NA could differ according to their interpretation. Parents who are depressed or experience significant fatigue could perceive their child's sleep problems as more severe. This could increase the estimated association between sleep characteristics and P-IPV exposure because victims of IPV are more likely to have poor mental health in the minimal adjusted models [4]. The full-adjusted models included parental mental health. Third, NSD was probably overestimated because it was calculated based on bedtime and waking time, but the child may fall asleep later. We did not use standardized validated questionnaires to assess the P-IPV exposure. In the same way, the interpretation of "insults or hurtful comments" and the frequency of P-IPV exposure ("never" to "often" without precise quantification) could be different according to the parental characteristics. When parents are tired, this could make them more susceptible. Furthermore, socially desirable responses may lead to underreporting of involvement in partner violence. Victims and authors may not report the violence to avoid feeling shame and guilt. Although we collected a comprehensive set of confounding variables, there are likely to be other unmeasured factors that would be interesting to investigate, such as other types of child maltreatment, and sleep-disordered breathing. Finally, cultural context influences the parental sleep-related practices, daily parenting practices and probably parental perception of their child's sleep problems [31]. Even if we took into account sleep routine and the parental immigrant status in our study, some cultural aspects could be responsible for our findings not being generalizable to all cultural contexts.

These findings highlight how early persistent and increasing P-IPV exposures are related to child's difficulties in falling and staying asleep between two and five years of age. Clinicians and professionals involved in caring for children who experience family violence should pay special attention to children's sleep. Several interventions to improve sleep quality in children have been developed including healthy sleep practices [38,39]. In the context of intimate partner violence, it could be more difficult to support parents to adopt these practices, and to ensure a
positive, calm and relaxed atmosphere in the child's environment. Specific interventions for families at risk,
including domestic violence, have been developed and may be of interest. [40]. However, the first and probably
indispensable element in ensuring the effectiveness of interventions in this context must be to prevent the child
from being exposed to IPV.
## Funding

The ELFE survey is a joint project between INED (Institut National d'Etudes Démographiques), INSERM (Institut National de la Santé et de la Recherche Médicale), EFS (Etablissement Français du Sang), InVS (Institut de Veille Sanitaire), INSEE (Institut National de la Statistique et des Etudes Economiques), the Ministry of Health (DGS, Direction Générale de la Santé), the Ministry of Environment (DGPR, Direction Générale de la Prévention des Risques), the Ministries of Health and Employment (DREES, Direction de la Recherche, des Etudes, de l'Evaluation et des Statistiques), and the CNAF (Caisse Nationale des Allocations Familiales), with the support the Ministry of Research and CCDSHS (Comité de Concertation pour les Données en Sciences Humaines et Sociales) and the Ministry of Culture (DEPS, Département des études, de la prospective et des statistiques). As part of the RECONAI platform, the study received state funding from the ANR within the framework of the “Future Investments” program (reference: ANR-11-EQPX-0038). The Ile-de-France region grant to the VEAVE project (How to reduce Violence against Children and Adolescents in the Ile-de-France region and its life-long consequences; Action Programme de recherche d'intérêt majeur, Convention région Île-de-France APHP n° 23002745-23002747). Marion Bailhache benefits from a funding by the INSERM Institut National de la Santé et de la Recherche Médicale (EN-2023CINT12).

## Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

## Key points

* Sleep quality is a precursor of further negative health outcomes.

* Exposure to Intimate Partner Violence (IPV) in childhood is associated with more sleep problems in adulthood and probably adolescence.

* Persistent and increasing Psychological-IPV prior to two years of age was associated with more difficulties falling asleep and frequent nighttime awakenings between two and five years of age.

* Associations between Psychological-IPV and frequent night awakening were stronger among girls than boys.
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<table><caption>**Table 1** Description of children participating in the French ELFE study from 2011 to 2016, and according to the trajectories of sleep between 2 and 5 yrs (n=9513).</caption><thead><tr><th rowspan="3">Variables</th><th rowspan="3">Miss</th><th colspan="8">Trajectories (%)</th><th rowspan="3">Overall<br>N = 9513</th></tr><tr><th colspan="2">Sleep onset difficulties</th><th colspan="3">Night awakening</th><th colspan="3">Night sleep duration</th></tr><tr><th>Few<br>N = 6308</th><th>Many<br>N = 3205</th><th>Few<br>N = 4656</th><th>Decreasing<br>N = 2685</th><th>Many<br>N = 2171</th><th>Short<br>N = 1978</th><th>Medium<br>N = 5398</th><th>Long<br>N = 2123</th></tr></thead><tbody><tr><td>Trajectories of Intimate Partner<br>Psychological Violence</td><td>0</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>A Minimal</td><td></td><td>66</td><td>58</td><td>66</td><td>62</td><td>58</td><td>61</td><td>64</td><td>63</td><td>63</td></tr><tr><td>B Prenatal</td><td></td><td>14</td><td>15</td><td>15</td><td>14</td><td>15</td><td>14</td><td>15</td><td>15</td><td>15</td></tr><tr><td>C Decreasing</td><td></td><td>9</td><td>11</td><td>9</td><td>10</td><td>10</td><td>10</td><td>9</td><td>10</td><td>9</td></tr><tr><td>D Increasing</td><td></td><td>7</td><td>10</td><td>6</td><td>9</td><td>10</td><td>9</td><td>7</td><td>9</td><td>8</td></tr><tr><td>E Persistent</td><td></td><td>4</td><td>6</td><td>4</td><td>5</td><td>7</td><td>6</td><td>5</td><td>3</td><td>5</td></tr><tr><td><strong>Child characteristics</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Premature birth</td><td>138</td><td>4</td><td>4</td><td>4</td><td>4</td><td>5</td><td>4</td><td>3</td><td>5</td><td>5</td></tr><tr><td>Low birth weigh</td><td>258</td><td>7</td><td>7</td><td>6</td><td>7</td><td>8</td><td>8</td><td>6</td><td>8</td><td>7</td></tr><tr><td>Child's biological sex: boy</td><td>73</td><td>50</td><td>51</td><td>50</td><td>51</td><td>52</td><td>58</td><td>50</td><td>46</td><td>50</td></tr><tr><td>Main day-care arrangement<sup>a</sup></td><td>98</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Collective care</td><td></td><td>14</td><td>15</td><td>15</td><td>15</td><td>13</td><td>17</td><td>16</td><td>11</td><td>15</td></tr><tr><td>Cared by employed person</td><td></td><td>38</td><td>36</td><td>40</td><td>36</td><td>33</td><td>37</td><td>39</td><td>32</td><td>37</td></tr><tr><td>Cared by family members/partner</td><td></td><td>48</td><td>49</td><td>45</td><td>49</td><td>53</td><td>46</td><td>45</td><td>57</td><td>48</td></tr><tr><td>Child had his/her own bedroom<sup>b</sup></td><td>51</td><td>77</td><td>74</td><td>78</td><td>75</td><td>73</td><td>71</td><td>76</td><td>79</td><td>76</td></tr><tr><td>Fall asleep in his/her own bed<sup>b</sup></td><td>52</td><td>95</td><td>87</td><td>95</td><td>92</td><td>87</td><td>85</td><td>94</td><td>94</td><td>92</td></tr><tr><td>End of the night in the parents' bed when<br>night awaking<sup>b</sup></td><td>197</td><td>19</td><td>36</td><td>7</td><td>38</td><td>43</td><td>39</td><td>24</td><td>15</td><td>25</td></tr><tr><td>Child's presence during parental conflict<sup>b</sup></td><td>3</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No or rare arguments</td><td></td><td>33</td><td>28</td><td>34</td><td>29</td><td>28</td><td>28</td><td>30</td><td>36</td><td>31</td></tr><tr><td>Rarely</td><td></td><td>33</td><td>31</td><td>32</td><td>35</td><td>30</td><td>31</td><td>33</td><td>32</td><td>32</td></tr><tr><td>Sometimes<br>often</td><td></td><td>30</td><td>34</td><td>29</td><td>31</td><td>37</td><td>34</td><td>32</td><td>28</td><td>32</td></tr><tr><td><strong>Parental characteristics</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Mother's age (years)<sup>c</sup></td><td>0</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>&lt;26</td><td></td><td>14</td><td>14</td><td>14</td><td>16</td><td>13</td><td>11</td><td>12</td><td>21</td><td>14</td></tr><tr><td>26-30</td><td></td><td>35</td><td>35</td><td>35</td><td>34</td><td>37</td><td>31</td><td>36</td><td>37</td><td>35</td></tr><tr><td>31-35</td><td></td><td>33</td><td>33</td><td>33</td><td>32</td><td>32</td><td>34</td><td>34</td><td>29</td><td>33</td></tr><tr><td>36-40</td><td></td><td>15</td><td>15</td><td>15</td><td>15</td><td>16</td><td>19</td><td>15</td><td>12</td><td>15</td></tr></tbody></table>
<table><tbody><tr><td>Father's age (years)<sup>c</sup></td><td>30</td><td>3</td><td>3</td><td>3</td><td>3</td><td>2</td><td>5</td><td>3</td><td>2</td><td>3</td></tr><tr><td>&lt;26</td><td></td><td>9</td><td>8</td><td>9</td><td>10</td><td>7</td><td>6</td><td>8</td><td>12</td><td>9</td></tr><tr><td>26-30</td><td></td><td>28</td><td>28</td><td>27</td><td>28</td><td>29</td><td>25</td><td>28</td><td>31</td><td>28</td></tr><tr><td>31-35</td><td></td><td>33</td><td>31</td><td>32</td><td>31</td><td>32</td><td>31</td><td>33</td><td>32</td><td>32</td></tr><tr><td>36-40</td><td></td><td>19</td><td>21</td><td>20</td><td>20</td><td>19</td><td>22</td><td>20</td><td>16</td><td>20</td></tr><tr><td>&gt;40</td><td></td><td>11</td><td>12</td><td>12</td><td>11</td><td>12</td><td>16</td><td>11</td><td>9</td><td>11</td></tr><tr><td>Mother's migrant status<sup>c</sup></td><td>17</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>French with 2 parents French</td><td></td><td>78</td><td>71</td><td>77</td><td>77</td><td>70</td><td>66</td><td>78</td><td>79</td><td>75</td></tr><tr><td>French with 1 parent not French</td><td></td><td>6</td><td>6</td><td>6</td><td>6</td><td>7</td><td>6</td><td>6</td><td>5</td><td>6</td></tr><tr><td>French with 2 parents not French</td><td></td><td>3</td><td>5</td><td>4</td><td>4</td><td>5</td><td>5</td><td>3</td><td>4</td><td>4</td></tr><tr><td>Not native French</td><td></td><td>13</td><td>18</td><td>13</td><td>14</td><td>18</td><td>23</td><td>13</td><td>12</td><td>15</td></tr><tr><td>Father's migrant status<sup>c</sup></td><td>615</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>French with 2 parents French</td><td></td><td>78</td><td>75</td><td>79</td><td>78</td><td>72</td><td>71</td><td>79</td><td>79</td><td>77</td></tr><tr><td>French with 1 parent not French</td><td></td><td>14</td><td>16</td><td>14</td><td>15</td><td>17</td><td>19</td><td>13</td><td>15</td><td>15</td></tr><tr><td>French with 2 parents not French</td><td></td><td>4</td><td>4</td><td>3</td><td>3</td><td>5</td><td>4</td><td>4</td><td>2</td><td>4</td></tr><tr><td>Not native French</td><td></td><td>4</td><td>5</td><td>4</td><td>4</td><td>6</td><td>6</td><td>4</td><td>4</td><td>4</td></tr><tr><td>Parental employment<sup>c</sup></td><td>10</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Two parents unemployed</td><td></td><td>6</td><td>6</td><td>5</td><td>7</td><td>6</td><td>5</td><td>5</td><td>7</td><td>6</td></tr><tr><td>Two parents working</td><td></td><td>63</td><td>60</td><td>64</td><td>60</td><td>60</td><td>65</td><td>63</td><td>57</td><td>62</td></tr><tr><td>One parent unemployed</td><td></td><td>31</td><td>34</td><td>31</td><td>33</td><td>34</td><td>30</td><td>32</td><td>36</td><td>32</td></tr><tr><td>Mother's educational level<sup>c</sup></td><td>97</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Secondary school or less</td><td></td><td>47</td><td>47</td><td>46</td><td>47</td><td>49</td><td>45</td><td>44</td><td>55</td><td>47</td></tr><tr><td>First cycle of higher education</td><td></td><td>19</td><td>19</td><td>19</td><td>20</td><td>18</td><td>19</td><td>20</td><td>18</td><td>19</td></tr><tr><td>≥Second cycle</td><td></td><td>34</td><td>34</td><td>35</td><td>33</td><td>33</td><td>36</td><td>36</td><td>27</td><td>34</td></tr><tr><td>Father's educational level<sup>c</sup></td><td>413</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Secondary school or less</td><td></td><td>52</td><td>53</td><td>50</td><td>53</td><td>54</td><td>51</td><td>50</td><td>58</td><td>52</td></tr><tr><td>First cycle of higher education</td><td></td><td>18</td><td>16</td><td>19</td><td>17</td><td>17</td><td>18</td><td>18</td><td>16</td><td>18</td></tr><tr><td>≥Second cycle</td><td></td><td>30</td><td>31</td><td>31</td><td>30</td><td>29</td><td>31</td><td>32</td><td>26</td><td>30</td></tr><tr><td>Desire of pregnancy</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Mother's hesitation or child unwanted</td><td>23</td><td>6</td><td>6</td><td>5</td><td>6</td><td>7</td><td>6</td><td>6</td><td>6</td><td>6</td></tr><tr><td>Father's hesitation or child unwanted</td><td>64</td><td>10</td><td>10</td><td>9</td><td>11</td><td>11</td><td>10</td><td>10</td><td>10</td><td>10</td></tr><tr><td>At least one parent smoker<sup>a</sup></td><td>693</td><td>44</td><td>48</td><td>44</td><td>45</td><td>47</td><td>39</td><td>44</td><td>53</td><td>45</td></tr><tr><td>Maternal psychological distress<sup>b</sup></td><td>53</td><td>4</td><td>7</td><td>3</td><td>5</td><td>7</td><td>4</td><td>4</td><td>6</td><td>5</td></tr><tr><td>Paternal psychological distress<sup>b</sup></td><td>955</td><td>2</td><td>2</td><td>1</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td></tr><tr><td>Familial characteristics</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Parents living not together<sup>c</sup></td><td>0</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td></tr><tr><td>Number of siblings<sup>c</sup></td><td>0</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td>0</td><td>40</td><td>45</td><td>40</td><td>43</td><td>43</td><td>43</td><td>40</td><td>43</td><td>41</td></tr></tbody></table>
<table><tbody><tr><td></td><td>1</td><td>38</td><td>35</td><td>38</td><td>35</td><td>37</td><td>34</td><td>39</td><td>35</td><td>37</td></tr><tr><td></td><td>2</td><td>16</td><td>15</td><td>17</td><td>15</td><td>14</td><td>16</td><td>16</td><td>15</td><td>16</td></tr><tr><td></td><td>≥3</td><td>6</td><td>5</td><td>5</td><td>7</td><td>6</td><td>7</td><td>5</td><td>7</td><td>6</td></tr><tr><td>Monthly household income by part (euros)<sup>c</sup></td><td>234</td><td></td><td></td><td></td><td></td><td></td><td>37</td><td>38</td><td>46</td><td>40</td></tr><tr><td></td><td>&lt;1286</td><td>39</td><td>41</td><td>38</td><td>40</td><td>42</td><td>28</td><td>29</td><td>28</td><td>29</td></tr><tr><td></td><td>[1286,1667)</td><td>29</td><td>28</td><td>28</td><td>30</td><td>29</td><td>16</td><td>14</td><td>12</td><td>14</td></tr><tr><td></td><td>[1667, 2083)</td><td>15</td><td>13</td><td>15</td><td>14</td><td>12</td><td>19</td><td>19</td><td>14</td><td>17</td></tr><tr><td></td><td>≥2083</td><td>17</td><td>18</td><td>19</td><td>16</td><td>17</td><td></td><td></td><td></td><td></td></tr><tr><td>Grand-parental support<sup>b</sup></td><td>973</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Both parents answer yes</td><td></td><td>63</td><td>67</td><td>64</td><td>65</td><td>65</td><td>65</td><td>64</td><td>65</td><td>64</td></tr><tr><td>One parent answer yes</td><td></td><td>5</td><td>4</td><td>4</td><td>5</td><td>5</td><td>5</td><td>4</td><td>4</td><td>5</td></tr><tr><td>Both parents answer no</td><td></td><td>32</td><td>29</td><td>32</td><td>30</td><td>30</td><td>30</td><td>32</td><td>31</td><td>31</td></tr><tr><td>Parent who sleeps the child at night<sup>b</sup></td><td>365</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Always the mother</td><td></td><td>14</td><td>15</td><td>13</td><td>15</td><td>17</td><td>16</td><td>13</td><td>15</td><td>14</td></tr><tr><td>Often the mother</td><td></td><td>32</td><td>31</td><td>30</td><td>31</td><td>33</td><td>33</td><td>32</td><td>28</td><td>31</td></tr><tr><td>Mother and partner</td><td></td><td>45</td><td>43</td><td>48</td><td>44</td><td>39</td><td>41</td><td>45</td><td>48</td><td>45</td></tr><tr><td>Often the partner</td><td></td><td>7</td><td>10</td><td>7</td><td>8</td><td>9</td><td>8</td><td>8</td><td>7</td><td>8</td></tr><tr><td>Always the partner</td><td></td><td>2</td><td>1</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td><td>2</td></tr><tr><td>Another person</td><td></td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td><td>0</td></tr></tbody></table>

<footnote><sup>a</sup>at age of one year</footnote>

<footnote><sup>b</sup>at age of two years</footnote>

<footnote><sup>c</sup>at two months of child</footnote>
<table><caption>**Table 2** Association between Intimate Partner Psychological Violence (P-IPV) trajectories and the trajectories of sleeping in the French ELFE study from 2011 to 2016: Multivariate logistic regressions with imputed weight data</caption><thead><tr><th rowspan="3">Variables</th><th colspan="2">Sleep onset difficulties<br>OR<br>95%CI</th><th colspan="2">Night awakenings<br>OR<br>95%CI</th><th colspan="3">Night sleep duration<br>OR<br>95%CI</th></tr><tr><th colspan="2">Many vs Few<br>N = 9513</th><th colspan="2">Decreasing vs Few<br>N = 7341</th><th colspan="3">Many vs Few<br>N = 6827</th></tr><tr><th></th><th></th><th></th><th></th><th>Short vs<br>Medium<br>N = 7367</th><th>Long vs<br>Medium<br>N = 7541</th><th>Short vs Long<br>N = 4090</th></tr></thead><tbody><tr><td colspan="8"><strong>Minimal adjusted models*</strong></td></tr><tr><td colspan="8">Trajectories of P-IPV</td></tr><tr><td>A Minimal</td><td>Reference</td><td>Reference</td><td>Reference</td><td>Reference</td><td>Reference</td><td>Reference</td><td>Reference</td></tr><tr><td>B Prenatal</td><td>1.23<br>[1.04-1.45]</td><td>0.95<br>[0.78-1.14]</td><td>1.11<br>[0.91-1.35]</td><td></td><td>0.97<br>[0.80-1.20]</td><td>1.02<br>[0.84-1.23]</td><td>0.96<br>[0.75-1.22]</td></tr><tr><td>C Decreasing</td><td>1.31<br>[1.07-1.59]</td><td>1.11<br>[0.89-1.39]</td><td>1.21<br>[0.96-1.54]</td><td></td><td>1.09<br>[0.87-1.38]</td><td>1.06<br>[0.84-1.34]</td><td>1.03<br>[0.78-1.36]</td></tr><tr><td>D Increasing</td><td>1.53<br>[1.24-1.91]</td><td>1.49<br>[1.15-1.91]</td><td>1.66<br>[1.29-2.13]</td><td></td><td>1.33<br>[1.02-1.73]</td><td>1.25<br>[0.96-1.60]</td><td>1.10<br>[0.80-1.50]</td></tr><tr><td>E Persistent</td><td>1.71<br>[1.31-2.22]</td><td>1.34<br>[0.98-1.84]</td><td>1.95<br>[1.42-2.69]</td><td></td><td>1.33<br>[0.97-1.80]</td><td>0.66<br>[0.44-1.98]</td><td>2.05<br>[1.34-3.14]</td></tr><tr><td colspan="8"><strong>Full adjusted models**</strong></td></tr><tr><td colspan="8">Trajectories of P-IPV</td></tr><tr><td>A Minimal</td><td>Reference</td><td>Reference</td><td>Reference</td><td>Reference</td><td>Reference</td><td>Reference</td><td>Reference</td></tr><tr><td>B Prenatal</td><td>1.17<br>[0.98-1.39]</td><td>0.88<br>[0.67-1.15]</td><td>0.94<br>[0.71-1.22]</td><td>0.93<br>[0.69-1.25]</td><td>1.11<br>[0.84-1.46]</td><td>0.94<br>[0.76-1.16]</td><td>1.12<br>[0.92-1.36]</td><td>0.87<br>[0.67-1.12]</td></tr><tr><td>C Decreasing</td><td>1.22<br>[0.99-1.49]</td><td>1.23<br>[0.89-1.69]</td><td>0.91<br>[0.67-1.23]</td><td>1.22<br>[0.85-1.74]</td><td>0.96<br>[0.69-1.33]</td><td>1.06<br>[0.83-1.35]</td><td>1.15<br>[0.90-1.46]</td><td>0.93<br>[0.69-1.25]</td></tr><tr><td>D Increasing</td><td>1.30<br>[1.03-1.64]</td><td>1.49<br>[1.04-2.12]</td><td>1.20<br>[0.83-1.71]</td><td>1.55<br>[1.04-2.28]</td><td>1.29<br>[0.89-1.86]</td><td>1.22<br>[0.92-1.62]</td><td>1.42<br>[1.09-1.84]</td><td>0.85<br>[0.59-1.22]</td></tr><tr><td>E Persistent</td><td>1.39<br>[1.05-1.85]</td><td>1.76<br>[1.12-2.75]</td><td>0.94<br>[0.59-1.48]</td><td>2.27<br>[1.39-3.71]</td><td>1.18<br>[0.76-1.83]</td><td>1.08<br>[0.77-1.49]</td><td>0.78<br>[0.52-1.17]</td><td>1.39<br>[0.89-2.15]</td></tr></tbody></table>

*Adjusted on household income, mother's age, parental education level, parental unwanted pregnancy, immigrant status.

**Adjusted on household income, mother's age, parental education level, parental immigrant status, number of siblings, child's biological sex, consumption of alcohol during pregnancy, Modified check list Autism for Toddler at two years of the child, prematurity, low birth weight, parental mental health, parental employment, main day-care arrangement at age 1 year, at least one parent smoker or not at age 1 year, sleeping routine at age 2 years, child's presence during arguments at age 2 years.
**Figure 1.** Description of the Intimate Partner Psychological Violence trajectories.
Insults or hurtful comments

**Figure 2.** Description of sleep trajectories.
Fig2.A Sleep onset difficulty; Fig2.B Night awakening; Fig2.C Night sleep duration

**Table 1** Description of children participating in the French ELFE study from 2011 to 2016, and according to the trajectories of sleeping between 2 to 5 yrs (n=9513).

**Table 2** Association between Intimate Partner Psychological Violence (P-IPV) trajectories and the trajectories of sleeping in the French ELFE study from 2011 to 2016: Multivariate logistic regressions with imputed weight data

**Figure S1.:** Directed Acyclic Graph

**Figure S2:** Flowchart

P-IPV intimate Partner Psychological Violence

**Table S1:** Description of children participating in the French ELFE study from 2011 to 2016, and according to the trajectories of P-IPV (n=9513)
<figure><img src="image_2.png" /><figcaption>**Figure 1.** Description of the Intimate Partner Psychological Violence trajectories. Insults or hurtful comments</figcaption></figure>
<figure><img src="image_3.png" /><figcaption>**Figure 2.** Description of sleep trajectories.</figcaption></figure>

Fig2.A Sleep onset difficulty; Fig2.B Night awakening; Fig2.C Night sleep duration
<figure><img src="image_4.png" /></figure>

**Minimal adjusted models:** Household income measured at two months, mother's age measured at two months, parental educational level measured at two months, parental unwanted pregnancy measured at two months, parental immigrant status measured at two months, trajectories of P-IPV (before and during pregnancy, during the first two months of child and during the second year of child)

**Fully adjusted models:** Household income measured at two months, mother's age measured at two months, parental educational level measured at two months, parental immigrant status measured at two months, number of siblings measured at two months, child's biological sex, prematurity, low birth weight, risk of autism measured at two years (M-CHAT), alcohol during pregnancy measured in interview at the maternity ward, parental employment measured at two months, main day-care arrangement measured at one years of child's age, parental tobacco use measured at one years, sleeping routine measured at two years, parental mental health measured at two years, child's presence during arguments measured at two years, trajectories of P-IPV

<caption>Figure S1.: Directed Acyclic Graph</caption>
<figure><img src="image_5.png" /><figcaption>Figure S2: Flowchart</figcaption></figure>

P-IPV intimate Partner Psychological Violence