Sleep, emotional and behavioral difficulties in children and adolescents

Pathways connecting family socioeconomic status in adolescence and sleep continuity in adult Black and White men

OBJECTIVE

To evaluate the roles of parenting and adolescent characteristics during ages 13 to 16 in connecting family socioeconomic status (SES) during adolescence with adult sleep in Black and White men.

DESIGN

Longitudinal school-based community study beginning in 1987-1988 when participants were enrolled in the first or seventh grade.

SETTING

Pittsburgh, PA.

PARTICIPANTS

291 men (54.4% Black, mean age = 33, SD = 2.5) participated in 2012-2014 in a week-long study of sleep measured by actigraphy and diary.

MEASURES

In adolescence (ages 13-16), measures of family SES based on occupation, education, income and public assistance; parenting based on monitoring, positive expectations for future, warm parent-child relationship, and communication; and adolescent characteristics based on anxiety, hyperactivity/impulsivity, and peer rejection.  In adulthood, participant SES, minutes awake after sleep onset (WASO), duration, and diary-assessed sleep quality.

RESULTS

Structural equation modeling confirmed significant indirect pathways: (1) low family SES in adolescence to negative parenting to low adult SES to greater WASO; (2) low family SES in adolescence to adolescent characteristics to low adult SES to greater WASO; (3) Black race to low family SES in adolescence to negative parenting to low adult SES to greater WASO; and (4) Black race to low family SES in adolescence to adolescent characteristics to adult SES to greater WASO. Similar models for duration and quality were not confirmed.

CONCLUSIONS

Parenting and adolescent characteristics may have an indirect association with adult sleep continuity. Parenting and mental health interventions in adolescence may improve adult sleep.

Associations Between Preschool Sleep Problems and Observed Dimensions of Elementary Classroom Engagement

Sleep has clear importance for academic success. However, most research in this area has focused on older children and adolescents and has used narrow measures of academic achievement, overlooking the importance of early sleep problems in shaping children's classroom behaviors that support academic success. Using a community sample (N = 276, 50% female), the current study examined associations between parent-reported preschool sleep problems (M _age = 3.84, SD = 0.83) and three dimensions of classroom engagement coded during live classroom observations in the first grade (M _age = 6.72, SD = 0.34). The moderating role of family socioeconomic status (SES) was also considered. A multivariate multilevel model found that more preschool sleep problems were associated with less focused engagement (defined as involvement in academic tasks, such as writing or asking questions), but more competing responses (defined as inappropriate or distracting behaviors). Preschool sleep problems were not associated with task management (defined as preparation for academic tasks, such as locating classroom materials). Although family SES did not moderate any of these associations, higher income-to-needs ratios in preschool were associated with more focused engagement and fewer competing responses. Findings highlight the role of early sleep problems in classroom behaviors that facilitate academic success. Targeting sleep problems prior to the school transition may serve as a useful approach to optimizing learning conditions during this key developmental period.

Changing school start times: impact on sleep in primary and secondary school students

STUDY OBJECTIVES

To examine the impact of changing school start times on sleep for primary (elementary school: ES) and secondary (middle and high school: MS/HS) students.

METHODS

Students (grades 3-12) and parents (grades K-12) were surveyed annually, before and for 2 years after school start time changes (ES: 60 min earlier, MS: 40-60 min later; HS: 70 min later). Student sleep and daytime sleepiness were measured with school-administered student surveys and parent-proxy online surveys.

RESULTS

Approximately 28,000 students annually completed surveys (~55% White, ~21% free/reduced lunch [FRL]). One-year post-change, weekday bedtimes and wake times were slightly earlier for ES students, with an 11-min decrease in sleep duration. MS and HS students reported slightly later weekday bedtimes, significantly later wake times, and significantly longer sleep duration (MS: 29 min; HS: 45 min). The percent of ES students reporting sufficient sleep duration, poor sleep quality, or daytime sleepiness did not change, but the percent of MS and HS students reporting sufficient sleep duration significantly increased and clinically significant daytime sleepiness decreased. All results were maintained at the 2-year follow-up. Benefits of later start times were similar across racial and free/reduced lunch groups.

CONCLUSIONS

This is the first large scale, longitudinal, and representative study to concurrently examine the impact of changing school start times across students in primary/secondary school. Findings suggest a minimal impact of earlier start times on ES students' sleep or daytime sleepiness, while further supporting the significant benefits of delaying MS and HS start times on student sleep and daytime sleepiness.

Changes in child abuse experience associated to sleep quality: results of the Korean Children & Youth Panel Survey

Background

A victim of child abuse can often develop mental illness. The early detection of mental illness of children could be supported by observing sleep quality. Therefore, we examined the relationship between sleep quality and the changes in child abuse by the child’s own parents over the study period.

Methods

Data from the 2011–2013 Korean Children and Youth Panel Survey was used, and 2012 was set as the baseline. Adolescents who had poor sleep quality in 2011 were excluded from the analysis to obtain the final study population of 1276 adolescents aged 14 and 15 years. The generalized estimating equation model (GEE) was used for statistical analysis.

Results

Children who had experienced and/or were currently experiencing child abuse showed significantly poorer sleep quality (current year abuse only: odds ratio [OR] = 0.57, 95% confidence interval [CI] = 0.41, 0.79; prior year abuse only: OR = 0.72, 95% CI = 0.52, 0.99; continuous abuse: OR = 0.56, 95% CI = 0.39, 0.80) compared to children who had no experience of child abuse.

Conclusion

Child abuse remains a traumatic experience that influences the quality of sleep and hinders the child’s proper psychological development. We suggest approaching this issue at both the community and national levels to protect the victims.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11309-3.

A 25-Year Review of Nighttime Fears in Children: Past, Present, and Future

Nighttime fears in children are common, interfere with daily functioning, and result in considerable disruption in the family. The aim of the present review was to examine empirical literature from the past 25 years that investigated the assessment of nighttime fears in young children and the efficacy and effectiveness of psychosocial treatments for children's nighttime fears. The last review of this literature was in 1997 and examined studies conducted in and prior to 1995 (King et al. in Clin Psychol Rev 17:431-443, 1997). Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review of the literature aimed at providing a synthesis of the Randomized Control Trials (RCTs) and controlled single-case multiple baseline design studies (MBLs) on the treatment of nighttime fears in children. A search of the literature identified 12 articles, with nine studies utilizing a between-group randomized controlled trial design and three studies utilizing a multiple baseline design. Results demonstrated significant improvements in children's nighttime fears and reductions in disruptive nighttime behaviors using behavioral interventions and cognitive-behavioral strategies. This review provides a commentary on the effectiveness and limitations of the assessment and treatment approaches for nighttime fears in children and suggests directions for future research.

Energy Drinks Consumption Associated with Emotional and Behavioural Problems via Lack of Sleep and Skipped Breakfast among Adolescents

The aim of our study was to explore whether energy drink consumption is associated with both emotional and behavioural problems and whether this association might be mediated by amount of sleep and breakfast consumption among adolescents. The nationally representative Health Behaviour in School-aged Children (HBSC) study, realised in 2018 in Slovakia in schools, was used to acquire needed data, with the research sample of 8405 adolescents from 11 to 15 years old (mean age = 13.43; 50.9% boys) who completed the questionnaires on their own in a presence of researchers and research assistants. Emotional and behavioural problems were assessed by a Strengths and Difficulties Questionnaire, while energy drinks consumption, breakfast consumption and sleep duration was assessed by questions in line with the HBSC study protocol. Linear regression models assessed the associations between energy drinks consumption and emotional and behavioural problems. Mediation by sleep duration and breakfast consumption was assessed with parallel mediation models. Energy drink consumption was significantly associated with emotional (p < 0.001) and behavioural problems (p < 0.001), with higher consumption of energy drinks leading to more emotional and behavioural problems. Results from a parallel mediation analysis indicated that energy drink consumption is indirectly related to both emotional and behavioural problems through its relationship with the amount of sleep and breakfast consumption. Parents and professionals working with adolescents should be aware that unhealthy dietary habits and lack of sleep might be related to emotional and behavioural problems.

Non-pharmacological sleep interventions for pediatric cancer patients and survivors: a systematic review protocol

BACKGROUND

Sleep disturbances constitute a common complication in pediatric cancer patients and survivors and are frequently severe enough to warrant treatment. Suboptimal sleep has been associated with decreased emotional well-being and cognitive functioning and increased behavioral problems. Standardized guidelines for non-pharmacological sleep interventions for adults with cancer exist, but no standard of care intervention or standard guidelines are available to guide such intervention in pediatric cancer patients and survivors. Therefore, effective behavioral interventions for improving sleep quality need to be identified. The objective of the review is to evaluate the effect of non-pharmacological sleep interventions on sleep quality in pediatric cancer patients and survivors.

METHODS

The review will consider studies that include children and adolescents between 0 and 18 years diagnosed with cancer or who have a history of cancer who have non-respiratory sleep disturbance. We will include experimental and quasi-experimental studies evaluating non-pharmacological interventions such as psychological interventions, technical/device interventions, interventions targeting physical activity, and complementary and alternative medicine interventions (e.g., yoga, massage, music). Interventions involving medications, ingestible supplements, products purported to work through absorption, and medical devices will be excluded. Primary outcome will be sleep quality as measured by methods including retrospective ratings, daily sleep diary, and validated questionnaires. Secondary outcomes will include total sleep time, sleep onset latency, wake after sleep onset, daytime sleepiness, and daytime sleep duration (naps) as measured by retrospective ratings, daily sleep diary, validated questionnaires, and/or actigraphy. Databases will include MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, CINAHL (Ebsco), and PsycINFO (Ovid) and will be queried from database inception to present. Two reviewers will independently screen all citations, full-text articles, and extract data. The study methodological quality will be assessed using Joanna Briggs Institute (JBI) critical appraisal tools. Data will be extracted and findings pooled and synthesized using a meta-aggregation approach via the JBI System for the Unified Management, Assessment, and Review of Information (SUMARI). If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., methodological quality, study design, outcome measures).

DISCUSSION

This systematic review will synthesize and consolidate evidence on existing non-pharmacological interventions to improve sleep in pediatric cancer patients and survivors. Findings may help inform practitioners working with pediatric cancer patients and survivors experiencing sleep disturbances and is intended to identify gaps and opportunities to improve methodical quality of further non-pharmacological sleep intervention research in this population toward developing an eventual standard of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020200397 .

Sleep and its relation to health-related quality of life in 3-10-year-old children

Background

Considering the reports of increasing sleep problems in children, affecting health and well-being in young children and their families, we found it important to gain more knowledge about sleep and its correlation to health-related quality of life (HRQoL) in young, healthy children. The aims with this study were to describe sleep quality, sleep duration, and HRQoL in healthy 3–10-year-old children and to test associations between children’s sleep and HRQoL.

Methods

Parents of 160 children (average age: 6.9 years, SD ±2.2) participated in the study. Sleep onset problems (SOP), sleep maintenance problems (SMP), and sleep duration were measured by the Pediatric Insomnia Severity Index (PISI). KIDSCREEN-27 was used to measure HRQoL in five dimensions: physical well-being, psychological well-being, autonomy and parent relation, social support and peers, and school environment.

Results

The average score was 2.2 for SOP (SD +/− 2.2) and 1.3 for SMP (SD +/− 1.6). Few children (2%) were reported to sleep less than 8 h per night. Younger children had statistically significant higher SOP and SMP than older children. Correlations were found between SOP and poor psychological well-being (p < 0.05, ρ = − 0.16), and between SMP and poor physical wellbeing (p < 0.05, ρ = − 0.16), psychological well-being (p < 0.05, ρ = − 0.21), poor school environment (p < 0.01, ρ = − 0.29), autonomy and parent relation (p < 0.05, ρ = − 0.16), and poor social support and peers (p < 0.05, ρ = − 0.19).

Conclusion

Children’s sleep associates with health-related quality of life and needs to be acknowledged in child health care settings and schools.

Association between sleep habits/disorders and emotional/behavioral problems among Japanese children

Actual sleep status and the association between sleep habits/disorders and emotional/behavioral problems among children in the development stage have not been fully clarified. A questionnaire survey was conducted on the sleep habits/disorders (Brief Child Sleep Questionnaire; BCSQ) and emotional/behavioral problems (Strengths and Difficulties Questionnaire; SDQ) of 87,548 children enrolled in ordinary classes in nine grade levels from the first grade of elementary school to the third grade of junior high school from December 2009 to April 2010. As school grade increased, children's bedtimes were delayed and sleep duration was reduced by 2.0 h over the nine grade levels. Based on the BCSQ, 18.3% of children were judged to have some type of sleep disorder, and about 30% to 40% of children had sleep symptoms at bedtime, during sleep, and at wake time. Multiple regression analysis showed that emotional and behavioral problems were associated with presence of any sleep symptom, longer sleep latency, and longer awake time after sleep onset, whereas total sleep time was not. Sleep symptoms at wake time were most strongly associated with emotional and behavioral problems. Status of sleep habits/disorders should be considered when interpreting emotional/behavioral problems in school-age children.

The CHD8/CHD7/Kismet family links blood-brain barrier glia and serotonin to ASD-associated sleep defects

Sleep disturbances in autism and neurodevelopmental disorders are common and adversely affect patient's quality of life, yet the underlying mechanisms are understudied. We found that individuals with mutations in CHD8, among the highest-confidence autism risk genes, or CHD7 suffer from disturbed sleep maintenance. These defects are recapitulated in Drosophila mutants affecting kismet, the sole CHD8/CHD7 ortholog. We show that Kismet is required in glia for early developmental and adult sleep architecture. This role localizes to subperineurial glia constituting the blood-brain barrier. We demonstrate that Kismet-related sleep disturbances are caused by high serotonin during development, paralleling a well-established but genetically unsolved autism endophenotype. Despite their developmental origin, Kismet's sleep architecture defects can be reversed in adulthood by a behavioral regime resembling human sleep restriction therapy. Our findings provide fundamental insights into glial regulation of sleep and propose a causal mechanistic link between the CHD8/CHD7/Kismet family, developmental hyperserotonemia, and autism-associated sleep disturbances.

Sleep Problems in Children with ASD and Gene Disrupting Mutations

Sleep difficulties are pervasive in autism spectrum disorder (ASD), yet how sleep problems relate to underlying biological mechanisms such as genetic etiology is unclear, despite recent reports of profound sleep problems in children with ASD-associated de novo likely gene disrupting (dnLGD) mutations, CHD8, DYRK1A, and ADNP. We aimed to inform etiological contributions to ASD and sleep by characterizing sleep problems in individuals with dnLGD mutations. Participants (N = 2886) were families who completed dichotomous questions about sleep problems within a medical history interview for their child with ASD (age 3-28 years). Confirmatory factor analyses compared between those with ASD and a dnLGD mutation and those with idiopathic ASD (i.e., no known genetic event, NON) highlighted four domains (sleep onset, breathing issues, nighttime awakenings, and daytime tiredness) with sleep onset as a strong factor for both groups. Overall, participant predictors indicated that internalizing behavioral problems and lower cognitive scores were related to increased sleep problems. Internalizing problems were also related to increase nighttime awakenings in the dnLGD group. As an exploratory aim, patterns of sleep issues are described for genetic subgroups with unique patterns including more overall sleep issues in ADNP (n = 19), problems falling asleep in CHD8 (n = 22), and increased daytime naps in DYRK1A (n = 23). Implications for considering genetically defined subgroups when approaching sleep problems in children with ASD are discussed.

Environmental exposures and sleep outcomes: A review of evidence, potential mechanisms, and implications

Environmental exposures and poor sleep outcomes are known to have consequential effects on human health. This integrative review first seeks to present and synthesize existing literature investigating the relationship between exposure to various environmental factors and sleep health. We then present potential mechanisms of action as well as implications for policy and future research for each environmental exposure. Broadly, although studies are still emerging, empirical evidence has begun to show a positive association between adverse effects of heavy metal, noise pollution, light pollution, second-hand smoke, and air pollution exposures and various sleep problems. Specifically, these negative sleep outcomes range from subjective sleep manifestations, such as general sleep quality, sleep duration, daytime dysfunction, and daytime sleepiness, as well as objective sleep measures, including difficulties with sleep onset and maintenance, sleep stage or circadian rhythm interference, sleep arousal, REM activity, and sleep disordered breathing. However, the association between light exposure and sleep is less clear. Potential toxicological mechanisms are thought to include the direct effect of various environmental toxicants on the nervous, respiratory, and cardiovascular systems, oxidative stress, and inflammation. Nevertheless, future research is required to tease out the exact pathways of action to explain the associations between each environmental factor and sleep, to inform possible therapies to negate the detrimental effects, and to increase efforts in decreasing exposure to these harmful environmental factors to improve health.

Linking autonomic nervous system reactivity with sleep in adolescence: Sex as a moderator

The purpose of the present study was to investigate relations between autonomic nervous system (ANS) reactivity across the parasympathetic and sympathetic branches and multiple sleep parameters in adolescence. Participants were 244 adolescents (Mage  = 15.79 years old, SD = 9.56 months; 67.2% White/European-American, 32.8% Black/African-American). Parasympathetic activity was indexed by respiratory sinus arrhythmia (RSA) withdrawal and sympathetic activity was indexed by skin conductance level reactivity (SCL-r), which were examined in response to a laboratory-based stressor (star-tracing task). Sleep was assessed with actigraphs in adolescents' homes for seven consecutive nights. Two sleep parameters were examined: sleep duration indexed by actual sleep minutes and sleep quality indexed by sleep efficiency from sleep onset to wake time. Regression analyses showed that more RSA withdrawal (lower RSA during task than baseline) was associated with shorter sleep, and more SCL-r (higher SCL during task than baseline) was associated with poorer sleep efficiency. Moderation analyses showed that associations linking RSA withdrawal with fewer sleep minutes and poorer sleep efficiency, and SCL-r with fewer sleep minutes were significant only for boys. Results illustrate that higher daytime physiological reactivity (increased RSA withdrawal and SCL-r) is negatively associated with sleep duration and efficiency for adolescents, especially boys.

Correlates of Sleep Duration in Early Childhood: A Systematic Review

OBJECTIVE

This systematic review aimed to summarize correlates of sleep duration in children under 5 years of age.

METHODS

Six electronic databases (PubMed, PsycINFO, MEDLINE, CINAHL, SPORTDiscus, and Scopus) were searched from inception to May 2019. Observational studies and intervention studies reporting cross-sectional results from baseline data were considered. Data were extracted using a predesigned form and potential correlates were categorized following a sociological framework.

RESULTS

One-hundred and sixteen studies, representing 329,166 children, met the inclusion criteria, with a high risk of bias in 62 included studies. A total of 83 correlates of sleep duration were identified. Among the associations studied four or more times, correlates of nap duration were child's age and nighttime sleep onset/bedtime; correlates of nighttime sleep duration were household income, parent marital status, parental adiposity level, nighttime sleep duration at younger age, nighttime sleep onset/bedtime, nighttime sleep wakeup time, and frequency of current bedtime routine; correlate of total sleep duration was screen time.

CONCLUSIONS

Young children from low-income households, single families, or having overweight parents may be at risk for short sleep duration. Promoting healthy sleep duration from an early age appears essential. Effective practices may include encouraging an earlier bedtime, limiting screen time, and establishing a regular bedtime routine. The absence of consistent evidence in the psychological, cognitive, and emotional domain as well as the physical environmental domain warrants further research.

Sleep Assessment for Sleep Problems in Children

The breadth of childhood sleep problems is broad and can be associated with biologic, psychiatric, behavioral, social, and environmental processes. Unrecognized childhood sleep problems may threaten daytime behaviors and negatively impact school and psychosocial functioning. Left unattended, overall child biopsychosocial development may be impaired. Thus, identifying and addressing sleep problems has potential to optimize childhood health, development, and overall well-being. Nurses need to be cognizant of detrimental impacts of child sleep deprivation and advocate for appropriate sleep assessments while offering sleep education to parents and children.

Sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life: bidirectional associations from early childhood to early adolescence

STUDY OBJECTIVES

To examine longitudinal, bidirectional associations among behavioral sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life (HRQoL) from early childhood to adolescence in a population sample of Australian children.

METHOD

Data were drawn from the Longitudinal Study of Australian Children, a national prospective cohort study with 4983 children participating in the Kindergarten cohort. Data were collected when children were aged 4-5, 6-7, 8-9, 10-11, and 12-13 years. At each study wave, the primary parent (97% mothers) reported on behavioral child sleep problems, internalizing and externalizing symptoms, and HRQoL domains (psychosocial and physical). Cross-lagged structural equation models were used to evaluate bidirectional associations.

RESULTS

At nearly every age, behavioral sleep problems were associated with worse subsequent psychosocial and physical HRQoL. Despite bidirectional associations between mental health and HRQoL at many waves, HRQoL domains more strongly predicted later internalizing symptoms, while externalizing symptoms more strongly predicted later HRQoL. Many of the bidirectional associations among sleep, mental health, and HRQoL were found earlier in childhood.

CONCLUSIONS

Behavioral sleep problems may forecast later HRQoL psychosocial and physical impairments. Attending to both sleep problems and HRQoL could prevent the progression of internalizing conditions, while a focus on externalizing concerns could prevent the worsening of these symptoms, sleep problems, and HRQoL, particularly during the transition to school.

Longitudinal association of nighttime sleep duration with emotional and behavioral problems in early childhood: results from the Danish Healthy Start Study

STUDY OBJECTIVES

To examine the longitudinal and bidirectional association between nighttime sleep duration and emotional and behavioral problems (EBPs) over 15 months among preschool children.

METHODS

Data of children aged 2 to 6 years from the control group of the Danish Healthy Start Study, a 15-month obesity prevention intervention, were used. Nighttime sleep duration was measured using a 7-day sleep record. EBPs were assessed by the Strengths and Difficulties Questionnaire Total Difficulties (SDQ-TD) score and Prosocial Behavior (SDQ-PSB) score. Multivariable regression models were conducted to examine the bidirectional associations between changes in nighttime sleep duration and SDQ scores.

RESULTS

With adjustment for child, family factors, and parental stress level, every hour extra nighttime sleep at baseline was associated with a 1.02 decrease in SDQ-TD score and 77% lower odds of having an abnormal SDQ-TD score (≥90th percentile) at the follow-up (p = 0.01). Children who increased their nighttime sleep duration over the 15-month demonstrated a similar concurrent reduction in SDQ-TD score (β = -1.28, p = 0.02) compared with those who decreased or had no change in nighttime sleep duration. After additional adjustment for sleep problem and habit variables, the significant associations remained. No associations were found between nighttime sleep duration and SDQ-PSB scores. Examination of SDQ scores as predictors of subsequent changes in nighttime sleep duration showed no significant associations.

CONCLUSIONS

Among preschool children, longer nighttime sleep duration was associated with a decline in EBPs, but not vice versa. Our study provides new longitudinal evidence to support sleep interventions to improve EBPs in early childhood.Clinical trials: The Healthy Start Study: https://clinicaltrials.gov/ct2/show/NCT01583335Trial registration: ID NCT01583335.

Longitudinal associations of sleep problems with alcohol and cannabis use from adolescence to emerging adulthood

STUDY OBJECTIVES

This study examined longitudinal associations of sleep problems with alcohol and cannabis use across six annual waves of data from adolescence to emerging adulthood.

METHODS

Participants were 3,265 youth from California (ages 16 to 22 across waves). At each wave, past-month alcohol use and cannabis use, mental health, and several dimensions of sleep health (i.e., social jetlag, bedtimes, time in bed, trouble sleeping) were assessed via questionnaire. Parallel process latent growth models examined the association between sleep and alcohol or cannabis use trajectories and the role of mental health in contributing to such trajectories.

RESULTS

Smaller declines in social jetlag (r = .11, p = .04), increases in trouble sleeping (r = .18, p < .01), and later weekday (r = .16, p < .01) and weekend bedtimes (r = .25, p < .01) were associated with increases in likelihood of alcohol use over time. Declines in weekend TIB (r = -.13, p = .03), as well as increases in weekday TIB (r = 0.11, p = 0.04) and later weekday (r = .18, p < .01) and weekend bedtime (r = .24, p < .01), were associated with increases in likelihood of cannabis use over time. Most associations remained significant after controlling for time-varying mental health symptoms.

CONCLUSIONS

Trajectories of sleep health were associated with trajectories of alcohol and cannabis use during late adolescence to emerging adulthood. Improving sleep is an important target for intervention efforts to reduce the risk of substance use during this critical developmental transition.

Sleep disturbances in autism spectrum disorder without intellectual impairment: relationship with executive function and psychiatric symptoms

The autism spectrum disorder (ASD) is a neurodevelopmental condition, frequently accompanied by medical and psychiatric pathology. One of the most commonly found problems associated with ASD is sleep disturbances, which are estimated to affect approximately 80% of the people with ASD, not only during childhood but also in the adolescence and adult stages. Nevertheless, the relationship of these sleep difficulties with autism severity, as well as other associated impairments such as executive functioning and psychiatric disorders (eg, depression), has not yet been widely studied. The main objective of the present study was to explore the relationship between sleep disturbances, subjective measures of executive function, and psychiatric pathology in the ASD population. To reach that goal, a group of 89 participants with ASD (44 children/adolescents and 45 adults) was recruited and evaluated with self-reported measures of executive function performance and psychiatric pathology tests. Multivariate analysis showed a significant association between sleep disturbances and psychiatric symptoms in both ASD groups, with greater sleep disturbances predicting more severe psychiatric pathology. No significant association was found with executive function in any group. Limitations included a small sample size and lack of objective measures. Sleep problems seem to be associated with the severity of psychiatric pathology throughout the lifespan, increasing the chance of developing psychiatric symptoms when they were present. Improving sleep quality in ASD at all ages may result in preventing and/or decreasing psychiatric pathology in this population.

Adverse Childhood Experiences Among Children with Neurodevelopmental Delays: Relations to Diagnoses, Behavioral Health, and Clinical Severity

Limited research has examined adverse childhood experiences (ACEs) among children at risk for neurodevelopmental delays. The purpose of this study was to (1) identify the prevalence of ACEs among children at risk for neurodevelopmental delays; (2) explore differences in rates of ACEs across neurodevelopmental diagnoses; and (3) examine relations between ACEs and indicators of behavioral health functioning (e.g., enuresis, feeding problems, sleeping problems, and functional impairment). Participants were 193 children ages 2 to 11 who received a developmental and behavioral pediatrics evaluation at a subspecialty clinic. Caregivers completed a survey about their child's ACEs, and researchers conducted an electronic health record review. Overall, 47% experienced at least one ACE. ACEs were not related to neurodevelopmental diagnosis or to externalizing symptoms. ACEs were related to difficulty sleeping, lower hyperactivity, and greater functional impairment at home. The relations between early adversity and poor behavioral health functioning may develop over time, creating an excellent window of opportunity for prevention work.

Nodding off but can't disconnect: development and validation of the iNOD index of Nighttime Offline Distress

BACKGROUND

There is a pressing need to update sleep models, education and treatment to better reflect the realities of sleep in a 24/7 connected social world. Progress has been limited to date by available measurement tools, which have largely focused on the frequency or duration of individuals' social media use, without capturing crucial sleep-relevant aspects of this inherently social and interactive experience.

METHODS

Survey data from 3008 adolescents (aged 10-18 years) was used to rigorously develop and validate a new self-report measure that quantifies difficulty disengaging from social media interactions at night: the index of Nighttime Offline Distress (iNOD). Exploratory and Confirmatory Factor analyses in a random split sample produced a ten-item two-factor solution, with subscales capturing concerns about Staying Connected and Following Etiquette (Cronbach's alphas = 0.91 and 0.92 respectively).

RESULTS

Those with higher scores on these subscales tended to report using social media for longer after they felt they should be asleep (r_s = 0.41 and 0.26, respectively), shorter sleep duration (r_s = -0.24 and -0.17, respectively) and poorer sleep quality (r_s = -0.33 and -0.31, respectively). Results also pointed towards a potentially fragmented process of sleep displacement for those who may struggle to disconnect - and to stay disconnected - from social interactions in order to allow sufficient uninterrupted sleep opportunity.

CONCLUSIONS

These findings can inform current models for understanding normal and disordered sleep during adolescence, whilst highlighting specific social concerns as important potential targets for sleep education efforts.

Stress, Sleep, and Coping Self-Efficacy in Adolescents

Adults are thought to show a sleep-stress spiral in which greater stress worsens sleep quality, which amplifies stress, which leads to worse sleep. This study examined whether adolescents show a similar spiral, and if so, whether coping self-efficacy-believing one can cope with stress-interrupts the spiral. Temporal dynamics of perceived stress, sleep quality, and coping self-efficacy were tracked in 381 9th graders (49% female, mean age 14.43, age range 14-16) using daily surveys across two school weeks (3184 observations). Though expected associations were evident between individuals, only a unidirectional path was found within individuals from sleep quality to perceived stress via coping self-efficacy. This challenges the conventional bidirectional understanding of sleep-stress relations and suggests coping self-efficacy as an intervention target.

Association Between Disturbed Sleep and Depression in Children and Youths: A Systematic Review and Meta-analysis of Cohort Studies

IMPORTANCE

Disturbed sleep represents a potentially modifiable risk factor for depression in children and youths that can be targeted in prevention programs.

OBJECTIVE

To evaluate the association between disturbed sleep and depression in children and youths using meta-analytic methods.

DATA SOURCES

Embase, MEDLINE, PsycINFO, Scopus, Web of Science, and ProQuest Dissertations & Theses Global were searched for articles published from 1980 to August 2019.

STUDY SELECTION

Prospective cohort studies reporting estimates, adjusted for baseline depression, of the association between disturbed sleep and depression in 5- to 24-year-old participants from community and clinical-based samples with any comorbid diagnosis. Case series and reports, systematic reviews, meta-analyses, and treatment, theoretical, and position studies were excluded. A total of 8700 studies met the selection criteria. This study adhered to the guidelines of the Preferred Reporting Items for Systematic Reviews (PRISMA) and Meta-analyses and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statements.

DATA EXTRACTION AND SYNTHESIS

Study screening and data extraction were conducted by 2 authors at all stages. To pool effect estimates, a fixed-effect model was used if I2 < 50%; otherwise, a random-effects model was used. The I2 statistic was used to assess heterogeneity. The risk of bias was assessed using the Research Triangle Institute Item Bank tool. Metaregression analyses were used to explore the heterogeneity associated with type of ascertainment, type of and assessment tool for disturbed sleep and depression, follow-up duration, disturbed sleep at follow-up, and age at baseline.

MAIN OUTCOME AND MEASURES

Disturbed sleep included sleep disturbances or insomnia. Depression included depressive disorders or dimensional constructs of depression. Covariates included age, sex, and sociodemographic variables.

RESULTS

A total of 22 studies (including 28 895 patients) were included in the study, of which 16 (including 27 073 patients) were included in the meta-analysis. The pooled β coefficient of the association between disturbed sleep and depression was 0.11 (95% CI, 0.06-0.15; P < .001; n = 14 067; I2 = 50.8%), and the pooled odds ratio of depression in those with vs without disturbed sleep was 1.50 (95% CI, 1.13-2.00; P = .005; n = 13 006; I2 = 87.7%). Metaregression and sensitivity analyses showed no evidence that pooled estimates differed across any covariate. Substantial publication bias was found.

CONCLUSIONS AND RELEVANCE

This meta-analysis found a small but statistically significant effect size indicating an association between sleep disruption and depressive symptoms in children and youths. The high prevalence of disturbed sleep implies a large cohort of vulnerable children and youths who could develop depression. Disrupted sleep should be included in multifaceted prevention programs starting in childhood.

Identifying bedrest using waist-worn triaxial accelerometers in preschool children

Purpose

To adapt and validate a previously developed decision tree for youth to identify bedrest for use in preschool children.

Methods

Parents of healthy preschool (3-6-year-old) children (n = 610; 294 males) were asked to help them to wear an accelerometer for 7 to 10 days and 24 hours/day on their waist. Children with ≥3 nights of valid recordings were randomly allocated to the development (n = 200) and validation (n = 200) groups. Wear periods from accelerometer recordings were identified minute-by-minute as bedrest or wake using visual identification by two independent raters. To automate visual identification, chosen decision tree (DT) parameters (block length, threshold, bedrest-start trigger, and bedrest-end trigger) were optimized in the development group using a Nelder-Mead simplex optimization method, which maximized the accuracy of DT-identified bedrest in 1-min epochs against synchronized visually identified bedrest (n = 4,730,734). DT's performance with optimized parameters was compared with the visual identification, commonly used Sadeh’s sleep detection algorithm, DT for youth (10-18-years-old), and parental survey of sleep duration in the validation group.

Results

On average, children wore an accelerometer for 8.3 days and 20.8 hours/day. Comparing the DT-identified bedrest with visual identification in the validation group yielded sensitivity = 0.941, specificity = 0.974, and accuracy = 0.956. The optimal block length was 36 min, the threshold 230 counts/min, the bedrest-start trigger 305 counts/min, and the bedrest-end trigger 1,129 counts/min. In the validation group, DT identified bedrest with greater accuracy than Sadeh’s algorithm (0.956 and 0.902) and DT for youth (0.956 and 0.861) (both P<0.001). Both DT (564±77 min/day) and Sadeh’s algorithm (604±80 min/day) identified significantly less bedrest/sleep than parental survey (650±81 min/day) (both P<0.001).

Conclusions

The DT-based algorithm initially developed for youth was adapted for preschool children to identify time spent in bedrest with high accuracy. The DT is available as a package for the R open-source software environment (“PhysActBedRest”).

A Good Night's Sleep: Learning About Sleep From Autistic Adolescents' Personal Accounts

Background

Sleep is a strong predictor of quality of life and has been related to cognitive and behavioral functioning. However, research has shown that most autistic people experience sleep problems throughout their life. The most common sleep problems include sleep onset delay, frequent night-time wakings and shorter total sleep time. Despite the importance of sleep on many domains, it is still unclear from first-hand accounts what helps autistic people to sleep. The purpose of this study is to explore together with autistic adolescents their sleep-related practices before bedtime and during the day which contribute to a good night’s sleep.

Methods

Fifty-four autistic adolescents collaborated with an academic researcher in a novel adapted photo-elicitation methodology, rooted in a Lifeworld framework. The adolescents were invited to collect and analyze their data. The data were also presented in a community knowledge exchange event.

Results

Several self-reported practices that facilitate better nocturnal sleep were identified. Those were organized into two thematics: Evening/bedtime factors and Day time factors. These included practices such as personalized sensory and relaxation tools before bed and during night-time, engaging in a range of physical activities during daytime and accommodating personal time to engage with highly preferred and intense focus activities and hobbies. It also included spending time in predictable and fun ways with family members before bedtime.

Conclusion

This is the first time that a study uses a novel methodological approach based on personal accounts elicited by photos rooted in a Lifeworld framework to describe personal sleep-related practices before bedtime and during the day to identify a “good night of sleep” in autistic adolescents. The outcomes from the current study showed that sleep facilitating factors are in a direct contrast to the sleep hygiene recommendations. Therefore, it is thus important for the sleep practitioners and healthcare providers to move beyond providing standardized sleep hygiene interventions. A Lifeworld led care model that pays attention to personal experiences, promotes sense of agency, evaluates both autism-specific strengths and struggles could and should complement biomedical approaches.

Lay Summary

This is the first study to examine autistic adolescents’ self-reported sleep habits and factors which facilitate autistic adolescents’ sleep by employing adapted photo-elicitation interviews. This study is innovative in at least three ways. First, it examines the factors that may facilitate a good night’s sleep through personal accounts of autistic adolescents. Second, this is the first sleep study to adopt a collaborative, flexible approach to understanding positive sleep factors in the lives of autistic adolescents. This study employed a personalized approach into collecting, categorizing, coding, and analyzing qualitative data allowing autistic adolescents and the researcher to work together across key stages of data collection and data analysis. Third, we adopted a theoretical framework that allows us to consider autistic adolescents in both agency and vulnerability positions when it comes to their sleep difficulties. Our results highlight that sleep should be treated individually and in relation to the environmental and personal factors that affect each autistic person. Hence, researchers and professionals may benefit from working collaboratively with autistic adolescents with the aim to identify individual strengths and adopt a positive narrative around sleep. Furthermore, it is important to further examine both the daytime and evening factors that may affect bedtime and the quality and quantity of sleep as well as the role of intense focused interests and physical activities that cultivate positive feelings and help autistic people to relax before bedtime.

The Young Adolescent Project: A longitudinal study of the effects of maltreatment on adolescent development

The Young Adolescent Project (YAP) is an ongoing longitudinal study investigating the effects of abuse and neglect on adolescent development. It is a multidisciplinary study guided by a developmental, ecological perspective, and designed to consider the physical, social, and psychological effects of childhood maltreatment through the transition from childhood to adolescence. Four waves of data collection have been completed, ranging from early (Mean age = 10.95) to late adolescence (Mean age = 18.24). Members of the maltreated group (n = 303) were selected from new cases that had been opened by the Department of Child and Family Services, whereas the comparison group (n = 151) were not involved with child welfare but lived in the same neighborhoods as the maltreated group. The study assessed a wide variety of domains including physical development (e.g., height, weight, body mass, pubertal development); physiological reactivity (e.g., cortisol); cognitive abilities; mental health (e.g., symptoms of depression, anxiety, trauma, and aggression); risk behavior (e.g., sexual activity, delinquency, or substance use); social development (e.g., self-esteem, competence, and social support); family environment; and exposure to community violence. Overall, our findings demonstrated the pervasive and persistent adverse effects of child maltreatment both within and across domains, but they also identified maltreated youth with positive functioning. Our hope is that this work will help move us toward identifying targets for intervention to cultivate resilience and positive adaptation after early maltreatment experiences.

Behavioural, emotional and rhythm-related disturbances in toddlers: Preliminary findings from a community-based study in Kerala, India

PURPOSE

The need to enhance mental health in primary care settings for infants and toddlers is increasingly becoming apparent. However, the lack of trained healthcare personnel and culturally appropriate measures makes it a challenge in low- and middle-income countries. A needs-based assessment of the extent of the problems in toddlers will help address the lacunae in providing mental health services.

METHODS

A needs-based assessment was carried out of a community sample of 9,287 mothers with toddlers aged between 13 and 25 months in Kerala, India. This assessment was conducted by junior public health nurses using an indigenously developed checklist titled 'Screening checklist for Behavioural, Emotional and Rhythm-related disturbances in Toddlers' (S-BERT).

RESULTS

According to the mothers surveyed, 30.4% of toddlers had concerning or distress causing behaviours. Three factors, namely behavioural, rhythm-related and emotional disturbances, were deemed significant when the item response theory was used to examine the factor structure of S-BERT.

CONCLUSION

This study suggests that behaviours that cause distress to mothers of toddlers are common, if queried specifically. Given the constraints in health resources as the cultural factors in operation, use of indigenous tools and principles of collaborative stepped care may be the way forward.

Development and Validation of Nomogram Prediction Model for Postoperative Sleep Disturbance in Patients Undergoing Non-Cardiac Surgery: A Prospective Cohort Study

PURPOSE

To develop a risk prediction nomogram of postoperative sleep disturbance (PSD) in patients undergoing non-cardiac surgery.

PATIENTS AND METHODS

Data on 881 consecutive patients who underwent non-cardiac surgery at the Affiliated Hospital of Xuzhou Medical University between June 2020 and April 2021 were prospectively collected. Of these, we randomly divided 881 non-cardiac patients into two groups, training cohort (n = 617) and validation cohort (n = 264) at the ratio of 7:3. Characteristic variables were selected based on the data of training cohort through least absolute shrinkage and selection operator (LASSO) regression. Multivariate logistic regression was used to identify the independent risk factors associated with PSD that then were incorporated into the nomogram. The predictive performance of the nomogram was measured by concordance index (C index), receiver operating characteristic (ROC) curve, and calibration with 1000 bootstrap samples to decrease the over-fit bias.

RESULTS

PSD was found in 443 of 617 patients (71.8%) and 190 of 264 patients (72.0%) in the training and validation cohorts, respectively. The perioperative risk factors associated with PSD were female sex, anxiety, dissatisfaction of ward environment, absence of combined regional nerve block, postoperative nausea and vomiting (PONV), the longer duration stayed in post anesthesia care unit (PACU), the higher dose of midazolam and sufentanil, the higher postoperative numeric rating score for pain (NRS) score. Incorporating these 9 factors, the nomogram achieved good concordance indexes of 0.82 (95% confidence interval [CI], 0.78-0.85) and 0.80 (95% CI, 0.74-0.85) in predicting PSD in the training and validation cohorts, respectively, and obtained well-fitted calibration curves. The sensitivity and specificity (95% CIs) of the nomogram were calculated, resulting in sensitivity of 74.0% (70.0-78.2%) and 75.3% (68.4-81.7%) and specificity of 79.3% (72.5-85.2%) and 70.3% (58.4-80.7%) for the training and validation cohorts, respectively. Patients who had a nomogram score of less than 262 or 262 or greater were considered to have low or high risks of PSD presence, respectively.

CONCLUSION

The proposed nomogram achieved an optimal prediction of PSD in patients undergoing non-cardiac surgery. The risks for an individual patient to harbor PSD can be determined by this model, which can lead to a reasonable preventive and treatment measures.

Associations of sleep with psychological problems and well-being in adolescence: causality or common genetic predispositions?

BACKGROUND

Whereas short and problematic sleep are associated with psychological problems in adolescence, causality remains to be elucidated. This study therefore utilized the discordant monozygotic cotwin design and cross-lagged models to investigate how short and problematic sleep affect psychological functioning.

METHODS

Adolescent twins (N = 12,803, 13-20 years, 42% male) completed questionnaires on sleep and psychological functioning repeatedly over a two-year interval. Monozygotic twin pairs were classified as concordant or discordant for sleep duration and trouble sleeping. Resulting subgroups were compared regarding internalizing problems, externalizing problems, and subjective well-being.

RESULTS

Cross-sectional analyses indicated associations of worse psychological functioning with both short sleep and problematic sleep, and cross-lagged models indicate bidirectional associations. Longitudinal analyses showed that an increase in sleep problems experienced selectively by one individual of an identical twin pair was accompanied by an increase of 52% in internalizing problem scores and 25% in externalizing problem scores. These changes were significantly different from the within-subject changes in cotwins with unchanged sleep quality (respectively, 3% increase and 5% decrease). Psychological functioning did, however, not worsen with decreasing sleep duration.

CONCLUSIONS

The findings suggest that sleep quality, rather than sleep duration, should be the primary target for prevention and intervention, with possible effect on psychological functioning in adolescents.

Sleep and Mood Disorders Among Youth

This article reviews the literature on mood disorders and sleep disorders among children and adolescents. Research suggests that sleep plays an important role in the development, progression, and maintenance of mood disorder symptoms among children and adolescents. Sleep problems as early as maternal perinatal insomnia may predict and predate depression among youth. Children and adolescents who develop comorbid mood disorders and sleep problems represent a particularly high-risk group with more severe mood episode symptoms, higher rates of self-harm and suicidality, and less responsivity to treatment. Treatment research supports the idea that sleep problems can be improved through behavioral interventions.

Mental Health of Parents and Preschool-Aged Children During the COVID-19 Pandemic: The Mediating Role of Harsh Parenting and Child Sleep Disturbances

In the context of the coronavirus disease-2019 (COVID-19) pandemic, mental health problems of parents and children have become a public issue. Herein, we explored the association between parental well-being index and child mental health problems during the pandemic and the mediating role of harsh parenting and child sleep disturbances. An online survey was conducted among 16,398 parents of children aged 3-6 years (48.1% girls, M_age = 4.69 years, SD_age = 0.75 years) from March 15 to 29, 2020. Child mental health (Strengths and Difficulties Questionnaire, SDQ), sleep problems (Children's Sleep Habits Questionnaire, CSHQ), and parental well-being index (World Health Organization-Five Well-Being Index, WHO-5), and harsh parenting were reported by parents. The results revealed that a higher parental well-being index was associated with lower child mental health problems. Harsh parenting and child sleep problems were significant mediators within the association. This study indicates the association between parental well-being index and child mental health during the pandemic and underlying mechanism, and has important implications for reducing parental and child mental health problems.

Sounding the Alarm on Sleep: A Negative Association Between Inadequate Sleep and Flourishing

OBJECTIVE

To assess the national prevalence of inadequate sleep among school-age children and its relationship with childhood flourishing.

STUDY DESIGN

This cross-sectional study analyzed 49 050 parental responses from the 2016-2017 National Survey of Children's Health for school-age children. Inadequate sleep duration was defined as <9 hours for 6- to 12-year-olds and <8 hours for 13- to 17-year-olds on an average weeknight. Five markers of flourishing were examined individually and as a combined measure. Logistic regression was used with complex survey design and applied weights.

RESULTS

Inadequate sleep was found in 36.4% of 6- to 12-year-olds and in 31.9% of 13- to 17-year-olds. Compared with children with adequate sleep, 6- to 12-year-olds with inadequate sleep had increased odds of not showing interest and curiosity in learning (aOR, 1.61; 95% CI, 1.34-1.94), not caring about doing well in school (aOR, 1.45; 95% CI, 1.23-1.71), not doing homework (aOR, 1.44; 95% CI, 1.24-1.68), and not finishing tasks (aOR, 1.18; 95% CI, 1.03-1.35). Children aged 13-17 years with inadequate sleep had increased odds of not doing homework (aOR, 1.36; 95% CI, 1.17-1.58), not staying calm and in control when challenged (aOR, 1.34; 95% CI, 1.16-1.54), not showing interest and curiosity in learning (aOR, 1.34; 95% CI, 1.14-1.58), not finishing tasks (aOR, 1.20; 95% CI, 1.03-1.40), and not demonstrating the combined flourishing measure (aOR, 1.35; 95% CI, 1.17-1.56).

CONCLUSIONS

Nationally representative data show that one-third of school-age children have inadequate sleep. Inadequate sleep is associated with decreased flourishing. These data will help inform sleep policies and optimize child development.

Deficits in Emotion Regulation Partly Mediate the Relation Between Sleep Problems and Depressive Symptoms in Adolescent Inpatients With Depression

Sleep problems are a risk factor for the development of depressive disorders and influence the severity and treatment of depressive symptoms negatively. To enhance treatment for depression in young people, it is important to advance the understanding of the relationship between sleep problems and depressive symptoms. Since deficits in emotion regulation are discussed as possible underlying mechanisms, the present study investigated the mediating effect of maladaptive and adaptive strategies for emotion regulation on the association between sleep problems and depressive symptoms. Emotion regulation strategies, depression and sleep quality were assessed via self-report in a large clinical sample of 602 adolescents (age 13-18 years) who reported clinically relevant symptoms of depression. The questionnaires were assessed at admission for inpatient psychiatric treatment. Correlation and mediation analyses were performed. There was a significant partial mediation effect (β = 0.554, p < 0.001, R ² = 0.527), indicating that sleep problems influenced depressive symptoms via the decreased use of adaptive strategies and the increased use of maladaptive strategies. Additionally, a direct effect of sleep problems on depressive symptoms emerged (β = 0.251, p < 0.001, R ² = 0.364). This cross-sectional study provides first indications that additional treatment modules focusing on sleep and ER skills in prevention and treatment programs for adolescents would be important steps. Longitudinal studies are needed to substantiate these results.

Interplay between social media use, sleep quality, and mental health in youth: A systematic review

Social media applications are increasingly prominent among youth. This systematic review provides a comprehensive assessment of the literature on the relationship between active social media use, sleep quality, and common mental health outcomes (anxiety, depression, and psychological distress) among youth. MEDLINE, PsychINFO, EMBASE and Scopus were searched for observational studies investigating this relationship among youth (aged 16-25). Thirty-six cross-sectional studies and six prospective cohort studies met the inclusion criteria. Among cross-sectional studies, significant associations between excessive social media use with poor mental health outcomes (n = 33), poor sleep quality (n = 24), and significant associations between poor sleep quality and negative mental health (n = 16) were found. In longitudinal studies, frequent social media use was a risk factor for both poor mental health (n = 6) and poor sleep outcomes (n = 5). Some studies showed sleep quality mediating the relationship between social media use and negative mental health outcomes in youth. Overall, included evidence links excessive social media use to poor sleep quality and negative mental health in youth. Given the public health implications of sleep problems, excessive social media use warrants further investigation to clarify the directionality and strength of their associations with poor sleep quality and negative mental health outcomes.

The Teensleep study: the effectiveness of a school-based sleep education programme at improving early adolescent sleep

Objective

To evaluate the impact of a school-based sleep education programme on adolescent sleep and sleep knowledge.

Methods

This is the first outcome report on ‘Teensleep’: a novel, teacher-led programme, comprising ten lessons that can be delivered flexibly. Students in Year 10 (n = 1504; mean age = 14.14 ± 0.35 years) from ten UK state (non-fee-paying) secondary schools received the lessons and parents received a leaflet. Effectiveness was assessed using measures across two time points (pre- and post-intervention). Students completed questionnaires on sleep knowledge, sleep quality, sleep behaviour, sleep hygiene, daytime sleepiness and health-related quality of life. A sub-sample provided objective (actigraphy, n = 84) and subjective (sleep diary, n = 74) sleep measures.

Results

Large improvements in sleep knowledge (d = 0.78), and smaller improvements in sleep quality (d = 0.15) and sleep hygiene (d = 0.11) were observed, but not in daytime sleepiness or health-related quality of life. Small and limited changes in subjective and objective sleep patterns were found. Baseline sleep quality was differentially associated with key outcomes, with those initially self-reporting poor sleep demonstrating an improvement in sleep quality, sleep hygiene and sleepiness.

Conclusion

Teensleep was effective at improving sleep knowledge but sleep changes were small. Such interventions have traditionally focused on gains for all students, but this study suggests that poor sleepers may be the most likely to experience immediate direct sleep benefits. Follow-up studies are required to investigate whether or not sleep education provides long-term benefits as a step towards preventative sleep medicine.

•

‘Teensleep’ is a teacher-led, school-based sleep education programme for adolescents.

•

Large-scale study: students received lessons in ten UK schools.

•

Programme effectiveness was evaluated using questionnaires and actigraphy.

•

Sleep knowledge, self-reported sleep quality and sleep hygiene improved after lessons.

•

Study suggests poor sleepers may be most likely to experience immediate benefits.

Association of Parent-Reported Sleep Problems in Early Childhood With Psychotic and Borderline Personality Disorder Symptoms in Adolescence

IMPORTANCE

Persistent nightmares in childhood have been prospectively associated with psychosis and borderline personality disorder (BPD) in adolescence. However, the extent to which this association is also true for behavioral sleep problems is still unknown, and the potential mechanisms are unexplored.

OBJECTIVE

To examine the prospective associations between several parent-reported sleep problems in early childhood and psychotic and BPD symptoms at 11 to 13 years of age and the potential mediation of the associations by depression at 10 years of age.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study assessed 13 488 participants in the Avon Longitudinal Study of Parents and Children birth cohort who were followed up for more than 13 years. Pregnant women from Avon, United Kingdom, with expected dates of delivery from April 1, 1991, to December 31, 1992, were invited to take part in the study. Data analysis was conducted from May 1 to December 31, 2019.

MAIN OUTCOMES AND MEASURES

Psychotic experiences at 12 to 13 years of age were assessed using the Psychosis-Like Symptom Interview, and BPD symptoms at 11 to 12 years of age were tested using the UK Childhood Interview for DSM-IV Borderline Personality Disorder. Parent-reported nighttime sleep duration, night awakening frequency, bedtime, and regularity of sleep routines were assessed when the child was 6, 18, and 30 months and 3.5, 4.8, and 5.8 years of age.

RESULTS

Data were available on 7155 participants (3718 girls [52%]) who reported on BPD symptoms and 6333 (3280 boys [52%]) who reported on BPD symptoms. Higher night awakening frequency at 18 months of age (odds ratio [OR], 1.13; 95% CI, 1.01-1.26) and less regular sleep routines at 6 months (OR, 0.68; 95% CI, 0.50-0.93), 30 months (OR, 0.64; 95% CI, 0.44-0.95), and 5.8 years (OR, 0.32; 95% CI, 0.19-0.53) of age were significantly associated with psychotic experiences in adolescence, whereas shorter nighttime sleep duration (OR, 0.78; 95% CI, 0.66-0.92) and later bedtime at 3.5 years of age (OR, 1.32; 95% CI, 1.09-1.60) were significantly associated with BPD symptoms. Results of mediation analysis were consistent with all these associations, except for later bedtime at 3.5 years and BPD in adolescence, which had no association. Depression at 10 years of age mediated the associations between frequent night awakenings at 18 months of age (bias-corrected estimate, -0.005; 95% CI, -0.008 to -0.002; P = .002) and irregular sleep routines at 5.8 years of age (bias-corrected estimate, -0.006; 95% CI, -0.010 to -0.003; P = .003) with psychosis.

CONCLUSIONS AND RELEVANCE

The findings suggest that some behavioral sleep problems in childhood are distinctively associated with the onset of psychosis and BPD in adolescence, following different pathways. Furthermore, depression at 10 years of age may mediate only the association with psychosis. These findings contribute to the design of more personalized interventions in psychosis and BPD.

ASSOCIATION BETWEEN TROUBLE SLEEPING AND ORAL CONDITIONS AMONG SCHOOLCHILDREN

Objective:

To investigate the prevalence of self-reported trouble sleeping due to dental problems and its association with oral conditions in schoolchildren.

Methods:

This is a cross-sectional study carried out with a representative sample of 1,589 schoolchildren aged 8-10 years enrolled in public schools from Florianópolis, Santa Catarina, Brazil. Non-clinical data included a questionnaire about socioeconomic indicators answered by parents/guardians. Children were questioned about whether they had trouble sleeping due to dental problems and about previous history of toothache. Clinical oral examinations were performed to evaluate dental caries - Decayed, Missing, and Filled Teeth Index (DMFT/dmft index) and its clinical consequences [PUFA/pufa index: considering the presence of pulpal involvement (P/p); ulceration of tissues due to tooth fragments from decayed crowns (U/u); fistula (F/f); and abscesses (A/a), and traumatic dental injuries (TDI)]. We conducted a descriptive analysis and used adjusted logistic regression models (p<0.05; 95%CI).

Results:

The prevalence of trouble sleeping due to dental problems was 28%. Children with untreated dental caries (OR 1.32; 95%CI 1.05-1.67) and clinical consequences from the PUFA/pufa index (OR 1.89; 95%CI 1.45-2.46) had higher chances of reporting trouble sleeping due to dental problems.

Conclusions:

Approximately one-third of the children declared having trouble sleeping due to dental problems. Untreated dental caries and its clinical consequences were associated with self-reported trouble sleeping due to dental problems in schoolchildren.

Genome-wide DNA methylation patterns associated with sleep and mental health in children: a population-based study

BACKGROUND

DNA methylation (DNAm) has been implicated in the biology of sleep. Yet, how DNAm patterns across the genome relate to different sleep outcomes, and whether these associations overlap with mental health is currently unknown. Here, we investigated associations of DNAm with sleep and mental health in a pediatric population.

METHODS

This cross-sectional study included 465 10-year-old children (51.3% female) from the Generation R Study. Genome-wide DNAm levels were measured using the Illumina 450K array (peripheral blood). Sleep problems were assessed from self-report and mental health outcomes from maternal questionnaires. Wrist actigraphy was used in 188 11-year-old children to calculate sleep duration and midpoint sleep. Weighted gene co-expression network analysis was used to identify highly comethylated DNAm 'modules', which were tested for associations with sleep and mental health outcomes.

RESULTS

We identified 64 DNAm modules, one of which associated with sleep duration after covariate and multiple testing adjustment. This module included CpG sites spanning 9 genes on chromosome 17, including MAPT - a key regulator of Tau proteins in the brain involved in neuronal function - as well as genes previously implicated in sleep duration. Follow-up analyses suggested that DNAm variation in this region is under considerable genetic control and shows strong blood-brain concordance. DNAm modules associated with sleep did not overlap with those associated with mental health.

CONCLUSIONS

We identified one DNAm region associated with sleep duration, including genes previously reported by recent GWAS studies. Further research is warranted to examine the functional role of this region and its longitudinal association with sleep.

Sleep across early childhood: implications for internalizing and externalizing problems, socioemotional skills, and cognitive and academic abilities in preschool

BACKGROUND

Sleep is thought to be important for behavioral and cognitive development. However, much of the prior research on sleep's role in behavioral/cognitive development has relied upon self-report measures and cross-sectional designs.

METHODS

The current study examined how early childhood sleep, measured actigraphically, was developmentally associated with child functioning at 54 months. Emphasis was on functioning at preschool, a crucial setting for the emergence of psychopathology. Participants included 119 children assessed longitudinally at 30, 36, 42, and 54 months. We examined correlations between child sleep and adjustment across three domains: behavioral adjustment (i.e., internalizing and externalizing problems), socioemotional skills, and academic/cognitive abilities. We further probed consistent associations with growth curve modeling.

RESULTS

Internalizing problems were associated with sleep variability, and cognitive and academic abilities were associated with sleep timing. Growth curve analysis suggested that children with more variable sleep at 30 months had higher teacher-reported internalizing problems in preschool and that children with later sleep timing at 30 months had poorer cognitive and academic skills at 54 months. However, changes in sleep from 30 to 54 months were not associated with any of the domains of adjustment.

CONCLUSIONS

Findings indicate that objectively measured sleep variability and late sleep timing in toddlerhood are associated with higher levels of internalizing problems and poorer academic/cognitive abilities in preschool.

Mental Health in the Young Athlete

PURPOSE OF REVIEW

The goal of the present paper is to provide a comprehensive overview of mental health concerns in young athletes, with a focus on common disorders, as well as population-specific risk factors.

RECENT FINDINGS

Athletes experience similar mental health concerns as non-athlete peers, such as anxiety, depression and suicidal ideation, ADHD, eating disorders, and substance abuse. However, they also experience unique stressors that put them at risk for the development or exacerbation of mental health disorders. Student athletes have to balance academics with rigorous training regimens while focusing on optimal performance and managing high expectations. Physical injuries, overtraining, concussion, sleep disorders, and social identity are some of the factors that also impact the mental health of student athletes. Existing literature highlights the need to develop proactive mental health and wellness education for young athletes, and to develop services that recognize the unique needs of this population.

Linear and Nonlinear Associations between Sleep and Adjustment in Adolescence

BACKGROUND & OBJECTIVES

A growing body of work supports linear associations between sleep and socioemotional adjustment in adolescence. However, associations between sleep and adjustment are not necessarily linear and investigations of nonlinear effects are scarce. This study examined linear and nonlinear relations between several sleep-wake parameters and externalizing behavior and internalizing symptoms in adolescence, and assessed the role of adolescent sex as a moderator of effects.

PARTICIPANTS

Participants were high school students (N = 180; M age = 17.49, SD = .62; 59% female; 68% White/European American, 32% Black/African American) from a wide range of socio-economic backgrounds living in semirural communities and small towns in Alabama.

METHODS

Sleep-wake parameters were indexed by actigraphy-derived sleep minutes and adolescents' reports on morningness-eveningness (circadian preference), sleep-wake problems (sleep quality), and sleepiness. Adolescents completed questionnaires on externalizing behaviors and internalizing symptoms.

RESULTS

Controlling for sleep duration, a higher preference for eveningness and poor sleep quality were associated in a linear fashion with increased externalizing and internalizing symptoms. Nonlinear relations between sleepiness and internalizing symptoms emerged with pronounced sex-related effects, including somewhat delayed accelerating relations for males and rapidly accelerating associations that tended to plateau for females.

CONCLUSIONS

Results illustrate the importance of examining multiple sleep-wake and adjustment variables as well as linear and nonlinear associations.

Better sleep, better life? How sleep quality influences children's life satisfaction

PURPOSE

To assess the association between children's sleep quality and life satisfaction; and to evaluate the underlying mechanisms of this relationship.

METHODS

Three pediatric cohorts in the National Institutes of Health (NIH) Environmental influences on Child Health (ECHO) Research Program administered Patient-Reported Outcome Measurement Information System (PROMIS®) parent-proxy measures to caregivers (n = 1111) who reported on their 5- to 9-year-old children's (n = 1251) sleep quality, psychological stress, general health, and life satisfaction; extant sociodemographic data were harmonized across cohorts. Bootstrapped path modeling of individual patient data meta-analysis was used to determine whether and to what extent stress and general health mediate the relationship between children's sleep quality and life satisfaction.

RESULTS

Nonparametric bootstrapped path analyses with 1000 replications suggested children's sleep quality was associated with lower levels of stress and better general health, which, in turn, predicted higher levels of life satisfaction. Family environmental factors (i.e., income and maternal mental health) moderated these relationships.

CONCLUSION

Children who sleep well have happier lives than those with more disturbed sleep. Given the modifiable nature of children's sleep quality, this study offers evidence to inform future interventional studies on specific mechanisms to improve children's well-being.

Do insomnia and/or sleep disturbances predict the onset, relapse or worsening of depression in community and clinical samples of children and youth? Protocol for a systematic review and meta-analysis

INTRODUCTION

Disturbed sleep represents a potentially important modifiable risk factor for the development of depression in children and youth. This protocol for a systematic review proposes to investigate whether insomnia and/or sleep disturbances predict child and youth depression in community and clinical-based samples.

METHODS AND ANALYSIS

The protocol adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. English-written, longitudinal studies that quantitatively estimated the prediction of depression by insomnia and/or sleep disturbances in individuals 5-24 years of age will be included. EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science and grey literature will be searched from 1980 to the present. For the selection of studies, two reviewers will be involved. Data extraction will be conducted by one author and checked independently by a second author. Risk of bias will be appraised using the Research Triangle Institute Item Bank tool. Heterogeneity will be measured using the I2 statistics. Meta-analysis will be carried out if ≥3 results are available and if outcome measures can be pooled. The choice between a random-effect or fixed-effect model will be based both on the I2 statistics and the participant and study characteristics of the combined studies. Results of the meta-analyses will be summarised by a forest plot. Analyses will be performed in subgroups stratified by key variables defined depending on the amount and type of information retrieved.A narrative synthesis will be conducted in place of the meta-analysis should the pooling of data not be possible. Quality of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation guidelines.As this is a protocol for systematic review and meta-analysis of published data, ethics review and approval are not required. The findings will be published in a peer-reviewed journal and disseminated at scientific conferences and in patient advocacy organisations.

PROSPERO REGISTRATION NUMBER

CRD42019136729.

The association between obesity and hyperactivity/anxiety among elementary school students in Japan

BACKGROUND

We aimed to evaluate the association between hyperactivity/anxiety and obesity among elementary school students in Matsuyama City, Japan.

METHODS

We conducted a cross-sectional study of all 46 elementary school students (24, 296 students) in Matsuyama City. The questionnaire included question items from the Strengths and Difficulties Questionnaire (SDQ), as well as questions about height and weight. The students were classified into two groups according to Rohrer index. After separating the data by gender, we examined the association between (1) obesity and hyperactivity, (2) obesity and anxiety, and (3) obesity and combination of hyperactivity and anxiety, by estimating relative risk using Poisson regression model. We also conducted stratified analyses to examine the effect modification by age groups and unbalance of diet on those associations. Moreover, we calculated relative excess risk due to the interaction (RERI) to examine whether there was an additive interaction between hyperactivity and anxiety.

RESULTS

Sixteen thousand forty-eight students were included in the present analysis. The prevalence ratio (PR) of being obese in girls who had both hyperactivity and anxiety was higher compared to girls without those symptoms (PR = 1.80; 95% CI 1.04-3.13). There was no significant difference in the prevalence ratio for obesity in boys, whether they were hyperactive, anxious, or neither. RERI was 0.00 for boys and 0.18 for girls.

CONCLUSION

We found a significant association between obesity and co-existence of hyperactivity and anxiety among elementary school girls. Our findings strengthen the need to further explore the association between childhood obesity, hyperactivity, and anxiety.

Sleep problems and depressive symptoms in toddlers and 8-year-old children: A longitudinal study

Sleep and depression are interlinked throughout the lifespan, but very few studies have examined the directionality of the sleep-depression link in children. The aim of the current study was to prospectively examine the bidirectional association between sleep problems and internalizing problems and depressive symptoms in toddlers and children aged 1.5 and 8 years. Data stem from the large ongoing population-based longitudinal study, the Norwegian Mother, Father and Child Cohort Study, recruited from October 1999 to July 2009. A total of 35,075 children were included. Information on sleep duration, nocturnal awakenings and internalizing problems (Child Behaviour Checklist) was provided by the mothers at 1.5 years, whereas data on sleep duration and depressive symptoms (Short Mood and Feelings Questionnaire) were provided by the mothers when the children were 8 years old. Odds ratios (ORs) were calculated using logistic regression analyses. After accounting for previous internalizing problems, short sleep duration (≤10 hr) and frequent (≥3) nightly awakenings at 1.5 years predicted the development of depressive symptoms at 8 years of age (adjusted OR = 1.28; 95% confidence interval [CI] 1.08-1.51, and adjusted OR = 1.27, 95% CI 1.08-1.50, respectively). Also, internalizing problems at 1.5 years predicted onset of later short sleep duration (adjusted OR = 1.83, 95% CI 1.32-2.54) after accounting for early sleep problems. This prospective study demonstrated a bidirectional association between sleep and internalizing/depressive symptoms from toddlerhood to middle childhood. Intervention studies are needed to examine whether targeting either of these problems at this early age may prevent onset of the other.

Auditory processing, co-morbidities, and parental report of sleep disturbance in children with auditory processing disorder (APD)

OBJECTIVES

To evaluate the prevalence of sleep disturbance and its relationship with auditory processing (AP) and co-morbidities in children diagnosed with auditory processing disorder (APD).

METHODS

Data from 109 children (Males = 59, Females = 50) with mean non-verbal intelligence quotient (NVIQ) of 89.44 (SD:18.16), aged between 6 and 16 years (mean: 10 years 7 months; SD: 2 years 9 months) with a diagnosis of APD were analysed. Participants performed ≤1.33 SD below the mean in two or more out of five SCAN-3 diagnostic APD tests that included 'Filtered Words' (FW), 'Auditory Figure Ground 0 dB' (AFG0), 'Competing Words-Directed Ear' (CW-DE), 'Competing Sentences' (CS) and 'Time Compressed Sentences' (TCS). Concern about sleep in addition to other symptoms and medical history were documented from structured parental history sheet which forms part of the routine APD assessment. Language impairment (LI), attention-deficit-hyperactivity-disorder (ADHD) and oppositional defiant disorder (ODD), and anxiety were evaluated using the 'Children's Communication Checklist-2' (CCC-2), 'Swanson Nolan and Pelham rating scale' (SNAP-IV) and 'Anxiety Scale for Children-Autism Spectrum Disorder' (ASC-ASD) respectively.

RESULTS

Sixty children had sleep disturbance, a prevalence of 55% (95% CI 45.2%-64.6%). The two groups of APD children, with (n = 49) and without sleep (n = 60) disturbance, did not vary in their auditory processing abilities. The sleep disturbed group had significant issues with pragmatic language impairment, hyperactivity/impulsivity, oppositional defiant symptoms and anxiety compared to the group without sleep disturbance when they were analysed separately. After the variables were considered in step wise fashion in binary logistic regression analyses, only pragmatic language impairment and anxiety predicted sleep disturbance (p < .01).

CONCLUSION

In APD the prevalence of sleep disturbance is high, justifying screening within a transdisciplinary APD assessment protocol. Sleep disturbance in APD is predicted by pragmatic language impairment and anxiety, but not by ADHD symptoms or ODD.

Sleep Disturbances in Survivors of Pediatric Acute Lymphoblastic Leukemia and Their Siblings

OBJECTIVE

Sleep disturbances have been identified by patients with cancer as common and distressing; however, conflicting evidence about the prevalence of these outcomes exists for survivors of childhood cancers. Additionally, little is known about how the experience of cancer might impact survivor siblings' sleep. The current study compared the sleep of survivors of acute lymphoblastic leukemia who were 2-7 years off therapy and their siblings to healthy control/sibling dyads.

METHODS

Participants (survivors, n = 45; survivor siblings, n = 27; controls, n = 45; control siblings, n = 41; 58% male) aged 8-18 (m = 11.64) completed a 7-day sleep diary and seven consecutive days of actigraphy. Parents (n = 90) completed the Children's Sleep Habits Questionnaire for each of their children.

RESULTS

No between-group differences were found on measures of sleep diaries or actigraphy. Parents reported that survivor siblings had significantly poorer sleep habits than survivors or controls. For survivors, greater time off treatment and younger age at diagnosis were associated with less total sleep time, more wake after sleep onset, and decreased sleep efficiency via actigraphy.

CONCLUSION

Sleep across all groups was consistent and below national guidelines. Although the survivor group did not have poorer sleep compared to their siblings or matched controls, within the survivor group, those who were diagnosed at an earlier age and those who were further off treatment had more disrupted sleep. Parent reports suggested that survivor siblings may be at risk for sleep problems.