Trauma-related sleep disturbance in youth

Characterization of sleep difficulties in maltreated children and adolescents

Numerous studies have identified connections between child maltreatment and sleep-related issues. However, poor is known on potential links between sleep patterns and day-to-day functioning, along with psychopathology in maltreated youths. Additionally, existing research on the relationship between sleep difficulties and maltreatment often lacks investigation into specific sleep difficulty profiles across different age ranges. The current study aimed to determine the prevalence of diverse sleep disturbance profiles in a sample of maltreated children and adolescents, exploring distinct sleep disorder profiles based on sex, age, and the type of maltreatment experienced. Potential variations in adaptive and psychopathological profiles between maltreated children with and without sleep disturbances were also explored. This retrospective study included 91 children and adolescents (56% males, 44% females), aged 6 to 17, with a history of maltreatment (physical maltreatment, sexual abuse, psychological abuse, or neglect), referring for a neuropsychiatric and psychological evaluation at a pediatric hospital. Data were obtained through a retrospective file review. Sleep difficulties were measured through the Sleep Disturbance Scale for Children; cognitive abilities, adaptive skills, and emotional and behavioral features were also investigated. Among maltreated youth, difficulties in initiating and maintaining sleep were the most frequently observed by caregivers. Poor sex differences emerged, whereas adolescents exhibited more daytime somnolence than school-age children. Children with sleep difficulties exhibited more anxiety symptoms and worse global functioning in comparison with children without sleep difficulties.Conclusion: Considering the vital impact of sleep quality on healthy development, practitioners should offer tailored services to child maltreatment victims. Enhancing the sleep quality of these children could help foster their resilience.

Do weighted blankets improve sleep among children with a history of maltreatment? A randomized controlled crossover trial

STUDY OBJECTIVES

Sleep disruption is prevalent and persistent among children who experience maltreatment/interpersonal trauma. Weighted blankets have gained popularity in recent years as a potential nonpharmacological intervention for improving sleep in various populations, but their efficacy has not been examined among maltreated children. The current study used a randomized, within-subjects, crossover design to examine whether the use of a weighted blanket improves objective and/or subjective indices of sleep among 30 children, ages 6-15 years (mean = 9.7, standard deviation = 2.9) adopted from foster care.

METHODS

Participants used a weighted blanket for 2 weeks and their usual (unweighted) blanket for 2 weeks in a counterbalanced order. Sleep outcomes were measured using actigraphy and subjective sleep diaries.

RESULTS

No differences in actigraphy-based or subjective estimates of total sleep time, sleep onset latency, wake after sleep onset, or sleep quality ratings were found based on blanket type. Child age, biological sex, timing of participation (school year vs summer months), and maltreatment/trauma history did not impact outcomes.

CONCLUSIONS

Although we did not find evidence that weighted blankets improve sleep among children with a history of maltreatment/interpersonal trauma, additional well-controlled studies using larger samples of children are needed.

CITATION

Cifre AB, Vieira A, Baker C, et al. Do weighted blankets improve sleep among children with a history of maltreatment? A randomized controlled crossover trial. J Clin Sleep Med. 2024;20(9):1405-1413.

Childhood maltreatment and insomnia in college students: The role of alexithymia and psychological distress

Insomnia, which is highly prevalent among college students, has been identified as one of the negative consequences of childhood maltreatment. While prior studies have uncovered distinct correlations between childhood maltreatment, insomnia, and other variables, the potential underlying mechanisms need to be further explored. This study focused on the chain-mediating role of alexithymia and psychological distress in the relationship between childhood maltreatment and insomnia. An online cross-sectional survey was conducted among Chinese college students, yielding 999 valid questionnaires that included demographic information, the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Toronto Alexithymia Scale (TAS), the 21-item Depression Anxiety Stress Scales (DASS-21), and the Insomnia Severity Index (ISI). A chain-mediating model was then tested. The results revealed significant positive correlations between each pair of the four variables. Alexithymia and psychological distress separately mediated the link between childhood maltreatment and insomnia (effect of alexithymia was 0.06 with 95 % CI [0.03, 0.09]; effect of psychological distress was 0.24 with 95 % CI [0.19, 0.29]). Additionally, a chain-mediating effect of alexithymia and psychological distress was observed (chain-mediating effect was 0.12 with 95 % CI [0.09, 0.15]). The findings suggest that emotional interventions may mitigate the long-term effect of childhood maltreatment on sleep problems among college students, by improving the ability to recognize emotions and decreasing emotional problems.

Predictors of early adulthood insomnia following exposure to a single mass violence attack during adolescence: 7-13 year follow-up from the Utøya and HUNT studies

Background: The long-term impact of mass violence attacks is practically unknown, especially in children and adolescents. In a previous study, we found that 8.5 years after a terror attack targeting mainly adolescents, nearly half of the survivors met diagnostic criteria for insomnia.Objectives: The aims of this study were to investigate: (1) whether exposure to a single mass violence event during adolescence increases the risk of insomnia almost a decade later above that expected for a non-exposed population; and (2) whether prior interpersonal violence exposure and early post-traumatic reactions predict later insomnia.Method: Participants were survivors of the 2011 Utøya Island terrorist attack (n = 279) and controls from the HUNT Norwegian general population study (n = 35,664). Early adulthood insomnia was assessed using four items from the Karolinska Sleep Questionnaire 8.5 years after the attack. Participants who had also completed earlier data collection waves for both studies (n = 116 and 2382, respectively) were included in logistic regression models testing the associations between predictors during adolescence and later insomnia.Results: Nearly a decade after the Utøya attack, 38.4% (n = 56) of the survivors reported symptoms of insomnia indicative of probable insomnia compared to 20.5% (n = 5771) of controls. Terror exposure during adolescence was a significant predictor of later insomnia [odds ratio (OR) = 3.18, 95% confidence interval (CI) = 2.05-4.87, p < .001]. Early post-trauma symptoms of anxiety and depression (OR = 1.34, 95% CI = 1.02-1.76, p = .033) and weekly headaches (OR = 1.64, 95% CI = 1.08-2.47, p = .018) were also significant predictors while controlling for background factors and other predictors.Conclusion: Long-term assessment and treatment are needed for survivors of mass violence to improve resilience and recovery.

Improving adolescent sleep in long-term Juvenile correctional settings: case examples with clinical, research, and policy implications

Poor sleep during adolescence is a public health concern that may be especially important to address among youth in juvenile correctional facilities, who tend to experience greater mental health challenges, substance use disorders, and traumatic stress exposure. However, evidence for addressing sleep in correctional settings is limited. Using de-identified composite clinical cases, this paper describes challenges and opportunities for addressing sleep disorders (i.e. insomnia) and promoting sleep health (i.e. improving duration, regularity, and behaviors) among adolescents in long-term juvenile correctional facilities. These clinical cases highlight common presenting problems and underscore the need for integrated sleep and mental health interventions as well as adaptations to enhance feasibility and efficacy of behavioral sleep treatment and sleep health promotion in juvenile correctional contexts. We conclude by summarizing clinical, research, and policy implications for addressing adolescent sleep problems and promoting sleep health and well-being in these contexts.

Sleep problems in adolescents with depression: Role of childhood trauma, alexithymia, rumination, and self-esteem

BACKGROUND

While sleep problems are common in adolescents with depression, the exact prevalence has not been reported. Although previous studies have shown that childhood trauma, alexithymia, rumination, and self-esteem are related to sleep problems, the interactions between these factors remain unclear.

METHODS

This study, conducted from March 1, 2021 to January 20, 2022, employed a cross-sectional design. The participants were 2192 adolescents with depression with a mean age of 15 years. The Chinese version of the Pittsburgh Sleep Quality Index, Childhood Trauma Questionnaire, Toronto Alexithymia Scale-20, Ruminative Response Scale, and Rosenberg Self-Esteem Scale were used to measure sleep problems, childhood trauma, alexithymia, rumination, and self-esteem, respectively. We used PROCESS 3.3 for SPSS to determine the chain mediating effect of alexithymia and rumination and the moderating effect of self-esteem in the relationship between childhood trauma and sleep problems.

RESULTS

Up to 70.71 % of adolescents with depression had sleep problems. Furthermore, alexithymia and rumination played a chain mediation role in the relationship between childhood trauma and sleep problems. Finally, self-esteem moderated the relationships between alexithymia and sleep problems and rumination and sleep problems.

LIMITATIONS

Owing to the study design, we cannot derive causal relationships between variables. Further, the self-reported data may have been influenced by subjective participant factors.

CONCLUSIONS

This study reveals potential ways of how childhood trauma influences sleep problems in adolescents with depression. These findings suggest that interventions targeting alexithymia, rumination, and self-esteem in adolescents with depression may be effective in reducing their sleep problems.

Development and validation of a nomogram for postoperative sleep disturbance in adults: a prospective survey of 640 patients undergoing spinal surgery

BACKGROUND

Postoperative sleep disturbance (PSD) is a prevalent clinical complication that may arise due to various factors. The purpose of this investigation is to identify the risk factors for PSD in spinal surgery and establish a risk prediction nomogram.

METHODS

The clinical records of individuals who underwent spinal surgery from January 2020 to January 2021 were gathered prospectively. The least absolute shrinkage and selection operator (LASSO) regression, along with multivariate logistic regression analysis, was employed to establish independent risk factors. A nomogram prediction model was devised based on these factors. The nomogram's effectiveness was evaluated and verified via the receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA).

RESULTS

A total of 640 patients who underwent spinal surgery were analyzed in this investigation, among which 393 patients experienced PSD with an incidence rate of 61.4%. After conducting LASSO regression and logistic regression analyses using R software on the variables in training set, 8 independent risk factors associated to PSD were identified, including female, preoperative sleep disorder, high preoperative anxiety score, high intraoperative bleeding volume, high postoperative pain score, dissatisfaction with ward sleep environment, non-use of dexmedetomidine and non-use of erector spinae plane block (ESPB). The nomogram and online dynamic nomogram were constructed after incorporating these variables. In the training and validation sets, the area under the curve (AUC) in the receiver operating characteristic (ROC) curves were 0.806 (0.768-0.844) and 0.755 (0.667-0.844), respectively. The calibration plots indicated that the mean absolute error (MAE) values in both sets were respectively 1.2% and 1.7%. The decision curve analysis demonstrated the model had a substantial net benefit within the range of threshold probabilities between 20% and 90%.

CONCLUSIONS

The nomogram model proposed in this study included eight frequently observed clinical factors and exhibited favorable accuracy and calibration.

TRIAL REGISTRATION

The study was retrospectively registered with the Chinese Clinical Trial Registry (ChiCTR2200061257, 18/06/2022).

How Are the Sleep Problems of Children in the US Foster Care System Addressed?

OBJECTIVE

Evidence of poor sleep health among children in foster care continues to mount, but information about whether and how sleep problems are addressed is unavailable. The goal of this study was to begin to fill these significant knowledge gaps.

METHODS

Four hundred eighty-five foster caregivers from across the United States completed a survey focused on the sleep health of one child, 4 to 11 years ( M = 6.4; SD = 2.2) currently in their care. Caregivers provided quantitative and qualitative responses to questions regarding training, information, and services received in relation to their child's sleep. Caregivers also reported on the factors and strategies they perceived as most important for helping children in their care sleep well.

RESULTS

Only 13% of caregivers reported receiving any information/education about sleep from agencies or case workers, whereas 55% had sought help from a health provider related to their child's sleep. Nearly half of all caregivers (46%) reported giving their child melatonin. Caregivers reported that a bedtime routine/consistency, reassurance of safety/love, and a calming environment were most important for helping their child sleep well. A recurrent theme in qualitative responses was a need to mitigate child fear/anxiety at night.

CONCLUSION

Children in foster care face a range of risk factors that increase the likelihood of poor/insufficient sleep, but these findings suggest this critical aspect of health requires greater clinical and research attention. As these data were collected during the initial months of the COVID-19 pandemic, replication studies are necessary.

Child and parent secondary outcomes in stepped care versus standard care treatment for childhood trauma

INTRODUCTION

Stepped care trauma-focused cognitive behavioral therapy (SC-TF-CBT) is comparable in efficacy to standard TF-CBT for child posttraumatic stress symptoms (PTSS), but less is known about the effectiveness of SC-TF-CBT on child and parent secondary outcomes. The aim of this community-based randomized clinical trial was to compare child- and caregiver-secondary outcomes among SC-TF-CBT versus TF-CBT participants.

METHODS

Children (ages 4 to 12) with PTSS and their caregivers were randomly assigned to either SC-TF-CBT (n = 91) or TF-CBT (n = 92). Secondary child (internalizing and externalizing behavior problems, anger outburst and sleep disturbances) and parent outcomes (PTSS, depression symptoms, and parenting stress) were measured at baseline, post-treatment and 6- and 12-month follow-up.

RESULTS

There were comparable changes at all-time points in child and caregiver secondary outcomes. Non-inferiority tests indicated that for completers and intent-to-treat samples, SC-TF-CBT was non-inferior to TF-CBT for all outcomes except parenting stress at 6-months. The analysis with completers did not support non-inferiority at post-treatment for internalizing and externalizing problems and at 6- and 12-month follow-up assessments for externalizing problems, but the intent-to-treat analysis did support non-inferiority.

LIMITATIONS

Limitations included modest rates of attrition, excluding in vivo component for standard TF-CBT, parent-only assessments, and no control condition.

CONCLUSIONS

SC-TF-CBT is an effective alternative treatment method although parents with high stress may need more support and children with externalizing problems may need more standard TF-CBT sessions.

Nightmares mediate the association between traumatic event exposure and suicidal ideation in frontline medical workers exposed to COVID-19

BACKGROUND

Trauma experience increases the risk of suicidal ideation, but little is known about potentially psychological mechanisms underlying this relationship. This study aims to examine the relationship between coronavirus disease 2019 (COVID-19)-related traumatic event (CTE) exposure and suicidal ideation among hospital workers, and identify mediating roles of sleep disturbances in this relationship.

METHODS

Workers in seven designated hospitals in Wuhan, China, were invited to participate in an online survey from May 27, 2020, to July 31, 2020. Participants completed a self-report questionnaire to evaluate demographic characteristics, level of CTE exposures, nightmare frequency, insomnia severity, symptoms of depression and anxiety, and suicidal ideation. A series of correlation analyses were performed, and a mediation model was generated to examine correlations between CTE exposure, sleep disturbances, and suicidal ideation.

RESULTS

A total of 16,220 hospital workers were included in the final analysis, 13.3% of them reported suicidal ideation in the past month. CTE exposure was significantly associated with insomnia severity, nightmare frequency, and suicidal ideation. After controlling potential confounders, nightmares but not insomnia, depression, or anxiety were shown to be independent risk factors for suicidal ideation. Pathway analyses showed that the relationship between CTE exposure and suicidal ideation was fully mediated by nightmares (proportion mediated 66.4%) after adjusting for demographic characteristics and psychological confounders.

LIMITATIONS

Cross-sectional design precluded the investigation of causal relationships.

CONCLUSIONS

CTE exposure increases risk of hospital workers' suicidal ideation that is mediated by nightmares, suggesting nightmares intervention might be considered as a component when developing suicide prevention strategies.

Psychotic Experiences and Sleep Quality in the Emerging Adulthood: The Interplay Between Emotional Neglect, Bodily Threat, and Defense Mechanisms

ABSTRACT

The present study investigated the integrated role of emotional neglect, bodily threat, and defense mechanisms in understanding sleep quality and psychosis experiences in a sample of emerging adults. A sample of 898 emerging adults (295 males) with an age range between 19 and 30 years participated in this study. The emotional neglect and bodily threat factors of the Traumatic Experiences Checklist, the Defense Style Questionnaire-40, the Pittsburgh Sleep Quality Index, and the psychosis factor of the Inventory of Personality Organization were administered. Results of path analyses showed that the emotional neglect and bodily threat factors predicted lower sleep quality. A path from emotional neglect and bodily threat to sleep quality via defense styles was also found. The defense styles mediated the relationships between emotional neglect and bodily threat factor with psychosis experiences. These findings provide new insight into the psychological mechanisms underlying the onset of poor sleep quality and psychotic experiences during emerging adulthood.

Call to action: Prioritizing sleep health among US children and youth residing in alternative care settings

Sleep health is a critical but under-recognized area of concern for the more than 650,000 children served by the US child welfare system each year. While sleep is vital to optimal child health and development, it is likely harmed by the multiple adversities and traumas experienced among children and youth residing in alternative care settings (ie, kinship care, nonrelative foster care, group homes). Children residing in alternative care settings have experienced, at a minimum, the trauma of removal from a biological parent's care and would benefit from holistic, comprehensive care approaches inclusive of sleep health. Furthermore, few studies are currently available to guide practitioners and policymakers in promoting sleep health among these children. In this Call to Action, our goal is to draw attention to the sleep health of children residing in alternative care settings. We highlight the need for a more robust evidence base to address major knowledge gaps and outline concrete steps toward building future promising sleep health-promoting practices and policies supporting children residing in alternative care settings.

Racial Stress and Trauma and the Development of Adolescent Depression: A Review of the Role of Vigilance Evoked by Racism-Related Threat

There are known disparities in the burden of illness and access/quality of care for African, Latino/a, Asian, and Native American (ALANA) patients diagnosed with depressive disorders, which may occur because of health inequities. Racial stress and trauma (RST), or the significant fear and distress that can be imparted from exposure to racism, is one such inequity linked to the development of depression. The current review summarizes past research examining the association between racism, RST, and depression, as well as avenues in which RST becomes biologically embedded in ALANA individuals. We describe multimodal research that supports vigilance as a potential mediator of the association between RST and depression and consider the nuanced role that vigilance plays during experiences with racism. Finally, we describe methodological advances in the assessment of vigilance evoked by RST and the clinical implications that may be generated by future improvements. In each of these areas, we present examples of how ongoing and future research can be leveraged to provide support for psychosocial programs that facilitate autonomous community healing and resilience, increase calls for public policy changes, and support clinical interventions that lessen the burden of racism on ALANA communities.

Associations of adverse childhood experiences with adolescent total sleep time, social jetlag, and insomnia symptoms

STUDY OBJECTIVE

Adverse childhood experiences (ACEs) are associated with sleep problems in adulthood, but less research has focused on ACEs and sleep during adolescence. The goal of the present study was to explore associations between ACEs reported at ages 5 and 9 years, and sleep (ie, total sleep time (TST), social jetlag, and insomnia symptoms) at age 15.

METHODS

Participants comprised 817 families from the Fragile Families and Child Wellbeing Study, a nationally representative sample of children born to unwed parents. Number of ACEs was constructed from primary-caregiver reports at ages 5 and 9, and sleep measures (ie, TST, social jetlag, and insomnia symptoms) were derived from adolescent-reported sleep behaviors at age 15.

RESULTS

Adjusting for sex and race/ethnicity, ACEs at age 9 were associated with longer weekend TST (B = 0.16, 95% CI = 0.04, 0.28), more social jetlag (B = 0.17, 95% CI = 0.07, 0.27), and higher odds of trouble falling asleep ≥3 times per week (Odds Ratio = 1.24, 95% CI = 1.01, 1.53). In females only, ACEs were associated with greater school night TST (B = 0.12, 95% CI = 0.01, 0.23). Results were similar after further adjustment for symptoms of anxiety and depression. Associations among ACEs, social jetlag, and insomnia symptoms appeared strongest among Non-Hispanic Black adolescents.

CONCLUSION

ACEs appear to be related to multiple aspects of sleep in adolescence. Additional research is needed to confirm these associations and examine the extent to which sleep disturbances associated with ACEs account for later health outcomes.