Anxiety Disorders and Sleep in Children and Adolescents

Associations of generalized anxiety and social anxiety symptoms with sleep duration, amount of intense exercise, and excessive internet use among adolescents

BACKGROUND

Among adolescents, symptoms of generalized anxiety disorder (GAD) and social anxiety disorder (SAD) are not only clinically significant but also continuingly increasing. During adolescence, individuals begin to establish distinct, self-determined lifestyle patterns. This study seeks to identify the associations between such lifestyle factors and the prevalence of GAD and SAD symptoms.

METHODS

The analyzable sample was based on a cross-sectional, nationally representative survey of Finnish 14-18 year old students from comprehensive schools, general upper secondary schools, and vocational institutions. The sample consisted of 60,252 boys and 71,118 girls, with the mean age of 16.05 years (standard deviation 1.06). Symptoms were identified using the GAD-7 (cutpoint of 10), the Mini-SPIN (cutpoint of 6), and the PHQ-2 (cutpoint of 3). Logistic regression models for both GAD and SAD symptoms were stratified by comorbidity group variables.

RESULTS

GAD symptoms were closely related to excessive internet use and decreased sleep duration among adolescents, regardless of comorbidity with depression or SAD. SAD symptoms were associated with excessive internet use and a lack of intense exercise, independent of comorbid depression or GAD.

CONCLUSIONS

The findings underscore the importance of considering lifestyle factors when developing interventions to mitigate GAD and SAD symptoms in adolescents. Interventions and policy recommendations aiming at improving adolescents' health behaviour and mental health should take into account the intertwining of these factors.

Anxiety, inhibitory control, physical activity, and internet addiction in Chinese adolescents: a moderated mediation model

BACKGROUND

Adolescents may have anxiety due to a series of events such as school work and social interaction. Improper handling of anxiety often leads to some negative consequences, such as Internet addiction. Therefore, this study further explored the relationship between anxiety and Internet addiction, as well as the mediating role of inhibitory control between the two, and also considered the moderating role of physical activity between anxiety and inhibitory control.

METHODS

A total of 1607 adolescents, comprising 664 boys and 943 girls with an average age of 15.86 years (SD = 0.73), from Shandong, Shanxi, Hebei, and Hunan provinces completed a self-report survey on physical activity, anxiety, inhibitory control, and Internet addiction. Descriptive analysis, correlation analysis, and mediation test were conducted.

RESULTS

The results revealed a significant positive correlation between anxiety and adolescent internet addiction (r = 0.413, p < 0.001), and a significant negative correlation with inhibitory control (r = -0.423, p < 0.001). Inhibitory control was found to be significantly positively correlated with physical exercise (r = 0.143, p < 0.001) and significantly negatively correlated with internet addiction (r = -0.368, p < 0.001). After controlling for demographic variables, anxiety significantly positively predicted Internet addiction (β = 0.311, p < 0.001) in adolescents, and it also indirectly predicted Internet addiction through inhibitory control (β = -0.231, p < 0.001). Physical activity significantly weakened the predictive effect of anxiety on inhibitory control (β = -0.092, p < 0.001).

CONCLUSIONS

This study further explored the issue of psychological mechanisms between anxiety and Internet addiction in adolescents, and added that physical activity alleviates the negative effects of anxiety on adolescents. Schools and families are encouraged to promote physical exercise among adolescents to alleviate the influence of negative emotions on their psychological and behavioral health.

Bidirectional associations between sleep and anxiety among Chinese schoolchildren before and after the COVID-19 lockdown

The COVID-19 pandemic has critical implications for mental health in children. This study examined how the COVID-19 lockdown affected sleep duration and anxiety symptoms in Chinese school-aged children and the bidirectional association between sleep and anxiety before and during the COVID-19 lockdown. A school-based longitudinal cohort study was conducted to examine the relationship between sleep duration and anxiety scores before and after the COVID-19 lockdown from January to May 2020. Generalized estimating equations model was used to identify variables that contributed to the changes in sleep duration. The bidirectional relationship between sleep duration and anxiety symptoms was explored by cross-lagged analysis. 7681 children completed two waves of surveys were included in the analysis. The daily exercise duration, anxiety symptoms, and sleep duration decreased significantly during the lockdown compared with that before the lockdown. Based on generalized estimating equations model, older age, secondary school, and higher anxiety scores of participants were positively associated with sleep duration, while female and no COVID-19 infection history were negatively associated with it. Cross-lagged analysis showed higher anxiety score of children before the lockdown was significantly associated with shorter sleep duration during the lockdown; and shorter sleep duration of children before the lockdown was also significantly associated with a higher anxiety score during the lockdown. Under the context of the COVID-19 pandemic, there were longitudinal, bidirectional associations between children's anxiety symptoms and sleep duration. For school students, mental health services and sleep education should be considered in the daily health education curriculum.

Common and differential variables of anxiety and depression in adolescence: a nation-wide smartphone-based survey

BACKGROUND

Mental health in adolescence is critical in its own right and a predictor of later symptoms of anxiety and depression. To address these mental health challenges, it is crucial to understand the variables linked to anxiety and depression in adolescence.

METHODS

Here, we analyzed data of 278 adolescents that were collected in a nation-wide survey provided via a smartphone-based application during the COVID-19 pandemic. We used an elastic net regression machine-learning approach to classify individuals with clinically relevant self-reported symptoms of depression or anxiety. We then identified the most important variables with a combination of permutation feature importance calculation and sequential logistic regressions.

RESULTS

40.30% of participants reported clinically relevant anxiety symptoms, and 37.69% reported depressive symptoms. Both machine-learning models performed well in classifying participants with depressive (AUROC = 0.77) or anxiety (AUROC = 0.83) symptoms and were significantly better than the no-information rate. Feature importance analyses revealed that anxiety and depression in adolescence are commonly related to sleep disturbances (anxiety OR = 2.12, depression OR = 1.80). Differentiating between symptoms, self-reported depression increased with decreasing life satisfaction (OR = 0.43), whereas self-reported anxiety was related to worries about the health of family and friends (OR = 1.98) as well as impulsivity (OR = 2.01).

CONCLUSION

Our results show that app-based self-reports provide information that can classify symptoms of anxiety and depression in adolescence and thus offer new insights into symptom patterns related to adolescent mental health issues. These findings underscore the potentials of health apps in reaching large cohorts of adolescence and optimize diagnostic and treatment.

Examining the influence of problematic internet use on sleep quality in Chinese adolescents: a study using the extended Stressor-Strain-Outcome (SSO) model

Objective

This study aims to explore how problematic internet use may affect the sleep quality of Chinese adolescents using the extended Stressor-Strain-Outcome (SSO) model. The model posits that stressors indirectly influence behavioral outcomes through the mediation of emotional and physiological strain responses.

Method

A sample of 4,365 adolescents in China participated in this study, which utilized questionnaires and other methods to develop a novel SSO model. In this model, problematic internet use was considered as the stressor, anxiety as an indicator of tension, and sleep quality as the ultimate outcome. Family health was introduced as a moderating variable.

Results

The study found that problematic internet use can significantly and positively predict adolescents' anxiety (β = 0.132, p < 0.001) and sleep quality (β = 0.362, p < 0.001). Furthermore, anxiety was identified as a significant mediating factor between problematic internet use and sleep quality [Effect = 0.066, p < 0.05, 95% CI (0.014, -0.0018)]. Family health was observed to have a moderating effect on the relationship between problematic internet use and anxiety (β = -0.075, p < 0.001).

Conclusion

The research indicates that problematic internet use not only directly increases individual anxiety as a stressor but also indirectly impacts sleep quality by exacerbating anxiety. However, a positive family health status can effectively moderate the adverse impact of problematic internet use on anxiety.

Trauma Exposure in Migrant Children: Impact on Sleep and Acute Treatment Interventions

Trauma exposure significantly impacts sleep in children. Nightmares are common. Evidence-based therapies are superior to medications but may not always be available in acute settings. No FDA-approved medications exist for the treatment of trauma-related sleep disturbances in youth. The evidence-base for the use of medications is largely based on case reports, retrospective chart reviews, clinical opinion, and adult studies. This evidence is reviewed for a number of medications, including prazosin, trazodone, alpha-2 agonists, quetiapine, and others.

Sleep, brain systems, and persistent stress in early adolescents during COVID-19: Insights from the ABCD study

PURPOSE

The first year of the COVID-19 pandemic constituted a major life stress event for many adolescents, associated with disrupted school, behaviors, social networks, and health concerns. However, pandemic-related stress was not equivalent for everyone and could have been influenced by pre-pandemic factors including brain structure and sleep, which both undergo substantial development during adolescence. Here, we analyzed clusters of perceived stress levels across the pandemic and determined developmentally relevant pre-pandemic risk factors in brain structure and sleep of persistently high stress during the first year of the COVID-19 pandemic.

METHODS

We investigated longitudinal changes in perceived stress at six timepoints across the first year of the pandemic (May 2020-March 2021) in 5559 adolescents (50 % female; age range: 11-14 years) in the United States (U.S.) participating in the Adolescent Brain Cognitive Development (ABCD) study. In 3141 of these adolescents, we fitted machine learning models to identify the most important pre-pandemic predictors from structural MRI brain measures and self-reported sleep data that were associated with persistently high stress across the first year of the pandemic.

RESULTS

Patterns of perceived stress levels varied across the pandemic, with 5 % reporting persistently high stress. Our classifiers accurately detected persistently high stress (AUC > 0.7). Pre-pandemic brain structure, specifically cortical volume in temporal regions, and cortical thickness in multiple parietal and occipital regions, predicted persistent stress. Pre-pandemic sleep difficulties and short sleep duration were also strong predictors of persistent stress, along with more advanced pubertal stage.

CONCLUSIONS

Adolescents showed variable stress responses during the first year of the COVID-19 pandemic, and some reported persistently high stress across the whole first year. Vulnerability to persistent stress was evident in several brain structural and self-reported sleep measures, collected before the pandemic, suggesting the relevance of other pre-existing individual factors beyond pandemic-related factors, for persistently high stress responses.

Sleep Disorders and Fatigue among Patients with MS: The Role of Depression, Stress, and Anxiety

Sleep disorders and fatigue represent prominent symptoms frequently experienced by individuals with multiple sclerosis (MS). Some psychological factors such as depression, stress, and anxiety seem to have a relationship with such problems. This study aimed to examine the role of depression, stress, and anxiety in predicting sleep disorders and fatigue among patients with MS. Employing a cross-sectional descriptive-correlational design, the study involved a sample size of 252 participants selected through purposive sampling based on inclusion and exclusion criteria. We utilized a demographic information questionnaire along with the Mini-Sleep Questionnaire (MSQ), Fatigue Severity Scale (FSS), and Depression, Anxiety, and Stress Scale (DASS-21) to collect data and analyzed them applying SPSS22, incorporating statistical measures including Pearson correlation and regression. The results of the Pearson correlation coefficient showed that sleep disorders had a positive and significant relationship with depression (r = 0.56; P < 0.001), stress (r = 0.40; P < 0.001), and anxiety (r = 0.52; P < 0.001). There was no significant relationship between age and the development of sleep disorders in total score (r = -0.001; P < 0.985), but age had a relationship with insomnia (r = -0.146; P < 0.021) and oversleeping (r = 0.153; P < 0.015). Age and fatigue did not have a significant relationship as well (r = -0.044; P < 0.941). In addition, fatigue had a positive and significant relationship with depression (r = 0.52; P < 0.001), stress (r = 0.48; P < 0.001), and anxiety (r = 0.54; P < 0.001). The results of the regression analysis also showed that depression, stress, and anxiety predict 0.37% of the total variance of sleep disorders (F = 48.34; P < 0.001) and 0.35% of the total variance of fatigue (F = 44.64; P < 0.001). Our findings suggest that depression, stress, and anxiety play a significant role in predicting sleep disorders and fatigue among patients with MS. This study has been reported in accordance with the TREND checklist for nonrandomized trials.

Sleep well, worry less: A co-design study for the development of the SMILE app

Objective

With the coronavirus disease 2019 pandemic exacerbating mental health concerns, the prevalence rates of anxiety and sleep problems have increased alarmingly among youth. Although 90% of patients with anxiety experience sleep problems, current interventions for anxiety often do not target sleep problems in youth. Given this lack, we designed the SMILE app, an intervention that addresses both anxiety and sleep problems simultaneously.

Methods

As users' perspectives are essential to ensure app engagement and uptake, the features, designs, and functions of the SMILE app were evaluated using a participatory app design approach. Participants (N = 17) were youth aged 15 to 25 who reported co-morbid anxiety and sleep issues above clinical thresholds. After completing an online screening survey assessing demographics, anxiety, and sleep problems, participants shared app feedback through group-based, semi-structured co-design sessions. Qualitative analyses were conducted to identify common themes from participants' feedback.

Results

While participants expressed enthusiasm for the SMILE app's features, particularly the Visualization, Journaling, and Psychoeducation features, and their variety, they criticized the design aspects of the app, such as the font and text amount. Most participants stated they would use the SMILE app or recommend it to a friend.

Conclusion

By actively involving the target population in the design process, the SMILE app has the potential to notably improve the mental well-being of youth, though further research and development are required to realize this potential fully.

Evaluation of the Psychometric Properties of the Persian Version of Spence Children's Anxiety Scale in Iranian Adolescents

The Spence Children's Anxiety Scale (SCAS) is a tool for measuring anxiety symptoms in children and adolescents. In this study, the psychometric properties of the Persian version of SCAS were investigated in an Iranian adolescents. This study was conducted on a sample of 684 adolescents. For standardization of SCAS, first- and second-order confirmatory factor analyses wereperformed. Also, to evaluate convergent and divergent validity, Fornell and Larcker criteria (1994), along with the Revised Children's Manifest Anxiety Scale (RCMAS)and Children's Depression Inventory (CDI), was used. A receiver operating characteristic (ROC) curve analysis was also performedto determine the cut-off point. The model fit of the correlated six-factor model was good however, a second-order model provided a statistically superior fit to the data. The reliability coefficients for the total scale and its dimensions were satisfactory (α > 0.7). Therefore, it can be concluded that the Persian version of SCAS has acceptable reliability and validity and can be used as a useful tool for early screening of anxiety in Iranian adolescents due to its easy use and specific design for children and adolescents.

The relationship between sleep disturbance and obsessive- compulsive symptoms: the mediation of repetitive negative thinking and the moderation of experiential avoidance

Background

Studies have found that sleep disturbance is associated with obsessive-compulsive symptoms. This study aimed to elaborate on the mediating and moderating mechanisms between these two variables. We hypothesized that repetitive negative thinking plays a mediating role in the relationship between sleep disturbance and obsessive-compulsive symptoms, and experiential avoidance plays a moderating role.

Method

This study included 639 Chinese adults. A questionnaire survey was used to assess sleep quality, obsessive-compulsive symptoms, experiential avoidance, repetitive negative thinking, and depression symptoms. A moderated mediation model was established.

Results

After controlling for depressive symptoms, repetitive negative thinking partially mediated the positive correlation between sleep disturbance and obsessive-compulsive symptoms. This indirect relationship was significant in individuals with lower experiential avoidance levels. Particularly, the relationship between sleep disturbance and repetitive negative thinking was significant among individuals with lower experiential avoidance levels, but not among individuals with higher experiential avoidance levels.

Conclusion

This study demonstrated that repetitive negative thinking partially mediated the impact of sleep disturbance on obsessive-compulsive symptoms. The findings suggest that when providing support to individuals with sleep disturbance and obsessive-compulsive symptoms, assessing their level of experiential avoidance is necessary for performing targeted interventions. Individuals with low experiential avoidance may benefit from a clinical intervention targeting repetitive negative thinking to improve sleep quality and obsessive-compulsive symptoms.

School-Based Sleep Education Program for Children: A Cluster Randomized Controlled Trial

Insufficient sleep contributes negatively to child developmental processes and neurocognitive abilities, which argues the need for implementing interventions to promote sleep health in children. In this study, we evaluated the effectiveness of a multimodal and multilevel school-based sleep education program in primary school children using a cluster randomized controlled design. Twelve schools were randomly assigned to either the sleep education or nonactive control groups. The sleep education group included a town hall seminar, small class teaching, leaflets, brochures, and a painting competition for children. Parents and teachers were invited to participate in a one-off sleep health workshop. Parental/caregiver-reported questionnaires were collected at baseline and 1-month follow-up. A total of 3769 children were included in the final analysis. There were no significant improvements observed in the sleep-wake patterns, daytime functioning, and insomnia symptoms between the two groups at follow-up, whereas the intervention group had significantly improved parental sleep knowledge than the controls (paternal: adjusted mean difference: 0.95 [95% confidence interval (CI): 0.18 to 1.71]; maternal: adjusted mean difference: 0.87 [95% CI: 0.17 to 1.57]). In addition, children receiving the intervention had a lower persistence rate of excessive beverage intake (adjusted odds ratio: 0.49 [95% CI: 0.33 to 0.73]), and experienced greater reductions in conduct problems (adjusted mean difference: 0.12 [95% CI: 0.01 to 0.24]) compared with the controls at 1-month of follow-up. Moreover, a marginally significant reduction for emotional problems in the intervention group was also observed (adjusted mean difference: 0.16 [95% CI: -0.00 to 0.32]). These findings demonstrated that school-based sleep education was effective in enhancing parental sleep knowledge and improving behavioral outcomes in children, but not sufficient in altering the children's sleep-wake patterns and sleep problems.

Eating habits matter for sleep difficulties in children and adolescents: A cross-sectional study

Background

Sleep difficulties are a common sleep-related problem among children and adolescents. However, the association between eating habits and sleep difficulties has not been extensively studied. Therefore, this study aimed to investigate the relationship between eating habits and sleep difficulties in children and adolescents.

Methods

This study utilized cross-sectional data from the 2013/2014 Health Behaviour in School-aged Children survey. A total of 213,879 young adolescents provided self-reported information on their weekday and weekend breakfast consumption, fruit and vegetable intake, sweet and soft drink consumption, and sleep difficulties. Covariates such as sex, age, family affluence, physical activity, and body mass index were also assessed. Multilevel generalized linear modelling was used to analyse the association between independent and dependent. Results were reported as odds ratios (OR) with 95% confidence intervals.

Results

Of all study participants, approximately 50% were girls. Regression models indicated that more frequent breakfast consumption was associated with fewer sleep difficulties (e.g., consuming breakfast on weekdays for 5 days: OR = 1.49, 95% CI: 1.45-1.54). Fruit and vegetable consumption once a week or more was also linked to fewer sleep difficulties (all OR > 1.08, ≥ 1.07). In addition, consuming fewer sweets and soft drinks was generally associated with fewer sleep difficulties.

Conclusion

This study provides evidence supporting the association between healthier eating habits and reduced sleep difficulties in children and adolescents. Future research using longitudinal or experimental designs is encouraged to confirm or negate these findings. Additionally, this study offers practical guidance for nutritional counselling professionals and sleep health promotion practitioners.

The relationships between sleep disturbances, resilience and anxiety among preschool children: A three-wave longitudinal study

OBJECTIVE

This study, based on a three-wave longitudinal study, aimed to examine bidirectional relationships between sleep disturbances, resilience and anxiety symptoms among preschool children.

METHODS

In total, 1169 children in the junior class of preschools were investigated three times with an interval of one year, in Anhui Province, China. Children's sleep disturbances, resilience and anxiety symptoms were all assessed in the three-wave surveys. Then, 906 children at baseline (T1), 788 children in the first follow-up study (T2), and 656 children in the second follow-up study (T3) were included in the analysis. Autoregressive cross-lagged modeling analyses were performed to examine bidirectional relationships between sleep disturbances, resilience and anxiety symptoms using Mplus 8.3.

RESULTS

The mean age of the children was 3.6 ± 0.4 years at T1, 4.6 ± 0.4 years at T2, and 5.6 ± 0.4 years at T3, respectively. The results indicated that sleep disturbances at T1 significantly predicted anxiety symptoms at T2 (β = 0.111, P = 0.001); and sleep disturbances at T2 significantly predicted anxiety symptoms at T3 (β = 0.108, P = 0.008). Resilience only at T2 significantly predicted anxiety symptoms at T3 (β = -0.120, P = 0.002). Anxiety symptoms did not significantly predict the two variables (sleep disturbances and resilience) at any wave.

CONCLUSION

This study suggests that more sleep disturbances are longitudinally associated with subsequent high anxiety symptoms; inversely, high resilience will alleviate subsequent anxiety symptoms. These findings highlight the importance that early screening for sleep disturbances and anxiety, and strengthening resilience are beneficial to prevent preschool children from developing higher anxiety symptoms.

Chronic rapid eye movement sleep restriction during juvenility has long-term effects on anxiety-like behaviour and neurotransmission of male Wistar rats

Modernity imposes a toll on the sleep time of young population, with concomitant increase in symptoms of anxiety and depression. Whether there is a causal relationship between these events are only now being experimentally tested in humans and rodents. In a previous study, we showed that chronic sleep deprivation in juvenile-adolescent male rats led to increased anxiety-like behaviour and changes in noradrenaline and serotonin in the amygdala and hippocampus. In the present study we investigated whether early chronic sleep restriction affects emotional behaviour, stress response and neurochemistry in adulthood. From 21 to 42 days of age, Wistar male rats were submitted to sleep restriction by the multiple platform method or allowed to sleep freely. Forty-five days after this period, rats were tested in the elevated plus maze (EPM) and blood samples were collected from non-tested rats or 30 and 60 min after the EPM for determination of plasma corticosterone levels. Levels of monoamines were determined in the frontal cortex, hippocampus, amygdala and hypothalamus 60 min after the EPM. Sleep restriction resulted in increased anxiety-like behaviour, decreased noradrenaline levels in the amygdala and dopamine levels in the ventral hippocampus. Anxiety index was positively correlated with increased serotonin metabolism in the frontal cortex and greater dopamine metabolism in the ventral hippocampus, and negatively correlated with dopamine levels in the ventral hippocampus. These results suggest that sleep restriction in juvenility and adolescence induces persistent changes in emotional behaviour in adult male rats and that levels of anxiety are correlated with increased serotonin and dopamine metabolism in specific brain areas.

The roles of parental absence, life skills and personality traits in mental health status among adolescents in rural China

PROBLEM

Mental health issues in adolescents are public health concerns worldwide including China. However, there is a lack of research examining the role of parental absence status, life skills, and personality traits on the mental health of adolescents in rural China.

METHOD

The purpose of this cross-sectional study was to examine the role of parental absence status, life skills, and personality traits on the mental health of adolescents in rural China. This study used self-developed demographic questionnaire, Mental Health Test (MHT), Middle School Student Life Skills Rating Scale, and Eysenck Personality Questionnaire. Binary logistic regression analyses were performed to examine the associated factors on different domains of MHT.

RESULTS

Adolescents in rural China reported high proportion of mental health disorders (MHDs), including learning anxiety, sensitiveness, self-accusation, and physical symptoms tendency. Although 75.6% experienced parental absence, this was not associated with MHT after controlling for all other variables. Better mental health was correlated with life skills including communication skills, interpersonal morality, self-efficacy, and stress coping. The instability-neuroticism personality trait was positively associated with MHDs.

DISCUSSION

Adolescents in rural China reported high positive rates of MHDs. Communication skills, interpersonal morality, self-efficacy, ability to cope with stress and Instability-neuroticism were important associated factors of MHDs.

APPLICATION TO PRACTICE

Life skills and personality are two important factors that should be considered when assessing the mental health status of adolescents and formulating interventions.

UK children's sleep and anxiety during the COVID-19 pandemic

Background

Sleep and mental wellbeing are intimately linked. This relationship is particularly important to understand as it emerges over childhood. Here we take the opportunity that the COVID-19 pandemic, and resulting lockdown in the UK, presented to study sleep-related behaviour and anxiety in school-aged children.

Methods

Parents and children were asked to complete questionnaires towards the start of the UK lockdown in April-to-May of 2020, then again in August of that year (when many restrictions had been lifted). We explored children’s emotional responses to the pandemic and sleep patterns at both time points, from the perspectives of parents and children themselves.

Results

Children’s bedtime anxiety increased at the start of the lockdown as compared to a typical week; however, by August, bedtime anxiety had ameliorated along with children’s COVID-19 related anxiety. Bedtime anxiety predicted how long it took children to fall asleep at night at both the start and the end of the lockdown. Bedtime and wake-up time shifted at the start of lockdown, but interestingly total sleep time was resilient (likely owing to an absence of early school start times) and was not predicted by child anxiety.

Conclusions

These findings further support calls for sleep quality (in particular, time taken to fall asleep) to be taken as a key indicator of mental health in children, particularly under usual circumstances when schools are open and sleep duration may be less resilient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00729-4.

A Comprehensive Review of the Literature on Sleep Difficulties and Suicidality in Youth to Inform an Integrative Developmental Model and Future Directions

Purpose of Review

Suicide is currently the second leading cause of death among youth. Identification of modifiable near-term risk factors can inform suicide prevention strategies. One promising, readily assessed factor is sleep. We critically review the literature on sleep and suicidal thoughts and behaviors among youth.

Recent Findings

Most studies examining the youth sleep-suicidality relationship are from epidemiological samples in which both sleep problems and suicidality were assessed over variable timeframes using limited items from scales not designed to measure these constructs. Nonetheless, these data overwhelmingly support an association between suicidality and a range of sleep difficulties (e.g., insomnia, short/long sleep, weekend oversleep), above and beyond depressive symptoms. Limited studies include clinical samples or prospective designs. We review potential mechanisms and present a developmentally-informed integrative model.

Summary

Literature supports a clear association between sleep difficulties and youth suicidality. Future directions include prospective longitudinal studies and targeted prevention efforts.

The modifiable biopsychosocial drivers of psychological distress for adolescents with asthma: Implications for Clinical Care

PURPOSE

Overwhelming distress exceeds the capacity of healthy coping strategies to feel better using healthy coping strategies alone, resulting in the use of unhealthy coping strategies. Unhealthy coping strategies may exacerbate asthma symptoms and asthma can contribute to overwhelming distress. This study aimed to review the modifiable drivers of overwhelming distress in adolescents with asthma.

METHODS

The biopsychosocial drivers of psychological distress for adolescents with asthma were explored within the domains of the modifiable biopsychosocial model of health and wellbeing.

RESULTS

Asthma in adolescents is associated with problems in the domains of environment, developmental outcomes, sense of belonging, health behaviours, coping, and treatment of illness.

CONCLUSIONS

The relationship between asthma and psychological distress highlights the need for holistic treatment of asthma. Further research is needed to establish causation between variables and to investigate whether interventions that address either asthma symptoms or biopsychosocial drivers of distress can improve both factors.

Do Anxiety and Mood Vary among Disparate Sleep Profiles in Youth with Craniopharyngioma? A Latent Profile Analysis

Craniopharyngioma is a histologically benign brain tumor that arises in the suprasellar region affecting critical neurovascular structures including the hypothalamic-pituitary-adrenal axis and optic pathways. Children with craniopharyngioma often experience excessive daytime sleepiness which may be compounded by anxiety and depression. The current study investigated disparate sleep profiles to better understand psychological adjustment among children diagnosed with craniopharyngioma. Method: Actigraphs recorded nightly sleep data, including measures of sleep onset latency and wake after sleep onset, in a cohort of 80 youth between the ages of 2 and 20 years (median age = 9). Parent reports of behavioral and emotional functioning were included in the analysis. A latent profile analysis examined disparate sleep profiles, and a multinomial logistic regression examined differences of anxiety and depression among the sleep profiles. Results: The latent profile analysis revealed three sleep profiles: "variable sleepers" (48.3%), "consistently poor sleepers" (45.4%), and "night wakers" (6.4%). Consistently poor sleepers had lower rates of anxiety (g = .76; p = .009) and depression (g = .81; p = .003) than variable sleepers and had significantly lower rates of anxiety than night wakers (g = .52; p = .05); all other differences were nonsignificant (ps > .05). Discussion: Youth with craniopharyngioma who have nightly variations in sleep may have worse psychological functioning than those with more consistent, albeit poor, sleep patterns. Patients with craniopharyngioma who report variable sleep should be assessed for anxiety and depression to prevent and intervene on emotional difficulties that may be reciprocally related to sleep.

Consequences of COVID-19 Confinement on Anxiety, Sleep and Executive Functions of Children and Adolescents in Spain

Children and adolescents are not indifferent to the dramatic impact of the COVID-19 pandemic, and the need to be forced to live in confinement. The change in life to which they have been abruptly subjected forces us to understand the state of their mental health in order to adequately address both their present and future needs. The present study was carried out with the intention of studying the consequences of confinement on anxiety, sleep routines and executive functioning of 1,028 children and adolescents, aged from 6 to 18 years, residing in Spain to; assess if there are differences regarding these consequences in terms of sex and age; how anxiety affects executive functioning in males and females; and to examine the possible correlations between the measured variables. For this purpose, an online questionnaire containing five sections was designed: the first section gathers information on sociodemographic and health data, while the following sections gather information from different standardized scales which measure anxiety, sleep and executive functions, whose items were adapted in order to be completed by parents, and/or legal guardians. The statistical analyzes carried out highlights significant differences in executive functioning between males and females. In turn, in regards to age, greater difficulties were detected in anxiety in the 9 to 12 age group and greater sleep disturbances between 13 and 18 year olds. On the other hand, significant differences were found in intra-sexual executive functioning depending on whether they presented greater or lesser anxiety, with executive functioning being more tendentiously maladjusted in males than in females, revealing a significantly relevant effect size (p = 0.001; ω2 = 0.27 BRIEF-2; ω2 = 0.19 BDEFS-CA; 95%). Positive correlations are obtained between state anxiety and sleep and executive functioning alterations. Finally, through Path Analysis, it is verified that state anxiety is the variable with the greatest weight within the model that would explain the alteration in the executive functioning of the present sample.

Chronic Sleep Reduction in Childhood and Adolescence

BACKGROUND

Habitually shortened nighttime sleep is a common phenomenon in childhood and adolescence, sometimes associated with chronic sleep reduction (CSR). CSR is associated with impairments of performance ability and emotional well-being. The extent to which children and adolescents in Germany suffer from CSR is unclear; it is also unclear what factors are predictive of CSR.

METHODS

In the present study, we carried out a telephone survey in a representative sample of 998 children and adolescents aged 12 to 17, asking them about their sleep behavior, sleep disturbances, and mental well-being. A standardized method was used.

RESULTS

The point prevalence of CSR was found to be 12.5% (95% confidence interval, [10.5; 14.6]). Children and adolescents affected by CSR reported a significantly higher frequency of insomnia, delayed sleep-phase syndrome, restless legs syndrome, and obstructive sleep apnea. Female sex, pro - longed absence from school or vocational training, emotional and behavioral disturbances, age over 15 years, bedtimes after 10:38 pm on nights before school (or vocational training), getting up after 10:04 on days off, and reported insomnia were all associated with CSR, with odds ratios (OR) ranging from 2.2 to 21.1 (R2 = 0.32 in a logistic regression model).

CONCLUSION

One in eight persons aged 12 to 17 in Germany, particularly girls, meets the criteria for CSR. CSR is associated with sleep disturbances and significantly impaired mental health and should, therefore, always be kept in mind in routine clinical practice. We provide a set of indicators for possible CSR that patients can easily be asked about.

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.

Associations Between Poor Sleep Quality, Anxiety Symptoms, and Depressive Symptoms Among Chinese Adolescents Before and During COVID-19: A Longitudinal Study

Since the novel coronavirus disease 2019 (COVID-19) outbreak, adolescents' emerging mental health and behavior issues have been an international public health concern. This longitudinal study aimed to examine the situation of poor sleep quality, anxiety, and depressive symptoms among Chinese adolescents and to explore the associations between them before and during COVID-19. A total of 1,952 middle and high school students as eligible participants at baseline (pre-COVID-19, Wave 1; response rate: 98.79%), 1,831 eligible students were followed up at Wave 2 (October 2019 to December 2019, pre-COVID-19; retention rate: 93.80%), and 1,790 completed the follow-up at Wave 3 (during the COVID-19; retention rate: 97.80%). The mean age of the baseline students was 13.56 (SD: 1.46) years. The differences in anxiety and depressive symptoms between Wave 1, Wave 2, and Wave 3 were not statistically significant. The proportion of students with poor sleep quality increased over time, from Wave 1 (21.0%) to Wave 3 (26.0%, OR = 1.37, 95% CI = 1.17-1.60, P = 0.001) and from Wave 2 (21.9%) to Wave 3 (OR = 1.29, 95% CI = 1.11-1.51, P < 0.001). The cross-lagged generalized linear mixed models revealed that the concurrent and cross-lagged associations of poor sleep quality with anxiety symptoms across the three waves were significant (P < 0.05) and vice versa. Only a marginally significant positive cross-lagged association between poor sleep quality at Wave 2 and depressive symptoms at Wave 3 was found (standardized β estimate = 0.044, SE = 0.022, P = 0.045). Sleep quality was adversely affected during COVID-19, and the bidirectional associations of poor sleep quality with anxiety symptoms could not be neglected.

Psychological Distress, Drug Use, and Internet Use: The Association with Poor Sleep Quality in a Sample of Secondary School Students

Sleep problems are common among children and adolescents. Sleep quality plays a significant role in their mental health. We aimed to determine the prevalence of poor sleep quality (PSQ) among secondary school students, identify sociodemographic factors associated with PSQ in this group, and examine the independent associations of psychological distress, stimulant use, and internet use with PSQ. Data were collected from 420 secondary school students from four different schools who were selected using a mixture of convenience and random sampling. A set of questionnaires was administered to collect data, and it consisted of 5 sections measuring: the sociodemographic, drug use, psychological distress, internet use, and sleep quality. A total of 378 questionnaires were analyzed. The participants comprised 174 (46.2%) males and 203 (53.8%) females who were between 10 and 21 years. The mean age was 14.78 years. The prevalence of those who had PSQ was 12.2%. A logistic regression model showed that anxiety (AOR = 1.20, 95% CI: 1.10-1.32), depression (AOR = 1.12, 95% CI: 1.00-1.25), and internet use (AOR = 1.02, 95% CI: 1.00-1.03) were significantly associated with PSQ. PSQ commonly exists among students and has a relationship with their psychological state and potentially addictive behavior, such as internet use. We prescribed the optimal treatment of psychological disorders and addictive behavior, of which sleep problems are a typical fallout.

Discrimination and Sleep Mediate Ethnic/Racial Identity and Adolescent Adjustment: Uncovering Change Processes With Slope-as-Mediator Mediation

This study employs slope-as-mediator techniques to explore how the daily association between ethnic/racial discrimination and sleep disturbances serves as an intermediary link between ethnic/racial identity (ERI) and psychological adjustment. In a diverse sample of 264 adolescents (Mage  = 14.3 years old, 70% female, 76% United States born, 25% African American, 32% Asian American, 43% Latinx), discrimination was associated with sleep disturbance. Furthermore, ERI commitment buffered the impact of discrimination on sleep, whereas ERI exploration exacerbated the impact of discrimination. Finally, the daily level association between discrimination and sleep (i.e., daily slope) mediated the association between ERI and adolescent adjustment. Substantive links between discrimination and sleep are discussed as well as broader applications of slope-as-mediator techniques.

The Role of Active Coping in the Relationship Between Learning Burnout and Sleep Quality Among College Students in China

Learning burnout negatively influences students' learning and well-being. Sleep quality is directly related to students' health and learning outcomes. Research indicates that sleep quality and coping style may be associated with learning burnout. However, the interrelationship among learning burnout, sleep quality, and coping style has not yet been fully studied. This study aimed to explore the relationship between sleep quality and learning burnout and examine whether coping mediates this relationship in Chinese university students. A total of 228 undergraduate students were recruited to participate in this research. The Simplified Coping Style Questionnaire (SCSQ), Learning Burnout Questionnaire (LBQ), and Pittsburgh Sleep Quality Index-Chinese (PSQI-C) were employed to collect data. The results showed the following: (1) poor sleep quality had a positive association with learning burnout, and (2) active coping style mediated the effects of poor sleep quality on learning burnout and the dimensions of learning burnout (depression and low sense of achievement). The findings of the current study contribute to knowledge of learning burnout and provide theoretical evidence for further educational interventions.

Novel insights from actigraphy: Anxiety is associated with sleep quantity but not quality during childhood

Anxiety and sleep function change dynamically across development, and sleep dysfunction has emerged as a correlate and predictor of anxiety in pediatric clinical samples. Despite this, previous research has not investigated how associations between qualitative and quantitative measures of sleep function change with anxiety across development, specifically from childhood to adolescence. The present study used actigraphy collection to examine whether associations between quantitative and qualitative sleep function and anxiety differed as a function of developmental stage in a community pediatric sample (8-17 years old; N = 92). Age moderated the association between anxiety and sleep quantity, but not sleep quality. Contrary to hypotheses, higher anxiety was related to increased sleep for children, but not adolescents. Results suggest age-related changes in the association between sleep function and anxiety across development, with implications for targeting sleep-related interventions for youth with anxiety.

Sleep disturbances and internalizing behavior problems following pediatric traumatic injury

OBJECTIVE

This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or extracranial/bodily injury (EI) in children and adolescents, relative to typically developing (TD) children. We also examined longitudinal relations between SD and internalizing problems postinjury.

METHOD

Participants (N = 87) ages 8-15 included youth with TBI, EI, and TD children. Injury groups were recruited from a Level 1 trauma center after sustaining vehicle-related injuries. Parent-reported SD and internalizing problems were assessed at preinjury/baseline, and 6 and 12 months postinjury. Linear mixed models evaluated the relation of group and time of assessment on outcomes.

RESULTS

Controlling for age, the combined traumatic injury group experienced significantly higher postinjury levels of SD (p = .042) and internalizing problems (p = .024) than TD children; however, TBI and EI injury groups did not differ from each other. Injury severity was positively associated with SD in the EI group only, but in both groups SD was associated with additional postinjury sequelae, including fatigue and externalizing behavior problems. Internalizing problems predicted subsequent development of SD but not vice versa. The relation between injury and SD 1 year later was consistent with mediation by internalizing problems at 6 months postinjury.

CONCLUSIONS

Children with both types of traumatic injury demonstrated higher SD and internalizing problems than healthy children. Internalizing problems occurring either prior to or following pediatric injury may be a risk factor for posttraumatic SD. Consequently, internalizing problems may be a promising target of intervention to improve both SD and related adjustment concerns. (PsycINFO Database Record

Cumulative Childhood Lead Levels in Relation to Sleep During Adolescence

STUDY OBJECTIVES

Lead exposure has been linked to adverse cognitive outcomes among children, and sleep disturbances could potentially mediate these relationships. As a first step, whether childhood lead levels are linked to sleep disturbances must be ascertained. Prior studies of lead and sleep are scarce and rely on parent-reported sleep data.

METHODS

The study population included 395 participants from the Early Life Exposure in Mexico to Environmental Toxicants project, a group of sequentially enrolled birth cohorts from Mexico City. Blood lead levels measured from ages 1 to 4 years were used to calculate a cumulative measure of early childhood lead levels. Average sleep duration, sleep fragmentation, and movement index were assessed once between the ages of 9 and 18 years with wrist actigraphs worn for a continuous 7-day interval. Linear regression models were fit with average sleep duration, fragmentation, or movement as the outcome and cumulative lead levels divided into quartiles as the exposure, adjusted for age, sex, and maternal education.

RESULTS

Mean (standard deviation) age at follow-up was 13.8 (1.9) years, and 48% of participants were boys. Median (interquartile range) cumulative childhood lead level was 13.7 (10.8, 18.0) μg/dL. Patients in the highest quartile of the cumulative childhood lead group had on average 23 minutes less sleep than those in the first quartile in adolescence (95% confidence interval [7, 39]; P, trend = .02). Higher cumulative lead level was associated with higher sleep fragmentation in younger adolescents (younger than 14 years) only (P, interaction = .02).

CONCLUSIONS

Shorter sleep duration may represent an as-yet unrecognized adverse consequence of lead exposure in youth.

Interactions between sleep duration and quality as predictors of adolescents' adjustment

OBJECTIVES

We examined interactions between adolescents' sleep duration and quality as predictors of their internalizing symptoms and externalizing behaviors. As a secondary aim, we assessed adolescent sex, race/ethnicity, and socioeconomic status (SES) as additional moderators of risk (ie, 3-way interactions among sleep duration; quality; and sex, race, or SES).

DESIGN

The study used a cross-sectional design.

SETTING

Participants were from small towns and semirural communities in Alabama.

PARTICIPANTS

The sample consisted of 235 adolescents (M_age = 15.78 years, SD = 9.60 months) and was diverse with respect to sex (54% female), race/ethnicity (32% Black/African American, 67% White), and SES.

MEASUREMENTS

Sleep duration (actual sleep minutes) was examined with actigraphs for 1 week. Adolescents reported on their subjective sleep quality, internalizing symptoms, and externalizing behavior with psychometrically sound measures.

RESULTS

Findings revealed interactions between sleep duration and sleep quality as predictors of adolescents' adjustment. Adolescents with both short sleep duration in conjunction with poor sleep quality had the highest levels of internalizing symptoms and aggressive and rule-breaking behavior. SES interacted with sleep duration and sleep quality to predict rule-breaking behavior, and the highest level of problems was observed for adolescents from lower-SES homes who had short sleep duration accompanied by poor sleep quality.

CONCLUSIONS

Findings identify the conjoint role of sleep duration and quality as predictors of adolescents' socioemotional adjustment and emphasize the importance of examining multiple sleep parameters simultaneously toward a better understanding of adaptation in adolescence.

Meta-analysis of the mental health status of left-behind children in China

The aims of this study were to systematically evaluate and comparatively analyse the mental health status of left-behind children (LBC) in China and to provide a scientific basis for mental intervention and healthy education for LBC. Six electronic databases were searched for studies (published from 1 January 2010 to 5 March 2018) of the mental health of LBC using the Mental Health Test scale. We only selected original articles that either reported the incidence of serious mental health status or the means and standard deviations of each factor score of the scale. The pooled rates and weighted mean difference were calculated. The results indicated that the incidence of serious mental health status of LBC is nearly 2.7 times higher than that of non-LBC. The scores for most of the factors analysed by the Mental Health Test of LBC were higher than those of non-LBC. In addition, the mental health status of left-behind girls is worse than that of left-behind boys. Except for impulsive tendency, there was no significant difference in the mental health status of LBC in primary and junior high schools. In terms of the different types of guardianship, the mental health status of LBC under a grandparent's guardianship and parental peer' guardianship is more serious than that of LBC under a single-parent guardianship. The mental health status of LBC is poor, particularly for left-behind girls. The primary mental problems faced by LBC are learning anxiety, social anxiety and physical symptoms. It is necessary to develop more targeted measures to prevent and manage LBC.

Sleep duration and social jetlag are independently associated with anxious symptoms in adolescents

Although short total sleep time (TST) is associated with increased anxious symptoms in adolescents, it is unknown whether social jetlag, a misalignment between sleep timing on the weekend and school week, is independently associated with anxious symptoms. In the current study, sleep timing, anxious symptoms, and demographic information were assessed from 3097 adolescents (48% female, mean ± SD age 15.59 ± .77 years) from the age 15 wave of the Fragile Families and Child Wellbeing Study. Social jetlag was calculated as the absolute value of the midpoint of sleep on the weekend minus the midpoint of sleep during the school week. Anxious symptoms were measured through the 6-item anxiety subscale of the Brief Symptom Inventory 18. We assessed associations between sleep variables and anxious symptoms using multiple linear regression. Adjusted analyses controlled for sex, race/ethnicity, age in years, body mass index percentile, number of other children below the age of 18 in the household, and primary caregiver (PCG) married/cohabiting with youth's biological parent, PCG employment status, PCG household income and PCG education level. In fully adjusted models (R² = .034), school night TST (b = -.04, ∆R² = .005, p < .001) was negatively associated with anxiety symptoms, while social jetlag (b = .04, ∆R² = .009, p < .001) was positively and independently associated with anxiety symptoms. Findings indicate small associations of school night TST and social jetlag with anxious symptoms. Thus, maintenance of optimal emotional health in adolescents may require both sufficient sleep duration and regularity of sleep timing across the week.

Increased Incidence of Obstructive Sleep Apnea in Hospitalized Children After Enterovirus Infection: A Nationwide Population-based Cohort Study

BACKGROUND

We report the first nationwide population-based cohort study using Taiwan's National Health Insurance Research Database on the association between enterovirus (EV) infection and the incidence of sleep disorders in a pediatric population.

METHODS

Two matched groups of children under 18 years of age were included in the analyses for nonapneic sleep disorder and obstructive sleep apnea (OSA). Among them, 316 subjects were diagnosed with OSA during the surveillance period, including 182 in the EV infection group and 134 in the non-EV infection group.

RESULTS

Hospitalization because of EV infection was associated with OSA after adjusting for age, sex, urbanization atopic disease and perinatal complications (adjusted hazard ratio: 1.62, 95% confidence interval: 1.18-2.21; P = 0.003). An additional factor significantly associated with sleep apnea was allergic rhinitis (hazard ratio: 4.82, 95% confidence interval: 3.45-6.72).

CONCLUSIONS

Children with severe EV infection (ie, requiring hospitalization) carry a significantly higher risk of developing OSA, particularly in those with allergic rhinitis. As pediatric obstructive sleep apnea is a treatable sleep disorder, we emphasize regular follow-up and early detection in children with EV infection.

Review: Schlafprobleme und psychische Störungen im Kindes- und Jugendalter

Zusammenfassung. Schlafprobleme und -störungen sind in Kindheit und Jugendalter weitverbreitet. Dieser Review beleuchtet den Zusammenhang zwischen Schlafproblemen und psychischen Störungen im Kindes- und Jugendalter. Schlafprobleme und -störungen gelten zum einen als Risikofaktoren für die Entwicklung psychischer Störungen, aber auch als Symptom und Auswirkung psychischer Störungen. Oft stehen Schlafverhalten und Psychopathologie in einer Wechselwirkung, sodass Schlafprobleme zur Intensität und Aufrechterhaltung psychischer Störungen beitragen. Dieser bidirektionale Zusammenhang ist sowohl in der frühen Kindheit als auch im Schulalter und bei Jugendlichen zu beobachten. Viele Studien konnten zeigen, dass es einen langfristigen Zusammenhang über die kindliche Entwicklung hinweg gibt. Sowohl Umweltfaktoren als auch genetische Faktoren scheinen bei der Entwicklung und Aufrechterhaltung dieses Zusammenhangs eine Rolle zu spielen. Diverse Forschungsergebnisse zeigen, dass die Behandlung von psychischen Störungen und die Behandlung von Schlafproblemen sich wechselseitig positiv beeinflussen. Daher ist die Berücksichtigung von Schlafproblemen in der Diagnostik und Behandlung, aber auch in der Prävention von psychischen Störungen dringend anzuraten.

Bidirectional Associations Between Child Sleep Problems and Internalizing and Externalizing Difficulties From Preschool to Early Adolescence

Importance

Although multiple cross-sectional and longitudinal studies have established that sleep problems and behavioral difficulties are associated in children, the directionality of this association and whether sleep problems are differentially associated with different types of childhood behavioral difficulties are unclear. Understanding these associations will inform the focus and timing of interventions.

Objective

To determine whether longitudinal and reciprocal associations exist between child sleep problems and externalizing, internalizing, or both behavioral difficulties.

Design, Setting, and Participants

Prospective cohort study using nationally representative data from the first 5 waves (2004, 2006, 2008, 2010, and 2012) of the kindergarten cohort (4983 children aged 4-5 years in 2004) collected for the Longitudinal Study of Australian Children. Associations were evaluated using cross-lagged structural equation model analyses performed from May 25, 2016, to September 20, 2017.

Main Outcomes and Measures

Child sleep problems and internalizing and externalizing behavioral difficulties. Sleep problems were defined using parent-reported child sleep problem severity and specific difficulties (ie, difficulty getting to sleep at night, not happy sleeping alone, waking during the night, and restless sleep) on 4 or more nights of the week. Child behavioral difficulties were defined using the parent-reported Strengths and Difficulties Questionnaire for externalizing difficulties (conduct problems and hyperactivity/inattention subscales) and internalizing difficulties (emotional problems subscale).

Results

The 4983 children enrolled in 2004 had a mean (SD) age of 4.7 (0.2) years and comprised a similar percentage of boys (2536 [50.9%]) and girls. In 2012, 3956 children (79.4%) aged 12 to 13 years were retained. Significant bidirectional associations were detected between sleep problems and externalizing difficulties during the elementary school transition period, with greater sleep problems associated with later externalizing behavior and vice versa (cross-lagged path coefficient, 0.04 [95% CI, 0.01-0.08] to 0.09 [95% CI, 0.06-0.13]). Although sleep was a significant driver of later internalizing difficulties (coefficient, 0.10 [95% CI, 0.07-0.14] to 0.16 [95% CI, 0.12-0.19]), the reverse association was not significant. In the final model that included all 3 constructs, the associations were attenuated but remained significant over time.

Conclusions and Relevance

These results suggest that future studies should investigate whether implementing sleep problem intervention decreases the occurrence of both externalizing and internalizing difficulties. Interventions targeting externalizing, but not internalizing, difficulties may benefit childhood sleep.

Maternal Sensitivity Predicts Fewer Sleep Problems at Early Adolescence for Toddlers with Negative Emotionality: A Case of Differential Susceptibility

Theory underscores the importance of parenting in sleep development, but few studies have examined whether links vary by temperament. To address this gap, we tested whether potential links between early maternal sensitivity and early adolescent sleep problems varied by child negative emotionality and delay of gratification. Using data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (N = 820), we found that high maternal sensitivity predicted fewer bedtime problems and longer sleep duration at 6th grade for toddlers with high negative emotionality, whereas low maternal sensitivity predicted the reverse. No differences were observed for low negative emotionality. Moreover, delay of gratification predicted fewer bedtime problems at 6th grade, but did not moderate associations between maternal sensitivity, negative emotionality, and sleep. Findings demonstrate that high, but not low, negative emotionality renders toddlers differentially susceptible and receptive to maternal sensitivity in relation to sleep.

Impact of a sleep course on sleep, mood and anxiety symptoms in college students: A pilot study

OBJECTIVE

To examine the impact of a sleep course on sleep-related behaviors, mood, and anxiety in college students.

PARTICIPANTS

Participants were 145 students enrolled in either the sleep course (n = 70) or a psychology course (n = 75); data were collected in September 2014, November 2014, and February 2015.

METHODS

Sleep characteristics and symptoms of depression and anxiety were assessed using validated questionnaires and sleep logs. Linear, logistic and proportional odds regression models were used to test course effects.

RESULTS

In November, sleep course students reported significant differences in sleep hygiene (SHI; p < .001), perceived sleep latency (PSQI; p < .05), and circadian sleep phase (MEQ; p < .05), compared to controls. In February, the sleep course students maintained most of the aforementioned gains and reported fewer symptoms of depression (CES-D; p = .05) and anxiety (BAI; p < .05).

CONCLUSIONS

These positive preliminary results indicate that focused education has the potential to improve sleep among college students.

Influence of sleep disorders on somatic symptoms, mental health, and quality of life in patients with chronic constipation

BACKGROUND

Sleep disturbance is a common symptom in CC patients, and it is positively related to greater somatic and psychiatric symptoms.

METHODS

The participants were 126 adult outpatients with CC. The measures were: constipation-Constipation Scoring System (CSS) and Patient Assessment of Constipation-Symptoms (PAC-SYM); sleep-Pittsburgh Sleep Quality Index (PSQI); anxiety-General Anxiety Disorder-7 (GAD-7); depression-Patient Health Questionnaire-9 (PHQ-9); and QOL-Patient Assessment of Constipation Quality of Life (PAC-QOL) and SF-36. Patients were divided into sleep-disorder and normal-sleep groups by their PSQI scores.

RESULTS

The sleep-disorder group had significantly higher rates of incomplete defecation and blockage and higher CSS scores, PAC-SYM total scores, and PAC-SYM rectal-item scores than the normal-sleep group. GAD-7 and PHQ-9 scores were significantly higher in patients with poor sleep. Furthermore, sleep disorders, depression, and anxiety were all positively correlated with constipation severity. "Worry/anxiety" score of PAC-QOL scale was significantly higher and scores for seven SF-36 subscales were significantly lower in patients with poor sleep. In addition, correlation analyses showed significant negative relations between QOL and constipation, sleep disturbance, anxiety as well as depression. However, multiple regression revealed that PAC-QOL was positively associated with severe constipation and SF-36 was negatively associated with anxiety and depression. But sleep disturbance was not the independent risk factor for QOL of CC patients.

CONCLUSION

Sleep disorders may worsen the physical- and mental health of CC patients. Sleep disturbance may lower CC patients' QOL indirectly through the combined effects of anxiety, depression, and constipation.

Association between depression and enterovirus infection: A nationwide population-based cohort study

Enterovirus (EV) infection is common among children and adolescents. Few studies have investigated the relationship of depression after EV infection. This study explores an association between EV infection and subsequent depression in children and adolescents and assesses the risk of depression after EV infection with central nervous system involvement in a nationwide population-based retrospective cohort.A random sample of 1,000,000 people was derived from Taiwan National Health Insurance Research Database and we identified enrollees less than 18 years with EV infection before 2005 and followed up until December 2009. A total 48,010 cases with EV infection and 48,010 healthy controls matched for sex, age, and residence were obtained. Association between EV infection and depression risk was assessed by Cox proportional hazards models to determine the hazard ratios (HRs) and confidence intervals (CIs). We further stratified EV infection into with central nervous system (CNS) involvement and without and compared with matched cohort.Children and adolescents with EV infection had no elevated risk of depression compared with healthy controls (adjusted HR, aHR = 1.00, 95% CI: 0.83-1.21). However, CNS EV infection was associated with increased risk of depression (aHR = 1.62, 95% CI: 1.02-2.58) in the fully adjusted Cox regression model.To the best of our knowledge, this is the first study investigating depression in children and adolescents with CNS EV infection. The results suggested that children and adolescents with CNS EV infection were a susceptible group for subsequent depressive disorders.

The direction of the relationship between symptoms of insomnia and psychiatric disorders in adolescents

BACKGROUND

This study assessed the direction of the relationship between symptoms of insomnia disorder, depression, various anxiety disorders and obsessive compulsive disorder (OCD) in adolescents after controlling for age, gender, chronotype, and outcome variable at baseline.

METHODS

Data was collected in eight high schools in Adelaide, South Australia, at two time-points approximately 6 months apart. The study was completed by 318 and 255 high school students at baseline and follow-up, respectively, aged 12-18 (M=14.96, SD=1.34) in grades 7-11 at baseline. Hierarchical regression analyses were used to assess each relationship, the first model controlling for age, gender and chronotype, and the second controlling for outcome variable at baseline.

RESULTS

Insomnia symptoms predicted and were predicted by symptoms of each psychiatric disorder in model 1. In model 2, insomnia symptoms predicted symptoms of depression, and vice-versa. Symptoms of insomnia also predicted symptoms of separation anxiety disorder (SAD) once SAD, but not vice-versa, in model 2. Symptoms of obsessive compulsive disorder (OCD) and social phobia (SP) predicted symptoms of insomnia disorder in model 2, but not vice-versa. Insomnia symptoms were no longer related to symptoms of other anxiety disorders in model 2.

LIMITATIONS

The use of self-report measures, and potential predisposing, precipitating, perpetuating or preventative factors were not assessed.

CONCLUSIONS

Symptoms of insomnia disorder are bidirectionally related to depressive symptoms independent from baseline symptoms, and unidirectionally related to symptoms of OCD and SP where OCD and SP are independent risk-factors of the development of insomnia symptoms.

The role of day-to-day emotions, sleep, and social interactions in pediatric anxiety treatment

Do day-to-day emotions, social interactions, and sleep play a role in determining which anxious youth respond to supportive child-centered therapy (CCT) versus cognitive behavioral therapy (CBT)? We explored whether measures of day-to-day functioning (captured through ecological momentary assessment, sleep diary, and actigraphy), along with clinical and demographic measures, were predictors or moderators of treatment outcome in 114 anxious youth randomized to CCT or CBT. We statistically combined individual moderators into a single, optimal composite moderator to characterize subgroups for which CCT or CBT may be preferable. The strongest predictors of better outcome included: (a) experiencing higher positive affect when with one's mother and (b) fewer self-reported problems with sleep duration. The composite moderator indicated that youth for whom CBT was indicated had: (a) more day-to-day sleep problems related to sleep quality, efficiency, and waking, (b) day-to-day negative events related to interpersonal concerns, (c) more DSM-IV anxiety diagnoses, and (d) college-educated parents. These findings illustrate the value of both day-to-day functioning characteristics and more traditional sociodemographic and clinical characteristics in identifying optimal anxiety treatment assignment. Future studies will need to enhance the practicality of real-time measures for use in clinical decision making and evaluate additional anxiety treatments.

Developmental Trajectories of Sleep Problems from Childhood to Adolescence Both Predict and Are Predicted by Emotional and Behavioral Problems

Although the prevalence rates of sleep disorders at different stages of childhood and adolescence have been well established, little is known about the developmental course of general sleep problems. This also holds true for the bidirectional relationship between sleep problems and emotional as well as behavioral difficulties. This longitudinal study investigated the general pattern and the latent trajectory classes of general sleep problems from a large community sample aged 5–14 years. In addition, this study examined the predictive value of emotional/behavioral difficulties (i.e., anxiety/depression, attention problems, and aggressive behavior) on sleep problems latent trajectory classes, and vice-versa. Participants (N = 1993) were drawn from a birth cohort of Western Australian children born between 1989 and 1991 who were followed until 14 years of age. Sleep problems were assessed at ages 5, 8, 10, and 14, respectively, whereas anxiety/depression, attention problems, and aggressive behavior were assessed at ages 5 and 17 years. Latent growth curve modeling revealed a decline in an overall pattern of sleep problems during the observed 10-year period. Anxiety/depression was the only baseline factor that predicted the longitudinal course of sleep problems from ages 5 to 14 years, with anxious and depressed participants showing faster decreasing patterns of sleep problems over time than those without anxiety or depression. Growth mixture modeling identified two classes of sleep problem trajectories: Normal Sleepers (89.4%) and Troubled Sleepers (10.6%). Gender was randomly distributed between these groups. Childhood attention problems, aggressive behavior, and the interaction between gender and anxiety/depression were significantly predictive of membership in the group of Troubled Sleepers. Group membership in Troubled Sleepers was associated with higher probability of having attention problems and aggressive behavior in mid-adolescence. Boys and girls with behavioral difficulties, and girls with emotional difficulties were at increased risk of having sleep problems during later childhood and adolescence. Developmental trajectories of sleep problems were also predictive of behavioral difficulties in later life. Findings from this study provide empirical evidence for the heterogeneity of sleep problems and their development, and emphasize the importance of understanding sleep problems and their relationship to children and adolescents’ mental health.

Is there an association between short sleep duration and adolescent anxiety disorders?

OBJECTIVE

The purpose of this study is to provide the first data on the prospective, reciprocal association between short sleep duration and DSM-IV anxiety disorders among adolescents.

METHODS

A community-based two-wave cohort study included 4175 youths aged 11-17 years at baseline, with 3134 of these followed up a year later, drawn from a metropolitan area with a population of over 4 million. Anxiety is defined as any DSM-IV anxiety disorder in the past year generalized anxiety: panic disorder, agoraphobia without panic, social phobia, and post-traumatic stress disorder. Short sleep duration is defined as ≤6 h of sleep per night.

RESULTS/CONCLUSIONS

In multivariate analyses, short sleep duration every night at baseline predicted anxiety disorders at follow-up, controlling for anxiety at baseline. Examining the reciprocal association, anxiety disorders at baseline did not predict short sleep duration at follow-up. We are the first to examine the reciprocal effects for anxiety disorders and sleep duration among adolescents using prospective data. The data suggest that reduced quantity of sleep may increase risk for anxiety, but anxiety does not increase risk for decreased sleep duration.

Annual Research Review: Sleep problems in childhood psychiatric disorders--a review of the latest science

BACKGROUND

Hippocrates flagged the value of sleep for good health. Nonetheless, historically, researchers with an interest in developmental psychopathology have largely ignored a possible role for atypical sleep. Recently, however, there has been a surge of interest in this area, perhaps reflecting increased evidence that disturbed or insufficient sleep can result in poor functioning in numerous domains. This review outlines what is known about sleep in the psychiatric diagnoses most relevant to children and for which associations with sleep are beginning to be understood. While based on a comprehensive survey of the literature, the focus of the current review is on the latest science (largely from 2010). There is a description of both concurrent and longitudinal links as well as possible mechanisms underlying associations. Preliminary treatment research is also considered which suggests that treating sleep difficulties may result in improvements in behavioural areas beyond sleep quality.

FINDINGS

To maximise progress in this field, there now needs to be: (a) greater attention to the assessment of sleep in children; (b) sleep research on a wider range of psychiatric disorders; (c) a greater focus on and examination of mechanisms underlying associations; (d) a clearer consideration of developmental questions and (e) large-scale well-designed treatment studies.

CONCLUSIONS

While sleep problems may sometimes be missed by parents and healthcare providers; hence constituting a hidden risk for other psychopathologies - knowing about these difficulties creates unique opportunities. The current excitement in this field from experts in diverse areas including developmental psychology, clinical psychology, genetics and neuropsychology should make these opportunities a reality.

Allergic Diseases and Internalizing Behaviors in Early Childhood

BACKGROUND AND OBJECTIVES

The relationship between allergic diseases and internalizing disorders has not been well characterized with regard to multiple allergic diseases or longitudinal study. The objective of this study was to examine the association between multiple allergic diseases in early childhood with validated measures of internalizing disorders in the school-age years.

METHODS

Children enrolled in the Cincinnati Childhood Allergy and Air Pollution Study underwent skin testing and examinations at ages 1, 2, 3, 4, and 7 years. At age 7, parents completed the Behavior Assessment System for Children, Second Edition (BASC-2), a validated measure of childhood behavior and emotion. The association between allergic diseases at age 4, including allergic rhinitis, allergic persistent wheezing, atopic dermatitis, and allergic sensitization, and BASC-2 internalizing, anxiety, and depression T scores at age 7 was examined by logistic and linear regression, adjusting for covariates.

RESULTS

The cohort included 546 children with complete information on allergic disease and BASC-2 outcomes. Allergic rhinitis at age 4 was significantly associated with elevated internalizing (adjusted odds ratio [aOR]: 3.2; 95% confidence interval [CI]: 1.8-5.8), anxiety (aOR: 2.0; 95% CI: 1.2-3.6), and depressive scores (aOR: 3.2; 95% CI: 1.7-6.5) at age 7. Allergic persistent wheezing was significantly associated with elevated internalizing scores (aOR: 2.7; 95% CI: 1.2-6.3). The presence of >1 allergic disease (aOR: 3.6; 95% CI: 1.7-7.6) and allergic rhinitis with comorbid allergic disease(s) (aOR: 4.3; 95% CI: 2.0-9.2) at age 4 had dose-dependent associations with internalizing scores.

CONCLUSIONS

Children with allergic rhinitis and allergic persistent wheezing at age 4 are at increased risk of internalizing behaviors at age 7. Furthermore, multiple allergic diseases had a dose-dependent association with elevated internalizing scores.