Prevalence and correlates of delayed sleep phase in high school students

Using the Person-Based Approach to Co-Create and Optimize an App-Based Intervention to Support Better Sleep for Adolescents in the United Kingdom: Mixed Methods Study

BACKGROUND

Poor sleep is a common problem in adolescents aged 14 to 18 years. Difficulties with sleep have been found to have a bidirectional link to mental health problems.

OBJECTIVE

This new research sought to involve young people in the co-creation of a new app, particularly those from underserved communities. The Sleep Solved app uses science-based advice to improve sleep-related behaviors and well-being. The app was developed using the person-based approach, underpinned by the social cognitive theory and the social-ecological model of sleep health.

METHODS

Young people (aged 14-18 y) were recruited from across the United Kingdom to contribute to patient and public involvement (PPI) activities. In partnership with our peer researcher (MHJ), we used a multitude of methods to engage with PPI contributors, including web-based workshops, surveys, think-aloud interviews, focus groups, and app beta testing.

RESULTS

A total of 85 young people provided PPI feedback: 54 (64%) young women, 27 (32%) young men, 2 (2%) genderfluid people, 1 (1%) nonbinary person, and 1 (1%) who reported "prefer not to say." Their levels of deprivation ranged from among the 40% most deprived to the 20% least deprived areas. Most had self-identified sleep problems, ranging from 2 to 3 times per week to >4 times per week. Attitudes toward the app were positive, with praise for its usability and use of science-based yet accessible information. Think-aloud interviews and a focus group identified a range of elements that may influence the use of the app, including the need to pay attention to language choices and readability. User experiences in the form of narrated audio clips were used to normalize sleep problems and provide examples of how the app had helped these users.

CONCLUSIONS

Young people were interested in using an app to better support their sleep and mental health. The app was co-created with strong links to theory- and evidence-based sleep hygiene behaviors. Future work to establish the effectiveness of the intervention, perhaps in a randomized controlled trial, would provide support for potential UK-wide rollout.

Just Let Me Sleep in: Identifying and Treating Delayed Sleep Phase Disorder in Adolescents

Individuals with delayed sleep phase disorder (DSPD) are unable to naturally fall asleep and awake at conventional times; for this reason, DSPD is often mistaken for insomnia. However, unlike many patients with insomnia, those with DSPD struggle to get up at appropriate times. DSPD is associated with school refusal, academic difficulties, and lower employment rate. DSPD in youth has prevalence as high as 16%, and is often comorbid with other psychiatric disorders. Treatments include appropriate light exposure during the day, melatonin use, developing an evening routine that minimizes arousal-increasing activities, and gradually shifting sleep-wake times toward more functional ones.

Classification and Epidemiology of Sleep Disorders in Children and Adolescents

Sleep disturbances are common in children and adolescents but still remain unrecognized and undertreated. Several classification systems of sleep disorders are available, which include recent attempts to develop more specific nosologic categories that reflect developmental aspects of sleep. The prevalence of sleep disorders has been studied across various samples of healthy, typically developing children and those with special medical, psychiatric, and neurodevelopmental needs. Sleep disorders are highly prevalent in children and adolescents with psychiatric disorders, making it important for mental health professionals to be aware of sleep problems and to address them in the context of psychiatric comorbidities.

The sleep-circadian interface: A window into mental disorders

Sleep, circadian rhythms, and mental health are reciprocally interlinked. Disruption to the quality, continuity, and timing of sleep can precipitate or exacerbate psychiatric symptoms in susceptible individuals, while treatments that target sleep-circadian disturbances can alleviate psychopathology. Conversely, psychiatric symptoms can reciprocally exacerbate poor sleep and disrupt clock-controlled processes. Despite progress in elucidating underlying mechanisms, a cohesive approach that integrates the dynamic interactions between psychiatric disorder with both sleep and circadian processes is lacking. This review synthesizes recent evidence for sleep-circadian dysfunction as a transdiagnostic contributor to a range of psychiatric disorders, with an emphasis on biological mechanisms. We highlight observations from adolescent and young adults, who are at greatest risk of developing mental disorders, and for whom early detection and intervention promise the greatest benefit. In particular, we aim to a) integrate sleep and circadian factors implicated in the pathophysiology and treatment of mood, anxiety, and psychosis spectrum disorders, with a transdiagnostic perspective; b) highlight the need to reframe existing knowledge and adopt an integrated approach which recognizes the interaction between sleep and circadian factors; and c) identify important gaps and opportunities for further research.

Cardiovascular risk in adults with Delayed Sleep Phase Syndrome (DSPS) and Attention-Deficit/Hyperactivity Disorder (ADHD)

TRIAL REGISTRATION

FASE, https://www.trialregister.nl/, #NTR3831.

Transdiagnostic Sleep and Circadian Intervention for Adolescents Plus Text Messaging: Randomized Controlled Trial 12-month Follow-up

OBJECTIVE

The Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C) was developed to improve sleep and circadian functioning in adolescents. This study examined the 12-month effects for TranS-C compared with psychoeducation (PE). We also investigated whether a text messaging intervention can promote maintenance of treatment effects.

METHOD

At the baseline, adolescents (58% female, average age = 14.8 years) with an eveningness chronotype were randomized to TranS-C (n = 89) or PE (n = 87). At 6-month follow-up, participants were randomized to receive text messages that had repeated treatment information (n = 47), text messages that prompted the recall of treatment information (n = 50), or no text messages (n = 47).

RESULTS

Relative to PE, TranS-C was associated with a reduced eveningness (b = 2.06, p = .005, d = 0.29) from the baseline to a 12-month follow-up. TranS-C treatment effects, relative to PE, were augmented by receiving text messages, compared to no text messages, for eveningness from baseline to 12-month follow-up (b = 1.38, p = .008, d = 0.28) and from 6- to 12-month follow-up (b = 1.07, p = .046, d = 0.21). Neither TranS-C nor text messages were significantly associated with other primary outcomes. TranS-C and text messages were significantly associated with improvements on selected secondary sleep and health outcomes through follow-up.

CONCLUSIONS

For adolescents with an eveningness chronotype, improved sleep and circadian functioning on selected outcomes were maintained over 12 months for TranS-C compared with PE. Text messages boosted the effects of TranS-C through 12-month follow-up.

Sleep and dropout from upper secondary school: A register-linked study

OBJECTIVE

The present study investigates the association between sleep in late adolescence and completion of upper secondary school.

METHODS

The data are drawn from the youth@hordaland study, a large population-based study conducted in 2012, linked with official educational data in Norway (N = 8838).

RESULTS

High school dropout was more prevalent among adolescents who had insomnia (20.6%) compared to those without insomnia (14.3%; adjusted risk ratios = 1.50; 95% confidence intervals: [2.19-2.92]). There was also a higher rate of school dropout among those who had symptoms of delayed sleep-wake phase (21%) compared to those without delayed sleep-wake phase (14.3%); adjusted risk ratios = 1.43, 95% confidence intervals: (1.28-1.59). School noncompleters were also characterized by reporting 44 minutes shorter sleep duration, longer sleep onset latency, and wake after sleep onset (both approx. 15 minutes) compared to school completers.

CONCLUSION

The importance of sleep for high school dropout rates highlights the importance of including sleep as a risk indicator and a possible target for preventive interventions in late adolescence.

Perspective: Teenagers and the sleep paradox

STUDY OBJECTIVES

Teenagers experience sleep deficits as they try to manage expectations with school, their social media presence, and increasingly competitive extracurriculars. Late-night screen time is a barrier to sleep hygiene. It is important to acknowledge and understand lifestyle challenges that can prevent teenagers from receiving adequate sleep every night. A teenager perspective on these issues and recommendations can incite better ways to outreach, educate, and support teenagers in maintaining good sleep.

METHODS

We describe what is known and not known about sleep health among teenagers and challenges to maintaining adequate sleep from the perspective of a third-year high school student. We also provide recommendations for outreach to promote early recognition of issues and tools that can support sleep hygiene to reinforce future mental and physical health.

RESULTS

While teenagers enjoy good sleep, this is limited by heavy loads of homework along with increasingly competitive extracurriculars, keeping up with social and cultural demands, and early school starts. Also, teenagers may not understand what adequate sleep entails and the full impact of sleep on well-being.

CONCLUSIONS

Social media provides a channel to extend outreach to teenagers to communicate the importance of consistent quality and quantity of sleep, increase awareness of sleep tracking tools, and highlight the impact of sleep on mental health. Additionally, better engagement is needed with schools and community to manage academic and extracurricular schedules that allow teenagers to schedule consistent bedtimes and wake times.

CITATION

Ramar S, Lloyd RM Perspective: teenagers and the sleep paradox. J Clin Sleep Med. 2023;19(8):1569-1571.

Seizure control with treatment of delayed sleep-wake phase disorder in juvenile myoclonic epilepsy: A case report

Juvenile Myoclonic Epilepsy (JME) is an idiopathic generalized epilepsy associated with a characteristic sleep/wake rhythm, with the tendency to go to bed later at night, to get up later in the morning. In the pediatric population, we have previously observed specific circadian and sleep/wake patterns of generalized seizures (6 am-12 pm) and myoclonic seizures (in wakefulness, 6 am to noon). Delayed Sleep-Wake Phase Disorder (DSWPD) is characterized by sleep initiation insomnia when attempting sleep at conventional times and difficulty waking at the required time. Here we present the case of a 20-year-old man with JME, diagnosed DSWPD (sleep schedule 3 am to 11 am), presenting with nocturnal seizures out of sleep, always between 5 and 6am. Improvements in seizure control (seizure frequency from 8 per month to 0 per month) were achieved with timed evening melatonin, combined with behavioral sleep-wake scheduling (sleep schedule 10 pm to 6 am) and morning light therapy. Recognition and characterization of DSWPD in JME, together with assessment of circadian and diurnal seizure patterns, may offer therapeutic consideration for better control of seizures.

Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions

STUDY OBJECTIVES

This review synthesizes the pediatric behavioral sleep intervention (BSI) evidence base, summarizes challenges in translating BSIs from research to practice, and provides recommendations for integrating implementation science methods to advance pediatric BSI research.

METHODS

We briefly review the common behavioral sleep disturbances among youth, discuss the pediatric BSIs with well-established evidence, and identify gaps in pediatric BSI research. We then identify contributors to the dearth of research evaluating pediatric BSIs in accessible settings and present a model for applying implementation science strategies to address identified gaps across the continuum of translational research.

RESULTS

Relatively few BSI trials include older children and adolescents. Similarly, there is limited research evaluating BSIs among racially and ethnically minoritized children and families and/or those of lower socioeconomic status backgrounds. Access to scalable and easily disseminable tools to treat pediatric sleep disturbances early in their development is crucial for promoting positive child outcomes. To address these gaps, researchers should apply implementation science theories, models, and frameworks to design new interventions for implementation, adapt existing interventions with end users and settings in mind, conduct hybrid effectiveness-implementation trials, and test implementation strategies.

CONCLUSIONS

Given the prevalence and consequences of poor sleep across developmental periods, pediatric BSIs must be effective as well as adaptable, scalable, and easily disseminable. Implementation science theories, models, and frameworks can enhance access to, engagement in, and the implementation and dissemination of scalable BSIs across diverse pediatric care settings and heterogeneous populations.

CITATION

Levenson JC, Williamson AA. Bridging the gap: leveraging implementation science to advance pediatric behavioral sleep interventions. J Clin Sleep Med. 2023;19(7):1321-1336.

Delayed sleep-wake phase disorder and its related sleep behaviors in the young generation

Delayed sleep-wake phase disorder (DSWPD) is a sleep disorder in which the habitual sleep-wake timing is delayed, resulting in difficulty in falling asleep and waking up at the desired time. Patients with DSWPD frequently experience fatigue, impaired concentration, sleep deprivation during weekdays, and problems of absenteeism, which may be further complicated by depressive symptoms. DSWPD is typically prevalent during adolescence and young adulthood. Although there are no studies comparing internationally, the prevalence of DSWPD is estimated to be approximately 3% with little racial differences between Caucasians and Asians. The presence of this disorder is associated with various physiological, genetic and psychological as well as behavioral factors. Furthermore, social factors are also involved in the mechanism of DSWPD. Recently, delayed sleep phase and prolonged sleep duration in the young generation have been reported during the period of COVID-19 pandemic-related behavioral restrictions. This phenomenon raises a concern about the risk of a mismatch between their sleep-wake phase and social life that may lead to the development of DSWPD after the removal of these restrictions. Although the typical feature of DSWPD is a delay in circadian rhythms, individuals with DSWPD without having misalignment of objectively measured circadian rhythm markers account for approximately 40% of the cases, wherein the psychological and behavioral characteristics of young people, such as truancy and academic or social troubles, are largely involved in the mechanism of this disorder. Recent studies have shown that DSWPD is frequently comorbid with psychiatric disorders, particularly mood and neurodevelopmental disorders, both of which have a bidirectional association with the pathophysiology of DSWPD. Additionally, patients with DSWPD have a strong tendency toward neuroticism and anxiety, which may result in the aggravation of insomnia symptoms. Therefore, future studies should address the effectiveness of cognitive-behavioral approaches in addition to chronobiological approaches in the treatment of DSWPD.

d-Glucosamine induces circadian phase delay by promoting BMAL1 degradation through AMPK/mTOR pathway

Circadian rhythms are closely linked to the metabolic network through circadian feedback regulation. The hexosamine biosynthetic pathway (HBP) is a branch of glucose metabolism that affects circadian rhythms through the O-linked N-acetylglucosamine modification (O-GlcNAcylation) of clock proteins. Here, we found out that, among the downstream metabolites regulated by d-glucosamine (GlcN) in HBP salvage pathway, only GlcN is able to induce circadian phase delay both in vitro and in vivo. Mechanistic studies indicated that the phase-shift induced by GlcN is independent of O-GlcNAcylation. Instead, GlcN selectively up-regulates p-AMPK activity, leading to the inhibition of mTOR signaling pathway, and thus down-regulation of p-BMAL1 both in human cell line and mouse tissues. Moreover, GlcN promoted BMAL1 degradation via proteasome pathway. These findings reveal a novel molecular mechanism of GlcN in regulating clock phase and suggest the therapeutic potential of GlcN as new use for an old drug in the future treatment of shift work and circadian misalignment.

Prospective association between evening circadian preference and academic functioning in adolescents: the role of daytime sleepiness

BACKGROUND

There is growing evidence for the role of circadian factors in adolescents' sleep and academic adjustment, with greater evening preference being linked to poorer academic functioning. However, studies have yet to evaluate this association prospectively in adolescence, nor have studies examined daytime sleepiness as a putative mechanism linking evening preference to poor academic functioning. The current study used a multi-informant design to test the prospective association of evening circadian preference, daytime sleepiness, and academic functioning (e.g., global academic impairment and grades) across 2 years in adolescence. As evening circadian preference, sleepiness, and academic problems are elevated in adolescents with ADHD, we used a sample enriched for adolescents with ADHD and explored whether ADHD moderated effects.

METHOD

Participants were 302 adolescents (M_age  = 13.17 years; 44.7% female; 81.8% White; 52% with ADHD). In the fall of eighth grade, adolescents reported on their circadian preference, and in the fall of ninth grade, adolescents and parents completed ratings of daytime sleepiness. In the middle of 10th grade, parents and teachers reported on adolescents' academic impairment and at the end of 10th grade, adolescents' grade point average (GPA) was obtained from school records.

RESULTS

Above and beyond covariates (e.g., adolescent sex, ADHD status, medication, sleep duration) and baseline academic impairment, greater self-reported evening preference in 8th grade predicted increased parent ratings of academic impairment in 10th grade indirectly via adolescent and parent ratings of daytime sleepiness in 9th grade. Furthermore, evening preference in 8th grade predicted greater teacher ratings of academic impairment and lower average GPA in 10th grade via parent ratings of daytime sleepiness in 9th grade, controlling for covariates and baseline GPA. ADHD status did not moderate indirect effects.

CONCLUSION

Findings underscore daytime sleepiness as a possible intervening mechanism linking evening preference to poor academic functioning across adolescence. Intervention studies are needed to evaluate whether targeting circadian preference and sleepiness improves academic functioning in adolescents.

The prevalence of sleep loss and sleep disorders in young and old adults

The ability to sleep declines with age. The National Sleep Foundation, USA has recommended a minimum sleep amount for all ages. Individuals who experience sleep lesser than the recommended amount could be sleep-deprived. Several factors like stress, altered circadian cycle, medical conditions, etc. cause sleep deficiency. Almost 50-60 % of elderly population suffer from sleep disorders such as sleep apnea, restless legs syndrome, REM sleep behavior disorder, etc. Chronic sleep deprivation may further lead to the development of diseases such as Alzheimer's and Parkinson's. This paper reviews the prevalence of sleep disorders and consequences of sleep loss in young and old adults.

Sleep Modulates Alcohol Toxicity in Drosophila

Alcohol abuse is a significant public health problem. While considerable research has shown that alcohol use affects sleep, little is known about the role of sleep deprivation in alcohol toxicity. We investigated sleep as a factor modulating alcohol toxicity using Drosophila melanogaster, a model for studies of sleep, alcohol, and aging. Following 24 h of sleep deprivation using a paradigm that similarly affects males and females and induces rebound sleep, flies were given binge-like alcohol exposures. Sleep deprivation increased mortality, with no sex-dependent differences. Sleep deprivation also abolished functional tolerance measured at 24 h after the initial alcohol exposure, although there was no effect on alcohol absorbance or clearance. We investigated the effect of chronic sleep deprivation using mutants with decreased sleep, insomniac and insulin-like peptide 2, finding increased alcohol mortality. Furthermore, we investigated whether pharmacologically inducing sleep prior to alcohol exposure using the GABA_A-receptor agonist 4,5,6,7-tetrahydroisoxazolo(5,4-c)pyridin-3-ol (THIP) mitigated the effects of alcohol toxicity on middle-aged flies, flies with environmentally disrupted circadian clocks, and flies with short sleep. Pharmacologically increasing sleep prior to alcohol exposure decreased alcohol-induced mortality. Thus, sleep prior to binge-like alcohol exposure affects alcohol-induced mortality, even in vulnerable groups such as aging flies and those with circadian dysfunction.

Melatonin in sleep disorders

Melatonin is the main hormone involved in the control of the sleep-wake cycle. It is easily synthesisable and can be administered orally, which has led to interest in its use as a treatment for insomnia. Moreover, as production of the hormone decreases with age, in inverse correlation with the frequency of poor sleep quality, it has been suggested that melatonin deficit is at least partly responsible for sleep disorders. Treating this age-related deficit would therefore appear to be a natural way of restoring sleep quality, which is lost as patients age. However, despite the undeniable theoretical appeal of this approach to insomnia, little scientific evidence is available that supports any benefit of this substitutive therapy. Furthermore, the most suitable dose ranges and pharmaceutical preparations for melatonin administration are yet to be clearly defined. This review addresses the physiology of melatonin, the different pharmaceutical preparations, and data on its clinical usefulness.

Impact of COVID-19 Pandemic on School-Aged Children's Physical Activity, Screen Time, and Sleep in Hong Kong: A Cross-Sectional Repeated Measures Study

Despite concerns about the negative effects of social distancing and prolonged school closures on children's lifestyle and physical activity (PA) during the COVID-19 pandemic, robust evidence is lacking on the impact of the pandemic-related school closures and social distancing on children's wellbeing and daily life. This study aimed to examine changes in the PA levels, sleep patterns, and screen time of school-aged children during the different phases of the COVID-19 outbreak in Hong Kong using a repeated cross-sectional design. School students (grades 1 to 12) were asked to report their daily electronic device usage and to fill in a sleep diary, recording their daily sleep onset and wake-up time. They were equipped with a PA monitor, Actigraph wGT3X-BT, to obtain objective data on their PA levels and sleep patterns. Students were recruited before the pandemic (September 2019-January 2020; n = 577), during school closures (March 2020-April 2020; n = 146), and after schools partially reopened (October 2020-July 2021; n = 227). Our results indicated lower PA levels, longer sleep duration, and longer screen time among participants recruited during school closures than those recruited before the COVID-19 outbreak. Primary school students were found to sleep on average for an extra hour during school closures. The later sleep onset and increased screen time documented during school closures persisted when schools partially reopened. Our findings illustrate the significant impact of social distancing policies during the COVID-19 pandemic on the sleep pattern, screen time, and PA level in school-aged children in Hong Kong. Professionals should urgently reinforce the importance of improving physically activity, good sleep hygiene, and regulated use of electronic devices for parents and school-aged children during this unprecedented time.

Factors Related to Oversleeping in Korean Young Adults, with a Focus on Sociodemographic Factors

Young adults the year after high school experience changes in lifestyle and circumstances and tend to experience more oversleeping. However, there are few studies on oversleeping in young adults. This study aims to identify the sociodemographic factors related to oversleeping among young adults in Korea using nationally representative data. This study analyzed self-reported and cross-sectional data in 2016 from a sample of 1876 participants from the Korean Children and Youth Panel Survey, which included respondents one year after high school graduation. Oversleeping was defined as sleeping 9 or more hours a day on average. Logistic regression models were analyzed to test a multivariate association between independent sociodemographic variables and oversleeping. Over one-tenth of young adults reported oversleeping. Oversleeping was associated with household income (OR = 0.99, p = 0.011) and smoking (OR = 1.52, p = 0.041). In addition, when compared to non-working college students, college students who were working (OR = 2.58, p = 0.021), non-students who were working (OR = 1.68, p = 0.048), and non-students who were not working (OR = 3.07, p < 0.001) were more likely to report oversleeping. Oversleeping among young adults was associated with major sociodemographic factors including household income (-), smoking (+), and academic and working status (+). These findings suggest the significant role of sociodemographic factors as predictors of oversleeping and emphasize the importance of examining various factors to achieve a better understanding of oversleeping in young adults.

Sleep and circadian differences between light and heavy adult alcohol drinkers

Background

Numerous studies have reported that eveningness is associated with increased alcohol consumption. However, biological markers of circadian timing, such as dim light melatonin onset (DLMO) and circadian photoreceptor responsivity (post‐illumination pupil response, PIPR), have rarely been assessed in the context of habitual alcohol consumption. This study aimed to examine sleep, circadian timing, and photoreceptor responsivity in adult alcohol drinkers.

Methods

Participants (21 to 45 years) included 28 light and 50 heavy drinkers. The 8‐day study consisted of a week of adlib sleep monitored with wrist actigraphy, followed by a 9‐h laboratory session with a photoreceptor responsivity and circadian phase assessment.

Results

The heavy drinkers obtained on average 28 more minutes of sleep (p = 0.002) and reported more eveningness than the light drinkers (p = 0.029). There was a trend for a shorter DLMO‐midsleep interval (p = 0.059) in the heavy drinkers, reflecting a tendency for them to sleep at an earlier circadian phase. The PIPR in the heavy drinkers was significantly smaller than in the light drinkers (p = 0.032), suggesting reduced circadian photoreceptor responsivity in the heavy drinkers. A larger PIPR was significantly associated with a later DLMO in the light drinkers (r = 0.44, p = 0.019), but this relationship was absent in the heavy drinkers (r = −0.01, p = 0.94).

Conclusions

These results are consistent with earlier reports of more eveningness and a shorter DLMO‐midsleep interval being associated with heavier alcohol drinking. The novel finding of reduced circadian photoreceptor responsivity in heavy drinkers is consistent with prior rodent studies. Future studies should explore the impact of habitual alcohol consumption on other measures of circadian photoreceptor responsivity.

Early-Life Sleep Deprivation Enhanced Alcohol Consumption in Adolescent Rats

Evidence in the literature suggests that sleep deprivation during early-life developmental stages, by impacting important processes such as the reward circuit maturation, may increase the vulnerability for alcohol and substance use. The mechanisms involved are not fully understood. In this study, utilizing our previously established model, we examined the impact of early-life sleep deprivation on alcohol consumption in adolescent rats. Male Sprague Dawley rats served as either the control (CON) or sleep-deprived (SD) group. Sleep deprivation was induced using a Pinnacle automated sleep deprivation apparatus. The SD group of rats was sleep deprived for 6–8 h/day for 14 days from postnatal day (PND)19 to PND32. At PND33, anxiety- and depression-like behaviors were assessed in rats using elevated plus maze and sucrose splash test, respectively. At PND39, alcohol consumption was assessed in rats for five consecutive days using the two-bottle choice paradigm, water versus 5% ethanol. SD rats exhibited significant anxiety- and depression-like behaviors as compared to CON rats. Interestingly, SD rats consumed a larger volume of alcohol when compared to CON rats, which was significantly higher at day 5 (mean of alcohol consumption (ml) ± SD; CON = 6.67 ± 3.42; SD = 19.00 ± 6.05, p = 0.0126). SD rats also showed high preference for alcohol over water, which was significantly higher at day 5 (mean of alcohol preference (%) ± SD; CON = 26.85 ± 14.97; SD = 57.69 ± 5.61, p = 0.014). Our data suggest that early-life sleep deprivation enhanced alcohol consumption in adolescent rats.

A Weight and Meta-Analysis on the Academic Achievement of High School Students

Understanding the determinants of academic achievement (AA) is crucial for virtually every stakeholder interested in personal development and individual and societal wellbeing. Extensive research in several areas, such as education, economics, or psychology, has addressed this topic, identifying a vast number of determinants that impact high school students’ AA. In this work, we perform a meta-analysis, including a weight analysis of 49 quantitative studies that investigate this topic, exploring the best predictors of high school students’ academic success. We also explore moderation effects. Our results show that academic self-efficacy and socioeconomic status are the best predictors of AA, and they are statistically significant. Other statistically significant predictors, albeit less common in the analyses, are mastery avoidance, motivation, sleep habits, and work avoidance. Implications for theory and practice and directions for future research are discussed.

Problem mobile gaming: The role of mobile gaming habits, context, and platform

Aims: Mobile gaming is a dominant form of gaming, known for its portability and for game characteristics that motivate continuous play and spending. Such involvement may also turn problematic, but research on problem gaming (PG) has tended to focus on non-mobile forms of gaming. The study was based on a cross-sectional observational design where students in upper secondary schools were recruited to a survey about mobile gaming. The age of the respondents ranged from 16 to 23 years (n = 519; 52.4% men; mean age = 17.2 years, SD = 1.1). Methods: We examined (1) gaming frequency, gaming contexts, and in-game spending in relation to PG; (2) gaming context in relation to academic achievement and sleep quality; and (3) PG according to gaming platform (i.e., playing on mobile, console/computer, or mixed platforms) with Kruskal−Wallis tests, chi-square tests and Spearman rank-order correlations. Results: PG was positively associated with mobile gaming hours per week (η² = .02, p < .01), minutes per session (η² = .03, p < .001), making in-app purchases (Cramer's V = .15, p < .05), and gaming during homework (Cramer's V = .14, p < .05). Statistically significant associations were found between mobile gaming in bed and later sleep midpoint for weekdays (r_s = .18, p < .001) and weekends (r_s = .11, p < .05). Mixed platform gamers had increased likelihood of PG, console/computer gamers had increased likelihood of being at risk for PG, and mobile gamers had lower risk for PG (Cramer's V = .18, p < .001). Conclusion: Future studies should include specific measures of mobile gaming as it appears implicated in problem gaming, albeit to a lesser degree than console and computer gaming.

The 103,200-arm acceleration dataset in the UK Biobank revealed a landscape of human sleep phenotypes

SignificanceHuman sleep phenotypes are diversified by genetic and environmental factors, and a quantitative classification of sleep phenotypes would lead to the advancement of biomedical mechanisms underlying human sleep diversity. To achieve that, a pipeline of data analysis, including a state-of-the-art sleep/wake classification algorithm, the uniform manifold approximation and projection (UMAP) dimension reduction method, and the density-based spatial clustering of applications with noise (DBSCAN) clustering method, was applied to the 100,000-arm acceleration dataset. This revealed 16 clusters, including seven different insomnia-like phenotypes. This kind of quantitative pipeline of sleep analysis is expected to promote data-based diagnosis of sleep disorders and psychiatric disorders that tend to be complicated by sleep disorders.

Sleep in Young People With Features of Borderline Personality Disorder: A Scoping Review

Sleep disturbance is commonly reported in young people with features of borderline personality disorder (BPD). Examining sleep quality and sleep-wake patterns in young people with features of BPD is essential to inform the development of sleep-improvement interventions. A scoping review was conducted according to the Joanna Briggs Institute methodology. The objectives were to map the literature regarding sleep in young people with features of BPD, highlight areas for further investigation, and provide methodological recommendations for future research. Seven data sets were included in the review. Young people with features of BPD had poorer objective and subjective sleep quality, disturbed sleep architecture (particularly rapid-eye-movement sleep), an increased vulnerability to delayed sleep phase syndrome, and more nightmares and dream anxiety, compared with healthy individuals. Future research should use both objective and subjective sleep measures, include clinical comparison groups, and focus specifically on young people with BPD.

The relationship between sleep and depression and bipolar disorder in children and young people

BACKGROUND

Sleep difficulties are often reported in practice, and are part of the diagnostic criteria for depression and bipolar disorder.

AIMS

To inform the understanding of the relationship between sleep and both depression and bipolar disorder.

METHOD

We conducted a narrative literature review of affective disorders and sleep difficulties in children and young people.

RESULTS

Specific sleep disorders, such as parasomnias, narcolepsy and sleep-related movement disorders, are associated with depression, whereas insomnia, obstructive sleep apnoea and circadian rhythm disorders are associated with both depression and bipolar disorder in children and young people. Conversely, children and young people with depression can present with a number of sleep difficulties, and these are associated with higher depression severity and greater fatigue, suicidal ideation, physical complaints, pain and decreased concentration. Sleep disturbances among adolescents with bipolar disorder can affect the severity of depressive and manic symptoms, are a poor prognostic indicator and have been associated with social and academic impairment. Antidepressants and antipsychotics can directly affect sleep architecture, which clinicians need to be aware of. Non-pharmacological interventions for sleep problems could prevent and/or minimise the risk of relapse in affective disorders.

CONCLUSIONS

Sleep difficulties can occur before, during and after an episode of depression or bipolar disorder, and have a higher prevalence in affective disorders compared with the general population. A multi-modal approach would include the treatment of both the affective and specific sleep disorder. Further research is needed in this field to understand the impact of combined interventions on clinical outcomes.

Prevalence and Factors Associated With the Risk of Delayed Sleep-Wake Phase Disorder in Japanese Youth

BACKGROUND

Delayed sleep-wake phase disorder (DSWPD) is more prevalent among the younger generation. However, the prevalence of this disorder in Asia, particularly Japan, has not yet been elucidated. Furthermore, the impact of DSWPD morbidity on daytime functioning and factors associated with the presence of the disorder remain unclear.

METHODS

A web-based survey was conducted among youth aged 15-30 years. In total, 7,810 individuals completed the questionnaire. The questionnaire included items on sociodemographic variables as well as the Japanese version of the Biological Rhythms Interview of Assessment in Neuropsychiatry self-report (J-BRIAN-SR), which assesses the risk of DSWPD, sleep behaviors and possibly related lifestyle variables, productivity loss [WHO Health and Work Performance Questionnaire (HPQ)], and health-related quality of life (HRQOL). The risk of DSWPD was indicated by a J-BRIAN-SR score greater than or equal to 40 points and days of absence ≥4 days per month. After comparing these variables for participants at risk of DSWPD and those who were not, the factors associated with the risk of DSWPD were examined using logistic regression analysis, with sociodemographic and lifestyle variables as independent variables.

RESULTS

The overall prevalence of participants at risk DSWPDs was 4.3%. Compared with participants without DSWPD, those at risk of DSWPD presented significantly worse HPQ and HRQOL scores. The risk of DSWPD was positively associated with the presence of currently treated diseases, length of nighttime liquid crystal display (LCD) viewing, and being a high school/university students. It was negatively associated with habitual exercise.

CONCLUSION

The risk of DSWPD seemed to be consistent with reports from Western countries, and individuals possibly affected by the disorder were thought to have deteriorated daytime functioning. In addition, lifestyle specific to youth, such as long-term LCD viewing at night and relatively loose social constraints, could be associated with the presence of DSWPD in this generation.

Understanding Sleep-Wake Behavior in Late Chronotype Adolescents: The Role of Circadian Phase, Sleep Timing, and Sleep Propensity

BACKGROUND

Adolescents with a late chronotype are at greater risk for mood disorders, risk-taking behaviors, school absenteeism, and lower academic achievement. As there are multiple causes for late chronotype, the field lacks studies on the relationship between mood, circadian phase, and phase angle of entrainment in late chronotype adolescents. Three objectives guide this explorative study: (1) to describe sleep, circadian phase, and phase angle of entrainment in late chronotype adolescents, (2) to explore how different levels of lateness are associated with sleep quality, sleep propensity, and mood, and (3) to investigate the influence of circadian phase on bedtime choice and sleep duration.

METHODS

Baseline data from 19 male adolescents (M = 16.4 ± 1.0 yrs), who were part of a larger intervention trial, were analyzed. Chronotype was measured with the Munich Chronotype Questionnaire, circadian timing via dim light melatonin onset (DLMO), and sleep habits with a 7-day sleep log. Further questionnaires assessed daytime sleepiness, sleep quality, and mood. Evening sleepiness and sustained attention were used as a proxy for evening sleep propensity.

RESULTS

On school nights, sleep duration averaged 7.78 h (±1.65), and 9.00 h (±1.42) on weekend nights. Mean DLMO was observed at 23.13 h (± 1.65), with a weekend phase angle of entrainment of 2.48 h. Regression fittings revealed a tendency for shorter phase angles with delayed DLMOs. Further analysis with chronotype subgroups revealed that this was only true for light and moderate late types, whereas extreme late types showed wide phase angles. Even though daytime sleepiness and sleep duration did not differ between subgroups, mood and sleep quality declined as lateness increased. Extreme late chronotypes experienced higher evening sleepiness, while slight late chronotypes showed higher evening attention. Chronotype but not DLMO predicted bedtime on school- and particularly weekend-nights.

CONCLUSIONS

Our findings suggest that with increasing lateness, the likelihood of experiencing poor sleep quality and mood disorders increases. As DLMO did not predict bedtime, our data indicate that the factors contributing to a late chronotype are versatile and complex, particularly for extreme late types. Further studies involving a larger and gender-balanced sample are needed to confirm findings.

Decrease in Social Zeitgebers Is Associated With Worsened Delayed Sleep-Wake Phase Disorder: Findings During the Pandemic in Japan

BACKGROUND

Delay in sleep-wake rhythms was observed in the general population during the coronavirus disease 2019 (COVID-19) pandemic. Patients with delayed sleep-wake phase disorder (DSWPD) may have also experienced exacerbation of symptoms, but no studies have investigated this topic. In this study, we aimed to retrospectively examine the changes in symptoms of outpatients with DSWPD both before and during the pandemic and to identify the factors associated with the exacerbation of sleep-wake rhythms.

METHODS

We included outpatients with DSWPD aged 16 years or older who visited the outpatient clinic due to sleep disorders between January and September 2020. Decreased social zeitgebers was defined as a reduction of 50% or more in the frequency of commuting to school or work during the COVID-19 pandemic. The severity of DSWPD was assessed using the clinical global impressions - severity of illness (CGI-S) at two points: before and during the pandemic. We defined the worsened, unchanged, and improved groups as those whose CGI-S scores worsened by at least one point, remained unchanged, and improved by at least one point, respectively. Multivariate logistic regression analysis was performed to determine the factors associated with worsened DSWPD symptoms.

RESULTS

Sixty patients with DSWPD were eligible for this study. Even before the pandemic, patients who were unemployed or did not attend school tended to show more severe DSWPD symptoms. During the pandemic, 27 patients belonged to the worsened group; 28 patients, unchanged group; and 5 patients, improved group. Decreased social zeitgebers (odds ratio [OR] = 6.668, 95% confidence interval [CI]: 1.653-26.891, p < 0.05) and comorbid mood disorders (OR = 8.876, 95% CI: 1.714-45.974, p < 0.05) showed independent significant associations with the worsening of DSWPD symptoms.

CONCLUSIONS

During the pandemic, the symptoms of DSWPD tended to worsen. The obtained findings emphasize the importance of social zeitgebers, suggesting the need for external motivation in DSWPD treatment.

Circadian rhythm sleep-wake disturbances and depression in young people: implications for prevention and early intervention

A rate-limiting step in the prevention and early intervention of depressive disorders in young people is our insufficient understanding of causal mechanisms. One plausible pathophysiological pathway is disturbance in the 24 h sleep-wake cycle and the underlying circadian system. Abnormalities in circadian rhythms are well documented in adults with various depressive disorders and have been linked to core clinical features, including unstable mood, daytime fatigue, non-restorative sleep, reduced motor activity, somatic symptoms, and appetite and weight change. In this Review, we summarise four areas of research: basic circadian biology and animal models of circadian disturbances; developmental changes in circadian rhythms during adolescence and implications for the emergence of adolescent-onset depressive syndromes; community and clinical studies linking 24 h sleep-wake cycle disturbances and depressive disorders; and clinical trials of circadian-based treatments. We present recommendations based on a highly personalised, early intervention model for circadian-linked depression in young people.

Depressed mood and repetitive negative thinking in Delayed Sleep-Wake Phase Disorder: Treatment effects and a comparison with good sleepers

Circadian dysregulation and depressed mood commonly co-occur in young people, yet mechanisms linking Delayed Sleep-Wake Phase disorder (DSWPD) with depression are poorly understood. The present study aimed to examine the role of repetitive negative thinking (RNT), by comparing sleep, RNT and depressive symptomology between 40 'good' sleeping young people and 63 with DSWPD, with (n = 30) and without (n = 33) self-reported doctor-diagnosed depression. Secondary analysis from a randomised controlled trial was also undertaken to observe changes in depressive symptoms and RNT as a result of treatment for DSWPD. The 60 young people with DSWPD (mean [SD] age of 15.9 [2.2] years, 63% female) received either short (green) or long (red) wavelength bright light therapy (BLT) over 3 weeks. Cross-sectional baseline comparisons revealed an escalating pattern of worse sleep, more RNT and higher depressed mood scores in the DSWPD young people compared to good sleepers. Across all participants, RNT accounted for the associations between sleep-onset difficulties and depressed mood at baseline. Symptoms of depression, RNT and sleep onset difficulties in DSWPD individuals significantly improved after treatment (d = 0.47-0.65) and at the 1- (d = 0.43-1.00) and 3-month follow-up (d = 0.39-1.38), yet there were no differences between short- and long-wavelength BLT. Results provide preliminary evidence that RNT may link delayed sleep phase with depression. BLT conferred sleep benefits, but also improvements in depressed mood and RNT, and thus represents a potentially cost-effective strategy for young people experiencing delayed sleep phase and low mood.

The association between internet usage and sleep problems among Japanese adolescents: three repeated cross-sectional studies

STUDY OBJECTIVES

Sleep problems and problematic internet use have important implications for adolescent health; however, there have been no large-scale surveys using comprehensive measures. We examined the association between internet use duration and sleep problems among Japanese adolescents.

METHODS

We used data from the Lifestyle Survey of Adolescents collected in 2012, 2014, and 2017. We calculated the change in sleep status (insomnia, sleep duration, bedtime, and sleep quality) and internet usage (screen time and services such as internet surfing, social media use, streaming such as YouTube, and online gaming). A binary logistic model was estimated for insomnia. Generalized ordered logit models were employed for the ordinal outcomes (sleep duration, bedtime, sleep quality, and multidimensional sleep health). Sampling weights were constructed based on participation rate on survey years and selection rates from population statistics.

RESULTS

We analyzed data from 248,983 adolescents. Sleep status was unchanged; however, many adolescents used more internet services and for longer durations. The odds ratio of internet screen time for all sleep problems (insomnia, shorter sleep duration, later bedtime, and worse sleep quality) gradually declined. Longer internet screen time (> 5 hours) was strongly associated with all sleep problems. Internet services were also associated with sleep problems; particularly, social media use and online gaming were linked to later bedtimes.

CONCLUSIONS

Despite the decreased strength in the association between internet usage and sleep problems, longer internet time was strongly associated with sleep problems. Public health interventions should consider internet use as an intervention target to improve adolescents' health.

Sleep and circadian instability in delayed sleep-wake phase disorder

STUDY OBJECTIVES

In patients with delayed sleep-wake phase disorder (DSWPD), the circadian clock may be more easily affected by light at night. This creates a potential vulnerability, whereby individuals with irregular schedules may have less stable circadian rhythms. We investigated the stability of circadian timing and regularity of sleep in patients with DSWPD and healthy controls.

METHODS

Participants completed 2 dim-light melatonin onset (DLMO) assessments approximately 2 weeks apart while keeping their habitual sleep/wake schedule. After the second DLMO assessment, light sensitivity was assessed using the phase-resetting response to a 6.5-hour 150-lux stimulus. The change in DLMO timing (DLMO instability) was assessed and related to light sensitivity and the sleep regularity index.

RESULTS

Relative to healthy controls, patients with DSWPD had later sleep rhythm timing relative to clock time, earlier sleep rhythm timing relative to DLMO, lower sleep regularity index, and greater DLMO instability. Greater DLMO instability was associated with increased light sensitivity across all participants, but not within groups.

CONCLUSIONS

We find that circadian timing is less stable and sleep is less regular in patients with DSWPD, which could contribute to etiology of the disorder. Measures of light sensitivity may be informative in generating DSWPD treatment plans.

Neurology of Sleep

Healthy sleep, including proper amounts in the 24-hour day/night period, is crucial for developing children. Sleep development in infants and children is characterized by increased amounts of sleep, including rapid eye movement and non-rapid eye movement (NREM) slow-wave sleep. Expected changes as well as deviations may contribute to sleep problems, which are common in typically developing children and very common in those with neurodevelopmental disorders and often are chronic. Periodic screening of children for sleep problems is important for timely and effective management of these.

Workshop report. Circadian rhythm sleep-wake disorders: gaps and opportunities

This White Paper presents the results from a workshop cosponsored by the Sleep Research Society (SRS) and the Society for Research on Biological Rhythms (SRBR) whose goals were to bring together sleep clinicians and sleep and circadian rhythm researchers to identify existing gaps in diagnosis and treatment and areas of high-priority research in circadian rhythm sleep-wake disorders (CRSWD). CRSWD are a distinct class of sleep disorders caused by alterations of the circadian time-keeping system, its entrainment mechanisms, or a misalignment of the endogenous circadian rhythm and the external environment. In these disorders, the timing of the primary sleep episode is either earlier or later than desired, irregular from day-to-day, and/or sleep occurs at the wrong circadian time. While there are incomplete and insufficient prevalence data, CRSWD likely affect at least 800,000 and perhaps as many as 3 million individuals in the United States, and if Shift Work Disorder and Jet Lag are included, then many millions more are impacted. The SRS Advocacy Taskforce has identified CRSWD as a class of sleep disorders for which additional high-quality research could have a significant impact to improve patient care. Participants were selected for their expertise and were assigned to one of three working groups: Phase Disorders, Entrainment Disorders, and Other. Each working group presented a summary of the current state of the science for their specific CRSWD area, followed by discussion from all participants. The outcome of those presentations and discussions are presented here.

Differences in sleep timing and related effects between African Americans and non-Hispanic Whites

STUDY OBJECTIVES

Prior studies have shown a morning chronotype for African Americans compared with non-Hispanic Whites, yet self-reported sleep timing is delayed in African Americans compared with Whites.

METHODS

We analyzed data from the Multi-Ethnicity Study of Atherosclerosis, a multisite community-based cohort. Self-reported and actigraphic sleep timing, chronotype measured by the modified Horne-Östberg Morningness-Eveningness Questionnaire, and risk of depression measured by the Center for Epidemiologic Studies Depression scale were examined using nonparametric approaches and linear or logistic regression while comparing between African Americans and Whites and evaluating the effects of delayed sleep phase.

RESULTS

In 1,401 participants, there was no difference in chronotype between African Americans and Whites. African Americans were 80% more likely to report a delayed sleep phase (defined as bedtime after midnight) on weekdays and 50% more likely on weekends than were Whites. Actigraphic data showed similar results. Actigraphic midsleep time was delayed 38 minutes on weekdays and 24 minutes on weekends in African Americans compared with Whites. Stratified analysis by chronotype showed that African Americans with a morning or intermediate chronotype had a significantly delayed sleep phase compared with Whites, but there was no difference between African Americans and Whites with an evening chronotype. Delayed sleep phase was associated with depression, but this relationship was only significant in White participants.

CONCLUSIONS

African Americans had a delayed sleep phase compared with Whites that was more pronounced in individuals with a morning or intermediate chronotype. Consequences of delayed sleep phase may vary by race and ethnicity.

Circadian typology and implications for adolescent sleep health. Results from a large, cross-sectional, school-based study

STUDY OBJECTIVES

To investigate circadian typology in a large, representative sample of Norwegian adolescents, and its implications for sleep health.

METHODS

The sample included 3920 1^st year high school students aged 16-17 years. Respondents completed a web-based survey, including the short version of the Horne-Ostberg Morningness-Eveningness Questionnaire (rMEQ), the Munich Chronotype Questionnaire (MCTQ) and items on sleep-related behaviors (eg electronic media usage in bed, consumption of caffeinated beverages), sleep beliefs and daytime sleepiness. Data were analyzed using one-way ANOVAs and Chi-squared tests.

RESULTS

In all, 7.8% were categorized as morning, 52.3% as intermediate and 39.9% as evening types, respectively. Evening types had later sleep timing, longer sleep latency, more social jetlag and shorter school day sleep duration than morning types, with intermediate types displaying a sleep pattern between these two extremes. None of the circadian types met the minimum recommended amount of sleep on school nights (ie 8+ hours), and only morning types had a mean sleep duration of 7+ hours (7:19 h, nearly 1 h more than evening types who slept 6:20 h, p < 0.001). Evening types reported more use of electronic media in bed, more consumption of caffeinated beverages and more daytime sleepiness than the other circadian types. They were also less satisfied with their school day sleep duration and perceived it more difficult to change their sleep pattern.

CONCLUSIONS

Results from this study suggest that eveningness represents a sleep health challenge for older adolescents.

Prevalence of Circadian Rhythm Sleep-Wake Disorder in Outpatients with Schizophrenia and Its Association with Psychopathological Characteristics and Psychosocial Functioning

The prevalence of circadian rhythm sleep-wake disorder (CRSWD) among patients with schizophrenia is not clear. The effect of comorbid CRSWD on such patients has also not been fully evaluated yet. Outpatients with schizophrenia in the maintenance phase who visited Tokyo Women’s Medical University Hospital between April 2018 and March 2019 participated in this study. The Brief Psychiatric Rating Scale (BPRS), the Clinical Global Impressions–Severity Illness Scale (CGI-S), Global Assessment of Functioning (GAF), World Health Organization Disability Assessment Schedule II, Insomnia Severity Index (ISI), and Morningness–Eveningness Questionnaire (MEQ) were administered, and the patient responses with and without CRSWD were compared. Of the 105 patients with schizophrenia, 19 (18.1%) had CRSWD. There were trends toward higher BPRS and lower GAF scores in the CRSWD group than in the non-CRSWD group, although these did not reach statistical significance following a false discovery rate correction. Among the BPRS subitems, the anxiety scores were significantly higher in the CRSWD group than in the non-CRSWD group (p < 0.01). CRSWD was highly prevalent among patients with schizophrenia in the maintenance phase. Comorbidities of CRSWD may affect psychopathological characteristics and psychosocial functioning.

Circadian depression: A mood disorder phenotype

Major mood syndromes are among the most common and disabling mental disorders. However, a lack of clear delineation of their underlying pathophysiological mechanisms is a major barrier to prevention and optimised treatments. Dysfunction of the 24-h circadian system is a candidate mechanism that has genetic, behavioural, and neurobiological links to mood syndromes. Here, we outline evidence for a new clinical phenotype, which we have called 'circadian depression'. We propose that key clinical characteristics of circadian depression include disrupted 24-h sleep-wake cycles, reduced motor activity, low subjective energy, and weight gain. The illness course includes early age-of-onset, phenomena suggestive of bipolarity (defined by bidirectional associations between objective motor and subjective energy/mood states), poor response to conventional antidepressant medications, and concurrent cardiometabolic and inflammatory disturbances. Identifying this phenotype could be clinically valuable, as circadian-targeted strategies show promise for reducing depressive symptoms and stabilising illness course. Further investigation of underlying circadian disturbances in mood syndromes is needed to evaluate the clinical utility of this phenotype and guide the optimal use of circadian-targeted interventions.

Circadian rhythms and substance use disorders: A bidirectional relationship

The circadian system organizes circadian rhythms (biological cycles that occur around 24 h) that couple environmental cues (zeitgebers) with internal functions of the organism. The misalignment between circadian rhythms and external cues is known as chronodisruption and contributes to the development of mental, metabolic and other disorders, including cancer, cardiovascular diseases and addictive disorders. Drug addiction represents a global public health concern and affects the health and well-being of individuals, families and communities. In this manuscript, we reviewed evidence indicating a bidirectional relationship between the circadian system and the development of addictive disorders. We provide information on the interaction between the circadian system and drug addiction for each drug or drug class (alcohol, cannabis, hallucinogens, psychostimulants and opioids). We also describe evidence showing that drug use follows a circadian pattern, which changes with the progression of addiction. Furthermore, clock gene expression is also altered during the development of drug addiction in many brain areas related to drug reward, drug seeking and relapse. The regulation of the glutamatergic and dopaminergic neurocircuitry by clock genes is postulated to be the main circadian mechanism underlying the escalation of drug addiction. The bidirectional interaction between the circadian system and drug addiction seems to be mediated by the effects caused by each drug or class of drugs of abuse. These studies provide new insights on the development of successful strategies aimed at restoring/stabilizing circadian rhythms to reduce the risk for addiction development and relapse.

Just Let Me Sleep in: Identifying and Treating Delayed Sleep Phase Disorder in Adolescents

Individuals with delayed sleep phase disorder (DSPD) are unable to naturally fall asleep and awake at conventional times; for this reason, DSPD is often mistaken for insomnia. However, unlike many patients with insomnia, those with DSPD struggle to get up at appropriate times. DSPD is associated with school refusal, academic difficulties, and lower employment rate. DSPD in youth has prevalence as high as 16%, and is often comorbid with other psychiatric disorders. Treatments include appropriate light exposure during the day, melatonin use, developing an evening routine that minimizes arousal-increasing activities, and gradually shifting sleep-wake times toward more functional ones.

Classification and Epidemiology of Sleep Disorders in Children and Adolescents

Sleep disturbances are common in children and adolescents but still remain unrecognized and undertreated. Several classification systems of sleep disorders are available, which include recent attempts to develop more specific nosologic categories that reflect developmental aspects of sleep. The prevalence of sleep disorders has been studied across various samples of healthy, typically developing children and those with special medical, psychiatric, and neurodevelopmental needs. Sleep disorders are highly prevalent in children and adolescents with psychiatric disorders, making it important for mental health professionals to be aware of sleep problems and to address them in the context of psychiatric comorbidities.

Sleep in older adolescents. Results from a large cross-sectional, population-based study

The aim of the present study was to describe sleep patterns in a large and representative sample of Norwegian adolescents. The sample included 4,010 first-year high school students, aged 16-17 years (54% female), who completed a web-based survey on sleep patterns. The process of going to sleep was addressed as a two-step sequence of (a) shuteye latency (interval from bedtime to shuteye time) and (b) sleep onset latency (interval from shuteye time to sleep onset). Results showed that 84.8% of the adolescents failed to obtain the recommended amount of sleep (8+ h) on schooldays, and 49.4% obtained less than 7 h. Mean bedtime on schooldays was 10:33 PM, with rise time 8:19 h later (time in bed). The adolescents reported long school-day shuteye latency (43 min), limiting sleep opportunity to 7:36 h. Sleep onset latency was 32 min and mean school-day sleep duration was only 6:43 h. On free days, 26.3% of the adolescents obtained less than 8 h of sleep, and 11.7% obtained less than 7 h. Mean bedtime was 00:33 AM, time in bed was 10:35 h, shuteye latency was 39 min and sleep onset latency was 24 min. Mean free-day sleep duration was 8:38 h. There were sex differences in several sleep parameters, including shuteye latency. The results indicate that the majority of Norwegian adolescents fail to obtain the recommended amount of sleep (8+ h) on schooldays. Long shuteye latency appears to be a main driver for short school-day sleep duration in adolescents.

Dynamic fluctuations of emotional states in adolescents with delayed sleep phase-A longitudinal network modeling approach

BACKGROUND

Very late sleep rhythms are risks for social adjustment problems in adolescence. Using ecological momentary assessment data, we quantified and visualized temporal and contemporaneous within-persons dynamical relations of sleepiness and emotions in adolescents with and without late sleep rhythms.

METHODS

We analyzed a temporal network via multilevel vector autoregression (mlVAR) modeling and a contemporaneous network through the partial associations between the residuals of temporal and the between-subject multilevel models. We tested whether these networks were different between those with a late circadian rhythm [concurrent delayed sleep phase (DSP) N = 172, 37% boys, 63% girls] and those without (N = 143, 22% boys, 78% girls).

RESULTS

In adolescents without DSP, the temporal networks showed continuity only for low mood from the previous to the following time point. In adolescents with DSP, there were more predictable patterns of emotions. Feelings of depression led to a decrease of positive emotions and increase of irritation and anxiety. The contemporaneous networks showed clusters of positive and negative emotions in both groups and sleepiness decreased the experience of positive emotions concurrently.

LIMITATIONS

DSP in our current study was based only on one out of three diagnostic criteria of the full disorder (DSM-5) and it was assessed only once.

CONCLUSIONS

These findings indicate that the dynamic organization of emotions and sleepiness is different in adolescents with and without DSP. DSP adolescents have more predictable and maladaptive emotional patterns during the day. Results provide new insight about why individuals with DSP are at a heightened risk for decreased emotional adjustment.

Sleep quality, sleep latency, and sleep duration: a national comparative study of university students in Jordan

BACKGROUND

Sleep problems have significant negative health consequences on university students.

STUDY AIM

To assess subjective sleep quality, sleep latency, and sleep duration in a national sample of university students and investigate differences in these components with selected variables.

METHODS

A cross-sectional analysis and multi-stage sampling were conducted to select a sample of 1308 students from three major areas in Jordan. Sleep quality, sleep latency, and sleep duration were measured by an Arabic version of the Pittsburgh Sleep Quality Index (PSQI). Data were analyzed using measures of frequency and central tendency and Kruskal-Wallis tests.

RESULTS

Two-thirds of university students described their sleep quality as fairly bad and very bad and 20 reported sleep latency of more than 30 min during the past month. There was a significant difference in subjective sleep quality according to the student's place of residence. Sleep latency differed according to students' income, physical activity, use of media devices before sleep, smoking status, and academic achievement. Significant differences were also found in sleep duration with students' academic achievement, academic level, and body mass index.

CONCLUSIONS

University students suffer from poor sleep quality, delayed sleep phase, and sleep deprivation. Lower-income, smoking, physical inactivity, and using media devices before sleep contributed to students' sleeping problems.

IMPLICATIONS

Interventional programs that focus on improving physical activity, controlling tobacco use, healthy sleep education, and reducing screen time are essential public health interventions to reduce sleep problems among youth.

Delayed sleep-wake phase disorder in young adults: prevalence and correlates from a national survey of Norwegian university students

BACKGROUND

Delayed sleep-wake phase disorder (DSWPD) during adolescence has been linked to impaired health and poor functioning. However there is a dearth of knowledge about DSWPD in young adulthood. We seek to contribute knowledge on the prevalence and correlates of DSWPD in this age group.

METHODS

Data were drawn from a 2018 national survey of students in higher education in Norway (the SHoT-study). All 162,512 fulltime students in Norway were invited to participate and 50,054 students (69.1% women) aged 18-35 years were included (response rate = 30.8%). DSWPD was assessed by self-report, and was operationalized according to the criteria for DSWPD in the most recent edition of the International Classification of Sleep Disorders. Correlates of DSWPD were examined by validated self-report instruments covering a wide range of demographic and health domains.

RESULTS

The overall prevalence of DSWPD was 3.3%, and significantly higher in male (4.7%) than female (2.7%) students. DSWPD was associated with being single, having financial difficulties, having divorced parents, being overweight/obese, and physical inactivity. Students with DSWPD had more sleep problems during weekdays, and higher levels of somatic and mental health problems. Students with DSWPD also had an elevated risk of self-harm-related thoughts and behaviors as well as suicidality.

CONCLUSION

DSWPD remains a significant problem among young adults, and the high symptom load across health domains indicates that suggests a need for existing evidence-based approaches to be scaled for college students who present with DSWPD.

Negative impact of COVID-19 pandemic on sleep quantitative parameters, quality, and circadian alignment: Implications for health and psychological well-being

The COVID-19 pandemic has spread worldwide, affecting millions of people and exposing them to home quarantine, isolation, and social distancing. While recent reports showed increased distress and depressive/anxiety state related to COVID-19 crisis, we investigated how home quarantine affected sleep parameters in healthy individuals. 160 healthy individuals who were in home quarantine in April 2020 for at least one month participated in this study. Participants rated and compared their quantitative sleep parameters (time to go to bed, sleep duration, getting-up time) and sleep quality factors, pre-and during home quarantine due to the COVID-19 pandemic. Furthermore, participants' chronotype was determined to see if sleep parameters are differentially affected in different chronotypes. Time to fall asleep and get-up in the morning were significantly delayed in all participants, indicating a significant circadian misalignment. Sleep quality was reported to be significantly poorer in all participants and chronotypes. Poor sleep quality included more daily disturbances (more sleep disturbances, higher daily dysfunctions due to low quality of sleep) and less perceived sleep quality (lower subjective sleep quality, longer time taken to fall asleep at night, more use of sleep medication for improving sleep quality) during home quarantine. Home quarantine due to COVID-19 pandemic has a detrimental impact on sleep quality. Online interventions including self-help sleep programs, stress management, relaxation practices, stimulus control, sleep hygiene, and mindfulness training are available interventions in the current situation.

Efficacy and safety of supplemental melatonin for delayed sleep-wake phase disorder in children: an overview

Delayed sleep–wake phase disorder (DSPD) is the most frequently occurring intrinsic circadian rhythm sleep–wake disorder, with the highest prevalence in adolescence. Melatonin is the first-choice drug treatment. However, to date melatonin (in a controlled-release formulation) is only authorised for the treatment of insomnia in children with autism or Smiths-Magenis syndrome. Concerns have been raised with respect to the safety and efficacy of melatonin for more general use in children, as melatonin has not undergone the formal safety testing required for a new drug, especially long-term safety in children. Melatonin is known to have profound effects on the reproductive systems of rodents, sheep and primates, as well as effects on the cardiovascular, immune and metabolic systems.

The objective of the present article was therefore to establish the efficacy and safety of exogenous melatonin for use in children with DSPD, based on in vitro, animal model and clinical studies by reviewing the relevant literature in the Medline database using PubMed.

Acute toxicity studies in rats and mice showed toxic effects only at extremely high melatonin doses (>400 mg/kg), some tens of thousands of times more than the recommended dose of 3–6 mg in a person weighing 70 kg. Longer-term administration of melatonin improved the general health and survival of ageing rats or mice. A full range of in vitro/in vivo genotoxicity tests consistently found no evidence that melatonin is genotoxic. Similarly long term administration of melatonin in rats or mice did not have carcinogenic effects, or negative effects on cardiovascular, endocrine and reproductive systems.

With regard to clinical studies, in 19 randomised controlled trials comprising 841 children and adolescents with DSPD, melatonin treatment (usually of 4 weeks duration) consistently improved sleep latency by 22–60 min, without any serious adverse effects. Similarly, 17 randomised controlled trials, comprising 1374 children and adolescents, supplementing melatonin for indications other than DSPD, reported no relevant adverse effects. In addition, 4 long-term safety studies (1.0–10.8 yr) supplementing exogenous melatonin found no substantial deviation of the development of children with respect to sleep quality, puberty development and mental health scores. Finally, post-marketing data for an immediate-release melatonin formulation (Bio-melatonin), used in the UK since 2008 as an unlicensed medicine for sleep disturbance in children, recorded no adverse events to date on sales of approximately 600,000 packs, equivalent to some 35 million individual 3 mg tablet doses (MHRA yellow card adverse event recording scheme).

In conclusion, evidence has been provided that melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in children, provided that it is administered at the correct time (3–5 h before endogenous melatonin starts to rise in dim light (DLMO)), and in the correct (minimal effective) dose. As the status of circadian rhythmicity may change during long-time treatment, it is recommended to stop melatonin treatment at least once a year (preferably during the summer holidays).

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Melatonin improves sleep onset without serious adverse effects in youths with DSPD. Change th text after the fourth bullet into: Melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in youths.

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Melatonin for indications other than DSPD, dose not cause relevant adverse effects.

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Long term melatonin treatment does not impair sleep, puberty, and mental health.

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Melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in youths.

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Melatonin should be administered at the correct time and in the minimal effective dose.

Migraine and Sleep in Children: A Bidirectional Relationship

Migraine and sleep disorders in children exhibit a bidirectional relationship. This relationship is based on shared pathophysiology. Migraine involves activation of the trigeminal vascular system. Nociceptive neurons that innervate the dura release various vasoactive peptides. Calcitonin gene-related peptide is the most active of these peptides. Neural pathways that are involved in sleep generation are divided into those responsible for circadian rhythm, wake promotion, non-rapid eye movement, and rapid eye movement sleep activation. Sleep state switches are a critical component of these systems. The cerebral structures, networks, and neurochemical systems that are involved in migraine align closely with those responsible for the regulation of sleep. Neurochemical systems that are involved with both the pathogenesis of migraine and regulation of sleep include adenosine, melatonin, orexin, and calcitonin gene-related peptide. Sleep disorders represent the most common comorbidity with migraine in childhood. The prevalence of parasomnias, obstructive sleep apnea, and sleep-related movement disorders is significantly greater in children migraineurs. Infantile colic is a precursor of childhood migraine. Treatment of comorbid sleep disorders is important for the appropriate management of children with migraine. Sleep-based behavioral interventions can be of substantial benefit. These interventions are particularly important in children due to limited evidence for effective migraine pharmacotherapy.