The Association Between Anxiety Symptoms and Sleep in School-Aged Children: A Combined Insight From the Children's Sleep Habits Questionnaire and Actigraphy

Validity and reliability of the Swedish version of the Children's Sleep Habits Questionnaire (CSHQ-SWE)

BACKGROUND

To translate and culturally adapt the Children's Sleep Habits Questionnaire (CSHQ) to a Swedish version, CSHQ-SWE, and to assess its validity and reliability for use with children with attention deficit hyperactivity disorder (ADHD).

METHODS

A total of 84 children with ADHD (51 boys and 33 girls; 6-12 years) and parents (7 men and 77 women; 28-51 years) were included in the study. CSHQ was translated and culturally adapted to Swedish, and assessed for concurrent validity with sleep actigraphy (analyzed by Kendall's Tau) and for reliability by internal consistency (analyzed by McDonald's Omega H). Face and content validity was evaluated by parents (n = 4) and healthcare professionals (n = 6) qualitatively (comprehensiveness, relevance, and comprehensibility assessed by interviews and analyzed by thematic analysis) and quantitatively (analyzed by content validity ratio and content validity index for 33 items and four non-scored inquiries).

RESULTS

Parent-reported sleep problems (CSHQ-SWE total score) were moderately correlated with less "Sleep Efficiency" (Tau = -0.305; p < 0.001) measured by sleep actigraphy. Parent-reported problems with "Sleep Onset Delay" was moderately correlated with measured time for "Sleep Onset Latency" (Tau = 0.433; p < 0.001). Parent-reported problems with "Night Wakings" were weakly correlated with measured time for "Wake After Sleep Onset" (Tau = 0.282; p < 0.001). Parents estimation of "Total daily sleep duration" was moderately correlated with measured "Total Sleep Time" (Tau = 0.386; p < 0.001). Five of the seven subscales reached an acceptable level for internal consistency (McDonald's Omega H > 0.700). Comprehensiveness, relevance, and comprehensibility of CSHQ-SWE were satisfactory overall. Content validity ratio was 0.80 to 1.00 for six items, 0.00 to 0.60 for 22 items, and < 0.00 for nine items. Content validity index was 0.22.

CONCLUSIONS

CSHQ-SWE demonstrated acceptable concurrent validity with objectively measured sleep and internal consistency, whereas the overall results of face and content validity assessment varied. The instrument needs to be further evaluated regarding construct validity, responsiveness, test-retest reliability, and its generalization to other populations.

Latent Profiles of Sleep Disturbance and Impairment in Elementary School-Age Youth: Concurrent and Longitudinal Associations with Emotional, Behavioral, and Academic Functioning

OBJECTIVE

The links from youth sleep problems to emotional, behavioral, and academic functioning are well documented. Latent variable mixture modeling (LVMM) has been used to explore these relations; however, additional research is needed in diverse samples and with self-reports of sleep-related difficulties. The objectives of the current study were to identify profiles based on patterns of sleep disturbance and impairment and explore associations among profiles and functioning at baseline and over a subsequent 6-month period.

METHODS

Participants were 278 third- through fifth-grade students (M age = 9.27; 51.8% male; 51.1% Hispanic/Latine) and homeroom teachers. Children completed measures of sleep disturbance and impairment, emotion (dys)regulation, and depressive, anxiety, and anger symptoms. Teachers completed measures of youth's emotional and conduct problems, emotion (dys)regulation, and academic performance. LVMM was conducted.

RESULTS

Three profiles emerged: (1) "Average Sleep Disturbance and Impairment" (n = 148); (2) "Elevated Sleep Disturbance and Average Sleep Impairment" (n = 40); and (3) "Elevated Sleep Disturbance and Impairment" (n = 90). Overall, youth with above average sleep problems had worse functioning at baseline. Further, youth in Profile 3 exhibited increases in self-reported symptoms of depression, anxiety, and anger, as well as worsening teacher-reported academic performance and conduct problems. In contrast, youth in Profile 2 exhibited improvements in self-reported symptoms of depression, anxiety, and anger, as well as teacher-reported emotion regulation, conduct problems, and academic performance.

CONCLUSIONS

Results highlight the importance of examining self-reports of sleep problems and the need for intervention among children exhibiting elevated sleep disturbance and impairment.

Sleep-Related Problems and Pediatric Anxiety Disorders

Sleep-related problems are highly prevalent among childhood and adolescent anxiety disorders. The objective of this review was to summarize the relevant clinical research literature as it pertains to the nature of the association between sleep-related problems and youth anxiety, developmental factors relevant to this association, and intervention efforts to target comorbid sleep challenges and anxiety. Limitations of the literature and future directions are discussed.

The association between family function and sleep disturbances of preschool children in rural areas of China: a cross-sectional study

This study aimed to explore the association between family function and sleep disturbances in preschool children in rural areas of China. Caregivers of preschool children completed sociodemographic questionnaires, the Children's Sleep Habits Questionnaire (CSHQ), the Self-rating Anxiety Scale (SAS) and the Family APGAR scale. Using sleep disturbances in children as the dependent variable, family function and other related factors as independent variables, binary logistic regression analyses were performed to examine associations between family function and sleep disturbances in children. A total of 3,636 caregivers of preschool children were enrolled in our study, and the prevalence of sleep disturbances among their preschool children was 89.4%. In our study, lower family function was associated with higher risk of sleep disturbances among preschool children. After adjusting for age (years), education level of mother, discipline attitudes of father and mother, only child status and caregivers' anxiety, the associations were statistically significant both in families of which caregivers of children are their parents or other relatives. (AOR for parents = 1.487, 95% CI:1.152-1.919, P = 0.002; AOR for other relatives = 1.963, 95% CI:1.302-2.958, P = 0.001). Our study results indicated that family function was associated with sleep disturbances in preschool children, and future high-quality cohort studies are needed to explore this topic in more detail.

Sleep and Mental Health Problems in Children and Adolescents

Previous reviews have described the links between sleep and mental health extensively. In this narrative review, we focus on literature published during the last decade investigating the links between sleep and mental health difficulties in childhood and adolescence. More specifically, we focus on the mental health disorders listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders. We also discuss possible mechanisms underlying these associations. The review ends with a discussion of possible future lines of enquiry.

Sleep to Internalizing Pathway in Young Adolescents (SIPYA): A proposed neurodevelopmental model

The prevalence of internalizing disorders, i.e., anxiety and depressive disorders, spikes in adolescence and has been increasing amongst adolescents despite the existence of evidence-based treatments, highlighting the need for advancing theories on how internalizing disorders emerge. The current review presents a theoretical model, called the Sleep to Internalizing Pathway in Young Adolescents (SIPYA) Model, to explain how risk factors, namely sleep-related problems (SRPs), are prospectively associated with internalizing disorders in adolescence. Specifically, SRPs during late childhood and early adolescence, around the initiation of pubertal development, contribute to the interruption of intrinsic brain networks dynamics, both within the default mode network and between the default mode network and other networks in the brain. This interruption leaves adolescents vulnerable to repetitive negative thought, such as worry or rumination, which then increases vulnerability to internalizing symptoms and disorders later in adolescence. Sleep-related behaviors are observable, modifiable, low-stigma, and beneficial beyond treating internalizing psychopathology, highlighting the intervention potential associated with understanding the neurodevelopmental impact of SRPs around the transition to adolescence. This review details support for the SIPYA Model, as well as gaps in the literature and future directions.

Sleep disturbances and sleep patterns in children with tic disorder: A case-control study

STUDY OBJECTIVES

To characterize sleep disturbances and sleep patterns in children with Tic disorder (TD), and explore their association with TD severity and types.

METHODS

A case-control study was conducted in 271 children with TD recruited from a clinical setting and 271 non-TD children recruited from a primary school, matched by age (mean = 8.47 years, SD = 1.53 years) and gender (15.1% female). The Children's Sleep Habits Questionnaire (CSHQ) was used to assess sleep patterns and sleep disturbances. The TD types and severity were assessed with the Yale Global Tic Severity Scale (YGTSS).

RESULTS

The TD children scored higher on CSHQ total score than non-TD group (t = 29.50, p < 0.001) and demonstrated severer global sleep disturbance. Compared to non-TD children, TD children presented with increased risks for global sleep disturbance (aOR: 1.95; 95% CI = 1.20-3.06), and most specific sleep disturbances, including bedtime resistance (aOR: 3.15; 95% CI = 1.96-5.06), sleep onset delay (aOR: 3.43; 95% CI = 1.58-7.46), sleep anxiety (aOR: 2.83; 95%CI = 1.83-4.38), parasomnias (aOR: 3.68; 95% CI = 2.02-6.62), night waking (aOR: 9.29; 95% CI = 2.64-32.65), sleep disordered breathing (aOR: 1.72; 95% CI = 1.03-2.90) and daytime sleepiness (aOR: 1.72; 95% CI = 1.09-2.74). Children with mild and moderate tics, Provisional Tic Disorder (PTD), Chronic Tic Disorder (CTD) and Tourette Syndrome (TS) presented with more global and more specific sleep disturbances. In addition, combined ADHD, etc.

CONCLUSION

Children with TD are major risks for increased sleep disturbances, especially for those with severe and chronic symptoms. Furthermore, comorbid ADHD increases risk in certain areas of sleep. These findings highlight the importance to consider sleep outcomes in the assessment and treatment for children with TD.

Sleep-disordered breathing and daytime sleepiness predict children's reading ability

BACKGROUND

Sleep problems are common in children and are known to detrimentally affect language and cognitive abilities, as well as academic achievement.

AIMS

We aimed to investigate effects of sleep on oral word and non-word reading in a large, cross-sectional sample of children.

SAMPLE

Of 428 children who attended a public psychological science event, 339 children aged 4-14 years (mean 8;10 ± 2;2) took part.

METHODS

Parents completed two sleep questionnaires (Children's Sleep Habits Questionnaire and Sleep-Disordered Breathing Questionnaire) whilst children completed the Test of Word Reading Efficiency.

RESULTS

Hierarchical multiple linear regression assessed whether parentally reported sleep problems were able to predict word and non-word oral reading speeds as measures of sight word reading and phonemic decoding efficiency, respectively. Children with parent-reported increased sleep-disordered breathing, daytime sleepiness, and shorter sleep latency had poorer performance on the reading task for both words and non-words, as well as the total combined score. The models explained 6-7% of the variance in reading scores.

CONCLUSIONS

This study illustrates associations between sleep and word and non-word reading. The small but significant effect is clinically meaningful, especially since adverse factors affecting children's reading ability are cumulative. Thus, for children with multiple risk factors for poor reading ability, sleep problems may be another avenue for treatment. Since reading ability is a strong predictor of later academic success and life outcomes, our study provides important evidence to suggest that children with sleep problems should also be screened for literacy difficulties, and children with literacy difficulties be screened for sleep problems.

Meta-analysis of age and actigraphy assessed sleep characteristics across the lifespan

STUDY OBJECTIVES

Sleep quantity and continuity vary across the lifespan. Actigraphy is a reliable and widely-used behavioral measure of sleep in research and personal health monitoring. This meta-analysis provides a novel examination of whether age (in years) is associated with actigraphy-assessed sleep across the lifespan.

METHODS

A systematic search of PubMed, Embase.com, Cochrane CENTRAL, and PsycINFO using "actigraphy" and "sleep" terms provided 7,079 titles/abstracts; studies of individuals with known psychiatric or medical comorbidities were excluded. Ninety-one articles (N = 23,365) provided data for six meta-analyses examining sleep duration (k = 89), sleep efficiency (k = 58), bedtime (k = 19) and waketime (k = 9) for individuals ages 6-21, and bedtime (k = 7) and waketime (k = 7) for individuals ages 22 and older.

RESULTS

At older ages, sleep duration was shorter (r = -0.12) and sleep efficiency was lower (r = -0.05). Older age was associated with later bedtime (r = 0.37) and wake-up time (r = 0.24) from ages 6-21, whereas older age was associated with earlier bedtime (r = -0.66) and wake-up time (r = -0.59) for ages 22 and above. The strength of these associations was modified by study continent, but not by any other moderator.

CONCLUSIONS

Age was negatively associated with actigraphy-assessed sleep duration and efficiency, but the effects were small in magnitude. On the other hand, large associations were observed between age and sleep timing, despite a smaller literature and the absence of analyzable data for ages 30-60. Changes in sleep timing, rather than changes in sleep duration or continuity, may better characterize the effects of age on human sleep.

Factors Affecting the Quality of Sleep in Children

Sleep quality is one of the domains of sleep. Having adequate quality sleep is defined as one’s “feeling fresh” after waking-up. Inadequate sleep quality results in sleep insufficiency producing a variety of symptoms and signs. The central nervous system is affected the most in children, although other system too may be involved. Several factors affect sleep quality in children including genetics, sleep habits, medical problems, parents/caregiver factors, screen time and the child’s environment. These factors are inter-related and dynamic. The outcome of sleep insufficiency is many involving neurocognitive and neurobehavior, mood and emotional issues and specific conditions, like pulmonary hypertension, cor pulmonale and obesity. Management should start with proper history taking to identify the multifaceted nature of the condition. Treatment is planned cognizant of the age of the patient and the associated etiological factors, and should involve both the children and their parents.

Sleep-Related Problems and Pediatric Anxiety Disorders

Sleep-related problems are highly prevalent among childhood and adolescent anxiety disorders. The objective of this review was to summarize the relevant clinical research literature as it pertains to the nature of the association between sleep-related problems and youth anxiety, developmental factors relevant to this association, and intervention efforts to target comorbid sleep challenges and anxiety. Limitations of the literature and future directions are discussed.

Sleep disturbance as a predictor of anxiety in children with Fetal Alcohol Spectrum Disorders and typically developing children

BACKGROUND

High levels of anxiety and sleep problems are common features of Fetal Alcohol Spectrum Disorders (FASD). The strong association between sleep and anxiety has been documented in typically developing (TD) populations and is thought to be bidirectional. The association between sleep and anxiety in children with FASD has not yet been examined.

METHODS

Caregivers of children with FASD (n = 91) and TD children (n = 103) aged 6-16 completed the Children's Sleep Habits Questionnaire (CSHQ), Spence Children's Anxiety Scale (SCAS), and a background questionnaire. Hierarchical multiple regression analyses, group comparisons and ANCOVA interaction models were used to test the associations between sleep and anxiety within and between the two groups.

RESULTS

Sleep disturbances and anxiety were at clinical levels for the majority of the FASD group, and significantly higher in the FASD group than the TD group. After controlling for age and sex, 27 % of the variance in anxiety scores in TD children was attributable to sleep problems, and 33 % in children with FASD.

CONCLUSION

This study highlights associations between parent-reported sleep and anxiety in FASD. Sleep disturbances were significant predictors of anxiety in both children with FASD and in TD children. Given the importance of sleep to healthy neurodevelopment, there is a pressing need for sleep intervention studies in children with FASD. Early identification and intervention for sleep problems in this condition should be a therapeutic priority.

Sleep Problems in School Aged Children: A Common Process across Internalising and Externalising Behaviours?

Sleep problems are common in childhood and impact cognitive, psychological and physical wellbeing. The current study investigated the association between sleep problems and internalising and externalising behaviour in 114 school-aged children (5–12 years) from four primary schools in Melbourne, Australia. Data were collected using the Sleep Disorder Inventory for Students to measure sleep and the Conners Behavior Rating Scale to assess behaviour, both by parent report. Hierarchical regression analysis, controlling for socioeconomic status and age, identified moderate associations between sleep problems and emotional distress, aggressive behaviour and hyperactivity/impulsivity. Findings suggest screening for sleep problems in children presenting clinically with behavioural issues is a potentially important clinical practice. Additionally, results support the elaboration of transdiagnostic theory, whereby sleep problems are a common process in both internalising and externalising behaviour in children.

Behavioral Sleep-Related Problems in Clinically Anxious Children: A Parent-Report Diary Study

Anxiety disorders and behavioral sleep-related problems (SRPs) frequently co-occur during childhood. However, few studies have used the recommended method of a sleep-diary. The present study examined parental perceptions of behavioral SRPs in anxious compared to non-anxious children using a sleep-diary. Parents of 22 clinically anxious children and 29 healthy controls (aged 6-13 years) completed a 7-day sleep-diary of their child's behavioral SRPs. Compared to non-anxious peers, anxious children were rated by parents as more often (a) having a negative mood before bed, (b) delaying bed, (c) requiring parental assistance during the night, especially on weeknights, (d) having difficulty waking on their own the next morning, (e) falling back to sleep after morning waking, and (f) waking in a negative mood. There were no significant group differences in sleep onset latency or sleep duration, and behavioral SRPs of anxious children did not negatively affect their functioning or that of their parents the next day based on parent report. Parents of anxious children are more likely to perceive their children as engaging in behavioral SRPs compared to parents of non-anxious children.

Co-Sleeping among School-Aged Anxious and Non-Anxious Children: Associations with Sleep Variability and Timing

Little is known about the co-sleeping behaviors of school-aged children, particularly among anxious youth who commonly present for the treatment of sleep problems. The current study examined the occurrence of co-sleeping in both healthy and clinically anxious children and its associated sleep patterns. A total of 113 children (ages 6-12), 75 with primary generalized anxiety disorder and 38 healthy controls, participated along with their primary caregiver. Families completed structured diagnostic assessments, and parents reported on their child's co-sleeping behaviors and anxiety severity. Children provided reports of anxiety severity and completed one week of wrist-based actigraphy to assess objective sleep patterns. A significantly greater proportion of anxious youth compared to healthy children co-slept, and greater anxiety severity was related to more frequent co-sleeping. Co-sleeping in anxious youth was associated with a delay in sleep timing and with greater sleep variability (i.e., more variable nightly sleep duration). All analyses controlled for child age, race/ethnicity, family income, and parental marital status. Co-sleeping is highly common in anxious school-aged children, with more than 1 in 3 found to co-sleep at least sometimes (2-4 times a week). Co-sleeping was even more common for youth with greater anxiety severity. Increased dependence on others to initiate and maintain sleep may contribute to poorer sleep in this population via shifted schedules and more variable sleep patterns.

Anxiety as a Common Biomarker for School Children With Additional Health and Developmental Needs Irrespective of Diagnosis

Currently very little evidence is available regarding the biological characteristics and common comorbid behaviors that are associated with children characterized by learning difficulties who require additional support at school. These children are usually referred to as having Additional Health and Developmental Needs by the Australian Government and the associated public education system more broadly though the problems may arise from academic, social and/or emotional stressors and may or may not include children with clinically diagnosed Neurodevelopmental Disorders. Thus, the aim of this study was to investigate the relationship between anxiety levels (Spence Children's Anxiety Scale- Parent Report), autism traits (Autism Spectrum Quotient - Child Version) and sleep quality (Sleep Disturbance Scale for Children) in children with Additional Health and Developmental Needs without an intellectual disability, but with either a diagnosis of Autism Spectrum Disorder (ASD) (N = 25), Speech and Language Impairment (N = 37) or Other Diagnosis (N = 22). Our results demonstrated that these children with Additional Health and Developmental Needs showed atypically high levels of anxiety and impaired sleep quality, with the ASD group reporting more impairments associated with comorbid anxiety and sleep quality than either of the other clinically diagnosed groups. In fact, greater anxiety level was associated with a greater number of autism traits and poorer sleep quality regardless of diagnostic group suggesting that anxiety is a common experience for children with Additional Health and Developmental Needs. It is suggested that assessment of anxiety, sleep behaviors and autism traits may be useful markers for early identification of children within this population, thus providing scope for early and targeted intervention.

(Re)Conceptualizing Sleep Among Children with Anxiety Disorders: Where to Next?

Children with anxiety disorders (AD) characteristically complain of sleep problems and the extent to which cognitive behavioral treatments (CBT) for childhood anxiety produce sleep-based improvements is a topic of increasing interest. The current paper reviews available evidence for subjective sleep complaints and objective sleep alterations in children and adolescents with AD, including investigations of potential changes in sleep following anxiety-focused CBT. Despite pervasive complaints of poor sleep, the empirical literature provides minimal evidence for actual sleep-wake alterations in this population of youth and evidence for sleep-based changes following treatment for anxiety is minimal. In line with calls for more comprehensive models of the role of sleep in developmental psychopathology, several fundamental gaps in understanding are described and highlighted as essential avenues for clarifying the nature and consequences of poor quality sleep among youth with clinical levels of anxiety. In a second section of the paper, an emerging body of novel, translational research investigating more intricate sleep-anxiety relationships is introduced with potential implications for both etiological models and treatment design and delivery.

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.

Relationship between subtypes and symptoms of ADHD, insomnia, and nightmares in connection with quality of life in children

OBJECTIVES

This study examined the links between sleep disorders and subtypes of attention deficit-hyperactivity disorder (ADHD-inattention, ADHD-combined, ADHD-hyperactive/impulsive) in childhood. We set up a hypothetical model linking different symptoms of both disorders to construct the underlying and shared pathways. By examining a sample of children with ADHD we firstly tested parts of the model.

METHODS

A total of 72 children with symptoms of ADHD (aged 6-13 years; 79.2% boys) were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition and the International Classification of Sleep Disorders, third edition in regards to ADHD and sleep disorders via standardized parent-rated questionnaires. Additionally, quality of life (QoL) was assessed. Overall, 46 children fulfilled the criteria of ADHD and were medication-naive.

RESULTS

On average, the whole sample had clinically elevated total scores of the Children's Sleep Habits Questionnaire in the validated German version (CSHQ-DE), indicating an increased prevalence of sleep disorders in children with ADHD. In accordance to our hypothetical model, children with primarily hyperactive-impulsive ADHD showed the highest CSHQ-DE scores. Moreover, we found a high impact for insomnia in this subgroup and a high comorbid load for the mutual occurrence of insomnia and nightmares. Furthermore, QoL was reduced in our whole sample, and again intensified in children with comorbid insomnia and nightmares.

CONCLUSION

We verified an elevated occurrence of sleep disorders in children with ADHD and were able to link them to specific subtypes of ADHD. These results were in line with our hypothetical model. Moreover, we found a clinically reduced QoL in mean for the whole sample, indicating the strong impact of ADHD in the lives of affected children, even intensified if children exhibited comorbid insomnia and nightmares. These results should be kept in mind regarding the treatment and therapy of this subgroup of children. Specific treatment strategies should be considered for these children.

The developmental trajectory of parent-report and objective sleep profiles in autism spectrum disorder: Associations with anxiety and bedtime routines

The present study compared the course of parent-report and actigraphy-derived sleep profiles over a 1-year period, in school-age children with autism spectrum disorder and typically developing children. The Children's Sleep Habits Questionnaire and 14 nights of actigraphy were used to assess sleep profiles. Parents also completed the Spence Children's Anxiety Scale, the Social Worries Questionnaire and the Bedtime Routines Questionnaire. Between-group differences in parent-reported sleep problems were less pronounced at follow-up compared to baseline. The course of objective sleep was comparable between groups, with a significant reduction in sleep duration over time in both groups. Children with autism spectrum disorder were further characterised by significantly more night-to-night variability in sleep quality, across both time points. Reductions over time in parent-reported sleep problems were significantly associated with reduced anxiety. Reductions in actigraphy-derived sleep efficiency were associated with an increased frequency of maladaptive activities in the hour before bedtime, in both children with and without autism spectrum disorder.