Clinical utility of the Chinese version of the Pediatric Daytime Sleepiness Scale in children with obstructive sleep apnea syndrome and narcolepsy

An Open-Label Pilot Trial of a Brief, Parent-Based Sleep Intervention in Children With ADHD

OBJECTIVE

To assess the effects of a brief parent-based behavioral sleep intervention in children with ADHD.

METHODS

Families with a child with ADHD and parent-reported sleep problems received a brief parent-based sleep intervention, which involved two one-to-one consultation sessions and one telephone follow-up with the parent/caregiver. Child's sleep and clinical symptoms, and parental sleep and daytime functioning were assessed at baseline, 2-week post-intervention, and 3-month follow-up.

RESULTS

Sixty eligible families (mean age of the child: 9.4 ± 1.5 years; boys: 75%) were recruited, and 43 (72%) completed the whole intervention. The intervention resulted in significant improvements in the child's sleep, clinical symptoms, and parental sleep and parenting stress, and these improvements were generally maintained at 3-month follow-up.

CONCLUSION

The findings supported the promising effects of a brief parent-based sleep intervention on improving sleep and clinical symptoms in children with ADHD and parental sleep and parenting stress. Further randomized clinical trials with long-term follow-up are needed to test the robustness of the effectiveness of the intervention.

Subtyping at-risk adolescents for predicting response toward insomnia prevention program

BACKGROUND

Previous study has shown that a brief cognitive-behavioral prevention insomnia program could reduce 71% risk of developing insomnia among at-risk adolescents. This study aimed to evaluate the differential response to insomnia prevention in subgroups of at-risk adolescents.

METHODS

Adolescents with a family history of insomnia and subthreshold insomnia symptoms were randomly assigned to a 4-week insomnia prevention program or nonactive control group. Assessments were conducted at baseline, 1 week, and 6- and 12-month after the intervention. Baseline sleep, daytime, and mood profiles were used to determine different subgroups by using latent class analysis (LCA). Analyses were conducted based on the intention-to-treat approach.

RESULTS

LCA identified three subgroups: (a) insomnia symptoms only, (b) insomnia symptoms with daytime sleepiness and mild anxiety, and (c) insomnia symptoms with daytime sleepiness, mild anxiety, and depression. The incidence rate of insomnia disorder over the 12-month follow-up was significantly reduced for adolescents receiving intervention in subgroup 3 compared with the controls (hazard ratio [HR] = 0.37; 95% confidence interval [CI]: 0.13-0.99; p = .049) and marginally for subgroup 2 (HR = 0.14; 95% CI: 0.02-1.08; p = .059). In addition, adolescents who received intervention in subgroups 2 and 3 had a reduced risk of excessive daytime sleepiness (subgroup 2: adjusted OR [AdjOR] = 0.45, 95% CI: 0.23-0.87; subgroup 3: AdjOR = 0.32, 95% CI: 0.13-0.76) and possible anxiety (subgroup 2: AdjOR = 0.47, 95% CI: 0.27-0.82; subgroup 3: AdjOR = 0.33, 95% CI: 0.14-0.78) compared with the controls over the 12-month follow-up.

CONCLUSIONS

Adolescents at risk for insomnia can be classified into different subgroups according to their psychological profiles, which were associated with differential responses to the insomnia prevention program. These findings indicate the need for further phenotyping and subgrouping at-risk adolescents to develop personalized insomnia prevention.

Secular trends in sleep and circadian problems among adolescents in Hong Kong: From 2011-2012 to 2017-2019

OBJECTIVE

The study aimed to investigate secular trends in sleep and circadian problems in Hong Kong Chinese adolescents.

METHODS

This study analyzed cross-sectional data from two large-scale school-based sleep surveys conducted in 2011-2012 and 2017-2019. Sleep and circadian problems, including sleep-wake pattern, insomnia, chronotype, social jetlag, daytime sleepiness, and other sleep-related factors, were compared between two survey years.

RESULTS

A total of 8082 adolescents (5639 students in 2011-2012 [Mean age: 14.4 years, 50.9% boys] and 2443 students in 2017-2019 [Mean age: 14.7 years, 54.0% boys]) were included in this 7-year study. The average time in bed of Hong Kong adolescents decreased from 8.38 hours to 8.08 hours from 2011-2012 to 2017-2019. There was a 0.28-hour delay in weekday bedtime, 0.54-hour advance in weekend wake-up time, and a 0.36-hour decline in average time in bed, resulting in increased trends of sleep loss (Time in bed <8h: OR = 2.06, 95%CI: 1.44-2.93, p < 0.01; Time in bed <7h: OR = 2.73, 95%CI: 1.92-3.89, p < 0.01), daytime sleepiness (OR = 1.70, 95%CI: 1.34-2.16, p < 0.01), and evening chronotype (OR = 1.26, 95%CI: 1.08-1.48, p < 0.01). The increased trend in insomnia disorder, however, was insignificant when covariates were adjusted.

CONCLUSION

A secular trend of reduced time in bed, delay in weekday bedtime, advance in weekend wake-up time, increase in evening chronotype and daytime sleepiness from 2011-2012 to 2017-2019 were observed. There is a timely need for systematic intervention to promote sleep health in adolescents.

Effects of childhood obstructive sleep apnea with and without daytime sleepiness on behaviors and emotions

OBJECTIVE

To investigate the relationship between obstructive sleep apnea (OSA) with and without excessive daytime sleepiness (EDS) and behavioral and emotional outcomes in non-obese prepubertal children.

METHODS

This was a retrospective analysis of children aged 5-11 years who presented to our unit for assessment of their sleep-related complaints. All children underwent polysomnography (PSG). They also completed the Pediatric Daytime Sleepiness Scale (PDSS) and a sleep diary. OSA was diagnosed if the obstructive apnea-hypopnea index (OAHI) was ≥1 event/hour. EDS was defined as PDSS >15. Behavioral and emotional outcomes were assessed using the Child Behavioral Checklist (CBCL).

RESULTS

Data from 391 children (mean age of 8.6 ± 1.7 years; 67 % male) were analyzed. Seventy children did not have OSA or EDS, 137 had OSA, 50 had reported having EDS but without OSA, and 134 children had both OSA and EDS. There were significantly higher CBCL total problems score in the combined group (61 ± 9) compared to the non-OSA/EDS group (54 ± 10), and the OSA-only group (54 ± 10) (p < 0.001). The presence of EDS was significantly associated with higher CBCL T score and higher odds for clinically significant behavioral problems (T score ≥65) after adjusting for age, sex, BMI z-score and average sleep duration (p < 0.001).

CONCLUSION

Excessive daytime sleepiness is an important contributory factor associated with suboptimal behavioral and emotional outcomes in children with OSA.

Comparative Analysis of Sleep Hygiene and Patterns among Adolescents in Two Russian Arctic Regions: A Pilot Study

PURPOSE

The circumpolar habitat stands as one of the most vulnerable environments for human activity and health. The primary study objective was to compare sleep-related factors, light exposure, social cues, and potential confounding variables among schoolchildren residing in the European Arctic region from two settlements situated below and above the Polar Circle using validated self-reported questionnaires.

MATERIALS AND METHODS

We recruited 94 children aged 13-15 years (40.4% males), matched by sex and age, from public educational institutions in two circumpolar settlements located below (Kem', Republic of Karelia; 64.6 NL) and above the Polar Circle (Apatity, Murmansk Region; 67.3 NL). Participants completed several surveys, including the Pediatric Daytime Sleepiness Scale, the Insomnia Severity Index, the Adolescent Sleep Hygiene Scale, and the Munich ChronoType Questionnaire, to evaluate sleep parameters and chronotype. The χ2 test was used to test for differences between proportions. Linear regression and multiple regression models with co-factors were applied to assess the relationship between studied indicators.

RESULTS

A noteworthy increase in physical activity was observed in children residing in Kem' compared to those in Apatity. Children from Apatity showed higher alcohol consumption than their counterparts from Kem'. The overall rate of excessive daytime sleepiness in the sample was 17.1%. Moderate insomnia symptoms were reported in 18.4% of adolescents living in Kem' and in 25% of respondents living in Apatity, respectively. Notably, participants from Kem' attained higher academic scores and had longer exposure to sunlight on schooldays. On the other hand, children from Apatity tended to have later bedtimes and sleep-onset times on schooldays. According to the Munich ChronoType Questionnaire data, a reliance on alarm clocks on schooldays, and a higher Sleep Stability Factor based on the Adolescent Sleep Hygiene Scale.

DISCUSSION

Our study indicating that higher physical activity and longer sunlight exposure among Kem' children on schooldays are associated with earlier wake-up times during schooldays, earlier bedtime whole week, reduced dependence on alarm clocks, and higher academic achievements. The results of older schoolchildren differ from many works published previously in the USA, Argentina, and Japan, which could be explained by the season when the study was performed. Here, we observed a negative impact on school performance and sleep parameters in children living in high latitudes, namely in circumpolar regions.

CONCLUSIONS

Our study points out that adolescents living above the Polar Circle tend to have sleep problems, e.g., late sleep-onset times, higher excessive daytime sleepiness, and insomnia-related symptoms, because of experiencing reduced exposure to natural light. Future research encompassing assessments across all four seasons will provide a more comprehensive understanding.

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

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

Effect of surgical intervention for childhood OSA on blood pressure: A randomized controlled study

OBJECTIVE

To investigate the effect of surgical intervention on 24-h ABP in children with OSA. It was hypothesized that blood pressure would improve following adenotonsillectomy.

METHODS

This was a two-centered investigator-blinded randomized controlled trial. Non-obese pre-pubertal children aged 6-11 years with OSA (obstructive apnea-hypopnea index, OAHI >3/h) underwent 24-h ABP monitoring at baseline and 9 months after the randomly assigned intervention, i.e. Early Surgery (ES) or Watchful Waiting (WW). Intention-to-treat analysis was performed.

RESULTS

137 subjects were randomized. Sixty-two (Age: 7.9y ± 1.3, 71% boys) and 47 (Age: 8.5y ± 1.6, 77% boys) participants from the ES and WW groups, respectively completed the study. Changes in ABP parameters were similar in the ES and WW groups (nighttime systolic BP z-scores: +0.03 ± 0.93 vs. -0.06 ± 1.04, p = 0.65; nighttime diastolic BP z-scores: -0.20 ± 0.95 vs. -0.02 ± 1.00, p = 0.35) despite a greater improvement in OSA in the ES group. However, a reduction in nighttime diastolic BP z-score correlated with improvements in OSA severity indexes (r = 0.21-0.22, p < 0.05), and a significant improvement in nighttime diastolic BP z-score [-0.43 ± 1.01, p = 0.027] following surgery was observed in participants with severe preoperative OSA (OAHI ≥10/h). The ES group had a significant increase in body mass index z-score after surgery [+0.27 ± 0.57, p < 0.001], which correlated with the increase in daytime systolic BP z-score (r = 0.2, p < 0.05).

CONCLUSION

Surgical treatment did not lead to significant improvements in ABP in OSA children except in those with more severe disease. The improvement in BP was partially masked by the weight gain following surgery.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn.

REGISTRATION NUMBER

ChiCTR-TRC-14004131).

Association of social jetlag and eating patterns with sleep quality and daytime sleepiness in Japanese high school students

A high prevalence of excessive daytime sleepiness and poor sleep quality has been reported in adolescents, but the effects of social jetlag on sleep quality and daytime sleepiness are unclear. Therefore, we assessed the association of sleep and eating patterns with daytime sleepiness and sleep quality among a total of 756 Japanese high school students. Participants completed the Pittsburgh Sleep Quality Index to evaluate sleep quality, the Pediatric Daytime Sleepiness Scale to evaluate daytime sleepiness, and an 8-day sleep diary. Data on average sleep duration, social jetlag, midsleep on free days sleep corrected, and the differences in the first and last meal timing between school days and non-school days were obtained from participants' sleep diaries. The results reveal that social jetlag is associated with differences in the first meal timing between school days and non-school days, and that social jetlag of more than 2 hr is associated with extremely poor sleep quality and excessive daytime sleepiness in Japanese high school students. Our findings suggest that reducing social jetlag to within a 2-hr window is important to prevent poor sleep quality and excessive daytime sleepiness for this population.

The impact of sleep-corrected social jetlag on mental health, behavioral problems, and daytime sleepiness in adolescents

STUDY OBJECTIVES

This study aimed to examine the effect of sleep-corrected social jetlag (SJLsc) on mental health, behavioral problems, and daytime sleepiness in adolescents.

METHODS

This was a cross-sectional study which included 4787 adolescents (Mean age: 14.83±1.6y, 56.0% girls) recruited from 15 secondary schools in Hong Kong. SJLsc was defined as the absolute difference between sleep-corrected midsleep on weekdays and weekends, at which the sleep debt has been considered. It was classified into three groups: low-level ("LSJLsc", <1h), mid-level ("MSJLsc", ≥1h and <2h), and high-level of SJLsc ("HSJLsc", ≥2h). Adolescents' mental health, behavioral problems and daytime sleepiness were measured by the General Health Questionnaire (GHQ-12), the Strengths and Difficulties Questionnaire (SDQ) and the Pediatric Daytime Sleepiness Scale (PDSS). Logistic regression analysis and restricted cubic spline regression (RCS) analysis were applied with consideration of confounders including age, gender, puberty and sleep problems.

RESULTS

Nearly half (46.9%) of adolescents had SJLsc for at least 1 h. Greater SJLsc was associated with more behavioral difficulties (MSJLsc: OR: 1.20, p = 0.03; HSJLsc: OR: 1.34, p = 0.02) when controlling for age, sex, puberty, chronotype, insomnia, and time in bed. There was a dose-response relationship in which higher SJLsc had an increased risk of conduct problems and hyperactivity, while only high-level SJLsc was associated with a peer relationship problem. In RCS analysis, SJLsc was associated with a higher likelihood of behavioral difficulties (p = 0.03) but not poor mental health or daytime sleepiness.

CONCLUSIONS

Sleep-corrected social jetlag was a unique risk factor for behavioral problems in adolescents. Our findings highlighted the need for interventions to promote healthy sleep-wake patterns in school adolescents.

Dim light melatonin patterns in unaffected offspring of parents with bipolar disorder: A case-control high-risk study

BACKGROUND

Circadian dysregulation has long been thought to be a key component in the pathophysiology of bipolar disorder (BD). However, it remains unclear whether this dysregulation constitutes a risk factor, manifestation, or consequence of BD. This study aimed to compare dim light melatonin secretion patterns between unaffected offspring of parents with BD (OBD) and offspring of control parents (OCP).

METHODS

This case-control study included unaffected OBD (mean age 14.0 years; male 50.0 %) and age- and sex-matched OCP (mean age 13.0 years; male: 43.5 %). Seventeen saliva samples were collected in dim light conditions. Dim light melatonin onset (DLMO), phase angles, and area under the curve (AUC) were calculated.

RESULTS

185 saliva samples from 12 OBD (n = 12) and 741 from OCP (n = 46) were collected. Unaffected OBD had a significant lower nocturnal melatonin level (14.8 ± 4.6 vs. 20.3 ± 11.7 pg/mL) and a smaller melatonin AUC within two hours after DLMO (35.5 ± 11.3 vs. 44.6 ± 18.1 pg/mL) but a significant larger phase angle between DLMO and sleep onset (2.2 ± 1.0 vs. 1.4 ± 1.2 h) than OCP. There was no significant between-group difference in DLMO. The graphic illustrations showed a considerably flattened melatonin secretion in unaffected OBD.

LIMITATIONS

The main limitations include lack of 24-h dim melatonin secretion measurement, large age range of participants, and small sample size.

CONCLUSIONS

These findings suggest that unaffected OBD already presented with circadian rhythm dysregulations. Future investigations are needed to clarify the role of abnormal melatonin secretion in the onset of BD.

Neurocognitive Consequences in Children with Sleep Disordered Breathing: Who Is at Risk?

Sleep-disordered breathing (SDB) is a prevalent disease in children characterized by snoring and narrowing of the upper airway leading to gas exchange abnormalities during sleep as well as sleep fragmentation. SDB has been consistently associated with problematic behaviors and adverse neurocognitive consequences in children but causality and determinants of susceptibility remain incompletely defined. Since the 1990s several studies have enlightened these associations and consistently reported poorer academic performance, lower scores on neurocognitive tests, and behavioral abnormalities in children suffering from SDB. However, not all children with SDB develop such consequences, and severity of SDB based on standard diagnostic indices has often failed to discriminate among those children with or without neurocognitive risk. Accordingly, a search for discovery of markers and clinically useful tools that can detect those children at risk for developing cognitive and behavioral deficits has been ongoing. Here, we review the advances in this field and the search for possible detection approaches and unique phenotypes of children with SDB who are at greater risk of developing neurocognitive consequences.

Evaluation of psychometric properties of patient-reported outcome measures frequently used in narcolepsy randomized controlled trials: a systematic review

Study Objectives

To systematically determine subjective and objective outcome measures used to measure the efficacy of narcolepsy interventions in randomized controlled trials (RCTs) in adults and children and assess psychometric properties of patient-reported outcome measures (PROMs) used.

Methods

We searched bibliographical databases and clinical trial registries for narcolepsy RCTs and extracted objective and subjective outcome measures. If PROMs were used, we searched for psychometric studies conducted in a narcolepsy population using bibliographical databases and appraised using Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines.

Results

In total, 80 different outcome measures were used across 100 RCTs. Epworth Sleepiness Scale (ESS) (n = 49) and Maintenance of Wakefulness Test (n = 47) were the most frequently used outcome measures. We found 19 validation studies of 10 PROMs in narcolepsy populations. There was limited evidence for validity or responsiveness of the ESS; yet sufficient reliability (pooled ICC: 0.81–0.87). Narcolepsy Severity Scale (NSS) had sufficient reliability (pooled ICC: 0.71–0.92) and both adult and pediatric versions had sufficient discriminant validity (treated/untreated). Content validity was only evaluated in pediatric populations for ESS-CHAD and NSS-P and rated inconclusive. Quality of evidence of the psychometric studies for all scales ranged from very low to low.

Conclusions

Although recognized by regulatory bodies and widely used as primary outcome measures in trials, there is surprisingly little evidence for the validity, reliability, and responsiveness of PROMs frequently used to assess treatment efficacy in narcolepsy. The field needs to establish patient-centered minimal clinically important differences for the PROMs used in these trials.

Pediatric Narcolepsy-A Practical Review

Pediatric narcolepsy is a chronic sleep-wakefulness disorder. Its symptoms frequently begin in childhood. This review article examined the literature for research reporting on the effects of treatment of pediatric narcolepsy, as well as proposed etiology and diagnostic tools. Symptoms of pediatric narcolepsy include excessive sleepiness and cataplexy. In addition, rapid-eye-movement-related phenomena such as sleep paralysis, sleep terror, and hypnagogic or hypnapompic hallucinations can also occur. These symptoms impaired children's function and negatively influenced their social interaction, studying, quality of life, and may further lead to emotional and behavioral problems. Therefore, early diagnosis and intervention are essential for children's development. Moreover, there are differences in clinical experiences between Asian and Western population. The treatment of pediatric narcolepsy should be comprehensive. In this article, we review pediatric narcolepsy and its treatment approach: medication, behavioral modification, and education/mental support. Pharmacological treatment including some promising newly-developed medication can decrease cataplexy and daytime sleepiness in children with narcolepsy. Other forms of management such as psychosocial interventions involve close cooperation between children, school, family, medical personnel, and can further assist their adjustment.

Development and Validation of the Pediatric Hypersomnolence Survey

BACKGROUND AND OBJECTIVES

Narcolepsy and idiopathic hypersomnia usually begin in early adolescence, but diagnostic delays ranging from 5 to 10 years are common, affecting disease burden. To improve early identification of these treatable conditions, we developed and validated the Pediatric Hypersomnolence Survey (PHS).

METHODS

Content was developed through literature review, patient focus groups, interviews with experts in the field, and field testing. We then validated the 14-item self-reported survey across 3 hospitals and web recruitment from patient groups. In the validation phase, we recruited a total of 331 participants (patients with narcolepsy type 1 [n = 64], narcolepsy type 2 [n = 34], idiopathic hypersomnia [n = 36], and other sleep disorders [n = 97] and healthy controls [n = 100], ages 8-18 years) to complete the survey. We assessed a range of psychometric properties, including discriminant diagnostic validity for CNS disorders of hypersomnolence using receiver operating characteristic curve analysis and reliability across a 1-week period.

RESULTS

Confirmatory factor analysis indicated a 4-domain solution with good reliability expressed by satisfactory omega values. Across groups, the PHS total score showed appropriate positive correlations with other validated surveys of sleepiness (r = 0.65-0.78, p < 0.001) and negative correlations with multiple sleep latency test measures (mean sleep latency: r = -0.27, p = 0.006; number of sleep-onset REM periods: r = 0.26, p = 0.007). Compared to controls and patients with other sleep disorders, the area under the curve for participants with narcolepsy or idiopathic hypersomnia was 0.87 (standard error 0.02, 95% CI 0.83-0.91) with high sensitivity (81.3, 95% CI 73.7%-87.5%) and specificity (81.2%, 95 CI 75.1%-86.4%). Test-retest reliability was r = 0.87.

DISCUSSION

The PHS is a valid and reliable tool for clinicians to identify pediatric patients with narcolepsy and idiopathic hypersomnia. Implemented in clinical practice, the PHS will potentially decrease diagnostic delays and time to treatment, ultimately reducing disease burden for these debilitating conditions.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that the PHS accurately identifies patients with central disorders of hypersomnolence.

The Associations of Electronic Media Use With Sleep and Circadian Problems, Social, Emotional and Behavioral Difficulties in Adolescents

BACKGROUND

Electronic media use (EMU) becomes one of the most common activities in adolescents. The present study investigated the deleterious influence of excessive EMU and EMU before bedtime on social, emotional, and behavioral difficulties (SEBD) in adolescents. The role of sleep and circadian problems in mediating the association of EMU with SEBD was examined.

METHODS

A cross-sectional survey study was conducted with 3,455 adolescents (55.7% female, mean age = 14.8 ± 1.57 years, 36.6% monthly family income < HK$15,000) between December 2011 and March 2012 in Hong Kong. The associations of EMU with sleep and circadian problems and SEBD were analyzed using multiple binary logistic regression and path analysis. Sleep problems were measured by the Insomnia Severity Index and the reduced Horne and Östberg Morningness and Eveningness Questionnaire. Circadian problems were calculated based on established formulas. SEBD was measured using the Strengths and Difficulties Questionnaire. Participants' mental health status was assessed by the General Health Questionnaire.

RESULTS

A longer duration of EMU, excessive EMU (daily duration ≥ 2 h), and bedtime EMU (an hour before bedtime) were associated with the risk of sleep and circadian problems, poor mental health, and SEBD (p < 0.05). Insomnia, eveningness, social jetlag, and sleep deprivation were found to mediate the associations of EMU (including bedtime EMU of computers, electronic game consoles, phones, and televisions, together with excessive EMU of computers for leisure purposes and phones) with mental health and SEBD.

CONCLUSIONS

The findings suggest the need for setting up guidelines and advocacy for education for appropriate EMU and intervention for the associated sleep and circadian problems to ameliorate EMU-related mental and behavioral health problems in adolescents.

The trajectories and associations of eveningness and insomnia with daytime sleepiness, depression and suicidal ideation in adolescents: A 3-year longitudinal study

BACKGROUND

Eveningness and insomnia are highly comorbid and closely related to psychopathology in adolescents. We aimed to prospectively investigate the trajectories and associations of eveningness and insomnia with daytime functioning, depression and suicidal risk in adolescents.

METHODS

A 3-year longitudinal study was conducted among 414 Chinese adolescents. The associations of eveningness and insomnia with daytime functioning, depression and suicidal ideation were analyzed using logistic regressions.

RESULTS

The prevalence rates of eveningness were similar at baseline and follow-up (19.3% vs 22.5%; p = 0.27), while the prevalence of insomnia increased at follow-up (29.2% vs 40.8%; p < 0.001). Among those eveningness adolescents (n=80) at baseline, 46.2% remained as stable evening-type at follow-up, and among those insomnia adolescents (n=121) at baseline, 64.5% had persistent insomnia at follow-up. Logistic regressions showed that stable, incident, and resolved eveningness were associated with excessive daytime sleepiness (EDS) at follow-up, while only persistent and incident insomnia increased the risk of EDS. Persistent and incident insomnia, as well as stable eveningness were independently associated with depression at follow-up. Persistent and incident insomnia, but not eveningness, were associated with suicidal ideation.

LIMITATIONS

The outcome assessments were based on self-reported questionnaires and the sample size is modest.

CONCLUSIONS

Persistent eveningness and insomnia are significantly associated with greater risks of EDS and depression in adolescents, while both persistent and incident insomnia, but not eveningness, increased the risk of suicidal ideation. These findings underscore the importance of addressing sleep and circadian factors in the management of adolescent mood and daytime functioning.

Effect of surgical intervention for mild childhood obstructive sleep apnoea on attention and behavioural outcomes: A randomized controlled study

BACKGROUND AND OBJECTIVE

We evaluated inattention and behavioural outcomes following surgery versus watchful waiting (WW) in school-aged children with mild obstructive sleep apnoea (OSA).

METHODS

A prospective randomized controlled study was performed in pre-pubertal children aged 6-11 years with polysomnography (PSG)-confirmed mild OSA. They were assigned randomly to early surgical intervention (ES) or WW. The surgical intervention consisting of tonsillectomy with or without adenoidectomy and turbinate reduction was carried out within 4-6 weeks after randomization. Both groups underwent PSG, attention and behavioural assessment and review by an otorhinolaryngologist at baseline and 9-month follow-up. The primary outcome was omission T score from Conners' continuous performance test (CPT). Secondary outcomes were parent-reported behaviours, quality of life, symptoms and PSG parameters.

RESULTS

A total of 114 participants were randomized. Data of 35 subjects from the ES and 36 from the WW group were available for final analysis. No significant treatment effect could be found in all CPT parameters and behavioural outcomes. Nevertheless, significantly greater reductions were seen in PSG parameters (obstructive apnoea-hypopnoea index [-1.4 ± 2.0 cf. +0.3 ± 4.1/h, p = 0.038] and arousal index [-1.3 ± 4.4 cf. +1.4 ± 4.5/h, p = 0.013]) and OSA-18 total symptom score (-17.3 ± 19.7 cf. -3.6 ± 14.1, p = 0.001) in the ES group. Subjects who underwent surgery also had significantly greater weight gain (+3.3 ± 2.1 cf. +2.2 ± 1.5 kg, p = 0.014) and increase in systolic blood pressure (+5.1 ± 12.4 cf. -1.2 ± 8.7 mm Hg, p = 0.016).

CONCLUSION

Despite improvements in PSG parameters and parent-reported symptoms, surgical treatment did not lead to parallel improvements in objective attention measures in school-aged children with mild OSA.

Different positron emission tomography findings in schizophrenia and narcolepsy type 1 in adolescents and young adults: a preliminary study

STUDY OBJECTIVES

The association between schizophrenia and narcolepsy has been controversial. We conducted a prospective case control study of schizophrenia and comorbid narcolepsy type 1 in adolescents compared with patients with either diagnosis alone and healthy controls using ¹⁸F-fluorodeoxy glucose positron emission tomography, sleep studies, and neurocognitive tests.

METHODS

We included 11 patients (9-20 years old) with schizophrenia and comorbid narcolepsy type 1, 11 with narcolepsy type 1, 11 with schizophrenia, and 11 controls. All groups were matched for age and sex. Participants were required to submit to clinical interviews for sleep and psychiatric disorders, sleep questionnaires, continuous performance test, Wisconsin card sorting test, sleep studies including polysomnography, multiple sleep latency test and actigraphy, and positron emission tomography studies. All data were analyzed to compare the differences between the 4 groups.

RESULTS

The positron emission tomography results demonstrated significant differences in the dual diagnoses group compared with the 3 other groups. Compared with the controls, the dual diagnoses group had a significant presence of hypometabolism in the right mid-frontal, right orbital inferior frontal, and right posterior cingulum and a significant presence of hypermetabolism in the left amygdala, bilateral striatum, bilateral substantia nigra, bilateral basal ganglia, and bilateral thalamus. Continuous performance tests and Wisconsin card sorting tests showed that the dual diagnoses group had the worst performance.

CONCLUSIONS

Patients with schizophrenia and comorbid narcolepsy type 1 had different positron emission tomography findings than those with either schizophrenia or narcolepsy type 1 alone. They also had more neurocognitive impairments and required additional interventions.

Diagnostic accuracy of screening questionnaires for obstructive sleep apnea in children: A systematic review and meta-analysis

This systematic review and meta-analysis evaluated the diagnostic accuracy of screening questionnaires for pediatric obstructive sleep apnea (OSA). Studies comparing any questionnaire with polysomnography for OSA detection in subjects aged ≤18 y were considered eligible for qualitative analysis. The quality assessment of diagnostic accuracy studies (QUADAS-2) tool was used for bias assessment. Only questionnaires adopted by at least four studies using the currently accepted diagnostic threshold of apnea-hypopnea index (AHI) ≥1 were included for further selective quantitative analyses. A bivariate meta-analysis was performed to calculate sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio; summary receiver operator characteristic curves were constructed. 37 studies (20 questionnaires) were eligible for qualitative analysis; none were considered of low quality. Among these articles, 13 studies and two questionnaires (sleep-related breathing disorder scale of the pediatric sleep questionnaire (SRBD-PSQ) and OSA-18) satisfied the criteria for quantitative synthesis. SRBD-PSQ had higher sensitivity (0.76) than OSA-18 (0.56), while OSA-18 exhibited higher specificity (0.73) than SRBD-PSQ (0.43). SRBD-PSQ performed well and was the most sensitive screening questionnaire using the diagnostic threshold of AHI ≥1 for pediatric OSA. However, further well-designed studies are still required to assess the role of SRBD-PSQ in real-world clinical populations.

Compromised Dynamic Cerebral Autoregulation in Patients With Central Disorders of Hypersomnolence

Objective: We aimed to investigate the dynamic cerebral autoregulation (dCA) in patients with central disorders of hypersomnolence during wakefulness.

Methods: Thirty-six patients with central disorders of hypersomnolence were divided into three groups according to polysomnography and multiple sleep latency test results: the idiopathic hypersomnia group (IH), narcolepsy type 1 without rapid-eye-movement sleep behavior disorder group (NT1-RBD), and narcolepsy type 1 with rapid-eye-movement sleep behavior disorder group (NT1 + RBD), with 12 patients in each group. Twelve sex- and age-matched healthy controls were recruited. We assessed the Epworth sleepiness scale (ESS) and dCA of all subjects. dCA was assessed by analyzing the phase difference (PD) using transfer function analysis. The ESS and dCA were analyzed before and after standardized treatment in 24 patients with narcolepsy type 1.

Results: The overall PD of the IH, NT1-RBD, and NT1 + RBD groups were lower than that of the control group (P < 0.001). There were no significant differences between the overall PD of the NT1-RBD and NT1 + RBD group (P > 0.05). The ESS scores decreased and the overall PD increased after treatment in 24 patients with narcolepsy type 1 (P < 0.001). Multivariable analysis showed that mean sleep latency in multiple sleep latency test was independently associated with impaired overall PD (P < 0.05).

Conclusions: The dCA is impaired in patients with central disorders of hypersomnolence. The impairment of dCA occurs irrespective of NT1-RBD/+RBD. The ESS score and dCA improved in patients with narcolepsy type 1 after medication treatment. The mean sleep latency in multiple sleep latency test was independently associated with impaired dCA.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02752139.

A Prevention Program for Insomnia in At-risk Adolescents: A Randomized Controlled Study

OBJECTIVES

To prevent the future development of insomnia in at-risk adolescents.

METHODS

A randomized controlled trial comparing 4 weekly insomnia prevention program with a nonactive control group. Subjects were assessed at baseline, postintervention, and 6 and 12 months after intervention. Assessors were blinded to the randomization. Analyses were conducted on the basis of the intention-to-treat principles.

RESULTS

A total of 242 adolescents with family history of insomnia and subthreshold insomnia symptoms were randomly assigned to an intervention group (n = 121; mean age = 14.7 ± 1.8; female: 51.2%) or control group (n = 121; mean age = 15.0 ± 1.7; female: 62.0%). There was a lower incidence rate of insomnia disorder (both acute and chronic) in the intervention group compared with the control group (5.8% vs 20.7%; P = .002; number needed to treat = 6.7; hazard ratio = 0.29; 95% confidence interval: 0.12-0.66; P = .003) over the 12-month follow-up. The intervention group had decreased insomnia symptoms (P = .03) and reduced vulnerability to stress-related insomnia (P = .03) at postintervention and throughout the 12-month follow-up. Decreased daytime sleepiness (P = .04), better sleep hygiene practices (P = .02), and increased total sleep time (P = .05) were observed at postintervention. The intervention group also reported fewer depressive symptoms at 12-month follow-up (P = .02) compared with the control group.

CONCLUSIONS

A brief cognitive behavioral program is effective in preventing the onset of insomnia and improving the vulnerability factors and functioning outcomes.

Social Jetlag and Excessive Daytime Sleepiness from a Sample of Russian Children and Adolescents

PURPOSE

Insufficient nocturnal sleep is a primary source of excessive daytime sleepiness. Most previous research has focused on the disparity between sleep demands and study start times in adolescents. Fewer studies have focused on elementary schoolchildren. We hypothesize that late sleep timing is connected to excessive daytime sleepiness in a sample of Russian children and adolescents. The major goals of our study were to evaluate excessive daytime sleepiness in Russian schoolchildren and adolescents using the Russian version of the Pediatric Daytime Sleepiness Scale (PDSS) and to estimate its relationship with sleep-wake parameters using the Munich Chronotype Questionnaire (MCTQ).

MATERIALS AND METHODS

Student subjects were from public educational facilities in the Republic of Karelia. They completed both the PDSS and the Munich Chronotype Questionnaire to estimate sleep parameters and chronotype (MSFsc). Five hundred and eleven students provided data for the PDSS and sleep-wake variables, and 479 for the full MCTQ data.

RESULTS

The overall prevalence of Excessive Daytime Sleepiness (EDS) in our sample was 18%. The total PDSS score was inversely correlated with sleep length on school nights and was independent of respondents' sex. Higher PDSS scores were associated with later bedtimes on school days and free days, and shorter sleep duration on school days. Late chronotype and more pronounced social jetlag were both positively correlated with high PDSS scores. A negative correlation was found between chronotype and the duration of the sleep period on weekdays (p < 0.001) and a positive correlation was found on weekends (p < 0.001). Longer average sleep duration was positively related to less daytime sleepiness.

CONCLUSION

This study suggests that excessive daytime sleepiness is chronotype-dependent. School start times could be shifted to a later hour to prolong sleep and reduce EDS.

Translation and Validation of a Chinese Version of the Cleveland Adolescent Sleepiness Questionnaire

PURPOSE

The Cleveland Adolescent Sleepiness Questionnaire was originally developed and published in English and has served as a valid and effective tool for the assessment of adolescents' experiences with sleepiness in a variety of situations. To allow for comparisons between sleepiness in adolescents from different cultures, and with different linguistic backgrounds, reliable and valid measurement tools are necessary. The purpose of this study was to translate and validate a Chinese version of the Cleveland Adolescent Sleepiness Questionnaire (C-CASQ).

MATERIALS AND METHODS

Sensitivity, specificity, internal consistency, and criterion validity data for the C-CASQ were tested using 458 adolescents in Taiwan. Data from 191 participants were used to establish internal consistency reliability and conduct exploratory factor analysis (EFA), while data from 267 participants were used to establish criterion validity and conduct confirmatory factor analysis (CFA). Initial criterion validity was established through a comparison of the C-CASQ with scores from the Chinese version of the Morningness-Eveningness Scale for Children, a measure of chronotype.

RESULTS

EFA resulted in four factors, consistent with the original English version of the CASQ, while CFA established goodness of fit. The scale demonstrated acceptable to good internal consistency (α = 0.77~0.86). Initial criterion validity was evident as the total score and each of the subscale scores on the C-CASQ was significantly higher (greater sleepiness) in evening-types.

CONCLUSION

The C-CASQ appears to be a psychometrically sound measure to evaluate sleepiness in Chinese-speaking adolescents.

The relationship between sleep habits, lifestyle factors, and achieving guideline-recommended physical activity levels in ten-to-fourteen-year-old Japanese children: A cross-sectional study

The current focus of meeting the physical activity guidelines for children and young people include preventing conditions such as high blood cholesterol, high blood pressure, metabolic syndrome, obesity, low bone density, depression, and injuries. However, the relationship between sleep habits and meeting physical activity guidelines is still unclear. This study aimed to assess this relationship among fifth- to eighth-grade (ages 10-14) Japanese children. This cross-sectional study included 3,123 children (boys: 1,558, girls: 1,565, mean age: 12.5 ± 1.2 years). Questionnaires were used to assess parameters such as moderate-to-vigorous physical activity per day, school and weekend night sleep durations, social jetlag, daytime sleepiness, napping, screen time, and breakfast intake. Participants were divided into an achievement and a non-achievement group depending on their physical activity guideline achievement status (i.e., whether they met the children's physical activity guideline of 60 min or more of moderate-to-vigorous physical activity per day). Then, to determine the sleep habits in relation to the children's achievement of guideline-recommended physical activity levels, multivariate logistic regression analyses were conducted. In fifth- and sixth-grade (ages 10-12) boys, an inverse association was observed between physical activity guideline achievement and daytime sleepiness. In seventh- and eighth-grade (ages 12-14) boys, physical activity guideline achievement was inversely associated with social jetlag and skipping breakfast. Additionally, in seventh- and eighth-grade girls, physical activity guideline achievement was inversely associated with inappropriate sleep duration on weekends and screen time. These results suggest that meeting the physical activity guideline is related to favorable sleep habits in Japanese children. However, their relevance may differ by school type and gender.

Evidence Base Update on Assessing Sleep in Youth

BACKGROUND

Sleep is vital to youth well-being and when it becomes disturbed - whether due to environmental or individual factors - mental and physical health suffer. Sleep problems can also be a symptom of underlying mental health disorders. Assessing different components of sleep, including quality and hygiene, can be useful both for identifying mental health problems and for measuring changes in well-being over time. However, there are dozens of sleep-related measures for youth and it can be difficult to determine which to select for a specific research or clinical purpose. The goal of this review was to identify sleep-related measures for clinical and/or research use in youth mental health settings, and to update the evidence base on this topic.

METHOD

We generated a list of candidate measures based on other reviews and searched in PubMed and PsycINFO using the terms "sleep" AND (measure OR assessment OR questionnaire) AND (psychometric OR reliability OR validity). Search results were limited to studies about children and adolescents (aged 2-17) published in English. Additional criteria for inclusion were that there had to be at least three publications reporting on the measure psychometrics in community or mental health populations. Sleep measures meeting these criteria were evaluated using the criteria set by De Los Reyes and Langer (2018).

RESULTS

Twenty-six measures, across four domains of sleep - insomnia, sleep hygiene, sleepiness, sleep quality - met inclusion criteria. Each measure had at least adequate clinical utility. No measure(s) emerged as superior across psychometric domains.

CONCLUSION

Clinicians and researchers must evaluate sleep measures for each use case, as the intended purpose will dictate which measure is best. Future research is necessary to evaluate measure performance in transdiagnostic mental health populations, including youth with serious mental illness.

Associations Between Quality of Life, Psychosocial Well-being and Health-Related Behaviors Among Adolescents in Chinese, Japanese, Taiwanese, Thai and the Filipino Populations: A Cross-Sectional Survey

Health-related behaviors during adolescence have lifelong impacts. However, there are unclear areas regarding the associations between health-related quality of life and demographic characteristics, as well as physical and psychosocial indicators. The aim of this study was to examine the associations between quality of life and body weight, sleep outcome, social support by age, and cohabitants, given that income, self-esteem, lifestyle, emotional, social and behavioral problems were taken into account among adolescents in East and Southeast Asia. A cross-sectional survey was conducted in Zhengzhou of China, Hong Kong, Kansai region of Japan, Taipei of Taiwan, Bangkok of Thailand and Manila of the Philippines between 2016 and 2017 among 21,359 urban adolescents aged between 9 and 16. The results showed that adolescents who had better self-esteem and control of emotions and behaviors had much higher level of perceived quality of life. Those who were overweight or obese, sleepy in the daytime, and not living with parents had worse quality of life compared with those who were not. In conclusion, psychosocial well-being should have a higher priority in the promotion of quality of life among Asian adolescents. Nevertheless, further studies are required to explore the differences in perceived quality of life between genders and countries.

Psychometric properties of the Russian version of the Pediatric Daytime Sleepiness Scale (PDSS)

Insufficient sleep could severely impair both cognitive and learning skills. More prominent changes are found in children and adolescents. Tools used to estimate sleepiness in the adult population are commonly inappropriate for children. The objective of our study was to provide a reliable instrument to measure excessive sleepiness for upcoming studies in Russian-speaking children, applying the Russian version of Pediatric Daytime Sleepiness Scale (PDSS). The following tasks were resolved in our study: translation, validation, and analysis of psychometric properties of the Russian adaptation of the PDSS by standard tests. After the semantic validation of the instrument through a multi-stage translation process we checked its psychometric validation. A total of 552 students, consisting of N = 285 for the exploratory factor analysis (EFA), N = 267 for the confirmatory factor analysis (CFA) and N = 204 for test-retest analysis of public elementary schools located in Northern Russia completed the PDSS and Munich Chronotype Questionnaire to estimate sleep parameters in the classroom during the lessons. Response rate was 90%; excluded cases contained no data. Further, 204 of our participants completed the PDSS in a 3 months interval to check the test-retest reliability. Internal consistency was measured by Cronbach's alpha coefficients and CFA was used to test factorial validity of the tool. Concurrent validity and test-retest reliability were assessed via intra-class coefficient. Internal consistency of the PDSS scale was high (Cronbach's α = 0.8). The construct validity of the PDSS was supported by CFA (factor loadings were from 0.438 to 0.727) and the test-retest reliability demonstrated by the intra-class coefficient was 0.70. The total PDSS score was independent of sex. The mean total value of PDSS was 11.95 ± 6.24. Higher scores on PDSS were negatively correlated with sleep duration. Thus, the construct validity of the instrument remains valid and could be used for Russian-speaking youth samples in the evaluation of daytime sleepiness. It could be useful in future applications by sleep scientists and health practitioners.

How Well Do Children Understand the Vocabulary of Sleep?

BACKGROUND

Sleep surveys, such as the Pediatric Daytime Sleepiness Scale (PDSS), are used to determine a variety of concerns associated with sleep, including excessive daytime sleepiness (hypersomnolence), bedtime sleep behaviors, night awakenings, sleep duration, and sleep-disordered breathing. However, the literacy ability of the patient may not be adequate to ensure comprehension of questions and provision of accurate responses.

OBJECTIVE

To assess children's understanding of the sleep-associated vocabulary included in the PDSS.

METHODS

A cross-sectional, open-response survey was developed for use with students age 4 to 12 years. Prior to completing the instrument, each student was asked the meaning of six key sleep-related words used in the PDSS: drowsy, sleepy, alert, awakened, tired, and awake. The parents/caregivers were requested to record their child's definitions of these key words exactly as stated. Identification of words for "suitable" definitions was undertaken through consultation of three online dictionaries. This enabled the qualitative process associated with open-response surveys to be followed: identification of common themes, chunking of information, and criteria for coding responses. The final sample consisted of word definitions from 325 students (152 boys and 173 girls) from a school enrollment of 727 (45%).

KEY RESULTS

A high percentage of children provided "suitable" responses for the words sleepy (84%) and tired (75%). The percentage of "suitable" responses for the words drowsy and awakened gradually increased across the age groups. The words alert and awake were challenging for the children to define, with the sleep-associated definition for alert only being provided by 31% of children overall and awake only being provided by 48% overall. In total, 57% of children were able to provide suitable definitions for at least four words.

CONCLUSIONS

Our findings suggest that the results of many sleep surveys using these terms may not yield results that accurately reflect a child's actual state of daytime sleepiness and sleep/wake behaviors. Prior to administering a sleep survey, physicians need to clearly explain the meanings of sleep-associated words used in the survey and thus gain a more accurate reflection of a child's sleep and daytime behaviors. [HLRP: Health Literacy Research and Practice. 2019;3(1):e53-e69.].

PLAIN LANGUAGE SUMMARY

Sleep surveys are used to identify problems with sleep. Children with poor health literacy due to age may not understand the questions and may not provide adequate answers. Children's understanding of sleep-associated vocabulary was assessed using six words: drowsy, sleepy, alert, awakened, tired, and awake. Many of these words were found to be difficult for the children to define.

Factor structure of the Brazilian version of Pediatric Daytime Sleepiness Scale

The present study aimed to analyze the construct validity of the Pediatric Daytime Sleepiness Scale (PDSS) for the evaluation of the daytime sleepiness construct in adolescents through confirmatory factorial analysis. The cross-sectional study was carried out with a sample of 773 adolescents aged 14 to 19 years, enrolled in the state schools of Paranaguá, Paraná, Brazil. We investigated the sex, age, school year, study shift, occupational status, socioeconomic level and daytime sleepiness. The PDSS questions were not normal (p <0.001) and the mean total score was 14.87 (5.62). With Schwarz's BIC adjustment indicators = 142,389 and Akaike's AIC = 105,389, the model reached the criteria of the global adjustment indicators of the model in the confirmatory analysis, in which RMSEA = 0.020; CFI = 0.986; TLI = 0.977; SRMR = 0.021, with 17 degrees of freedom, KMO = 0.8504 and Cronbach's Alpha = 0.737, with three correlations. We conclude that the construct validity of the PDSS remains valid and confirms its factor structure with only one factor. Thereby, it was verified that the operationalization of the construct sleepiness of adolescents through this scale is adequately conceptualized to the behavior of the age group.

Eveningness chronotype, insomnia symptoms, and emotional and behavioural problems in adolescents

OBJECTIVE

Eveningness tendency and insomnia are common in adolescents, but whether they have an independent or synergistic effect on the risk of psychopathology have remained undefined. The present study aimed to examine eveningness chronotype and insomnia symptoms in relation to mental health and emotional and behavioural problems in a community-based adolescent population.

METHODS

A total of 4948 adolescents (weighted mean age: 14.5 ± 1.8 years, weighted percentage of females: 48.9%) completed the measures. Insomnia was assessed by the Insomnia Severity Index (ISI), and chronotype preference was measured by the reduced version of the Morningness-Eveningness Questionnaire (MEQ). Emotional and behavioural problems and mental health were assessed by the Strengths and Difficulties Questionnaire (SDQ) and the General Health Questionnaire (GHQ-12), respectively. Potential confounders including demographic factors, pubertal status, general health, and sleep duration were controlled for in the analyses.

RESULTS

Insomnia symptoms were prevalent in evening-type adolescents (52% vs intermediate-type: 34.3%, morning-type: 18.0%, p < 0.001), especially two subtypes of insomnia symptoms, including difficulty initiating sleep and difficulty maintaining sleep. Eveningness and insomnia were independently associated with an increased risk of having emotional and behavioural problems (eveningness: adjusted odds ratio [AdjOR] = 1.88, 95% confidence interval [CI] = 1.61-2.19, p < 0.001; insomnia: AdjOR = 3.66, 95% CI = 2.73-4.91) as well as poor mental health in adolescents (eveningness: AdjOR = 1.25, 95% CI = 1.04-1.52, p < 0.001; insomnia: AdjOR = 3.63, 95% CI = 2.41-5.03).

CONCLUSIONS

Eveningness and insomnia symptoms are independently associated with the risk of psychopathology in adolescents. Our findings underscore the need to address both sleep and circadian factors in assessing and managing emotional and behavioural problems in the adolescent population.

Neurocognition, sleep, and PET findings in type 2 vs type 1 narcolepsy

OBJECTIVE

To analyze differences in functional brain images collected in patients with type 2 and type 1 narcolepsy compared to normal controls and the relationship among brain images, objective neuropsychologic tests, and sleep findings.

METHODS

Data collection included comprehensive clinical investigation, study of sleep/wake with actigraphy, polysomnography, Multiple Sleep Latency Test, human leukocyte antigen typing, ¹⁸F-fluorodeoxyglucose PET, and cognitive tests obtained from 29 patients with type 2 narcolepsy, 104 patients with type 1 narcolepsy, and 26 sex- and age-matched normal control individuals. Conners' Continuous Performance Test (CPT II) and Wisconsin Card-Sorting Task were performed simultaneously with the FDG-PET examination. After analyses of variance, data between patients with type 1 and type 2 narcolepsy were compared by post hoc analysis, and correlation between functional brain imaging findings and results of neurocognitive tests was obtained.

RESULTS

All patients with narcolepsy presented with at least 2 sleep-onset REM periods (SOREMP) and subjective sleepiness. Patients with type 2 narcolepsy compared to patients with type 1 narcolepsy had significantly less SOREMP, longer mean sleep latencies, and lower body mass indexes, apnea-hypopnea indexes, and frequency of human leukocyte antigen DQ-Beta1*0602. In patients with type 2 narcolepsy, FDG-PET studies showed significantly less hypermetabolism in the fusiform gyrus, striatum, hippocampus, thalamus, basal ganglia, and cerebellum than in patients with type 1 narcolepsy, and significantly less hypometabolism in the regions of frontal lobe, posterior cingulum, angular gyrus, and part of the parietal lobe; these changes were associated with fewer errors on the CPT.

CONCLUSION

Young patients with type 2 narcolepsy have fewer clinical impairments and less distinct brain functional abnormalities than patients with type 1 narcolepsy, who are significantly more affected.

Proposal of cutoff points for pediatric daytime sleepiness scale to identify excessive daytime sleepiness

The objective of the present study was to propose cutoff points for the Pediatric Daytime Sleepiness Scale (PDSS) through sensitivity and specificity analyses in order to identify excessive daytime sleepiness, considering parameters such as duration and quality of sleep, health perception, stress control and depressive moods (feelings of sadness) in adolescents. A total of 1,132 adolescents, aged 14-19 years old, of both sexes, from the public high school of São José - SC, answered the questionnaire with information on age, daytime sleepiness, sleep duration, health perception, stress management, depressive moods (feelings of sadness) and quality of sleep. The Receiver Operating Characteristic (ROC) curve was used to estimate cutoff points considering the sensitivity and specificity values ​​that best identify adolescents with excessive daytime sleepiness, using independent variables as a reference. The majority of the sample was female (54.2%), aged 14-16 years. The girls presented worse quality of sleep (66.4%), and the boys had a more positive perception of health (74.8%), better stress control (64.8%) and lower depressive moods (feelings of sadness) (63.3%). The largest area in the ROC curve was the one that considered sleep quality as a parameter in both sexes (area of the curve = 0.709 and 0.659, respectively, for boys and girls, p < 0.001). Considering sleep quality as a reference, the cutoff point for excessive daytime sleepiness was 15 points. The other parameters used were also significant (p < 0.005). Poor sleep quality was the parameter most strongly related to daytime sleepiness, and a cutoff of 15 points for the PDSS for both sexes should be used in the definition of excessive daytime sleepiness. For the other parameters, stress management, depressive mood (feelings of sadness) and health perception, different cutoff points are suggested for boys and girls.

ANALYSIS OF DAYTIME SLEEPINIESS IN ADOLESCENTS BY THE PEDIATRIC DAYTIME SLEEPINESS SCALE: A SYSTEMATIC REVIEW

Objective:

To systematically review the use of the Pediatric Daytime Sleepiness Scale (PDSS) in the analysis of daytime sleepiness in children and adolescents.

Data source:

The electronic databases PubMed and SciELO were consulted between 2003 and 2015. As inclusion criterion, studies were considered in English, Spanish and Portuguese, original articles of any type of design, articles with a sample of children and/or adolescents, articles that used the PDSS. Duplicate articles, articles with no relation to the theme, articles with another investigated population, and articles that the parents answered the instrument for their children were excluded. To find the material with these features, the terms “Daytime sleepiness” AND “adolescents” and “Daytime sleepiness” AND “children” were used in the searches. In addition, the descriptor “Pediatric Daytime Sleepiness Scale” was used to filter more specifically.

Data synthesis:

Initially, 986 studies related to daytime sleepiness were identified. Considering the inclusion criteria, we analyzed 26 studies composed of 18,458 subjects aged 0 to 37 years. The diurnal sleepiness score ranged from 6.7±0.6 to 25.7±0.6 points. In general, all included studies investigated other sleep variables in addition to daytime sleepiness, such as: sleep duration, sleep quality, sleep hygiene or sleep disorders (narcolepsy and cataplexy), respiratory disorders, neurological and developmental disorders.

Conclusions:

There was a moderate use of PDSS to evaluate daytime sleepiness. This instrument allows the monitoring of factors that influence excessive daytime sleepiness in children and adolescents.

Sleepiness in Adolescents

Sleepiness and sleep deprivation among adolescents are increasingly being recognized as a public health concern. Many of the determinants of this growing problem lie beyond the biomedical scope of explanation. In this article, the authors begin with a review of the prevalence and consequences of sleepiness in adolescents and then present the approach to a sleepy adolescent and the underlying cause. The topic is discussed from clinical as well as public health perspectives.

Subjective sleep measures for adolescents: a systematic review

BACKGROUND

Sleep disturbances in adolescents have received significant attention because of their high prevalence and the negative health outcomes. Relative to objective measures, subjective sleep instruments have been the most practical tools used to identify sleep problems and assess responses to interventions in research and clinical settings. This systematic review aims to examine the psychometric properties of subjective measures that are used to assess sleep quality and disturbances among adolescents, identify the strength and limitation of each measurement and inform recommendations for practice.

METHODS

PubMed, Embase and PsycInfo were searched from 2000 through May 2016. The reference lists of important articles were included if they met the inclusion criteria. The available measures were evaluated and classified as positive, intermediate or poor according to the quality criteria for health status questionnaires.

RESULTS

Thirteen self-reported or parent-reported sleep measures met the inclusion criteria. Of the measurements reviewed, six were generic instruments assessing overall sleep quality and disturbances; five were dimension-specific instruments measuring daytime sleepiness, sleep insufficiency and sleep hygiene; and two were condition-specific instruments for insomnia. None of the subjective sleep measures for adolescents has a psychometric profile with all essential measurement properties. Specifically, the generic sleep measurements capture multiple dimensions but face issues of participant burden and compatibility. Among the domain-specific tools, the Cleveland Adolescent Sleepiness Questionnaire and the Chronic Sleep Reduction Questionnaire have achieved good psychometric merits but need further evaluation for responsiveness. Likewise, essential measurement properties of condition-specific tools for insomnia have yet to be established.

CONCLUSIONS

Because of the limited evidence, no definite recommendations can be made at this point. However, each available measurement has its own uniqueness and strength despite the limitations. Future research on measurement development and evaluation for adolescent sleep is needed to ensure the relevance and suitability to different stages of adolescence and social contexts.

Psychometric Properties of Turkish Version of Pediatric Daytime Sleepiness Scale (PDSS-T)

PURPOSE

The aim of the research was to evaluate the psychometric properties of the Pediatric Daytime Sleepiness Scale-Turkish Version (PDSS-T).

METHODS

The researchers chose a study sample of 522 grade 5-11 students. Data were collected using a demographic data collection form and the PDSS-T.

RESULTS

Cronbach α for the scale was .79 and Kaiser-Meyer-Olkin coefficient was .78. Item-total correlations for the scale varied between .53 and .73 (p < .001). The indices of model fit were determined to be the root mean square error of approximation at .07, the goodness of fit index at .97, and the comparative fit index at .97.

CONCLUSIONS

The study's results showed that PDSS-T is a valid and reliable instrument for detecting Turkish-speaking children's and adolescents' daytime sleepiness. PDSS-T is convenient for professionals to prevent and manage daytime sleepiness.

Brain imaging and cognition in young narcoleptic patients

The relationship between functional brain images and performances in narcoleptic patients and controls is a new field of investigation. We studied 71 young, type 1 narcoleptic patients and 20 sex- and age-matched control individuals using brain positron emission tomography (PET) images and neurocognitive testing. Clinical investigation was carried out using sleep-wake evaluation questionnaires; a sleep-wake study was conducted with actigraphy, polysomnography, multiple sleep latency test (MSLT), and blood tests (with human leukocyte antigen typing). The continuous performance test (CPT) and Wisconsin card sorting test (WCST) were administered on the same day as the PET study. PET data were analyzed using Statistical Parametric Mapping (version 8) software. Correlation of brain imaging and neurocognitive function was performed by Pearson's correlation. Statistical analyses (Student's t-test) were conducted with SPSS version-18. Seventy-one narcoleptic patients (mean age: 16.15 years, 41 boys (57.7%)) and 20 controls (mean age: 15.1 years, 12 boys (60%)) were studied. Results from the CPT and WCST showed significantly worse scores in narcoleptic patients than in controls (P < 0.05). Compared to controls, narcoleptic patients presented with hypometabolism in the right mid-frontal lobe and angular gyrus (P < 0.05) and significant hypermetabolism in the olfactory lobe, hippocampus, parahippocampus, amygdala, fusiform, left inferior parietal lobe, left superior temporal lobe, striatum, basal ganglia and thalamus, right hypothalamus, and pons (P < 0.05) in the PET study. Changes in brain metabolic activity in narcoleptic patients were positively correlated with results from the sleepiness scales and performance tests. Young, type 1 narcoleptic patients face a continuous cognitive handicap. Our imaging cognitive test protocol can be useful for investigating the effects of treatment trials in these patients.

Craniofacial characteristics related to daytime sleepiness screened by the paediatric daytime sleepiness scale

The present cross-sectional study aimed to assess daytime sleepiness in Chinese adolescents using the Paediatric Daytime Sleepiness Scale (PDSS) and to identify associations between PDSS answers and craniofacial characteristics. A group of 265 Chinese adolescents aged 11-17 years self-completed the PDSS, and their extra- and intra-oral craniofacial characteristics were recorded. Among the participants, 59.7% (157) experienced one or more daytime sleepiness events. No significant associations were found between total PDSS scores and the craniofacial parameters, but when PDSS answers were assessed at the item level, several craniofacial characteristics were found to be positively associated with daytime sleepiness, such as hypertrophic tonsils (P = 0.05), a relatively large tongue (P < 0.01), a bilateral Class II molar relationship (P < 0.05) and increased overjet (P < 0.05). A short lower face (P < 0.01) and a convex profile (P < 0.01) were found to be negatively associated with daytime sleepiness. Daytime sleepiness is commonly reported among Chinese adolescents seeking orthodontic treatment and there are potential associations between the condition and craniofacial characteristics. An assessment of daytime sleepiness is recommended to orthodontists in young patients presenting with hypertrophic tonsils, relative large tongues and Class II tendency malocclusions, and appropriate medical referrals should also be considered.

Narcolepsy-cataplexy and schizophrenia in adolescents

BACKGROUND

Despite advances in the understanding of narcolepsy, little information the on association between narcolepsy and psychosis is available, except for amphetamine-related psychotic reactions. Our case-control study aimed to compare clinical differences and analyze risk factors in children who developed narcolepsy with cataplexy (N-C), schizophrenia, and N-C followed by schizophrenia.

METHODS

Three age- and gender-matched groups of children with N-C schizophrenia (study group), N-C (control group 1), and schizophrenia only (control group 2) were investigated. Subjects filled out sleep questionnaires, sleep diaries, and quality of life scales, followed by polysomnography (PSG), multiple sleep latency tests (MSLT), routine blood tests, HLA typing, genetic analysis of genes of interest, and psychiatric evaluation. The risk factors for schizophrenia also were analyzed.

RESULTS

The study group was significantly overweight when measuring body mass index (BMI) (P=.016), at narcolepsy onset compared to control group 1, and the study group developed schizophrenia after a mean of 2.55±1.8 years. Compared to control group 2, psychotic symptoms were significantly more severe in the study group, with a higher frequency of depressive symptoms and acute ward hospitalization in 8 out of 10 of the subjects. They also had poorer long-term response to treatment, despite multiple treatment trials targeting their florid psychotic symptoms. All subjects with narcolepsy were HLA DQ B1(∗)0602 positive. The study group had a significantly higher frequency of DQ B1(∗)-03:01/06:02 (70%) than the two other groups, without any significant difference in HLA-DR typing, tumor necrosis factor α (TNF-α) levels, hypocretin (orexin) receptor 1 gene, HCRTR1, and the hypocretin (orexin) receptor 2 gene, HCRTR2, or blood infectious titers.

CONCLUSION

BMI and weight at onset of narcolepsy as well as a higher frequency of DQ B1(∗)-03:01/06:02 antigens were the only significant differences in the N-C children with secondary schizophrenia; such an association is a therapeutic challenge with long-term persistence of severe psychotic symptoms.

Sleep hygiene intervention for youth aged 10 to 18 years with problematic sleep: a before-after pilot study

Background

The current study aimed to examine the changes following a sleep hygiene intervention on sleep hygiene practices, sleep quality, and daytime symptoms in youth.

Methods

Participants aged 10–18 years with self-identified sleep problems completed our age-appropriate F.E.R.R.E.T (an acronym for the categories of Food, Emotions, Routine, Restrict, Environment and Timing) sleep hygiene programme; each category has three simple rules to encourage good sleep. Participants (and parents as appropriate) completed the Adolescent Sleep Hygiene Scale (ASHS), Pittsburgh Sleep Quality Index (PSQI), Sleep Disturbance Scale for Children (SDSC), Pediatric Daytime Sleepiness Scale (PDSS), and wore Actical® monitors twice before (1 and 2 weeks) and three times after (6, 12 and 20 weeks) the intervention. Anthropometric data were collected two weeks before and 20 weeks post-intervention.

Results

Thirty-three youths (mean age 12.9 years; M/F = 0.8) enrolled, and retention was 100%. ASHS scores significantly improved (p = 0.005) from a baseline mean (SD) of 4.70 (0.41) to 4.95 (0.31) post-intervention, as did PSQI scores [7.47 (2.43) to 4.47 (2.37); p < 0.001] and SDSC scores [53.4 (9.0) to 39.2 (9.2); p < 0.001]. PDSS scores improved from a baseline of 16.5 (6.0) to 11.3 (6.0) post- intervention (p < 0.001). BMI z-scores with a baseline of 0.79 (1.18) decreased significantly (p = 0.001) post-intervention to 0.66 (1.19). Despite these improvements, sleep duration as estimated by Actical accelerometry did not change. There was however a significant decrease in daytime sedentary/light energy expenditure.

Conclusions

Our findings suggest the F.E.R.R.E.T sleep hygiene education programme might be effective in improving sleep in children and adolescents. However because this was a before and after study and a pilot study with several limitations, the findings need to be addressed with caution, and would need to be replicated within a randomised controlled trial to prove efficacy.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12612000649819

Sleep patterns and school performance of Korean adolescents assessed using a Korean version of the pediatric daytime sleepiness scale

PURPOSE

Korean adolescents have severe nighttime sleep deprivation and daytime sleepiness because of their competitive educational environment. However, daytime sleep patterns and sleepiness have never been studied using age-specific methods, such as the pediatric daytime sleepiness scale (PDSS). We surveyed the daytime sleepiness of Korean adolescents using a Korean translation of the PDSS.

METHODS

We distributed the 27-item questionnaire, including the PDSS and questions related to sleep pattern, sleep satisfaction, and emotional state, to 3,370 students in grades 5-12.

RESULTS

The amount of nighttime sleep decreased significantly with increasing age. During weekday nights, 5-6(th) graders slept for 7.95±1.05 h, 7-9(th) graders for 7.57±1.05 h, and 10-12(th) graders for 5.78±1.13 h. However, the total amounts of combined daytime and nighttime sleep during weekdays were somewhat greater, 8.15±1.12 h for 5-6(th) graders, 8.17±1.20 h for 7-9(th) graders, and 6.87±1.40 h for 10-12(th) graders. PDSS scores increased with age, 11.89±5.56 for 5-6(th) graders, 16.57±5.57 for 7-9(th) graders, and 17.71±5.24 for 10-12(th) graders. Higher PDSS scores were positively correlated with poor school performance and emotional instability.

CONCLUSION

Korean teenagers sleep to an unusual extent during the day because of nighttime sleep deprivation. This negatively affects school performance and emotional stability. A Korean translation of the PDSS was effective in evaluating the severity of daytime sleepiness and assessing the emotional state and school performance of Korean teenagers.