Sleep patterns are associated with common illness in adolescents

The mediating effect of after-midnight use of digital media devices on the association of internet-related addictive behavior and insomnia in adolescents

Background

There is evidence that overexposure to digital media devices (DMD) can not only lead to addictive patterns of internet use, but also cause insomnia symptoms. The aim of this cross-sectional study among adolescents is to provide an estimate of the prevalence of sleep impairments and to explore the mediating role of after-midnight use of DMD between internet-related addictive behavior (IRAB) and insomnia.

Methods

2,712 school students from Styrian schools participated in a population-representative online survey in a supervised school setting in spring 2022. School students were screened using established and validated scales. Data analysis was carried out using multiple imputation, linear multilevel regression and mediation analysis.

Results

Prevalence estimation indicates high proportions of clinically relevant moderate [12.6% (11.3%; 14.1%)] and severe [3.6% (2.9%; 4.4%)] insomnia, with an additional 30.6% (29.0%; 32.2%) at subthreshold level. DMD are typically used after midnight an average of 1.66 (1.58; 1.75) evenings with subsequent school day per school week. Linear multilevel regression analysis shows significant associations for sleep disparities as outcome variable e.g., with generalized anxiety [b = 0.329 (0.287; 0.371)], after-midnight use of DMD [b = 0.470 (0.369; 0.572)] and IRAB [b = 0.131 (0.097; 0.165)]. Mediation analysis shows a mediated proportion of 18.2% (13.0%; 25.0%) of the association of IRAB and insomnia by after-midnight use of DMD [Indirect effect: b = 0.032 (0.023; 0.040), direct effect: b = 0.127 (0.083; 0.170)].

Conclusions

Although the cross-sectional nature of this study limits causal inference, the results indicate a need for policies, which are already in preparation in Styria as part of a respective action plan.

Normal Sleep in Children and Adolescence

Adequate sleep is essential for healthy development in childhood and adolescence. Healthy sleep contributes to good physical health, immune function, mental health, and academic performance. The regulation and architecture of sleep change greatly across childhood and adolescence, and the ability to obtain sufficient sleep is impacted by a range of factors that change with maturation. This article describes normal sleep across childhood and adolescence and discusses some of the most common barriers to adequate sleep, including early school start times, technology use, and changes to circadian rhythms, and sleep homeostasis across puberty.

An Independent Evaluation of the Psychometric Properties of the Russian Version of the Pediatric Daytime Sleepiness Scale (PDSS)

Background

The quality of sleep significantly impacts children's day-to-day performance, with at least 20% reporting issues with sleepiness. Valid tools for assessing the quality of sleep are needed.

Objective

In this study, we assessed the psychometric properties of the Russian version of the Pediatric Daytime Sleepiness Scale (PDSS). The initial adaptation of the PDSS was conducted on a sample from the Arctic regions of Russia. This location may have influenced the scale's generalizability due to variations in natural daylight across different areas of the country.

Design

To rectify this, we gathered a comprehensive, geographically diverse sample from Russia. This combined dataset comprised 3772 participants between 10 to 18 years of age, from nine different regions of Russia.

Results

We confirmed the unifactorial structure of the PDSS, which showed no regional effects. The psychometric analysis indicated that one item from the 8item PDSS could be removed, thereby improving the scale's model fit. We also observed gender and age impacts on sleep quality: boys reported fewer sleep-related issues than girls, and younger children reported fewer problems than older children.

Conclusion

This study validates the usefulness and reliability of the Russian version of the PDSS, thereby enhancing its general applicability. Furthermore, we replicated previously reported age and sex effects on the sleep quality of school-aged children.

Short Sleep Duration is Associated with Prolonged Virus Shedding in SARS-CoV-2 Omicron-Infected Patients

Purpose

Sleep disturbance has been implicated in poor prognosis of coronavirus disease 2019 (COVID-19), but less is known about the influence of short sleep duration on COVID-19 outcomes. We aim to investigate whether short sleep duration is associated with prolonged virus shedding duration in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron-infected patients.

Patients and Methods

A total of 270 patients with a laboratory confirmed COVID-19 diagnosis during SARS-CoV-2 Omicron-predominant period were recruited. Self-reported sleep duration of the patients was collected. The two-way analysis of variance (ANOVA) was used to determine the interactions between sleep duration and variables, and multivariate logistic regression analysis was used to analyze the effect of independent variables on longer virus shedding duration.

Results

The two-way ANOVA revealed a significant sleep duration × snoring interaction effect for virus shedding duration, and a sleep duration × sex interaction effect for virus shedding duration. Multivariate logistic regression model illustrated that patients sleeping <6 h were at greater risk of prolonged virus shedding duration compared to those sleeping ≥6 hours (OR = 1.80, 95% CI = 1.01-3.26), independent of age, sex, co-existing diseases, vaccination condition, and antiviral treatment.

Conclusion

Short sleep duration (<6 h) was associated with increased virus shedding in SARS-CoV-2 Omicron-infected patients.

The association between self-reported sleep problems, infection, and antibiotic use in patients in general practice

Objectives

There is emerging evidence that sleep problems and short sleep duration increase the risk of infection. We aimed to assess whether chronic insomnia disorder, chronic sleep problems, sleep duration and circadian preference based on self-report were associated with risk of infections and antibiotic use among patients visiting their general practitioner (GP).

Methods

We conducted a cross-sectional study of 1,848 unselected patients in Norway visiting their GP during 2020.The patients completed a one-page questionnaire while waiting for the consultation, that included the validated Bergen Insomnia Scale (BIS), questions on self-assessed sleep problem, sleep duration and circadian preference and whether they have had any infections or used antibiotics in the last 3 months. Relative risks (RR) were estimated using modified Poisson regression models.

Results

The risk of infection was 27% (95% CI RR 1.11-1.46) and 44% higher (95% CI 1.12-1.84) in patients sleeping < 6 h and >9 h, respectively, compared to those sleeping 7-8 h. The risk was also increased in patients with chronic insomnia disorder or a chronic sleep problem. For antibiotic use, the risk was higher for patients sleeping < 6 h, and for those with chronic insomnia disorder or a chronic sleep problem.

Conclusions

Among patients visiting their GP, short sleep duration, chronic insomnia and chronic sleep problem based on self-report were associated with higher prevalence of infection and antibiotic use. These findings support the notion of a strong association between sleep and infection.

Sleep variability over a 2-week period is associated with restfulness and intrinsic limbic network connectivity in adolescents

STUDY OBJECTIVES

Sleep duration and intraindividual variability in sleep duration undergo substantial changes in adolescence and impact brain and behavioral functioning. Although experimental work has linked acute sleep deprivation to heightened limbic responding and reduced regulatory control, there is limited understanding of how variability in sleep patterns might interact with sleep duration to influence adolescent functioning. This is important for optimal balancing of length and consistency of sleep. Here, we investigated how objective indices of sleep duration and variability relate to stress, restfulness, and intrinsic limbic network functioning in adolescents.

METHODS

A sample of 101 adolescents ages 14-18 reported their stressors, after which they wore wrist actigraph watches to monitor their sleep and rated their restfulness every morning over a 2-week period. They also completed a resting-state fMRI scan.

RESULTS

Adolescents reporting more stress experienced shorter sleep duration and greater sleep variability over the 2-week period. Longer nightly sleep duration was linked to feeling more rested the next morning, but this effect was reduced in adolescents with high cumulative sleep variability. Sleep variability showed both linear and quadratic effects on limbic connectivity: adolescents with high sleep variability exhibited more connectivity within the limbic network and less connectivity between the limbic and frontoparietal networks than their peers, effects which became stronger once variability exceeded an hour.

CONCLUSIONS

Results suggest that cumulative sleep variability is related to stress and limbic network connectivity and shows interactive effects with sleep duration, highlighting the importance of balancing length and consistency of sleep for optimal functioning in adolescence.

What's "app"-ning to adolescent sleep? Links between device, app use, and sleep outcomes

This study investigated the associations between adolescent evening use of technology devices and apps, night time sleep, and daytime sleepiness. Participants were 711 adolescents aged 12-18 years old (46% Female, M_age = 15.1, SD = 1.2). Time spent using technology devices and apps in the hour before bed, and in bed before sleep onset, was self-reported. Participants additionally completed a questionnaire about their sleep on school nights and next day sleepiness. In the hour before bed, 30 min of phone use was associated with a 9-min delay in bedtimes. Thirty minutes spent using laptops, gaming consoles, and watching YouTube was associated with later lights out times of 9 min, ∼16 min and ∼11 min respectively, while watching TV was associated with a 9 min earlier lights out times. Using gaming consoles and watching YouTube were associated with greater odds of receiving insufficient sleep (≤7 h TST). In bed before sleep onset, 30 min spent using laptops, phones, iPad/tablets, and watching YouTube were linked with later lights out times of ∼7 min for phones and laptops, 9 min for iPad/tablets, and ∼13 min for YouTube. Watching Netflix was associated with greater daytime sleepiness. YouTube at this time point was associated with increased odds of sleeping ≤7 h on school nights. Adolescents are engaging with a wide range of technology devices and apps in the evenings. However, certain devices and apps (e.g., phones, laptops, gaming and YouTube) might lead to more negative sleep outcomes for adolescents on school nights compared to others.

Sleep duration prior to an enterotoxigenic Escherichia coli challenge predicts diarrhea severity during infection

BACKGROUND

Acute diarrhea is the most frequent diagnosis among ill travelers. Sleep loss may weaken the body's defense against pathogens and increase susceptibility to infection. The relationship between sleep and infectious diarrhea has not been studied and was assessed utilizing data from a controlled human infection model (CHIM) for enterotoxigenic Escherichia coli (ETEC).

METHODS

During a CHIM assessing the efficacy of an immunoprophylactic targeting ETEC against moderate-to-severe diarrhea (MSD) following challenge, we measured sleep via actigraphy over an 8-day inpatient period. We hypothesized better sleep pre-challenge would predict illness symptomatology following challenge.

RESULTS

Among 57 participants (aged 34.4 ± 8.1 years, 64% male), there was no relationship between sleep metrics and incidence of MSD. However, longer total sleep time the night preceding ETEC challenge was associated with lower maximum 24 h diarrhea volume (B = -1.80, p = 0.01) and total diarrhea volume (B = -2.45, p = 0.01).

CONCLUSIONS

This novel study showed that shorter sleep duration predicted diarrhea severity over the course of an ETEC infection. Future work should experimentally manipulate sleep to further clarify its impact on diarrhea-related outcomes for ETEC and other important enteric pathogens.

Potential Role of Sleep Deficiency in Inducing Immune Dysfunction

Sleep deficiency and insomnia deteriorate the quality of patients’ lives, yet the exact influence of these factors on the immune system has only begun to gain interest in recent years. Growing evidence shows that insomnia is a risk factor for numerous diseases, including common infections and autoimmune diseases. Levels of inflammatory markers also seem to be abnormal in sleep deficient individuals, which may lead to low-grade inflammation. The interpretation of studies is difficult due to the equivocal term “sleep disturbances,” as well as due to the various criteria used in studies. This narrative review aims to summarize the available knowledge regarding the bidirectional influence of the immune system and sleep disturbances.

Sleep disruption induces activation of inflammation and heightens risk for infectious disease: Role of impairments in thermoregulation and elevated ambient temperature

Thermoregulation and sleep are tightly coordinated, with evidence that impairments in thermoregulation as well as increases in ambient temperature increase the risk of sleep disturbance. As a period of rest and low demand for metabolic resources, sleep functions to support host responses to prior immunological challenges. In addition by priming the innate immune response, sleep prepares the body for injury or infection which might occur the following day. However when sleep is disrupted, this phasic organization between nocturnal sleep and the immune system becomes misaligned, cellular and genomic markers of inflammation are activated, and increases of proinflammatory cytokines shift from the nighttime to the day. Moreover, when sleep disturbance is perpetuated due to thermal factors such as elevated ambient temperature, the beneficial crosstalk between sleep and immune system becomes further imbalanced. Elevations in proinflammatory cytokines have reciprocal effects and induce sleep fragmentation with decreases in sleep efficiency, decreases in deep sleep, and increases in rapid eye movement sleep, further fomenting inflammation and inflammatory disease risk. Under these conditions, sleep disturbance has additional potent effects to decrease adaptive immune response, impair vaccine responses, and increase vulnerability to infectious disease. Behavioral interventions effectively treat insomnia and reverse systemic and cellular inflammation. Further, insomnia treatment redirects the misaligned inflammatory- and adaptive immune transcriptional profiles with the potential to mitigate risk of inflammation-related cardiovascular, neurodegenerative, and mental health diseases, as well as susceptibility to infectious disease.

Adolescent Technology-use Rules and Sleep in a Large Representative Sample

PURPOSE

This study investigated the prevalence of technology-use rules, typical sleep habits, and associations between rules and sleep using the representative 2017-2018 California Health Interview Survey adolescent sample.

METHODS

Adolescents aged 12-17 years completed the California Health Interview Survey, including queries of (1) rules at home regarding times to turn off or put away electronics and (2) school-night bedtime and rise time. Rates of rules and associations between rules and sleep were investigated using descriptive statistics and bivariate and multivariable analyses.

RESULTS

Seventy-two percent reported technology-use rules. Rates were comparable across subgroups. Rules and sleep were not significantly associated after adjusting for covariates. Reported time in bed fell below National Sleep Foundation guidelines for 38% of participants.

CONCLUSIONS

Most adolescents reported technology-use rules at home. Associations between rules and bedtime were mixed, suggesting that further exploration of contextual and developmental factors is needed. Many reported inadequate sleep duration, supporting sleep as a key topic in adolescent health.

Adolescent sleep health and school start times: Setting the research agenda for California and beyond: A research summit summary: A research summit summary

In fall 2019, California passed and signed into law SB328, the first US statewide legislation explicitly designed to protect adolescent sleep health by requiring most California public school districts to start no earlier than 8:00 AM for middle schools and 8:30 AM for high schools. Recognizing the unique opportunity presented by the bill's 3-year implementation period, a group of experts in adolescent sleep and school start times held a virtual summit on January 22-23, 2021 to (1) summarize the research on adolescent sleep and school start time change; (2) develop recommendations for relevant, refined, and innovative research areas and research questions; (3) provide input regarding research design, methodology, and implementation; and (4) offer a forum for networking, exchanging ideas, and establishing interdisciplinary research collaborations. Participants represented a multidisciplinary range of academic backgrounds including sleep and circadian biology, neuroscience, education, medicine, public health, mental health, safety, public policy, economics, implementation science, criminology, diversity studies, and science communication. This paper summarizes summit presentations regarding current knowledge on adolescent sleep health and school start times and key research recommendations from small group workshops on topics including research design and tools, methodological issues, sleep health disparities, logistical challenges in conducting school-based research, public-health impact, and novel and expanded approaches to research.

Role of sleep deprivation in immune-related disease risk and outcomes

Modern societies are experiencing an increasing trend of reduced sleep duration, with nocturnal sleeping time below the recommended ranges for health. Epidemiological and laboratory studies have demonstrated detrimental effects of sleep deprivation on health. Sleep exerts an immune-supportive function, promoting host defense against infection and inflammatory insults. Sleep deprivation has been associated with alterations of innate and adaptive immune parameters, leading to a chronic inflammatory state and an increased risk for infectious/inflammatory pathologies, including cardiometabolic, neoplastic, autoimmune and neurodegenerative diseases. Here, we review recent advancements on the immune responses to sleep deprivation as evidenced by experimental and epidemiological studies, the pathophysiology, and the role for the sleep deprivation-induced immune changes in increasing the risk for chronic diseases. Gaps in knowledge and methodological pitfalls still remain. Further understanding of the causal relationship between sleep deprivation and immune deregulation would help to identify individuals at risk for disease and to prevent adverse health outcomes.

Validity and reliability of the Turkish version of Sleep Disturbance Scale for Children

OBJECT

This study examines the validity and reliability of the Sleep Disturbance Scale for Children (SDSC) in the Turkish language.

METHOD

This scale was translated into the Turkish language by applying the translation-back translation method and content validity analysis. A total of 1903 participants aged 5-15 years were included in the study. A sociodemographic data form, SDSC, and the Children's Sleep Habits Questionnaire (CSHQ) were filled by the parents. Internal consistency analysis, correlation analysis, test-retest analysis, and confirmatory factor analysis were applied to evaluate the reliability and validity of the applied scale.

RESULTS

The internal consistency of the scale was high (Cronbach α = 0.84). Test-retest reliability was found to be high as well. According to the confirmatory factor analysis, the Turkish version of the scale was compatible with the model of the original scale. According to the T-score evaluation, the frequency of sleep disorders was determined to be 4.15%, and the most common sleep disorder was sleep hyperhidrosis. Correlations between the scores of the SDSC and CSHQ were at a satisfactory level.

CONCLUSIONS

These results revealed that the SDSC is a valid and reliable scale that can be used in children aged 5-14 years in Turkey to question sleep disorder symptoms.

Normal Sleep in Children and Adolescence

Adequate sleep is essential for healthy development in childhood and adolescence. Healthy sleep contributes to good physical health, immune function, mental health, and academic performance. The regulation and architecture of sleep change greatly across childhood and adolescence, and the ability to obtain sufficient sleep is impacted by a range of factors that change with maturation. This article describes normal sleep across childhood and adolescence and discusses some of the most common barriers to adequate sleep, including early school start times, technology use, and changes to circadian rhythms, and sleep homeostasis across puberty.

Perceived Barriers and Facilitating Factors in Implementing Delayed School Start Times to Improve Adolescent Sleep Patterns

BACKGROUND

Most adolescents in the United States do not obtain sufficient sleep. Early school start times play a significant role in adolescent sleep deprivation. Most primary and secondary schools begin classes earlier than the 8:30 am. Perceived barriers to implementing a delayed school start time have been suggested in the literature but have not been quantified. This study explored perceived barriers and facilitating factors for implementing delayed high-school start times.

METHODS

A cross-sectional study. School administrators who had delayed their school start times were invited to complete an online questionnaire ranking the perceived barriers and facilitating factors for implementing the delayed start times.

RESULTS

Most commonly cited perceived barriers were lack of a tiered bus system, school athletes missing more afternoon classes, and less time after school for athletics. Most commonly cited facilitating factors were school-administrator involvement in the decision-making process and sleep education for family members and school administrators.

CONCLUSIONS

Participants found that providing sleep education to fellow administrators, teachers, school staff members, families, and students and including them in the decision-making process positively facilitated the implementation of delayed school start times. Perceived barriers to implementation may be overcome with support from stakeholders and planning committees.

Sex differences in self-report anxiety and sleep quality during COVID-19 stay-at-home orders

BACKGROUND

COVID-19 and home isolation has impacted quality of life, but the perceived impact on anxiety and sleep remains equivocal. The purpose of this study was to assess the impact of COVID-19 and stay-at-home orders on self-report anxiety and sleep quality, with a focus on sex differences. We hypothesized that the COVID-19 pandemic would be associated with increased anxiety and decreased sleep quality, with stronger associations in women.

METHODS

One hundred three participants (61 female, 38 ± 1 years) reported perceived changes in anxiety and sleep quality due to stay-at-home orders during the COVID-19 pandemic and were administered the Spielberger State-Trait Anxiety Inventory (STAI), Pittsburgh Sleep Quality Index (PSQI), and Insomnia Severity Index (ISI). Chi-square and T test analyses were utilized to assess sex differences in reported anxiety and sleep. Analysis of covariance was used to compare the associations between reported impact of COVID-19 and anxiety/sleep parameters.

RESULTS

Women (80.3%) reported higher prevalence of increased general anxiety due to COVID-19 when compared to men (50%; p = 0.001) and elevated STAI state anxiety compared to men (43 ± 1 vs. 38 ± 1 a.u., p = 0.007). Despite these differences in anxiety, the perceived impact of COVID-19 on PSQI was not different between sexes. However, when stratified by perceived changes in anxiety due to COVID-19, participants with higher anxiety responses to COVID-19 had higher ISI compared to those with no perceived changes in anxiety (9 ± 1 vs. 5 ± 1 a.u., p = 0.003). Additionally, participants who reported reduced sleep quality due to COVID-19 reported higher state anxiety (45 ± 1 a.u.) compared to those that perceived no change (36 ± 2 a.u., p = 0.002) or increased (36 ± 2 a.u., p < 0.001) sleep quality.

CONCLUSION

COVID-19 and state-ordered home isolation was associated with higher anxiety and reduced sleep quality, with a stronger association in women with respect to anxiety.

Neural activity moderates the association between sleep and risky driving behaviors in adolescence

The biological, environmental, and psychosocial changes that occur in adolescence engender an increase in risk taking often linked to the high rates of motor vehicle crashes amongst young drivers. Most U.S. adolescents suffer from poor sleep, which is known to exacerbate the risk of driving crashes; however, research has yet to uncover a neurobiological link between sleep and risky driving in adolescence. Here, we examined potential moderators of the sleep-risk relation in fifty-six adolescents (14-18y/o) as they completed a driving task during fMRI. While poor sleep was associated with increased risky driving (i.e., running more yellow lights), good sleep emerged as a novel buffer against risky driving in lower sensation-seeking adolescents. Neural activity in the ventral striatum (VS), a key node of the risk-taking circuit, also moderated the sleep-risk association: sleep was related to risk-taking in individuals demonstrating high, but not low, VS response during risky decision-making, suggesting that reward-related neural response may underly the connection between sleep and risk-taking in adolescence. This study sheds light on the risk of driving crashes in youth by highlighting sleep as both an exacerbator and a buffer of risky driving in adolescence. Taken together, these results underscore the importance of improving adolescent sleep.

Sleep Predicts Collegiate Academic Performance: Implications for Equity in Student Retention and Success

College students show high levels of insufficient sleep, excessive daytime sleepiness, sleep schedule irregularity, poor sleep quality, and inadequate sleep hygiene. This article describes the evidence linking poor sleep with impaired academic performance; discusses mediating environmental, behavioral, and demographic factors that correlate with sleep; and highlights examples of successful health promotion initiatives on college campuses. Given that students who are traditionally minoritized on college campuses tend to have worse sleep, improving sleep health emerges as an important issue for retention, equity, and inclusion.

Sex differences in insomnia and risk for psychopathology in adolescence

This review examines sex differences in sleep disturbance and risk for psychopathology, with a particular focus on the emergence of insomnia and risk for depression among adolescents. Possible explanations for the female preponderance of adolescent insomnia is discussed. The significance of the temporal relationship between adolescent insomnia and depression is discussed, as the extant literature suggests that insomnia tends to precede depression more than the inverse. Whether a causal relationship may exist between the two conditions and possible mechanisms underlying sex differences are highlighted along with important areas for future research.

Qualitative Development and Content Validation of the PROMIS Pediatric Sleep Health Items

Objective: To develop the Patient Reported Outcome Measurement Information System (PROMIS) Pediatric Sleep Health item pool and evaluate its content validity. Participants: Participants included 8 expert sleep clinician-researchers, 64 children ages 8-17 years, and 54 parents of children ages 5-17 years. Methods: We started with item concepts and expressions from the PROMIS Sleep Disturbance and Sleep Related Impairment adult measures. Additional pediatric sleep health concepts were generated by expert (n = 8), child (n = 28), and parent (n = 33) concept elicitation interviews and a systematic review of existing pediatric sleep health questionnaires. Content validity of the item pool was evaluated with item translatability review, readability analysis, and child (n = 36) and parent (n = 21) cognitive interviews. Results: The final pediatric Sleep Health item pool includes 43 items that assess sleep disturbance (children's capacity to fall and stay asleep, sleep quality, dreams, and parasomnias) and sleep-related impairments (daytime sleepiness, low energy, difficulty waking up, and the impact of sleep and sleepiness on cognition, affect, behavior, and daily activities). Items are translatable and relevant and well understood by children ages 8-17 and parents of children ages 5-17. Conclusions: Rigorous qualitative procedures were used to develop and evaluate the content validity of the PROMIS Pediatric Sleep Health item pool. Once the item pool's psychometric properties are established, the scales will be useful for measuring children's subjective experiences of sleep.

The Sleep-Immune Crosstalk in Health and Disease

Sleep and immunity are bidirectionally linked. Immune system activation alters sleep, and sleep in turn affects the innate and adaptive arm of our body's defense system. Stimulation of the immune system by microbial challenges triggers an inflammatory response, which, depending on its magnitude and time course, can induce an increase in sleep duration and intensity, but also a disruption of sleep. Enhancement of sleep during an infection is assumed to feedback to the immune system to promote host defense. Indeed, sleep affects various immune parameters, is associated with a reduced infection risk, and can improve infection outcome and vaccination responses. The induction of a hormonal constellation that supports immune functions is one likely mechanism underlying the immune-supporting effects of sleep. In the absence of an infectious challenge, sleep appears to promote inflammatory homeostasis through effects on several inflammatory mediators, such as cytokines. This notion is supported by findings that prolonged sleep deficiency (e.g., short sleep duration, sleep disturbance) can lead to chronic, systemic low-grade inflammation and is associated with various diseases that have an inflammatory component, like diabetes, atherosclerosis, and neurodegeneration. Here, we review available data on this regulatory sleep-immune crosstalk, point out methodological challenges, and suggest questions open for future research.

Cognitive and Behavioral Interventions to Improve Sleep in School-Age Children and Adolescents: A Systematic Review and Meta-Analysis

STUDY OBJECTIVES

Sleep problems are common in children and adolescents and can aggravate comorbid disorders. This meta-analysis examined the effect of cognitive and behavioral sleep interventions (with four or more treatment sessions) from randomized controlled trials on school-age children and adolescents.

METHODS

In a systematic literature search, six randomized controlled trials were identified (n = 528; mean age = 14.6 years; female = 63%) that reported total sleep time (TST), sleep onset latency (SOL), wake after sleep onset, and daytime sleepiness from ratings and actigraphy.

RESULTS

After intervention, no effect was seen on self-reported TST, but when measured with actigraphy, an effect favoring the intervention group was observed (+11.47 minutes, P = .05). SOL decreased in the intervention group compared to the control group after intervention as measured by both sleep diaries (-9.31 minutes, P = .007) and actigraphy (-19.48 minutes, P < .0001). Effect sizes ranged from small to large. No effect was found for wake after sleep onset or daytime sleepiness. Short-term (4 to 8 weeks) follow-up data from four studies indicated maintained positive effects on SOL: sleep diaries -15.85 minutes (P = .01) and actigraphy -23.67 minutes (P < .0001). At follow-up, the effects on wake after sleep onset from ratings (-14.41 minutes, P = .001) and actigraphy (-7.54 minutes, P = .01) were significant, favoring the intervention group (moderate to large effect sizes). No effect on TST was indicated.

CONCLUSIONS

Cognitive and behavioral sleep interventions are indicated to improve sleep in school-age children and adolescents. However, because treatment protocols were heterogeneous and risk of bias high, results should be interpreted with caution. Large and rigorous trials are needed.

Transcriptional Signatures of Sleep Duration Discordance in Monozygotic Twins

Introduction

Habitual short sleep duration is associated with adverse metabolic, cardiovascular, and inflammatory effects. Co-twin study methodologies account for familial (eg, genetics and shared environmental) confounding, allowing assessment of subtle environmental effects, such as the effect of habitual short sleep duration on gene expression. Therefore, we investigated gene expression in monozygotic twins discordant for actigraphically phenotyped habitual sleep duration.

Methods

Eleven healthy monozygotic twin pairs (82% female; mean age 42.7 years; SD = 18.1), selected based on subjective sleep duration discordance, were objectively phenotyped for habitual sleep duration with 2 weeks of wrist actigraphy. Peripheral blood leukocyte (PBL) RNA from fasting blood samples was obtained on the final day of actigraphic measurement and hybridized to Illumina humanHT-12 microarrays. Differential gene expression was determined between paired samples and mapped to functional categories using Gene Ontology. Finally, a more comprehensive gene set enrichment analysis was performed based on the entire PBL transcriptome.

Results

The mean 24-hour sleep duration of the total sample was 439.2 minutes (SD = 46.8 minutes; range 325.4-521.6 minutes). Mean within-pair sleep duration difference per 24 hours was 64.4 minutes (SD = 21.2; range 45.9-114.6 minutes). The twin cohort displayed distinctive pathway enrichment based on sleep duration differences. Habitual short sleep was associated with up-regulation of genes involved in transcription, ribosome, translation, and oxidative phosphorylation. Unexpectedly, genes down-regulated in short sleep twins were highly enriched in immuno-inflammatory pathways such as interleukin signaling and leukocyte activation, as well as developmental programs, coagulation cascade, and cell adhesion.

Conclusions

Objectively assessed habitual sleep duration in monozygotic twin pairs appears to be associated with distinct patterns of differential gene expression and pathway enrichment. By accounting for familial confounding and measuring real life sleep duration, our study shows the transcriptomic effects of habitual short sleep on dysregulated immune response and provides a potential link between sleep deprivation and adverse metabolic, cardiovascular, and inflammatory outcomes.

Sleep: An underemphasized aspect of health and development in neurorehabilitation

Sleep deficiency has unique causes and implications for children with neonatal brain injury; contributing to the development or exacerbation of neurodevelopmental impairments and yet it is an underemphasized aspect of health and development. There is very little research evidence to guide the management of sleep disorders in children with cerebral palsy, a common neurodevelopmental disability of childhood. This paper is a comprehensive review and analysis of the literature regarding what is known about sleep quantity and quality in children with cerebral palsy. The specific implications for children with cerebral palsy are explored including the adverse effects of sleep deficiency on general child development, physical health and growth, and mental functioning. The consequences for the family are also discussed. Finally, the assessment and management of sleep problems are summarized to provide guidance to clinicians who work in neurodevelopmental medicine.

Association Between Night Waking and Child Health During the First 3 Years of Life

OBJECTIVE

Night awakening is a common concern for parents and professionals in early childhood and a risk factor for child growth and development. This study examined the concurrent and longitudinal associations of night awakening with child health and illness during the first 3 years of life.

METHODS

Longitudinal data from 1364 infants in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development were used in this study. At ages 6, 15, 24, and 36 months, mothers reported on the frequency of their child's night awakening in the past week, overall health, and occurrences of illness. Information on demographic factors, including child sex and ethnicity/race, maternal education, and family income as well as child breastfeeding status was obtained at 1 month. Structural equation modeling, including latent growth curve modeling, was performed.

RESULTS

Age-related changes in weekly frequency of night awakening and overall child health were characterized by curvilinear patterns between 6 and 36 months. Although more frequent night awakenings were associated with poorer health at 6 months, a faster decline in night awakenings was associated with a slowed health decline over time. Furthermore, more frequent night awakenings were concurrently associated with more occurrences of illness at ages 6, 15, and 24 months. The association between night awakening and illness dissipated by 36 months.

CONCLUSION

Night awakening is concurrently and longitudinally associated with poorer health and more illnesses in early childhood.

Self-reported sleep pattern, quality, and problems among schooling adolescents in southwestern Nigeria

OBJECTIVE

Understanding sleep patterns and related factors is vital to development in adolescence, but there is a dearth of this information among adolescents in developing countries such as Nigeria. Therefore, this study describes the sleep patterns, problems, and predictors of poor sleep quality among schooling adolescents.

METHODS

In a cross-sectional study design, 450 adolescents were selected and interviewed about their sleep experience and problems over the preceding one-month period using a validated form with components adapted from the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Data were analyzed using descriptive statistics, χ², and logistic regression model with p set at 0.05.

RESULTS

The mean age of respondents was 13.4 ± 1.2 years. Only half (50.2%) had a global PSQI score of <6, suggesting little or no difficulty with sleep. Significantly, a higher proportion of respondents spent a short time in bed before sleep, ≤15 min among those who had good sleep quality (81.4%) compared with those who had poor sleep quality (65.2%) (p < 0.001). The odds of having poor sleep quality was significantly higher in the subgroup who had ≤8.5 h sleep than those who had 8.5 h sleep or more (adjusted odds ratio = 4.62; 95% confidence interval = 2.61, 8.17, p < 0.001).

CONCLUSION

Remarkably poor sleep quality exists among schooling adolescents in Ibadan, Nigeria, and sleep problems are prevalent, especially among those with short sleep duration.

The association between maternal postnatal depressive symptoms and offspring sleep problems in adolescence

BACKGROUND

Sleep problems are associated with increased risk of physical and mental illness. Identifying risk factors is an important method of reducing public health impact. We examined the association between maternal postnatal depression (PND) and offspring adolescent sleep problems.

METHOD

The sample was derived from Avon Longitudinal Study of Parents and Children (ALSPAC) participants. A sample with complete data across all variables was used, with four outcome variables. A sensitivity analysis imputing for missing data was conducted (n = 9633).

RESULTS

PND was associated with increased risk of sleep problems in offspring at ages 16 and 18 years. The most robust effects were sleep problems at 18 years [adjusted odds ratio (OR) for a 1 s.d. increase in PND, 1.26, 95% confidence interval (CI) 1.15-1.39, p < 0.001] and waking more often (adjusted OR 1.14, 95% CI 1.05-1.25, p = 0.003). This remained after controlling for confounding variables including antenatal depression and early sleep problems in infancy.

CONCLUSIONS

PND is associated with adolescent offspring sleep problems. Maternal interventions should consider the child's increased risk. Early sleep screening and interventions could be introduced within this group.

Daily timing of the adolescent sleep phase: Insights from a cross-species comparison

Adolescence is a time of tremendous adjustment and includes changes in cognition, emotion, independence, social environment, and physiology. One of the most consistent changes exhibited by human adolescents is a dramatic delay in the daily timing of the sleep-wake cycle. This delay is strongly correlated with pubertal maturation and is believed to be influenced by gonadal hormone-induced changes in the neural mechanisms regulating sleep and/or circadian timing. Data from both human and non-human animals indicate that developmental changes in the intrinsic period of the circadian mechanism or its sensitivity to light are not adequate to explain adolescent changes in the daily timing of sleep and wakefulness. Rather, current evidence suggests that pubertal changes in the homeostatic drive to sleep and/or behaviorally induced changes in the amount and/or timing of light exposure permit adolescents to stay up later in the evening and cause them to wake up later in the morning.

Optimizing sleep to maximize performance: implications and recommendations for elite athletes

Despite a growing body of literature demonstrating a positive relationship between sleep and optimal performance, athletes often have low sleep quality and quantity. Insufficient sleep among athletes may be due to scheduling constraints and the low priority of sleep relative to other training demands, as well as a lack of awareness of the role of sleep in optimizing athletic performance. Domains of athletic performance (e.g., speed and endurance), neurocognitive function (e.g., attention and memory), and physical health (e.g., illness and injury risk, and weight maintenance) have all been shown to be negatively affected by insufficient sleep or experimentally modeled sleep restriction. However, healthy adults are notoriously poor at self-assessing the magnitude of the impact of sleep loss, underscoring the need for increased awareness of the importance of sleep among both elite athletes and practitioners managing their care. Strategies to optimize sleep quality and quantity in athletes include approaches for expanding total sleep duration, improving sleep environment, and identifying potential sleep disorders.

Digital media use in the 2 h before bedtime is associated with sleep variables in university students

Digital media use is widespread in University students, and use of digital media near bedtime has a broadly negative effect on sleep outcomes. Adequate and good quality sleep is important for physical and mental health, but few studies have rigorously measured both sleep and digital media use. In this study, we investigated whether self-reported sleep patterns were associated with digital media use in a first-year University student (N = 254, 48% male) population. Students tracked their sleep through daily online diaries and provided digital media use data in 15-min blocks for 2 h prior to bedtime on nine occasions. A longer duration of digital media use was associated with reduced total sleep time and later bedtime, while greater diversity of digital media use was associated with increased total sleep time and earlier bedtime. Analysis of activities in the last hour before bedtime indicated that activity type plays a role in digital media's effect on sleep, with computer work, surfing the Internet, and listening to music showing the strongest relationship to multiple sleep variables. These findings have implications for physical and mental health of University students and can inform design of devices to minimize negative effects of digital media on sleep.

Perceived Immune Status and Sleep: A Survey among Dutch Students

Reduced immune functioning may have a negative impact on sleep and health, and vice versa. A survey among Dutch young adults (18–35 years old) was administered to collect information on perception of reduced immunity and its relationship to sleep disorders, sleep duration, and quality. Sleep disorders were assessed with the SLEEP-50 questionnaire subscales of sleep apnea, insomnia, circadian rhythm disorder, and daily functioning. Dutch young adults (N = 574) completed the survey. Among them, subjects (N = 209; 36.4%) reported perceived reduced immunity. Relative to those with a normal immune status, subjects reporting reduced immunity had significantly higher scores (p = 0.0001) on sleep apnea (2.6 versus 3.6), insomnia (5.1 versus 6.8), and circadian rhythm disorder (2.1 versus 2.7). Subjects reporting reduced immunity also had significantly poorer daily functioning scores (5.4 versus 7.6, p = 0.0001). No differences were observed in total sleep time, but those reporting reduced immunity had significantly poorer ratings of sleep quality (6.8 versus 7.2, p = 0.0001). Our findings suggest that perceived reduced immunity is associated with sleep disturbances, impaired daily functioning, and a poorer sleep quality. Experimental studies including the assessment of immune biomarkers and objective measures of sleep (polysomnography) should confirm the current observations.

Developmental changes in sleep biology and potential effects on adolescent behavior and caffeine use

Adolescent development includes changes in the biological regulatory processes for the timing of sleep. Circadian rhythm changes and changes to the sleep-pressure system (sleep homeostasis) during adolescence both favor later timing of sleep. These changes, combined with prevailing social pressures, are responsible for most teens sleeping too late and too little; those who sleep least report consuming more caffeine. Although direct research findings are scarce, the likelihood of use and abuse of caffeine-laden products grows across the adolescent years due, in part, to excessive sleepiness.

Reduced sleep duration and history of work-related injuries among Washington State adolescents with a history of working

BACKGROUND

The relationship between sleep and occupational injury risk has not been adequately explored for working adolescents.

METHODS

Data were analyzed from the 2010 Washington State Healthy Youth Survey of 8th, 10th, and 12th grade public school students. Teens reported average school and weekend night sleep hours and history of work-related injury that received medical treatment. Multivariable logistic regression evaluated the association between sleep duration and occupational injury.

RESULTS

Of 4,144 working teens, 6.4% reported ever having an occupational injury. Teens who sleep ≤5 hr/school night had greater odds of a history of occupational injury than those sleeping 8 hr (OR:2.91, 95% CI:1.85-4.57). No significant association was observed for weekend night sleep duration.

CONCLUSIONS

Reduced school night sleep was associated with increased odds of work-related injury in adolescents. Long hours and late night schedules may contribute to decreased sleep time and potentially have other health and developmental impacts for youth.

Mexican American adolescents' sleep patterns: contextual correlates and implications for health and adjustment in young adulthood

Late adolescence is a period of substantial risk for unhealthy sleep patterns. This study investigated the contextual correlates and health and adjustment implications of sleep patterns among Mexican American youth (N = 246; 51% female). We focused on Mexican American youth because they represent a large and rapidly increasing subgroup of the US population that is at higher risk for health and adjustment problems; this higher risk may be explained, in part, by sleep patterns. Using data from seven phone diary interviews conducted when youth averaged 18 years of age, we assessed average nighttime sleep duration and night-to-night variability in sleep duration. Guided by socio-ecological models, we first examined how experiences in the family context (time spent and quality of relationships with parents, parents' familism values) and in extra-familial contexts (school, work, peers) were related to sleep duration and variability. The findings revealed that time spent in school, work, and with peers linked to less sleep. Further, conflict with mothers was related to greater sleep variability. Next, we tested the implications of sleep in late adolescence for health (perceived physical health, body mass index) and adjustment (depressive symptoms, risky behaviors) in young adulthood. These findings indicated that more sleep variability predicted relative decreases in health and increases in risky behaviors, and shorter sleep duration predicted relative decreases in poorer perceived health for males. The discussion highlights the significance of the transition to young adulthood as a target for sleep research and the importance of studying sleep within its socio-cultural context.

Sleep in infancy and childhood: implications for emotional and behavioral difficulties in adolescence and beyond

PURPOSE OF REVIEW

Extensive scientific efforts have been made in an attempt to identify early markers of behavioral and emotional problems. In this context, sleep has received considerable research attention, as it appears to be closely linked to developmental psychopathology. The present review synthesizes some of the most recent findings regarding the concurrent and longitudinal associations between psychopathology and behavioral manifestations of sleep in childhood and adolescence.

RECENT FINDINGS

Recent evidence suggests that compromised sleep is associated with both internalizing and externalizing problems in childhood and adolescence. Moreover, sleep problems have been shown to predict the development of various emotional and behavioral problems, including depression, anxiety, attention-deficit hyperactivity disorder, risk-taking and aggression. Yet, inconsistencies are apparent, particularly among findings that are based on objective sleep measurement.

SUMMARY

Taken together, most recent findings suggest that poor sleep in childhood and adolescence constitutes a risk factor for psychopathological symptoms. Accordingly, the importance of early detection and intervention should be a primary goal in clinical settings. In the research domain, the underlying mechanism of these associations should receive future research attention, in an attempt to broaden the understanding of the relationship between sleep and psychopathology.