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

ANXIOUSNESS AND QUALITY OF SLEEP IN CHILDREN WHO WERE IN QUARANTINE DURING THE COVID-19 PANDEMIC

OBJECTIVE

to assess the level of anxiety and characterize the quality of sleep in children living in radioactively con-taminated areas in comparison with children who were not affected by the Chornobyl-affected contingents that werequarantined in connection with the COVID-19 pandemic.

MATERIALS AND METHODS

The indicators of the level of anxiety were studied using the scale of self-assessment of thelevel of anxiety Ch.D. Spielberger, sleep quality was assessed using a standardized questionnaire for self-completionof PSQI and 137Cs content was measured in children. The main group consisted of 96 children who were quarantineddue to the COVID-19 pandemic and permanently lived in radioactively contaminated areas of Zhytomyr and Rivneregions with a soil contamination density of 137Cs from 18 kBq/m2 to 235 kBq/m2. The age of children ranged from10 to 17 years. Among them were 33 boys and 63 girls. The comparison group consisted of 52 children of similar age,including 26 boys and 26 girls. These children lived permanently in Kyiv and were not victims of the Chornobyl dis-aster.

RESULTS

It was found that children who were quarantined for COVID-19 (both residents of radioactively contami-nated areas and children who do not belong to the contingents affected by the Chornobyl disaster) had an increasedlevel of reactive (RA) and personal anxiety (PA). The comparative analysis showed that children of the same sex ofthe main group and the comparison group did not differ in terms of PA and RA. At the same time, studies have shownthat girls, both in the main group and in the comparison group, were characterized by higher levels of PA and RAthan boys. It was determined that poor sleep quality was common in both children living in radioactively contami-nated areas (42.71 %) and children in the comparison group (42.44 %). Among the sleep disorders in children ofboth observation groups, «day dysfunction» was most often detected.

CONCLUSIONS

There was a direct correlation between the overall PSQI score and the level of reactive, personal anx-iety and the overall PSQI score. Using regression analysis, the presence of a linear association of the level of incorporated 137Cs (Bq) with the indicator of personal anxiety of children living in radioactively contaminated territory (b = -0.716, p < 0.001) was proved.

Sleep, screen time and behaviour problems in preschool children: an actigraphy study

Inadequate sleep and excessive exposure to media screens have both been linked to poorer mental health in youth. However, the ways in which these interact to predict behaviour problems have yet to be examined using objective sleep measurement. The lack of objective evidence for these relationships in young children has recently been defined by the World Health Organization (2019) as a gap in the field. We thus aimed to test the interacting effects of screen exposure and objectively measured sleep on behaviour problems in the preschool age. A total of 145 children aged 3-to-6-years participated in this cross-sectional study. Sleep was assessed objectively using actigraphy for 1-week, and subjectively using parent-reported daily sleep diaries. Parents reported the child's daily duration of screen exposure, and completed the Strengths and Difficulties Questionnaire. Results showed that actigraphic sleep duration, timing and efficiency were associated with screen exposure. The link between screen time and behaviour problems was moderated by sleep duration, as it was significant only for children with sleep duration of 9.88 h or less per night. Sleep duration also moderated the relation between screen time and externalizing-but not internalizing-problems. Hence, the combination of increased screen exposure and decreased sleep duration may be particularly adverse for child mental health. While these key relationships should be further examined in longitudinal and experimental investigations, our findings shed light on their complexity, underscoring the importance of the moderating role of sleep.

A Comprehensive Overview of the Physical Health of the Adolescent Brain Cognitive Development Study Cohort at Baseline

Physical health in childhood is crucial for neurobiological as well as overall development, and can shape long-term outcomes into adulthood. The landmark, longitudinal Adolescent Brain Cognitive Development StudySM (ABCD study®), was designed to investigate brain development and health in almost 12,000 youth who were recruited when they were 9-10 years old and will be followed through adolescence and early adulthood. The overall goal of this paper is to provide descriptive analyses of physical health measures in the ABCD study at baseline, including but not limited to sleep, physical activity and sports involvement, and body mass index. Further this summary will describe how physical health measures collected from the ABCD cohort compare with current normative data and clinical guidelines. We propose this data set has the potential to facilitate clinical recommendations and inform national standards of physical health in this age group. This manuscript will also provide important information for ABCD users and help guide analyses investigating physical health including new avenues for health disparity research as it pertains to adolescent and young adult development.

The association between bullying-victimisation and sleep disturbances in adolescence: Evidence from a twin study

Bullying-victimisation has been associated with sleep disturbances. This study investigated the degree to which subtypes of bullying-victimisation in adolescence are linked with sleep disturbances. Genetic and environmental contributions underlying bullying-victimisation and sleep disturbances were investigated. Participants (3,242-5,076 pairs) from a longitudinal community twin study reported on their bullying-victimisation at the age of 14 years, and sleep quality and insomnia symptoms at age 16. Regression analyses were used, accounting for the role of individual and family factors. Structural equation twin model fitting was conducted. Bullying-victimisation was modestly associated with sleep quality and insomnia symptoms (r = 0.22-0.23) and a similar strength of associations was found across bullying-victimisation subtypes (r = 0.11-0.22). Bullying-victimisation, sleep quality and insomnia symptoms were predominantly influenced by genes (25-59%) and non-shared environments (40-62%). The association between bullying-victimisation and sleep quality was explained by genetic and non-shared environmental influences. For insomnia symptoms and sleep quality, the association with bullying-victimisation was in part explained by a genetic overlap. Associations between bullying-victimisation and sleep disturbances are not limited to specific aspects of bullying-victimisation but appear to exist for all subtypes. These findings stimulate research questions regarding the mechanisms underlying these links. For example, could certain heritable traits, such as temperament, increase vulnerability to experiencing sleep disturbances and being bullied? Research on bullying and sleep should aim to take the role of genetic predisposition into account, while also noting that it is not the only causal influence. Understanding more about these pathways could strengthen the development of techniques to prevent these difficulties from occurring.

Valerian Root in Treating Sleep Problems and Associated Disorders-A Systematic Review and Meta-Analysis

Sleep problems are widely prevalent and associated with various comorbidities including anxiety. Valerian (Valeriana officinalis L.) is a popular herbal medicine used as a sleep aid, however the outcomes of previous clinical studies are inconsistent. This study was conducted to update and re-evaluate the available data in order to understand the reason behind the inconsistent outcomes and to provide a broader view of the use of valerian for associated disorders. PubMed, ScienceDirect, and Cochrane Library were searched to retrieve publications relevant to the effectiveness of valerian as a treatment of sleep problems and associated disorders. A total of 60 studies (n=6,894) were included in this review, and meta-analyses were performed to evaluate the effectiveness to improve subjective sleep quality (10 studies, n=1,065) and to reduce anxiety (8 studies, n=535). Results suggested that inconsistent outcomes were possibly due to the variable quality of herbal extracts and that more reliable effects could be expected from the whole root/rhizome. In addition, therapeutic benefits could be optimized when it was combined with appropriate herbal partners. There were no severe adverse events associated with valerian intake in subjects aged between 7 and 80 years. In conclusion, valerian could be a safe and effective herb to promote sleep and prevent associated disorders. However, due to the presence of multiple active constituents and relatively unstable nature of some of the active constituents, it may be necessary to revise the quality control processes, including standardization methods and shelf life.

The Impact of Anxiety on Behavioral Sleep Difficulties and Treatment in Young Children: A Review of the Literature

Sleep difficulties are a common pediatric complaint, and the majority of these sleep difficulties are behavioral in nature (e.g., difficulties initiating or maintaining sleep). Although research supports behavioral interventions to improve sleep in young children with behavioral sleep difficulties, anxiety and child distress are common in this age range and these factors can impact treatment outcomes directly (e.g., increased distress and resistance at bedtime) and indirectly (e.g., poor parental compliance with behavioral strategies). Anxiety is an important aspect of treatment in adolescents and adults with behavioral sleep difficulties, but this factor is rarely considered in the literature for younger children. Thus, this manuscript reviews the literature on anxiety as it relates to behavioral sleep difficulties in young children (i.e., the preschool and surrounding age range), provides an overview of empirically supported behavioral intervention and research incorporating anxiety into behavioral sleep treatments, and provides recommendations and future directions for continuing to advance the literature and treatment in this area.

What Is “Chronic” in “Chronic Sleep Reduction” and What Are Its Consequences? A Systematic Scoping Review of the Literature

Purpose of Review

In this scoping review, we aimed to (1) provide an overview of chronic sleep reduction by systematically reviewing the existing literature (limited to systematic reviews and meta-analyses), (2) investigate the evidence of the effects of short sleep duration on daytime functioning, and (3) identify research gaps in this field.

Recent Findings

The results showed that (1) clear definitions of chronicity of sleep reduction are lacking—none of the included reviews/meta-analyses provided a full definition—and (2) short sleep duration appeared to be related to obesity and diabetes, whereas relations with cardiovascular disease (CVD), cognitive functioning, emotional problems, general health, and mortality, showed either small effects and appeared to be complex (e.g., for CVD and cognitive functioning), or studies were scarce or completely lacking (e.g., mortality in children/adolescents and emotional problems in adults).

Summary

Although short or insufficient sleep is highly prevalent and is associated with impaired mental and physical wellbeing, as well as pervasive negative consequences for daytime functioning, the concepts of “chronicity” and “chronic sleep reduction” have not been clearly defined and its effects on health are therefore still largely unknown. Moreover, there are large research gaps concerning studies on the relations between short sleep and health consequences. Further studies are recommended to define and operationalize chronicity of sleep reduction and develop measurements that adequately represent the complexity of the concept.

Disturbed sleep in children born extremely preterm is associated with behavioural and emotional symptoms

AIM

To determine whether children born extremely preterm are at increased risk for sleep disturbances and to explore relationships between extremely preterm birth, sleep and attention-deficit/hyperactivity disorder (ADHD) symptoms and emotional symptoms.

METHOD

EPICure2 cohort study. Parents of 165 children born ≤26 weeks' gestation (53% male) and 121 children born at term (43% male) completed the Children's Sleep Habits Questionnaire, sleep disordered breathing subscale of the Pediatric Sleep Questionnaire, the emotional problems scale of the Strengths and Difficulties Questionnaire and the ADHD Rating Scale-5 at 11 years of age.

RESULTS

Extremely preterm children had greater habitual snoring (adjusted odds ratio 6.8; 95% confidence interval 2.3, 20.3), less frequently fell asleep within 20 minutes (Cohen's d 0.33), higher night wakings (d 0.44) and daytime sleepiness scores (d 0.40) than term-born children; there was no between-group difference in sleep duration scores. Among children without severe disability, night wakings scores partially mediated the relationship between preterm birth and inattention (additional 5% of variance explained), hyperactivity/impulsivity (13%) and emotional problems (9%). Snoring partially mediated the relationship between preterm birth, hyperactivity/impulsivity and inattention (additional 1-5% of variance).

CONCLUSION

Children born extremely preterm are at increased risk of disturbed sleep compared to term-born children. As night wakings partially mediated the relationship between preterm birth and ADHD symptoms and emotional problems, reducing sleep disturbance may improve sleep and reduce attention and emotional problems in this population.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Sleep behavior and problems in children and adolescents of a psychiatric day clinic sample: results and requirements for systematic diagnostic]

Sleep behavior and problems in children and adolescents of a psychiatric day clinic sample: results and requirements for systematic diagnostic Abstract. Sleep disorders are common in adults as well as children and adolescents. Children and adolescents in psychiatric treatment (CAP) are especially affected by sleep problems. Cognitive behavioral therapy represents the first-line treatment, preceded by a standardized procedure for sleep diagnostics. To date, no study has investigated sleep behavior in CAP day clinics in Germany. In this study, N = 46 children/adolescents receiving CAP treatment in a day clinic completed a sleep diary (7 days) and a sleep anamnesis scheme with the help of their parents, and their sleep behavior was assessed by a clinician. Furthermore, a parent- and a self-report questionnaire plus a clinical assessment of the mental disorders in the children/adolescents were collected. 52 % of the children/ adolescents exhibited sleep disorders or sleep abnormalities (= sleep disorder symptoms in the context of comorbid disorders), in particular problems falling asleep or to falling asleep and sleeping through the night (26 %). In addition, 33 % reported having nightmares. Their sleep behavior correlated significantly with their external behavior problems (r = .38 .61, p = .02-.04); their sex (female: p = .01-≤ .001, |d| = 1.57-2.50) and their age (older: p = .05, |d| = .78) also significantly influenced sleep behavior. Particularly external behavior problems were associated with sleep problems in this day-care population. In summary, a multi-method-multi-informant procedure should be established for the systematic diagnostics of sleep abnormalities, together with individualized cognitive-behavioral therapy of sleep problems, especially in patients with external behavior problems.

Neighborhood Socio-Economic Factors and Associations with Infant Sleep Health

Background: Sleep health is important for development and improves overall health. There are large socioeconomic gradients in sleep health, from childhood through adulthood. Recent findings suggest that children from neighborhoods with poorer socioeconomic conditions have more sleep problems. The current study aimed to investigate the associations between neighborhood factors and infant sleep health.

PARTICIPANTS AND METHODS

Secondary data analysis using Multilevel Modeling (MLM) was conducted for a subsample of 2445 women from the All our Families longitudinal cohort study, for whom early pregnancy neighborhood data could be geocoded. The Vancouver Area Neighborhood Deprivation Index (VANDIX) was calculated using census data to assess neighborhood SES. Neighborhood disorder was measured using community crime reports from police services. Mothers rated the perceived safety of their neighborhood and reported on their infants' nighttime sleep consolidation, awakenings, and onset latency at 12 months postpartum.

RESULTS

MLM indicated that neighborhood disorder and maternal perceptions of unsafety predicted less consolidated sleep after accounting for individual and family-level factors including maternal ethnicity, household income, breastfeeding duration, and co-sleeping. Neighborhood deprivation was indirectly related to less consolidated sleep among 12-month-old infants through more reports of disorder and maternal perceptions of less safety.

CONCLUSIONS

Consistent with the socio-ecological model of sleep, neighborhood-level, family, and individual factors influence infant sleep health. Policy efforts to increase neighborhood safety and public health initiatives to increase awareness of the importance of sleep could help improve infant sleep health.

The multidimensionality of inter-parental conflict on aggression and mental health among adolescents

The research sets out to reveal that multidimensionality of inter-parental conflict is a limitation in the direction of research which suggests that inter-parental conflict is a risk factor to poor mental health and aggression in adolescents. To validate the above assertion, 394 adolescents (227 males; mean age = 15.6, SD = 1.74) were purposively sampled for the study. Two hypotheses were formulated and tested and data were analyzed using the multiple regression analysis and Multivariate Analysis of Variance/Analysis of Variance (MANOVA/ANOVA) statistics. Results indicated that all dimensions of inter-parental conflict and its full scale had a significantly positive correlation with aggression while all dimensions of inter-parental conflict had a significant negative correlation with adolescents' mental health. Results further showed that all dimensions of inter-parental conflict jointly associated with aggression but only the dimensions of frequency and intensity independently related with aggression. All dimensions of inter-parental conflict jointly related with mental health while intensity, resolution, coping efficacy and self-blame dimensions independently associated with mental health of adolescents. Based on the above, the researchers recommended that the dimensionality of inter-parental conflict should be considered in further research and that intervention programs should aim at promoting positive family relationship, reducing family stress and promoting positive mental health as adolescents grow and develop in the course of time.

The Adaptive GameSquad Xbox-Based Physical Activity and Health Coaching Intervention for Youth With Neurodevelopmental and Psychiatric Diagnoses: Pilot Feasibility Study

Background

The prevalence of neurodevelopmental and psychiatric diagnoses (NPDs) in youth is increasing, and unhealthy physical activity (PA), diet, screen time, and sleep habits contribute to the chronic disease disparities and behavioral challenges this population experiences.

Objective

This pilot study aims to adapt a proven exergaming and telehealth PA coaching intervention for typically developing youth with overweight or obesity; expand it to address diet, screen, and sleep behaviors; and then test its feasibility and acceptability, including PA engagement, among youth with NPDs.

Methods

Participants (N=23; mean age 15.1 years, SD 1.5; 17 males, 9 people of color) recruited in person from clinic and special education settings were randomized to the Adaptive GameSquad (AGS) intervention or wait-list control. The 10-week adapted intervention included 3 exergaming sessions per week and 6 real-time telehealth coaching sessions. The primary outcomes included feasibility (adherence to planned sessions), engagement (uptake and acceptability as reported on process questionnaires), and PA level (combined light, moderate, and vigorous as measured by accelerometer). Descriptive statistics summarized feasibility and engagement data, whereas paired, two-tailed t tests assessed group differences in pre-post PA.

Results

Of the 6 coaching sessions, AGS participants (n=11; mean age 15.3 years, SD 1.2; 7 males, 4 people of color) completed an average of 5 (83%), averaging 81.2 minutes per week of exergaming. Of 9 participants who completed the exit questionnaire, 6 (67%) reported intention to continue, and 8 (89%) reported feeling that the coaching sessions were helpful. PA and sleep appeared to increase during the course of the intervention over baseline, video game use appeared to decrease, and pre-post intervention PA per day significantly decreased for the control (−58.8 min; P=.04) but not for the intervention group (−5.3 min; P=.77), despite potential seasonality effects. However, beta testers and some intervention participants indicated a need for reduced complexity of technology and more choice in exergames.

Conclusions

AGS shows promise in delivering a health behavior intervention remotely to youth with NPDs, but a full-scale efficacy trial with a larger sample size is needed to confirm this finding. On the basis of feedback from beta testers and intervention participants, the next steps should include reduced technology burden and increased exergame choice before efficacy testing.

Trial Registration

ClinicalTrials.gov NCT03665415; https://clinicaltrials.gov/ct2/show/NCT03665415.

Have the sleep habits in children of health workers been more affected during the COVID-19 pandemic?

BACKGROUND

Changes have occurred in children's sleep habits during the coronavirus disease 2019 (COVID-19) pandemic. The purpose of this study was to compare the sleep patterns during the COVID-19 pandemic of school age children of health worker parents (Group 1) and non-health worker parents (Group 2).

METHOD

One hundred twenty-two participants were included in Group 1 and 250 in Group 2. The families' sociodemographic characteristics (education levels and occupations of mothers and fathers, parental shift-working status, monthly family income, number of children in the family, and place of residence), general information for the children taking part (diagnosis of COVID-19 or COVID-19 related isolation, distance education, participation in sporting activities, time spent watching TV, time devoted to reading, time spent on telephones/tablets/computers, and time spent on indoor activities), and the responses given to the Children's Sleep Habits Questionnaire (CSQH)-abbreviated form were all examined.

RESULTS

Group 1 consisted of 122 individuals, 66 (54.1%) female and 56 (45.9%) male, and Group 2 of 250 individuals, 129 (51.6%) female and 121 (48.4%) male. Statistically significant differences were determined between the groups in terms of parental education levels and occupations, family monthly income, number of children in the family, place of residence, parental shift-working status, and length of time spent on indoor activities. Total CSHQ scores were 41.57 ± 7.57 (20-60) in Group 1 and 39.6 ± 8.47 (17-68) in Group 2 (p:0.03).

CONCLUSION

Greater impairment of sleep habits of school age children of health workers compared to those of non-health workers in the COVID-19 pandemic is proved for the first time in this study. Further assessment of the effects of the COVID-19 pandemic on children's sleep habits is now required, and appropriate measures must be taken in the light of the results obtained.

Parental perceived child sleep problems: A concept analysis

PURPOSE

This paper aims to delineate a conceptual analysis of parental perceived child sleep problems.

DESIGN AND METHODS

Rodger's evolutionary approach to concept analysis was employed. A systematic literature search of PubMed, CINAHL, Medline, and PsycINFO was conducted from inception to June 2020. Peer-reviewed papers written in English focusing on parental perception of their children's sleep problems were included.

RESULTS

A total of 47 papers were included for analysis. Parental perceived child sleep problems can be defined as parental reliance on their observations and beliefs, and perceived locus of control to appraise an array of children's sleep-related signs and behaviors, which may contain bias but still reflects certain aspects of children's sleep health status. A wide range of physiological, psychosocial, familial, environmental, and cultural factors may contribute to parental perceived child sleep problems, which may further contribute to parent-child dyads' physical and mental health as well as the whole family's general wellness.

PRACTICE IMPLICATIONS

Defining the concept of parental perceived child sleep problems facilitate health professionals a foundation for consistent use, understanding, and evaluation of parent-reported child sleep outcome. Future research on the standard conceptual and operational definition of parental perceived child sleep problem, and its potential antecedents and consequences is warranted. The characteristic of parental perceived sleep problems, together with child sleep history and objective sleep measures should be integrated to evaluate child sleep health.

Modifiable parental factors in adolescent sleep: A systematic review and meta-analysis

Sleep problems are prevalent during adolescence, but parents may be able to support adolescents to sleep better. A systematic search of records from six databases from inception up to November 2019, identified 103 peer-reviewed publications that examined behaviourally and cognitively modifiable parental factors associated with sleep in adolescents aged 12-18 years. Although included studies were largely cross-sectional and heterogeneous, with heavy reliance on self-reported measures, associations with sound, convergent levels of evidence were found for: 1) parental rule-setting for bedtimes and parent sleep behaviours with longer sleep duration in adolescents; 2) healthy parent sleep and family functioning with better adolescent sleep quality; and 3) parental warmth with better adolescent daytime functioning. Effect sizes were in the small to moderate range. The identified parental factors are recommended targets for inclusion in parenting programs to support adolescent sleep, however, would require validation in intervention studies. Opportunities for research are outlined for the identified parental factors, sleep domains with limited evidence, and better understanding the mechanisms or possible moderators in the associations between parental factors and sleep outcomes.

Alteration of fear behaviors in sleep-deprived adolescent rats: increased fear expression and delayed fear extinction

Disruption of sleep due to acute or chronic stress can lead to changes in emotional memory processing. Sleep disturbances are highly prevalent in post-traumatic stress disorder (PTSD), but still, the contribution of sleep deprivation on the susceptibility to PTSD has received little attention. To determine whether rapid eye movement sleep deprivation (SD) alters the development of fear expression or fear-associated memory impairment in adolescent rats, we performed animal emotional behavior tests using an SD animal model with the flowerpot technique. SD rats showed an increase in locomotor activity frequency and a decrease in sucrose consumption compared to control rats. An increase in freezing behavior during shock trials was observed in SD rats. Noticeably, it was observed that when applying the SD condition after fear stimuli exposure, fear extinction was delayed more in SD rats than in control rats. Overall, these results indicate that SD in adolescent rats leads to increased locomotor activity and anhedonic behavior, as well as increased fear expression and delayed fear extinction, suggesting that SD would lead to increased severity of PTSD-like phenotype.

Long-term exposure to ambient PM1 strengthened the association of depression/anxiety symptoms with poor sleep quality: The Henan Rural Cohort study

Evidence from numerous epidemiological studies for the relationship between mental disorder and sleep quality was inconclusive and few studies assessed the modification effect of exposure to ambient air PM1 (particulate matter with an aerodynamic diameter ≤ 1.0 µm) on this association. In this study, 27,572 participants aged 18-79 years from The Henan Rural Cohort study were included in the final analyses. The Patient Health Questionnaire-2 (PHQ-2) and Generalized Anxiety Disorder-2 (GAD-2) scales were used to estimate the frequency of depression and anxiety symptoms of all participants, respectively. The Pittsburgh Sleep Quality Index (PSQI) scale was used to assess night sleep quality and PSQI global score (GSC) ≥ 6 was classified as poor sleep quality. The three-year average exposure concentration of PM1 before the baseline survey was determined as long-term exposure concentration of ambient PM1. Logistic regression model was conducted to estimate the independent or joint effect of depression/anxiety symptoms and ambient PM1 exposure on poor sleep quality. In the adjusted models, the odds ratios (ORs) and 95% confidence intervals (95% CIs) of poor sleep quality associated with depression and anxiety symptoms were 3.75 (3.37, 4.17) and 3.42 (3.06, 3.81), respectively, and that associated with long-term exposure to PM1 was 1.06 (1.03, 1.09). An interaction effect was observed between anxiety symptoms score and PM1 concentration on poor sleep quality. With the increment of PM1 concentration, the association was strengthened between depression/anxiety symptoms and poor sleep quality. Besides, compared with the reference group, the ORs (95% CIs) of poor sleep quality in those with comorbidity of depression and anxiety symptoms were 4.98 (3.95, 6.29), 5.23 (3.98, 6.87), 5.76 (4.42, 7.49), and 5.58 (3.83, 8.14), respectively, from the first to the fourth quartile level of the PM1 concentration. These findings suggested that long-term exposure to PM1 strengthened the association of depression/anxiety symptoms with poor sleep quality in rural China.

Individual differences in the effects of child sleep problems on early executive functioning

Sleep is a critical health behavior with important implications for child development. This chapter discusses the effects of sleep problems on early child executive functioning (EF), with an emphasis on individual differences that might moderate this relationship. Specifically, we (1) provide a brief background on sleep and EF in early childhood; (2) review literature on the association between sleep and EF; (3) review literature on individual differences in the effects of sleep problems on EF; (4) offer recommendations for future research on moderators of the sleep-EF association, and (5) briefly describe an ongoing study examining the moderators of the sleep-EF association within a longitudinal study from pregnancy to preschool.

Prospective Examination of Adolescent Sleep Patterns and Behaviors Before and During COVID-19

Study Objectives

To prospectively examine changes in adolescent sleep before and during the COVID-19 pandemic in adolescents with and without ADHD.

Methods

Participants were 122 adolescents (ages 15–17; 61% male; 48% with ADHD). Parents reported on adolescents’ sleep duration and difficulties initiating and maintaining sleep (DIMS); adolescents reported on sleep patterns, sleep duration, delayed sleep/wake behaviors, and daytime sleepiness before (September 2019 to February 2020) and during (May–June 2020) COVID-19. Adolescents also reported on their health behaviors, COVID-19-related negative affect, and difficulties concentrating due to COVID-19.

Results

Parents reported adolescents had more DIMS during COVID-19 than before COVID-19, with clinically elevated rates increasing from 24% to 36%. Both bedtimes and waketimes shifted later during COVID-19, and adolescents reported more delayed sleep/wake behaviors. Adolescents also reported less daytime sleepiness and longer school night sleep duration during COVID-19. In considering differences between adolescents with and without ADHD, adolescents with ADHD did not experience an increase in school night sleep duration and were less likely to obtain recommended sleep duration during COVID-19. In the full sample, controlling for ADHD status, COVID-19-related sadness/loneliness was associated with increases in DIMS, and spending less time outside and more COVID-19-related worries/fears were associated with increases in delayed sleep/wake behaviors during COVID-19.

Conclusions

COVID-19 had negative and positive impacts on adolescent sleep. Adolescents with ADHD did not experience the benefit of increased school night sleep duration during COVID-19 like adolescents without ADHD. Negative affect and health behaviors may be useful intervention targets for reducing negative impacts of COVID-19 for adolescent sleep.

Psychiatric morbidity and dietary habits during COVID-19 pandemic: a cross-sectional study among Egyptian Youth (14–24 years)

Background

The coronavirus disease 2019 (COVID-19) is influencing all segments of society, including youth. Although the physical complaints in the time of COVID-19 are broadly-studied, a paucity of research targeted psychological ones on the precious youth population. This study aimed to describe the real-time state of Egyptian youth’s psychiatric morbidity, dietary changes, and coping methods during this pandemic and explore probable factors influencing them. A descriptive cross-sectional study was conducted using an online survey among 447 Egyptian participants aged 14–24 years. Sociodemographic data, dietary habits, and coping methods during COVID-19 were collected. The Arabic versions of the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder Scale (GAD-7), and the Insomnia Severity Index (ISI) were used to assess depression, anxiety and insomnia, respectively.

Results

Overall, 80.5%, 74.0%, and 73.8% of the participants had different grades of depression, anxiety, and insomnia symptoms. 37.4% gained weight. Emotional and night eating emerged as new habits during the pandemic among 17.9% and 29.3% of the participants, respectively. Each of depression, anxiety, and insomnia was significantly associated with each other, female gender and having a COVID-19 infected relative. Adolescents had significantly higher scores of depression and anxiety. Those with a history of physical illness had significantly higher scores of anxiety and insomnia. Bodyweight and dietary changes were significantly associated with depression, anxiety, and insomnia. Participants reported various positive and negative coping methods.

Conclusion

Psychiatric morbidity and dietary changes are evident in young people during COVID-19 pandemic. Psychological well-being and dietary habits are important but often overlooked components of youth well-being especially in challenging times. Depression, anxiety, and insomnia were almost always present and dietary changes were significantly associated with the presence of them.

Hair Cortisol Concentration as a Biomarker of Sleep Quality and Related Disorders

Cortisol is the end product of the hypothalamic-pituitary-adrenal (HPA) axis, and its production is increased mainly in stressful situations or in chronic disorders accompanied by stress enhancement. Altered cortisol concentrations have been reported in a number of neuropsychiatric diseases and sleep disorders. Cortisol concentrations have been measured using several methods, and in several matrixes, such as blood, saliva, and urine. However, lately, hair cortisol, for several reasons, has emerged as a promising biomarker of long-term retrospective HPA activation. Several experimental approaches for cortisol measurement with the corresponding concentration reference ranges and a summary of findings from scientific literature on this field are presented. There is evidence of a close relationship between HPA functional alteration and the development of neuropsychiatric disorders. Sleep disorders are the most common manifestation in several neuropsychiatric conditions, and have also been associated to cortisol alterations in both adults and children. Many studies indicate that hair cortisol constitutes a valuable tool for further contributing to existing data on salivary, plasma, or urinary cortisol concentrations in patients with sleep disorders.

Sleep disturbances and first onset of major mental disorders in adolescence and early adulthood: A systematic review and meta-analysis

Despite several high-quality reviews of insomnia and incidence of mental disorders, prospective longitudinal relationships between a wider range of sleep disturbances and first onset of a depressive, bipolar, or psychotic disorders during the peak age range for onset of these conditions has not been addressed. Database searches were undertaken to identify publications on insomnia, but also on other sleep problems such as hypersomnia, short sleep duration, self-identified and/or generic 'sleep problems' and circadian sleep-wake cycle dysrhythmias. We discovered 36 studies that were eligible for systematic review and from these publications, we identified 25 unique datasets that were suitable for meta-analysis (Number>45,000; age ∼17). Individuals with a history of any type of sleep disturbance (however defined) had an increased odds of developing a mood or psychotic disorder in adolescence or early adulthood (Odds ratio [OR]:1.88; 95% Confidence Intervals:1.67, 2.25) with similar odds for onset of bipolar disorders (OR:1.72) or depressive disorders (OR:1.62). The magnitude of associations differed according to type of exposure and was greatest for sleep disturbances that met established diagnostic criteria for a sleep disorder (OR: 2.53). However, studies that examined observer or self-rated symptoms, also reported a significant association between hypersomnia symptoms and the onset of a major mental disorder (OR:1.39). Overall study quality was moderate with evidence of publication bias and meta-regression identified confounders such as year of publication. We conclude that evidence indicates that subjective, observer and objective studies demonstrate a modest but significant increase in the likelihood of first onset of mood and psychotic disorders in adolescence and early adulthood in individuals with broadly defined sleep disturbances. Although findings support proposals for interventions for sleep problems in youth, we suggest a need for greater consensus on screening strategies and for more longitudinal, prospective studies of circadian sleep-wake cycle dysrhythmias in youth.

Challenges in researching the immune pathways between early life adversity and psychopathology

Exposure to childhood adversity is a critical risk factor for the development of psychopathology. A growing field of research examines how exposure to childhood adversity is translated into biological risk for psychopathology through alterations in immune system functioning, most notably heightened levels of inflammation biomarkers. Though our knowledge about how childhood adversity can instantiate biological risk for psychopathology is growing, there remain many challenges and gaps in the field to understand how inflammation from childhood adversity contributes to psychopathology. This paper reviews research on the inflammatory outcomes arising from childhood adversity and presents four major challenges that future research must address: (a) the measurement of childhood adversity, (b) the measurement of inflammation, (c) the identification of mediators between childhood adversity and inflammation, and (d) the identification of moderators of inflammatory outcomes following childhood adversity. We discuss synergies and inconsistencies in the literature to summarize the current understanding of the association between childhood adversity, a proinflammatory phenotype, and the biological risk for psychopathology. We discuss the clinical implications of the inflammatory links between childhood adversity and psychopathology, including possibilities for intervention. Finally, this review conclude by delineates future directions for research, including issues of how best to detect, prevent, and understand these “hidden wounds” of childhood adversity.

Development and Validation of the Pediatric Sleep Practices Questionnaire: A Self-Report Measure for Youth Ages 8-17 Years

Objective: To develop and evaluate the validity of a self-report measure of sleep practices for youth 8-17 years. Methods: Following recommended guidelines for the development of patient reported outcomes (PROs), sleep practice concepts were identified through expert (n = 8) and child (n = 28) concept elicitation interviews and a systematic literature review. Items were developed based on these concepts and tested in cognitive interviews with children (n = 32). Psychometric analyses were applied to item response data collected from a diverse sample of youth 8-17 years (n = 307). Construct validity was evaluated through tests of associations between sleep practices and sleep disturbance and sleep-related impairment. Finally, clinical validity of the tool was assessed by comparing scores of youth with and without a parent-identified sleep problem. Results: The final Pediatric Sleep Practices Questionnaire (PSPQ) included 15 items that were used to identify 5 sleep practices: sleep timing, sleep routines and consistency, technology use before bedtime, sleep environment, and the need for parental presence to fall asleep. A confirmatory factor analysis supported the hypothesized structure (all factor loadings ≥ 0.72) and PSPQ indices were significantly associated with self-reported sleep disturbances and sleep-related impairment. Finally, children with parent-reported sleep problems had shorter sleep opportunity, later bedtimes, greater need for parental presence, poorer bedtime routines, and more technology use than children without parent-reported sleep problems. Conclusions: The PSPQ was developed using best-practice PRO development methodology. The PSPQ can be used in clinical settings and for research assessment to capture modifiable sleep practices that may promote or interfere with healthy sleep.

Associations of sleep with psychological problems and well-being in adolescence: causality or common genetic predispositions?

BACKGROUND

Whereas short and problematic sleep are associated with psychological problems in adolescence, causality remains to be elucidated. This study therefore utilized the discordant monozygotic cotwin design and cross-lagged models to investigate how short and problematic sleep affect psychological functioning.

METHODS

Adolescent twins (N = 12,803, 13-20 years, 42% male) completed questionnaires on sleep and psychological functioning repeatedly over a two-year interval. Monozygotic twin pairs were classified as concordant or discordant for sleep duration and trouble sleeping. Resulting subgroups were compared regarding internalizing problems, externalizing problems, and subjective well-being.

RESULTS

Cross-sectional analyses indicated associations of worse psychological functioning with both short sleep and problematic sleep, and cross-lagged models indicate bidirectional associations. Longitudinal analyses showed that an increase in sleep problems experienced selectively by one individual of an identical twin pair was accompanied by an increase of 52% in internalizing problem scores and 25% in externalizing problem scores. These changes were significantly different from the within-subject changes in cotwins with unchanged sleep quality (respectively, 3% increase and 5% decrease). Psychological functioning did, however, not worsen with decreasing sleep duration.

CONCLUSIONS

The findings suggest that sleep quality, rather than sleep duration, should be the primary target for prevention and intervention, with possible effect on psychological functioning in adolescents.

Parents' Perceptions of Their Children's Engagement in a Consumer-Based Meditation Mobile App: Cross-Sectional Survey Study

BACKGROUND

In the United States, nearly half (48%) of school-aged children experience sleep disturbance that results in less than the recommended sleep duration, which may negatively impact mental health and behavior. Mindfulness interventions may improve sleep and mental health in youth. However, there are gaps in the literature regarding how children (2-12 years) and adolescents (13-17 years) practice mindfulness and the extent to which they benefit from these practices.

OBJECTIVE

The purpose of this study was to determine parents' perceptions of their children's engagement with a consumer-based mindfulness meditation app and the extent to which they believe their children have benefitted from using the app, particularly with regard to sleep.

METHODS

This study is a secondary analysis of a cross-sectional survey in adult subscribers (N=11,108) to the mindfulness meditation mobile app Calm. Participants who indicated that they had a child or children younger than 18 years (2944/11,108) who used the Calm app were asked additional questions related to their perceptions of their children's engagement with Calm. Descriptive statistics were used to assess children's app engagement, and chi-square tests and binary logistic regression models were used to assess differences in children's usage based on gender and age.

RESULTS

Among the survey respondents, approximately half of the parents (1537/2944, 52.21%) reported that their children used Calm. Children used Calm mostly for (1) sleep (1168/1537, 75.99%), (2) stress (491/1537, 31.95%), (3) depression or anxiety (430/1537, 27.98%), and (4) improvement of overall health (215/1537,13.99%). Older children were more likely to begin using Calm to reduce stress, depression, or anxiety, whereas younger children were more likely begin using Calm to improve sleep. Most children used Calm when lying down to go to bed (1113/1529, 72.79%). Children were most likely to use sleep stories at night (1144/1207, 94.78%), followed by music and soundscapes (749/1114, 67.24%), meditations (736/1120, 65.71%), and breathing exercises (610/1092, 55.86%). Nearly all parents believed that using sleep stories was helpful for their children's sleep (1090/1128, 96.63%), and the majority of parents felt that the other components were also helpful for their children's sleep (music and soundscapes [570/728, 78.30%], meditations [445/696, 63.94%], and breathing exercises [610/1092, 55.86%]).

CONCLUSIONS

To our knowledge, this is the first study to explore parents' perceptions of how their children or adolescents use a popular consumer-based mindfulness mobile app (ie, Calm). As the majority of children use the app for sleep, mindfulness meditation mobile apps should consider incorporating age-appropriate sleep content to meet the needs of this audience. More research is needed to confirm the feasibility and effectiveness of mindfulness meditation apps for improving sleep and mental health in children and adolescents.

Attention Problems and Comorbid Symptoms following Child Sexual Abuse

Treatment utilization following child sexual abuse (CSA) is essential in combatting the various negative consequences of CSA. Youth may present to treatment for CSA with symptoms that cut across multiple diagnostic presentations that impact their ability to successfully engage in treatment. In particular, children who have difficulties with attention may have unique treatment needs following CSA. The purpose of this study was to examine how attention problems interplay with comorbid symptoms and how these clinical presentations impact treatment outcomes for youth who have been sexually abused. Participants included 323 families presenting to treatment for CSA. Youth were 7 to 19 years old, 78.5% female, and 76.6% identified as Caucasian/White. Results indicated that 22.9% of the youth presented with clinically elevated attention problems as collected through parent-report of the Child Behavior Checklist (CBCL). Results demonstrated that child survivors of CSA who presented with attention problems self-reported more psychological concerns (e.g., symptoms of depression, anxiety, and post-traumatic stress). At post-treatment, attention problems, interpersonal problems, and thought problems were significantly reduced for youth initially presenting with attention problems. Further implications for treatment following CSA and unique needs for youth with attention problems are discussed.

Self-reported sleep patterns and quality amongst adolescents: cross-sectional and prospective associations with anxiety and depression

BACKGROUND

Sleep problems are common in adolescence, and frequently comorbid with both anxiety and depression. Research studies have suggested a bidirectional relationship between sleep and psychopathology, which includes evidence that sleep interventions can alleviate symptoms of anxiety and depression. However, little is known about the nature of sleep problems amongst adolescents with anxiety and depression, and whether specific sleeping difficulties are involved in the longitudinal relationship between sleep, anxiety and depression.

METHOD

The sample was derived from the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based, prospective, birth cohort study of children born in 1991-1992. Data were explored from a subset of participants who took part in a clinical assessment at age 15, on self-report sleep patterns and quality, and diagnostic outcomes of anxiety and depression (N = 5,033). Subsequent diagnostic and symptom severity data on anxiety and depression at ages 17, 21 and 24 were also examined.

RESULTS

Cross-sectional and longitudinal analyses were conducted to explore the relationship between sleep problems, anxiety and depression. Results revealed that adolescents aged 15 with depression experience difficulties with both sleep patterns and sleep quality, whereas adolescents with anxiety only reported problems with sleep quality. A range of sleep variables at age 15 predicted the severity of anxiety and depression symptoms and the diagnoses of anxiety and depressive disorders at age 17, 21 and 24 years.

CONCLUSIONS

The results provide further insight into the nature of sleep problems amongst adolescents with anxiety and depression, and the prospective relationship between sleep disturbance and future psychopathology. These data suggest that targeting sleep difficulties during adolescence may have long-term mental health benefits.

Is sleep the red flag to psychopathology's bull?

'Hippocrates flagged the value of sleep for good health' was the first line of the Annual Research Review (ARR) by Gregory and Sadeh (2016) in this journal, titled Sleep problems in childhood psychiatric disorders - a review of the latest science. Where Hippocrates has been referred to as the 'Father of Medicine', Professor Avi Sadeh has been respected as a 'Father of Paediatric Sleep Medicine' by those who had the privilege to meet him or read his science. Sadly, Avi Sadeh passed away in the same year this ARR was published. What he left behind was a legacy - including his predecessors (Professor Mary Carskadon), successors and those he inspired, who could be guided by the key findings from his 2016 ARR. These include (a) greater attention to the assessment of sleep in children; (b) sleep research on a wider range of psychiatric disorders; (c) a greater focus on and examination of mechanisms underlying associations; (d) a clearer consideration of developmental questions; and (e) large-scale well-designed treatment studies.

Genome-wide DNA methylation patterns associated with sleep and mental health in children: a population-based study

BACKGROUND

DNA methylation (DNAm) has been implicated in the biology of sleep. Yet, how DNAm patterns across the genome relate to different sleep outcomes, and whether these associations overlap with mental health is currently unknown. Here, we investigated associations of DNAm with sleep and mental health in a pediatric population.

METHODS

This cross-sectional study included 465 10-year-old children (51.3% female) from the Generation R Study. Genome-wide DNAm levels were measured using the Illumina 450K array (peripheral blood). Sleep problems were assessed from self-report and mental health outcomes from maternal questionnaires. Wrist actigraphy was used in 188 11-year-old children to calculate sleep duration and midpoint sleep. Weighted gene co-expression network analysis was used to identify highly comethylated DNAm 'modules', which were tested for associations with sleep and mental health outcomes.

RESULTS

We identified 64 DNAm modules, one of which associated with sleep duration after covariate and multiple testing adjustment. This module included CpG sites spanning 9 genes on chromosome 17, including MAPT - a key regulator of Tau proteins in the brain involved in neuronal function - as well as genes previously implicated in sleep duration. Follow-up analyses suggested that DNAm variation in this region is under considerable genetic control and shows strong blood-brain concordance. DNAm modules associated with sleep did not overlap with those associated with mental health.

CONCLUSIONS

We identified one DNAm region associated with sleep duration, including genes previously reported by recent GWAS studies. Further research is warranted to examine the functional role of this region and its longitudinal association with sleep.

Children's sleep, impulsivity, and anger: shared genetic etiology and implications for developmental psychopathology

BACKGROUND

Prior research has established links between poor sleep and problems in emotion regulation. Impulsivity and anger/frustration are core features of child psychopathology. Further, sleep problems are commonly associated with psychopathology. This study examined shared and unique genetic and environmental influences on sleep, impulsivity, and anger/frustration in the middle childhood period with potential ramifications for psychopathology.

METHODS

Families (29.9% monozygotic, 38.6% same-sex dizygotic, 31.5% opposite-sex dizygotic) from a longitudinal twin study participated (N = 613 twins). Twins (M_age  = 8.37, SD = 0.66; 49% female; 58% non-Latinx European American, 30% Latinx) wore actigraph watches for seven days to assess sleep. Primary caregivers (95.3% mothers) completed standardized questionnaires to assess twins' temperament (impulsivity, anger/frustration).

RESULTS

Univariate ACE twin structural equation models indicated strong genetic influences (76%) on impulsivity, whereas the largest proportion of variance in anger/frustration was attributed to the shared environment (56%). Bivariate model fitting indicated that sleep-impulsivity and sleep-anger/frustration associations in children are genetic; thus, a mutual underlying genetic factor likely contributes to the commonality in these associations.

CONCLUSIONS

Given evidence that sleep problems, impulsivity, and anger/frustration are mechanisms associated with psychopathology, our findings suggest a genetic commonality and the need to focus on shared and unique risk factors when understanding etiology. Early intervention and prevention efforts should target both sleep problems and high levels of impulsivity and anger/frustration in children, which may have implications for later psychopathology.

Maternal perceptions of sleep problems among children and mothers during the coronavirus disease 2019 (COVID-19) pandemic in Israel

Despite the marked impact of the coronavirus disease 2019 (COVID‐19) pandemic on the life of families and its possible negative implications for sleep, little is known about how sleep among parents and children has been impacted by this current crisis. In the present study, we addressed, for the first time, possible consequences of the COVID‐19 crisis and home confinement on maternal anxiety, maternal insomnia, and maternal reports of sleep problems among children aged 6–72 months in Israel (N = 264). Our results revealed a high frequency of maternal clinical insomnia during the COVID‐19 pandemic: 23% during the pandemic, compared to only 11% before the pandemic (retrospective reports about 1–2 months before the pandemic). About 80% of mothers reported mild‐to‐high levels of current COVID‐19 anxiety. The majority of mothers reported no change in their child’s sleep quality, duration, and sleeping arrangement. However, about 30% reported a negative change in child’s sleep quality and a decrease in sleep duration, and there were also mothers who reported a positive change. These findings suggest that the changes in sleep patterns during the COVID‐19 pandemic are varied and that no unified change for the worse should be expected. Further consideration of changes in sleep within the family context during this ongoing crisis is needed.

Sleep problems and depressive symptoms in toddlers and 8-year-old children: A longitudinal study

Sleep and depression are interlinked throughout the lifespan, but very few studies have examined the directionality of the sleep-depression link in children. The aim of the current study was to prospectively examine the bidirectional association between sleep problems and internalizing problems and depressive symptoms in toddlers and children aged 1.5 and 8 years. Data stem from the large ongoing population-based longitudinal study, the Norwegian Mother, Father and Child Cohort Study, recruited from October 1999 to July 2009. A total of 35,075 children were included. Information on sleep duration, nocturnal awakenings and internalizing problems (Child Behaviour Checklist) was provided by the mothers at 1.5 years, whereas data on sleep duration and depressive symptoms (Short Mood and Feelings Questionnaire) were provided by the mothers when the children were 8 years old. Odds ratios (ORs) were calculated using logistic regression analyses. After accounting for previous internalizing problems, short sleep duration (≤10 hr) and frequent (≥3) nightly awakenings at 1.5 years predicted the development of depressive symptoms at 8 years of age (adjusted OR = 1.28; 95% confidence interval [CI] 1.08-1.51, and adjusted OR = 1.27, 95% CI 1.08-1.50, respectively). Also, internalizing problems at 1.5 years predicted onset of later short sleep duration (adjusted OR = 1.83, 95% CI 1.32-2.54) after accounting for early sleep problems. This prospective study demonstrated a bidirectional association between sleep and internalizing/depressive symptoms from toddlerhood to middle childhood. Intervention studies are needed to examine whether targeting either of these problems at this early age may prevent onset of the other.

Editorial Perspective: Perils and promise for child and adolescent sleep and associated psychopathology during the COVID-19 pandemic

It is anticipated that the novel coronavirus disease 2019 (COVID-19) pandemic and associated societal response will have wide-ranging impacts on youth development and mental health. Sleep is crucial for child and adolescent health and well-being, and the potential for sleep problems to emerge or worsen during and following the pandemic is high. This may be particularly true for children and adolescents who are at heightened risk for the onset of sleep and mental health disturbances and for those whom developmental changes impacting sleep are rapidly occurring. Youth with preexisting psychopathologies (including anxiety and depression) and neurodevelopmental conditions (including attention-deficit/hyperactivity disorder and autism spectrum disorder) could be especially vulnerable to disturbed sleep during this period of change and uncertainty. It is thus imperative that sleep considerations be part of research and clinical initiatives aimed at understanding and mitigating the impact of the COVID-19 pandemic in children and adolescents. This article considers ways in which the pandemic may impact sleep, including research and clinical implications.

How do stress, sleep quality, and chronotype associate with clinically significant depressive symptoms? A study of young male military recruits in compulsory service

OBJECTIVE

Although studies have shown an association between poor sleep and chronotype with psychiatric problems in young adults, few have focused on identifying multiple concomitant risk factors.

METHODS

We assessed depressive symptoms (Beck Depression Inventory [BDI]), circadian typology (Morningness-Eveningness Questionnaire [MEQ]), sleep quality (Pittsburgh Sleep Quality Index [PSQI]), perceived stress (Perceived Stress Scale [PSS]), social rhythm (Social Rhythm Metrics [SRM]), and salivary cortisol (morning, evening and night, n=37) in 236 men (all 18 years old). Separate analyses were conducted to understand how each PSQI domain was associated with depressive symptoms.

RESULTS

Depressive symptoms were more prevalent in individuals with higher perceived stress (prevalence ratio [PR] = 6.429, p < 0.001), evening types (PR = 2.58, p < 0.001) and poor sleepers (PR = 1.808, p = 0.046). Multivariate modeling showed that these three variables were independently associated with depressive symptoms (all p < 0.05). The PSQI items subjective sleep quality and sleep disturbances were significantly more prevalent in individuals with depressive symptoms (PR = 2.210, p = 0.009 and PR = 2.198, p = 0.008). Lower levels of morning cortisol were significantly associated with higher depressive scores (r = -0.335; p = 0.043).

CONCLUSION

It is important to evaluate multiple factors related to sleep and chronotype in youth depression studies, since this can provide important tools for comprehending and managing mental health problems.

Digital Cognitive Behavioral Therapy for Insomnia for Adolescents With Mental Health Problems: Feasibility Open Trial

BACKGROUND

Insomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is seldom directly treated, and the effects of digital cognitive behavioral therapy (CBT) for insomnia (CBTi) on the mental health of adolescents with significant mental health problems are unknown.

OBJECTIVE

This open study aimed to assess the feasibility of adding supported Web-based CBT for insomnia to the usual care of young people aged 14 to 17 years attending specialist child and adolescent mental health services (CAMHS).

METHODS

A total of 39 adolescents with insomnia aged 14 to 17 years attending specialist CAMHS were assessed and offered digital CBTi. The digital intervention was Sleepio, an evidence-based, self-directed, fully automated CBTi that has proven effective in multiple randomized controlled trials with adults. Self-report assessments of sleep (Sleep Condition Indicator [SCI], Insomnia Severity Scale, and Web- or app-based sleep diaries), anxiety (Revised Child Anxiety and Depression Scale [RCADS]), and depression (Mood and Feelings Questionnaire [MFQ]) were completed at baseline and post intervention. Postuse interviews assessed satisfaction with digital CBTi.

RESULTS

Average baseline sleep efficiency was very poor (53%), with participants spending an average of 9.6 hours in bed but only 5.1 hours asleep. All participants scored less than 17 on the SCI, with 92% (36/39) participants scoring 15 or greater on the Insomnia Severity Scale, suggesting clinical insomnia. Of the 39 participants, 36 (92%) scored 27 or greater on the MFQ for major depression and 20 (51%) had clinically elevated symptoms of anxiety. The majority of participants (38/49, 78%) were not having any treatment for their insomnia, with the remaining 25% (12/49) receiving medication. Sleepio was acceptable, with 77% (30/39) of the participants activating their account and 54% (21/39) completing the program. Satisfaction was high, with 84% (16/19) of the participants finding Sleepio helpful, 95% (18/19) indicating that they would recommend it to a friend, and 37% (7/19) expressing a definite preference for a digital intervention. Statistically significant pre-post improvements were found in weekly diaries of sleep efficiency (P=.005) and sleep quality (P=.001) and on measures of sleep (SCI: P=.001 and Insomnia Severity Index: P=.001), low mood (MFQ: P=.03), and anxiety (RCADS: P=.005).

CONCLUSIONS

Our study has a number of methodological limitations, particularly the small sample size, absence of a comparison group and no follow-up assessment. Nonetheless, our findings are encouraging and suggest that digital CBTi for young people with mental health problems might offer an acceptable and an effective way to improve both sleep and mental health.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11324.

Internalizing symptoms and sleep outcomes in urban children with and without asthma

STUDY OBJECTIVES

This study examines associations between internalizing symptoms and sleep in a sample of urban children with and without asthma, whether asthma status moderates these associations, and whether associations differ by ethnic group.

METHODS

Participants were Latino, African American (AA), and non-Latino white (NLW) urban 7- to 9-year-olds with (n = 259) and without (n = 122) persistent asthma. Teacher-reported internalizing symptoms (anxiety, depressive, and somatic) were assessed using the Behavioral Assessment System for Children-2. Sleep duration, variability in sleep duration, and sleep onset latency were assessed with actigraphy.

RESULTS

Depressive symptoms were associated with variability in sleep duration and shorter sleep onset latency; somatic symptoms were associated with variability in sleep duration. In Latino children, depressive symptoms were associated with shorter sleep onset latency. In AA children, anxiety, depressive, and somatic symptoms were associated with variability in sleep duration; somatic symptoms were related to variability in sleep duration in NLW children. The association between internalizing symptoms and sleep outcomes did not differ by asthma status. However, asthma status was a significant moderator when examining these associations by ethnic group: among AA children, depressive symptoms were significantly related to variability in sleep duration only in children with asthma, whereas in NLW children, somatic symptoms were related to variability in sleep duration only in children without asthma.

CONCLUSIONS

Targeting specific internalizing symptoms and sleep outcomes may be beneficial in the development of interventions tailored for urban children with and without asthma from specific ethnic groups.

Sleep difficulties in children with Tourette syndrome and chronic tic disorders: a systematic review of characteristics and associated factors

Sleep difficulties are common in children and young people with Tourette syndrome and chronic tic disorders (TS/CTD). However, it is unclear whether sleep problems can be considered typical of the TS/CTD phenotype or whether they reflect concomitant factors such as individual patient characteristics (e.g. medication use), underlying neurodevelopmental disorders and/or co-occurring psychiatric symptoms. To help address this question, this review systematically explored types and frequency of sleep problems in children and young people with TS/CTD, while also examining the heterogeneity and methodological quality of studies. Psycinfo, Ovid Medline, Embase, and Web of Science databases were searched using a range of terms relating to tics, sleep and co-occurring psychopathology. Studies were considered that included a sample of children with TS/CTD (n &gt; 5) for whom sleep difficulties were measured. Eighteen studies met criteria for inclusion in the review. Findings supported the high prevalence of sleep difficulties in children with TS/CTD, though estimates of sleep difficulties ranged from 9.7% to 80.4%. Twelve studies reported on other factors affecting sleep in this patient group including tic severity, comorbid psychopathological or neurodevelopmental disorders and medication use. Studies varied in terms of methodology, sample characteristics and research quality, but most concluded that children with TS/CTD experienced high levels of sleep difficulties with children with co-occurring anxiety most at risk. The current review highlights the need for further empirical investigation of sleep in children with TS/CTS, with a view to informing understanding and clinical management.

The association between sleep problems and academic performance in primary school-aged children: Findings from a Norwegian longitudinal population-based study

The purpose of this study was to examine the longitudinal association between concurrent, transitory and persistent difficulties initiating and maintaining sleep (DIMS) on academic performance in children in a. longitudinal child-cohort (N = 3986) targeting school-aged children when they were 7-9 years (T1) and 11-13 years (T2) old, whilst controlling for mental health problems. DIMS were parent-reported at T1 and T2 and academic performance teacher-reported at T2. Mental health was based on child self-report at T2 using the Strength and Difficulties Questionnaire (SDQ). In all, 10.6% (n = 423) of the children had poor school performance at T2. These had more symptoms of externalizing and internalizing mental health problems (p. < 001) compared to their peers at T2. A logistic regression analysis showed that both concurrent DIMS (at T2, but not at T1) and persistent DIMS (at both T1 and T2) was associated with elevated risk of poor academic performance. After controlling for mental health problems, only persistent DIMS was associated with increased risk of poor academic performance. Transitory DIMS (DIMS at T1 but not at T2) did not increase the risk of later poor academic performance. A mediation analysis also revealed that the association between DIMS and poor school performance was mediated by mental health problems, in addition to an overall significant direct relative effect of DIMS on poor school performance in the persistent DIMS group. These findings support the notion that sleep problems in children are associated with impaired academic performance, and extends past findings demonstrating that sleep problems may not increase the risk of poor academic performance unless they persist over time. The negative effects of persistent sleep problems suggest that more emphasis should be put on preventive interventions of sleep problems in school-aged children.

Childhood sleep disturbances and white matter microstructure in preadolescence

BACKGROUND

Sleep problems occur in up to 30% of children and have been associated with adverse developmental outcomes. However, due to a lack of longitudinal neuroimaging studies, the neurobiological changes that may underlie some of these associations have remained unclear. This study explored the association between sleep problems during childhood and white matter (WM) microstructure in preadolescence.

METHODS

Children from the population-based birth cohort, the Generation R Study, who had repeatedly assessed sleep problems between 1.5 and 10 years of age and a MRI scan at age 10 (N = 2,449), were included. Mothers reported on their child's sleep problems using the Child Behavior Checklist (CBCL 1.5-5) when children were 1.5, 3, and 6 years of age. At age 2, mothers completed very similar questions. At age 10, both children and their mothers reported on sleep problems. We used whole-brain and tract-specific fractional anisotropy (FA) and mean diffusivity (MD) values obtained through diffusion tensor imaging as measures of WM microstructure.

RESULTS

Childhood sleep problems at 1.5, 2, and 6 years of age were associated with less WM microstructural integrity (approximately 0.05 SD lower global FA score per 1-SD sleep problems). In repeated-measures analyses, children with more sleep problems (per 1-SD) at baseline had lower FA values at age 10 in particular in the corticospinal tract (-0.12 SD, 95% CI:-0.20;-0.05), the uncinate fasciculus (-0.12 SD, 95% CI:-0.19;-0.05), and the forceps major (-0.11 SD, 95% CI:-0.18;-0.03), although effect estimates across the tracts did not differ substantially.

CONCLUSIONS

Childhood sleep disturbances are associated with less WM microstructural integrity in preadolescence. Our results show that early neurodevelopment may be a period of particular vulnerability to sleep problems. This study cannot demonstrate causality but suggests that preventive interventions addressing sleep problems should be further explored to test whether they impact adverse neurodevelopment.

Childhood Trauma and Stressful Life Events Are Independently Associated with Sleep Disturbances in Adolescents

Adolescence is a critical developmental period associated with an increase in stress, the appearance of anxiety and depressive symptoms, and changes in sleep patterns. Even though the disruption of sleep patterns in stress and anxiety and depressive disorders is well known, the independent effects of childhood trauma and stressful life events on sleep patterns are less understood. We tested the independent effects of stress (childhood trauma and stressful life events) while controlling for anxiety and depression on adolescent sleep patterns. Seven hundred fifty-two adolescents (age 12-15 years) completed self-report questionnaires about childhood trauma, stressful life events, anxiety, and depression. Four sleep factors identifying movement during sleep, sleep regularity, sleep disturbances, and sleep pressure were extracted in the principal component analysis of sleep questions. Both childhood trauma and recent stressful life events were significantly associated with sleep disturbances before and after controlling for anxiety and depression.

Der Zusammenhang zwischen Schlafproblemen, unzureichender Schlafdauer und psychischen Auffälligkeiten bei Kindern und Jugendlichen

Zusammenfassung. Schlafprobleme und eine unzureichende Schlafdauer können die psychische Gesundheit im Kindes- und Jugendalter nachhaltig beeinträchtigen. Daten von 6.670 Jungen und Mädchen im Alter von 11 – 13 und 14 – 17 Jahren, aus dem Kinder- und Jugendgesundheitssurvey (KIGGS), wurden getrennt nach Geschlechtern analysiert, um zu untersuchen, ob Schlafprobleme und eine unzureichende Schlafdauer mit einer höheren Risikowahrscheinlichkeit für psychische Auffälligkeiten einhergehen. Während Schlafprobleme unabhängig von Geschlecht und Alter mit einem höheren Risiko für alle Symptombereiche (OR = 1.52 – 3.49) verbunden sind, findet sich hinsichtlich einer geringen Schlafdauer nur bei Mädchen eine höheres Risikowahrscheinlichkeit für Auffälligkeiten im externalisierenden und internalisierenden Bereich. Damit scheint sich der Zusammenhang zwischen unzureichender Schlafdauer und psychischen Auffälligkeiten bei Jungen und Mädchen zu unterscheiden. Mögliche Ursachen und Implikationen für die pädiatrische und psychiatrische Praxis werden diskutiert.

Sleep Patterns and Anxiety in Children Interact to Predict Later Suicidal Ideation

Elevated levels of childhood anxiety pose risk for suicide; however, factors that accentuate this risk are unknown. Seventy-one children participated in a longitudinal study investigating anxiety and sleep in childhood (between 7-11 years) and later suicidal ideation (SI; M = 3.3 years later). Sleep was assessed via subjective reports and objective measures (actigraphy and polysomnography). Children with greater anxiety symptoms were at greater risk for later SI when sleep disturbances were present in childhood. Results suggest that sleep disruption may amplify SI risk in anxious children.