Patterns of sleep problems and internalizing and externalizing problems among Chinese adolescents: A latent class analysis

The Prevalences of Behavioral Problems in Children and adolescents in Chengdu, Sichuan, China and Associated Risk Factors: A Multi-Center Cross-Sectional Study

This study aimed to investigate the prevalence of behavioral problems in children and adolescents in Chengdu, Sichuan, China and the associated risk factors. A questionnaire survey was conducted with the students and their parents or caregivers from five primary and middle schools to investigate the parent-child relationship, family financial situations, health risk behaviors, and behavioral problems. A total of 8157 questionnaires were distributed, and 7928 (97.19%) valid questionnaires were returned. Among the 7928 valid questionnaires, 3846 were completed by female students and their parents or caregivers, and 4082 were completed by male students and their parents or caregivers. The average age of the surveyed students was 10.62 years. The prevalence rate of behavioral problems in children and adolescents was 13.79%, and the prevalence rate of behavioral problems significantly varied by gender and age. The female students had a higher prevalence rate of behavioral problems than male students (14.6% versus 13.0%). The students aged 12-16 years had a higher prevalence rate of behavioral problems than those aged 6-11 years (16.4% versus 12.2%). A correlation between behavioral problems and weekly pocket money was detected in the children and adolescents. Poor parent-child relationships, excessive screen time for both parents and children, short duration of sleep, and excessive intake of sugar-sweetened beverages could lead to a significant increase to the risk of developing behavioral problems in children and adolescents. Health-risky behaviors in children and adolescents were closely correlated to their behavioral problems. More attention should be paid to encouraging children and adolescents to live healthy lifestyles and tackling their behavioral problems.

The association of chronotype on depression in adolescents: the mediating role of sensation seeking and sleep quality

OBJECTIVES

This study explores the relationships among chronotype, sensation seeking, sleep quality and depressive symptoms in adolescents with diagnosed depression, aiming to clarify the mechanisms by which chronotype is associated with depression.

METHODS

This cross-sectional study assessed 216 adolescents with diagnosed depression using a demographic questionnaire, the Morningness-Eveningness Questionnaire, the Sensation Seeking Scale, the Pittsburgh Sleep Quality Index, and the Beck Depression Inventory. Descriptive and correlational analyses were performed using SPSS 27.0, and structural equation modeling was conducted via AMOS to explore the mediating roles of sensation seeking and sleep quality in the relationship between chronotype and depression.

RESULTS

The study found that 60.6% of adolescents with depression were evening chronotypes. Evening chronotype was associated with higher sensation seeking (r = -0.134, p < 0.05), poorer sleep quality (r = -0.303, p < 0.01), and more severe depressive symptoms (r = -0.376, p < 0.01). Chronotype showed a direct effect on depressive symptoms (effect size = -0.318, 95% CI = -0.602 to -0.049, p < 0.05) and an indirect effect via sleep quality, accounting for 80.5% of the total effect. While sensation seeking alone was not a significant mediator, it contributed to a chain mediation with sleep quality, accounting for 13% of the total effect (combined effect size = -0.053, 95% CI = -0.163 to -0.005, p < 0.01).

CONCLUSIONS

Chronotype may play a significant role in adolescent depression, with both direct and indirect effects mediated by sleep quality and sensation seeking. The findings highlight the potential importance of sleep quality as a mediating factor, indicating that interventions targeting sleep improvement could be a promising avenue for further exploration in alleviating depressive symptoms in adolescents.

Sleep Profiles Among Ethnically-Racially Minoritized Adolescents: Associations with Sociocultural Experiences and Developmental Outcomes

OBJECTIVE

This study used latent profile analyses to (1) identify heterogeneous patterns of sleep profiles; (2) examine how discrimination was related to sleep profiles; and (3) investigate how developmental outcomes varied across sleep profiles among ethnically-racially minoritized adolescents.

METHOD

Participants were 350 ethnically-racially minoritized adolescents (69% female; 22% Black-African American, 41% Asian American, and 37% Latinx; Mage = 14.27 years old, SD = 0.61) completed self-reported presurvey measures of everyday discrimination, ethnic-racial discrimination, and self-reported post-survey measures of depressive symptoms, somatic symptoms, self-esteem, and rumination. Objectively and subjectively measured sleep were assessed utilizing a short-term longitudinal (i.e., two-week) design, where adolescents wore a wrist actigraph and completed daily diaries for 14 consecutive days.

RESULTS

Drawing on multiple objectively and subjectively measured sleep indicators, three profiles were identified: Nighttime Sleeper (76.57%), Disrupted Sleeper (14.29%), and Daytime Sleeper (9.14%). Adolescents experiencing higher levels of ethnic-racial discrimination were more likely to be characterized in the Disrupted Sleeper, relative to the Nighttime Sleeper profile. Compared with Asian and Latinx Americans, Black adolescents were more likely to be in the Daytime Sleeper, relative to the Nighttime Sleeper profile. Those in the Disrupted Sleeper profile exhibited the worst developmental outcomes.

CONCLUSIONS

The findings inform clinical interventions focusing on sleep experiences, especially as they relate to protective processes for coping with discrimination. Clinical efforts (e.g., sleep education or therapy to develop routines for adaptive napping) may be beneficial to facilitating healthy sleep behaviors and mitigating sleep disturbances, which in turn, improve developmental well-being among ethnically-racially minoritized adolescents.

Sleep patterns and smartphone use among left-behind children: a latent class analysis and its association with depressive symptoms

Background

Left-behind children in China face challenges in sleep patterns, technology use, and mental health. This study uses an individual-centered approach to derive behavioral profiles associated with depressive symptoms.

Methods

Data from 131,586 left-behind children aged 8 to 18 years from the Chinese Psychological Health Guard for Children and Adolescents Project were analyzed. Participants were recruited from 569 centers across schools, community institutes, orphanages, and children's hospitals throughout China. Latent class analysis was conducted using weekday and weekend sleep duration and smartphone use as indicators. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D).

Results

Four distinct classes emerged: Sufficient Sleep Low Users (23.6%), Moderate Sleep Medium Users (25.2%), Limited Sleep High Users (22.1%), and Healthy Sleep Low Users (29.2%). Significant differences in CES-D scores were found between classes (F(3, 131579) = 4929, p <.001, η² = 0.101). The Limited Sleep High Users class reported the highest levels of depressive symptoms (M = 11.60, SE = 0.0658), while the Sufficient Sleep Low Users class reported the lowest (M = 3.67, SE = 0.0346). A linear relationship between sleep duration and depressive symptoms was observed. Significant weekday-weekend differences in smartphone use were noted in the unhealthy categories.

Conclusions

This study reveals complex associations between sleep patterns, smartphone use, and depressive symptoms among left-behind children. The identified behavioral profiles provide insights into population heterogeneity and inform targeted intervention strategies. Findings emphasize the importance of addressing both sleep and technology use in mental health initiatives for this vulnerable population.

Prospective associations between heterogeneous sleep profiles and depressive symptoms in adolescents: The mediating role of coping styles

INTRODUCTION

Extant literature has linked sleep disturbance to depressive symptoms. However, the coexistence of naturally occurring sleep profiles among adolescents and the prospective associations between sleep profiles and depressive symptoms remain poorly understood. This study aims to uncover sleep patterns in Chinese adolescents based on a comprehensive set of sleep features (e.g., latency, daytime dysfunction, etc.) derived from the Pittsburg Sleep Quality Index (PSQI) and investigate the relationship between these profiles and subsequent depressive symptoms mediated by positive and negative coping styles.

METHODS

Five thousand five hundred five adolescents from Shandong province, China, enrolled (Mage = 16.83 years; 49.9% girls) in a two-wave longitudinal study (T1 in August 2023; T2 in February 2024). Latent class analysis (LCA) was conducted to identify adolescent sleep patterns. Mediation and sensitivity analyses were used to examine prospective associations between sleep patterns, coping styles, and depressive symptoms.

RESULTS

Four qualitatively distinct sleep profiles emerged: Healthy Sleepers (18.9%), Latency but Functioning Sleepers (13.6%), Efficient but Dysfunctional Sleepers (57.5%), and Medicated Maladaptive Sleepers (10.0%). Using the Healthy Sleepers as a reference group, Latency but Functional Sleepers, Efficient but Dysfunctional Sleepers, and Medicated Maladaptive Sleepers all predicted subsequent depressive symptoms through positive coping styles rather than negative coping styles. The relative indirect effects were 0.19, 0.19, and 0.32, respectively.

CONCLUSIONS

The study underscored that adolescents exhibit distinct sleep patterns, and specific sleep profiles may be prospectively associated with depressive symptoms mediated by positive coping styles.

Heterogeneity in sleep problems and suicide risk among adults with depression: a cross-sectional study

In this paper, we investigated the relationship between different levels of sleep and the risk of suicide among depressive patients. The sample consisted of 301 adults with depression who were recruited from a hospital in Ningxia, China. The Pittsburgh Sleep Quality Index (PSQI) and the Self-Rating Depression Scale (SDS) were applied to evaluate the quality of sleep and the degree of depression. The Suicidal Risk Factor Assessment Form evaluated suicide risk. A Latent Class Analysis (LCA) has been performed with MPLUS 7.0 to investigate the most probable category of the PSQI sub-scales. Multivariate Logistic Regression was applied to analyse the relation between Sleep Quality and Suicide Hazard in Adult Depressive Patients. Classes identified were "Global sleep impairment", "Poor sleep quality", "Short sleep duration" and "Good sleep quality." Patients with poor overall sleep quality and clear daytime dysfunction had a higher risk of suicide than those with good sleep quality. The results are helpful in understanding the relationship between the variability of sleep patterns and the risk of suicide among depressed people, and it is suggested that some sleep variables may have a higher predictive value than others. The results will provide guidance on how to improve and implement therapy for depressive disorders in adults, and to lower suicidal rates.

Sleep patterns in adolescents and associations with substance use

OBJECTIVES

Good sleep during adolescence is crucial for maintaining physical and psychological health; however, sleep disturbance during this period may contribute to health risks, such as substance use. This study aimed to identify the latent sleep patterns across male and female adolescents, and their association with drug use.

METHOD

A cross-sectional study was conducted involving 1391 high school students (aged 15-17; 56.4% female). Participants completed the brief Pittsburgh Sleep Quality Index alongside other sleep measures, and the Timeline Follow-Back and Drug Use History Questionnaire to measure substance use. A multiple-group latent class analysis was used to identify sleep patterns across sexes, and pairwise Logistic Regression models to compare their association with substance use.

RESULTS

Four sleep patterns were identified with varying degrees of sleep difficulties: "Good Sleep" (43.3%), "Night Awakenings" (31.8%), "Poor Efficiency and Sleep Onset" (9.4%), and "Poor Sleep" (15.5%). Female adolescents were more likely to belong to Poor Sleep and Poor Efficiency and Sleep Onset patterns, and male adolescents to Good Sleep. Likewise, binge drinking and using alcohol for a longer period were associated with experiencing Poor Efficiency and Sleep Onset (OR=1.03 and 2.3, respectively); smoking tobacco within the past month was linked to Night Awakenings (OR=2.2); and using cannabis or illegal drugs to the Poor Sleep pattern (OR=2.4 and 2.6, respectively).

CONCLUSIONS

Varied sleep difficulties exist among adolescents that significantly correlate with different aspects of drug use. Targeted interventions that address both sleep and drug prevention are recommended.

Sleep and internalizing problems in primary school children with attention-deficit hyperactivity disorder

BACKGROUND

Internalizing and externalizing problems have received great attention, and children with ADHD exhibit high rates of comorbid internalizing and externalizing disorders. This study aimed to explore the relationship between sleep and internalizing problems in children with attention-deficit hyperactivity disorder (ADHD) and the probable mediating role of externalizing problems.

METHODS

A total of 203 primary school children diagnosed with ADHD for the first time were recruited for this study. Children with ADHD were evaluated by Children's Sleep Habits Questionnaire (CSHQ), Strengths and Difficulties Questionnaire (SDQ). Internalizing problems were represented by emotional symptoms and peer problems of SDQ, and externalizing problems were represented by conduct problems and hyperactivity-inattention problems of SDQ. Multi-step linear regression analysis was used to investigate the mediating effect of externalizing problems on the relationship between sleep and internalizing problems.

RESULTS

Sleep in children with ADHD was associated with emotional problems in internalizing problems, and conduct problems in externalizing problems mediated the association between sleep and emotional problems.

CONCLUSION

For children with ADHD, when it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize and deal with emotional problems.

IMPACT

1. We first explored the possible mediating role of conduct problems between sleep and emotional problems in primary school children with ADHD. 2. When it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize emotional problems for children with ADHD. 3. For children with ADHD with potential internalizing problems, especially emotional problems, interventions for their sleep and externalizing problems may be the possible methods to deal with.

Relationship Between Sleep Problems and Memory Impairment Among Nurses

BACKGROUND

Sleep problems are common among nurses and can lead to various health problems. Further, the relationship between multiple sleep problems and memory impairment in clinical nurses remains unknown. Therefore, in this study, we aimed to explore the relationship between sleep problems and memory impairment among nurses.

METHODS

Multistage cluster-stratified random sampling was performed from tertiary hospitals in Shandong, China. Overall, a total of 1833 nurses were included in the final analysis. The Chinese version of the Pittsburgh Sleep Quality Index and prospective and retrospective memory questionnaire were administered to the participants.

RESULTS

The sleep quality of the nurses decreased during the normal epidemic prevention and control period compared with that before the epidemic in terms of sleep duration, sleep efficiency, and sleep disturbances. Nurses who reported cumulative or specific sleep problems (e.g., high sleep latency, sleep disturbances, and daytime dysfunction) and those in the "daily disturbances" and "poor sleep quality" groups had a higher risk of memory impairment than the others.

CONCLUSION

Sleep problems might be important for memory impairment among nurses. These findings may help identify nurses at considerable risk of memory impairment in clinical practice.

Latent profile of the insomnia severity index: A longitudinal study

STUDY OBJECTIVES

To identify the distinct classification of insomnia symptoms and to explore their association with sleep problems and depression.

METHODS

Latent profile analysis was used to examine patterns of insomnia symptoms in two samples. Discovery and replication samples comprised 1043 (Mean age at baseline = 18.95 ± 0.93 years, 62.2% females) and 729 (Mean age at baseline = 18.71 ± 1.02 years, 66.4% females) college students, respectively. Participants completed measures of sleep problems (insomnia symptoms, sleep quality, susceptibility to insomnia, perceived consequences of insomnia, dream recall frequency, and percentage of recurring nightmares) and other psychological variables (rumination and depression). Binary logistic regression was used to analyze the effects of different types of insomnia symptoms at baseline on sleep problems and depression two years later.

RESULTS

Four classes of insomnia symptoms were identified, and classified as "non-insomnia" (class 1, 45.7%), "mild subjective symptoms but severe subjective feelings" (class 2, 23.9%), "severe subjective symptoms but mild subjective feelings" (class 3, 22.0%), and "high insomnia risk" (class 4, 8.4%), respectively. Compared with the group classified as non-insomnia group, other classifications significantly predicted insomnia two years later, only class 4 significantly predicted depression, and class 3 significantly predicted susceptibility to insomnia, after adjusting gender, insomnia, depression, and susceptibility to insomnia at baseline.

CONCLUSIONS

The findings highlighted the importance of identifying the patterns of insomnia symptoms, and the need for tailored intervention to improve sleep problems. Additionally, when screening for insomnia symptoms, simplified screening using Insomnia Severity Index (ISI) dimensions or items should be considered.

Associations of 24-hour movement behaviors with externalizing and internalizing problems among children and adolescents prescribed with eyeglasses/contact lenses

Background

Emerging evidence points towards the psychological benefits of meeting 24-hour movement behavior (24-HMB) guidelines, but such associations have not yet been investigated among children and adolescents of prescribed eyeglasses/contact lenses. To this end, we examined associations of meeting 24-HMB guidelines with internalizing and externalizing challenges in this population.

Methods

We used data from the 2021 National Survey of Children's Health, a cross-sectional survey including a representative sample of US children and adolescents. Data on movement behaviors (physical activity [PA], sedentary behavior operationalized via screen time [ST], and sleep duration [SL]) and internalizing and externalizing problems were collected through caregiver proxy reports. Caregivers completed questionnaires for 6030 (2799 girls) US children and adolescents of prescribed eyeglasses/contact lenses. Logistic regression analyses were conducted to determine the above-presented associations.

Results

Only 7.1 % of those prescribed eyeglasses/contact lenses met all three 24-HMB guidelines, while they were more likely to meet SL guideline alone (32.1 %) in relation to other independent guidelines including PA (2.5 %) and ST (10.9 %). Compared to not meeting any of the three 24-HMB guidelines, meeting at least two guidelines (25.22 %) was significantly linked to lower odds of internalizing problems and externalizing problems.

Conclusion

Meeting at least two components of the 24-HMB guidelines was beneficially linked to internalizing and externalizing problems. Thus, strategies or intervention programs that focus on meeting 24-HMB guidelines should be implemented among children and adolescents of those prescribed eyeglasses/contact lenses to foster coping with psychological issues.

Latent Profiles of Sleep Patterns in Early Adolescence: Associations With Behavioral Health Risk

PURPOSE

The present study characterized sleep profiles in a national longitudinal sample of early adolescents and examined whether profiles predicted later behavioral problems.

METHODS

Three waves of data (2016-2021) were obtained from the Adolescent Behavior and Cognitive Development study, including 3,326 participants with both weekday and weekend sleep data measured by Fitbit wearables (age range 10.58-13.67 years; 49.3% female). Latent profile analysis was utilized to identify sleep profiles using multiple sleep indicators (duration, latency, efficiency, wake minutes, wake counts, and midpoint). We then explored whether demographic predictors predicted profile membership and tested the latent sleep profiles' predictive utility of internalizing and externalizing symptoms.

RESULTS

Four profiles were identified: average sleep (40.39%), high duration & high wakefulness (28.58%), high efficiency, low duration &low wakefulness (16.86%), and low duration & low efficiency (14.17%). Participants with older age, males, higher body mass index, and advanced pubertal status were more likely to be classified in the low duration & low efficiency profile than the average group. Participants with lower income, minority identification, older age, and higher body mass index were more likely to be classified in the high efficiency, low duration &low wakefulness than the average group. Participants with lower parental education and males were more likely to be in the high sleep duration & high wakefulness than the average group. The low duration & low efficiency group had the highest attention problems, social problems, and rule-breaking behaviors.

DISCUSSION

Our findings highlight unique sleep patterns in early adolescence and their prospective links with internalizing and externalizing problems.

The relationship between alexithymia, emotion regulation, and sleep problems in school-aged children: A multicentric study

OBJECTIVES

Alexithymia, mood dysregulation, and sleep quality have complicated effects on children's development. The current study aimed to investigate the relationship between alexithymia, emotion regulation, psychiatric problems, and sleep problems among Egyptian school-aged children.

METHODS

A total of 564 Egyptian children, aged 6 to 14, were divided into two groups based on their total Children's Sleep Habits Questionnaire abbreviated score: group 1 (N = 300) with sleep problems and group 2 (N = 264) with non-sleep problems. Their parents completed the Strengths and Difficulties Questionnaire (SDQ) and subjectively assessed the children's emotions using the Children's Alexithymia Measure (CAM) and the Clinical Evaluation of Emotional Regulation-9 (CEER-9).

RESULTS

Males were more proportional in the sleep problems group than others. The sleep problem group was significantly younger and had a longer daily sleep duration than the non-sleep problem group. Alexithymia and emotion dysregulation had the highest mean in the sleep problem group. Furthermore, alexithymia, emotion dysregulation, emotion difficulty, conduct, and prosocial problems were the most significant contributing factors and risk factors for sleep problems in children.

CONCLUSION

Sleep problems in children were associated with younger male children with lengthy daily sleep duration and emotional, behavioural, and prosocial difficulties. Furthermore, alexithymia and emotion dysregulation are significant contributors and risk factors for sleep problems in school-aged children.

Sleep problems in adolescents with depression: Role of childhood trauma, alexithymia, rumination, and self-esteem

BACKGROUND

While sleep problems are common in adolescents with depression, the exact prevalence has not been reported. Although previous studies have shown that childhood trauma, alexithymia, rumination, and self-esteem are related to sleep problems, the interactions between these factors remain unclear.

METHODS

This study, conducted from March 1, 2021 to January 20, 2022, employed a cross-sectional design. The participants were 2192 adolescents with depression with a mean age of 15 years. The Chinese version of the Pittsburgh Sleep Quality Index, Childhood Trauma Questionnaire, Toronto Alexithymia Scale-20, Ruminative Response Scale, and Rosenberg Self-Esteem Scale were used to measure sleep problems, childhood trauma, alexithymia, rumination, and self-esteem, respectively. We used PROCESS 3.3 for SPSS to determine the chain mediating effect of alexithymia and rumination and the moderating effect of self-esteem in the relationship between childhood trauma and sleep problems.

RESULTS

Up to 70.71 % of adolescents with depression had sleep problems. Furthermore, alexithymia and rumination played a chain mediation role in the relationship between childhood trauma and sleep problems. Finally, self-esteem moderated the relationships between alexithymia and sleep problems and rumination and sleep problems.

LIMITATIONS

Owing to the study design, we cannot derive causal relationships between variables. Further, the self-reported data may have been influenced by subjective participant factors.

CONCLUSIONS

This study reveals potential ways of how childhood trauma influences sleep problems in adolescents with depression. These findings suggest that interventions targeting alexithymia, rumination, and self-esteem in adolescents with depression may be effective in reducing their sleep problems.

Sleep and behavioral problems in Down syndrome: differences between school age and adolescence

Background

Individuals with Down syndrome (DS) are at risk of developing sleep problems. In spite of the well-established knowledge on the presence of sleep difficulties in DS individuals and the associated emotional and behavioral problems, less is known about the possible differences in the kind of associations between sleep and emotional/behavioral problems across different age ranges.

Methods

In this retrospective study, we included 289 participants with DS aged 6-18 years with the aims to explore differences in the distribution of sleep problems between specific age groups (school age vs. adolescence) and to identify specific age-based associations between sleep problems and emotional/behavioral problems.

Results

Some differences in the distribution of sleep problems have emerged between age groups. Moreover, differences in the patterns of association between emotional/behavioral difficulties and sleep problems-in particular, sleep-related breathing difficulties and parasomnias-have been observed. However, sleep-wake transition disorders and excessive daily somnolence appear to be related to emotional and behavioral problems (both internalizing and externalizing), in general, across school age and adolescence.

Discussion

These results remark the importance of appropriate neuropsychiatric and psychological evaluation taking into account the age-specific needs and features of individuals with DS.