Sleep problems, internalizing and externalizing symptoms, and domains of health-related quality of life: bidirectional associations from early childhood to early adolescence

The relationship between sleep difficulties and externalizing and internalizing problems in children and adolescents with mental illness

Sleep difficulties are presumably a transdiagnostic factor in the complex aetiology of psychiatric disorders in youth. This study assessed the prevalence of sleep difficulties in children and adolescents seeking specialized psychiatric care, examined the relationships of internalizing and externalizing problems, and considered the moderating role of sex and age on these relationships. Parent-reported data on difficulties initiating sleep, difficulties maintaining sleep, early morning awakenings and daytime fatigue from a large sample of children and adolescents referred for specialized psychiatric care (n = 4638; < 18 years) were used to estimate prevalence rates. To examine associations between these sleep difficulties and internalizing/externalizing problems, multiple linear regression analyses were conducted on available data (n = 3768) stratified in three age groups (1.5-5 years; 6-11 years; 12-18 years). Overall prevalence, i.e. at least one sleep difficulty was reported to be often or always present, was 65%. Difficulties initiating sleep occurred the most, closely followed by daytime fatigue. In all age groups, sleep difficulties were positively related to internalizing and externalizing problems. In young children and school-age children, age moderated the interaction between sleep difficulties and internalizing problems. To conclude, prevalence rates of sleep difficulties in children with mental illness appear higher than it has been reported in the general youth population, especially difficulties initiating sleep and daytime fatigue. We observed that the associations between internalizing problems and sleep difficulties in young children and school-age children seemed to be amplified with age, suggesting a negative, bidirectional, spiral in development.

Effects of Stepped Cognitive Behavioral Therapy on Child Depressive and Externalizing Symptoms in Autistic Children With Anxiety

Despite the strong evidence basis for the treatment of anxiety in autistic youth, accessibility remains a significant challenge. Stepped care addresses this gap, although there is limited research into its broad effects in autistic youth with anxiety. In this project, 76 autistic youth with anxiety entered parent-led-bibliotherapy for 12 weeks; 44 stepped up to receive therapist-led cognitive behavioral therapy (CBT). Those who did not step up entered a maintenance phase. Youth were assessed for externalizing and depressive symptoms at mid-treatment, post-treatment, and 3 months after treatment (3MFU). Focal symptoms decreased across groups at all timepoints; those who entered maintenance experienced greater decreases. At 3MFU there were no differences between groups. Parents were assessed for depression, anxiety, and stress at the same timepoints; no significant changes were observed.

Relationship between screen use and internalizing/externalizing problems among preschoolers: the mediation of circadian rhythm

BACKGROUND

Circadian disruption has been proposed as an etiological mechanism for psychopathology, yet its role in the relationship between screen use and emotional and behavioral problems remains under-investigated. This study aimed to examine the mediating effect of circadian rhythm in this relationship among young children.

METHODS

This cross-sectional study analyzed data from 1111 children aged 2 to 7 years recruited from six kindergartens between March 2022 and June 2024. Parents reported children's screen time and use before sleep. Parents and teachers assessed internalizing and externalizing problems using the Strengths and Difficulties Questionnaire. Circadian rhythm, including chronotype and midsleep on free days corrected for sleep debt (MSFsc), was measured using the Children's ChronoType Questionnaire. In a subsample, MSFsc was also measured using actigraphy and sleep diaries.

RESULTS

Screen use was significantly associated with parent-reported internalizing and externalizing problems. Chronotype significantly mediated the relationships between screen use and parent-reported outcomes, whereas the results were not reproducible using MSFsc derived from survey, actigraphy and sleep diaries.

CONCLUSION

The mediation of delayed circadian phase in the relationship between screen use and internalizing and externalizing problems in young children may be negligible. Future research should explore the role of other circadian parameters in this relationship.

IMPACT STATEMENT

Circadian disruption has been suggested as a potential mechanism linking screen-based media exposure to psychopathology. Using a triangulation approach that combined multiple data sources-survey, actigraphy, and sleep diaries-we found that the mediating effects of delayed circadian phase in the relationships between screen use and internalizing and externalizing problems were minimal in children aged 2 to 7 years. Future research should explore alternative circadian pathways and examine the long-term developmental effects of screen use during early childhood.

Assessment of Multiple Dimensions of Psychological Well-Being in Swiss Youth Born with a Unilateral Cleft Lip and Palate

ObjectiveThis study examines the psychological well-being of Swiss youths born with a unilateral cleft lip and palate (UCLP), in a multi-dimensional and clinical perspective.DesignRetrospective cross-sectional study.SettingSelf-report questionnaires completed by youths born with UCLP, followed at a specialized cleft clinic in Switzerland, and by peers without UCLP, recruited in schools of the Vaud county, Switzerland.ParticipantsYouths aged 7.5 to 16, born with UCLP (clinical group, n = 41, 29.2% female) or without UCLP (control group, n = 56, 49.0% female).Outcome measuresAdverse life events (ALE; Adverse Life Events), behavioral and emotional symptoms (Strengths and Difficulties Questionnaire and Post-Traumatic Checklist Scale), bodily self-esteem (Body Esteem Scale), quality of life (Kidscreen-27), emotion regulation (Cognitive Emotion Regulation Questionnaire), social support (Sarason's Social Support Questionnaire).ResultsMost outcomes showed no significant group-difference. Compared to matched peers, youths with UCLP reported lower psychological quality of life and social support satisfaction, along with positive factors of fewer ALE and lower non-adaptive emotion regulation. In youths with UCLP, higher scores for ALE were associated with higher total scores for behavioral and emotional symptoms. Higher scores for bodily self-esteem were associated with higher scores for satisfaction of social support and adaptive emotion regulation.ConclusionsYouths with UCLP show globally similar psychological well-being as matched peers. We observed some vulnerabilities but also protective factors, which support the need for psychological perspective within multidisciplinary care. The relationships between dimensions suggest specific targets that may have an impact in context of intervention.

Sleep problems and chronic conditions in single parents in Ghana: Serial mediating roles of health-related quality of life and functional limitations

OBJECTIVES

Data on the association between sleep problems and chronic conditions among single parents in low- and middle-income countries (LMICs) are limited, and no study has, to date, reported the serial mediation effects of functional limitations and poor health-related quality of life (HRQoL) in this association. This study examines the extent to which functional limitations and poor HRQoL serially explain the link between sleep problems and chronic conditions among single parents in Ghana.

METHODS

Data on 627 single mothers and fathers were obtained through a multi-stage stratified sampling technique. Sleep duration, nocturnal sleep problems, and daytime sleep problems were used to assess sleep problems. The EQ-5D-3L questionnaire was used to measure HRQoL. Multivariable OLS models and bootstrapping serial mediation analyses were performed to evaluate the hypothesized associations.

RESULTS

The mean age (SD) was 45.0 (14.66) years; 67.3% females. After full adjustment, sleep problems were significantly associated with increases in chronic conditions (β = .238, 95%CI = .100-.377), poor HRQoL (β = .604, 95%CI = .450-.757), and functional limitations (β = .234, 95%CI = .159-.307). Chronic conditions were positively influenced by poor HRQoL (β = .352, 95%CI = .284-.421) and functional limitations (β = .272, 95%CI = .112-.433). Sleep problems were indirectly related to chronic conditions via poor HRQoL (β = .213, BootSE = .039, 95%CI = .143-.295), functional limitations (β = .063, BootSE = .029, 95%CI = .013-.130) and functional limitations → HRQoL (β = .099, BootSE = .025, 95%CI = .054-.152), mediating 34.70%, 10.31% and 16.15% of the total effect, respectively.

CONCLUSIONS

Sleep problems and poor HRQoL were positively associated with chronic conditions. Functional limitations and poor HRQoL partially and serially explained this association. Efforts to address chronic conditions among single parents should consider interventions for sleep problems and physiological health outcomes, particularly in LMICs.

Emotion dysregulation mediates the relationship between sleep problems and externalizing symptoms in early adolescents: A four-wave longitudinal study

BACKGROUND

Despite the growing body of longitudinal research linking sleep problems and externalizing symptoms, regarding the direction of the effects of both variables, the results have been inconsistent. Given the mixed findings and inconsistent results in the literature, we propose that emotion dysregulation may link sleep problems and externalizing symptoms.

METHODS

The participants (N = 1281, 49.65 % female; M = 12.73 years at time 1, SD = 0.68) were middle school students who completed assessments for sleep problems, externalizing symptoms, and emotion dysregulation. The interval between each wave was six months, for two consecutive years. Autoregressive mediation models using longitudinal data and cross-sectional mediation models using baseline data were evaluated and compared through structural equation modeling.

RESULTS

The results revealed that severe sleep problems (at T1, T2, or T3) were associated with higher levels of externalizing symptoms later in adolescence (at T2, T3, or T4), but not vice versa. In addition, analyses of indirect effects indicated that emotion dysregulation mediated this link, such that greater sleep problems led to more emotion dysregulation, which, in turn, led to more externalizing symptoms.

CONCLUSION

The findings highlight the critical role that emotional regulation plays in the link between sleep problems and externalizing symptoms and emphasize the need for students as well as middle school administration to pay close attention to both the sleep and externalizing symptoms of early adolescents.

Trajectories of sleep problems and the longitudinal associations with mental health difficulties among Chinese adolescents

OBJECTIVE

Growing research highlights the negative impact of sleep problems on adolescent mental health. However, the developmental trajectory of sleep problems during adolescence and their relationship with mental health difficulties, including both internalizing and externalizing symptoms, remain unclear. Additionally, the direction of the effects between sleep problems and mental health difficulties is not well established. This study aims to identify the developmental trajectories of sleep problems and examine their association with mental health difficulties in both internalizing and externalizing domains.

METHOD

The study involved 1,281 Chinese middle school students (645 males, mean age at initial assessment = 12.73, SD = 0.68). Data were collected at four time points (T1, T2, T3, T4) over approximately 6-month intervals, spanning from the first semester of seventh grade to the second semester of 8th grade.

RESULTS

Latent growth modeling revealed an overall increasing trend in sleep problems. Parallel latent growth modeling indicated that trajectories of sleep problems were positively related to the developmental trends of mental health difficulties, as shown by intercept-intercept and slope-slope associations. The cross-lagged panel model demonstrated significant bidirectional associations between sleep problems and internalizing symptoms. In contrast, we observed unidirectional associations between sleep problems and externalizing symptoms. Hence, sleep problems were a significant predictor of subsequent externalizing symptoms, with no significant reverse effect observed.

CONCLUSION

These findings suggest that future research should explore whether interventions targeting sleep problems can reduce the incidence of both internalizing and externalizing symptoms. Additionally, interventions aimed at internalizing symptoms may potentially improve adolescent sleep, while those targeting externalizing symptoms may not have the same effect.

Sleep insufficiency and bedtime irregularity in children with ADHD: A population-based analysis

BACKGROUND

Sleep is impaired in children with attention-deficit/hyperactivity disorder (ADHD). However, population-based examination of indicators of sleep insufficiency and bedtime irregularity is limited. This investigation examined associations between ADHD, weeknight sleep insufficiency, and bedtime irregularity in a nationally-representative child sample, and indicators of these sleep outcomes in ADHD.

METHODS

Parents of children aged 3-17 years with ADHD (n = 7671) were surveyed through the 2020-2021 National Survey of Children's Health. Inverse probability of treatment weighting generated a weighted matched control sample (n = 51,572). Weighted generalized linear models were performed without and with age-stratification to examine associations between ADHD and sleep, adjusting for sociodemographics in the full sample, and between nineteen sociodemographic and clinical variables and sleep in ADHD.

RESULTS

Having ADHD was associated with increased odds of sleep insufficiency and bedtime irregularity relative to controls, even after adjusting for sociodemographic variables. In ADHD, older age was associated with lower sleep insufficiency and greater bedtime irregularity. Black race, increased poverty, higher ADHD severity, depression, and increased screen time were associated with greater sleep insufficiency and bedtime irregularity. Adverse childhood experiences (ACEs) were associated with greater sleep insufficiency. Behavioral/conduct problems, female sex, and absence of both ADHD medication use and ASD diagnosis were associated with poorer bedtime irregularity. Age-stratified results are reported in text.

CONCLUSIONS

Children with ADHD face heightened risk for insufficient sleep and irregular bedtimes. Findings suggest intervention targets (e.g., Black race, poverty, depression, screen time) to improve both sleep insufficiency and bedtime irregularity. Results highlight ACEs and behavioral/conduct problems as targets to improve sleep insufficiency and bedtime regularity, respectively. Age-stratified findings are discussed.

Trajectories of actigraphy-derived sleep duration, quality, and variability from childhood to adolescence: downstream effects on mental health

STUDY OBJECTIVES

We examined growth trajectories of four actigraphy-derived sleep parameters (sleep minutes, sleep efficiency, and variability in sleep minutes and efficiency across a week of assessments) across childhood and adolescence and examined individual differences in trajectories according to participants' race/ethnicity and sex. We also assessed the predictive effect of growth trajectories of sleep parameters on growth trajectories of mental health outcomes and moderation by race and sex.

METHOD

Youth (N = 199, 49% female, 65% white, 32% black, 3% biracial) and their parents participated in five waves of data (M ages were 9, 10, 11, 17, and 18 across waves). Participants were from a diverse range of socioeconomic backgrounds.

RESULTS

Across participants, sleep minutes, sleep efficiency, and variability in sleep minutes and efficiency demonstrated significant linear change across childhood and adolescence. Whereas sleep duration shortened over time, sleep efficiency improved. Youth exhibited increases in night-to-night variability in sleep minutes and reductions in night-to-night variability in sleep efficiency. Highlighting the importance of individual differences, some race- and sex-related effects emerged. Black youth and male youth experienced steeper declines in their sleep duration across development relative to their respective counterparts. Black youth also demonstrated smaller improvements in sleep efficiency and greater variability in sleep efficiency compared to white youth. Finally, trajectories of sleep efficiency and variability in sleep minutes predicted trajectories of internalizing symptoms and externalizing behaviors.

CONCLUSIONS

Findings showed significant changes in developmental trajectories of four sleep parameters across childhood and adolescence. We discuss the empirical and translational implications of the findings.

Data-driven, generalizable prediction of adolescent sleep disturbances in the multisite Adolescent Brain Cognitive Development Study

STUDY OBJECTIVES

Sleep disturbances are common in adolescence and associated with a host of negative outcomes. Here, we assess associations between multifaceted sleep disturbances and a broad set of psychological, cognitive, and demographic variables using a data-driven approach, canonical correlation analysis (CCA).

METHODS

Baseline data from 9093 participants from the Adolescent Brain Cognitive Development (ABCD) Study were examined using CCA, a multivariate statistical approach that identifies many-to-many associations between two sets of variables by finding combinations for each set of variables that maximize their correlation. We combined CCA with leave-one-site-out cross-validation across ABCD sites to examine the robustness of results and generalizability to new participants. The statistical significance of canonical correlations was determined by non-parametric permutation tests that accounted for twin, family, and site structure. To assess the stability of the associations identified at baseline, CCA was repeated using 2-year follow-up data from 4247 ABCD Study participants.

RESULTS

Two significant sets of associations were identified: (1) difficulty initiating and maintaining sleep and excessive daytime somnolence were strongly linked to nearly all domains of psychopathology (r2 = 0.36, p < .0001); (2) sleep breathing disorders were linked to BMI and African American/black race (r2 = 0.08, p < .0001). These associations generalized to unseen participants at all 22 ABCD sites and were replicated using 2-year follow-up data.

CONCLUSIONS

These findings underscore interwoven links between sleep disturbances in early adolescence and psychological, social, and demographic factors.

The meditating role of sleep in the longitudinal associations between peer victimization and internalizing symptoms: A cross-lagged panel analysis

Adolescence is a time of heightened vulnerability for both peer victimization (PV) and internalizing symptoms. While the positive association between them is well established, there is little understanding of the mechanisms underpinning this relationship. To address this gap, the current study aimed to investigate sleep hygiene and school night sleep duration as individual and sequential mediators of the relationship between PV and both depressive and social anxiety symptoms during pre- to mid-adolescence. The study drew upon a community sample of 528 Australian youth aged 10-12 years at baseline (M age = 11.19, SD = .55; 51.1% boys) and data were collected over five annual measurement occasions. Direct and indirect longitudinal and bidirectional associations were examined using cross-lagged panel analysis. There was no evidence of sequential mediation through both sleep hygiene and sleep duration to depression and social anxiety. Instead, the findings show that sleep hygiene mediated the prospective association between PV and both depressive and social anxiety symptoms, and between PV and sleep duration. Overall, sleep hygiene represents a modifiable transdiagnostic factor that can be targeted to break the cycle of PV, inadequate sleep, and internalizing symptoms.

Predictors of health-related quality of life for children with neurodevelopmental conditions

Neurodevelopmental conditions can be associated with decreased health-related quality of life; however, the predictors of these outcomes remain largely unknown. We characterized the predictors of health-related quality of life (HRQoL) in a sample of neurodiverse children and youth. We used a cross-sectional subsample from the Province of Ontario Neurodevelopmental Disorders Network (POND) consisting of those children and young people in the POND dataset with complete study data (total n = 615; 31% female; age: 11.28 years ± 2.84 years). Using a structural equation model, we investigated the effects of demographics (age, sex, socioeconomic status), core features (Social Communication Questionnaire, Toronto Obsessive Compulsive Scale, Strengths and Weaknesses of attention deficit/hyperactivity disorder (ADHD)-symptoms and Normal Behavior), co-occurring symptoms (Child Behaviour Checklist), and adaptive functioning (Adaptive Behaviour Assessment System) on HRQoL (KINDL). A total of 615 participants had complete data for this study (autism = 135, ADHD = 273, subthreshold ADHD = 7, obsessive-compulsive disorder (OCD) = 38, sub-threshold OCD = 1, neurotypical = 161). Of these participants, 190 (31%) identified as female, and 425 (69%) identified as male. The mean age was 11.28 years ± 2.84 years. Health-related quality of life was negatively associated with co-occurring symptoms (B = - 0.6, SE = 0.20, CI (- 0.95, - 0.19), p = 0.004)) and age (B = - 0.1, SE = 0.04, CI (- 0.19, - 0.01), p = 0.037). Fewer co-occurring symptoms were associated with higher socioeconomic status (B = - 0.5, SE = - 0.05, CI (- 0.58, - 0.37), p < 0.001). This study used a cross-sectional design. Given that one's experiences, needs, supports, and environment and thus HrQoL may change significantly over the lifespan and a longitudinal analysis of predictors is needed to capture these changes. Future studies with more diverse participant groups are needed. These results demonstrate the importance of behavioural and sociodemographic characteristics on health-related quality of life across neurodevelopmental conditions.

Sexual dimorphism in cortical theta rhythms relates to elevated internalizing symptoms during adolescence

Psychiatric disorders frequently emerge during adolescence, with girls at nearly twice the risk compared to boys. These sex differences have been linked to structural brain differences in association regions, which undergo profound development during childhood and adolescence. However, the relationship between functional activity in these cortical regions and the emergence of psychiatric disorders more broadly remains poorly understood. Herein, we investigated whether differences in internalizing and externalizing symptoms among youth are related to multispectral spontaneous neural activity. Spontaneous cortical activity was recorded using magnetoencephalography (MEG) in 105 typically-developing youth (9-15 years-old; 54 female) during eyes-closed rest. The strength of spontaneous neural activity within canonical frequency bands was estimated at each cortical vertex. The resulting functional maps were submitted to vertex-wise regressions to identify spatially specific effects whereby sex moderated the relationship between externalizing and internalizing symptoms, age, and spontaneous neural activity. The interaction between sex, age, and internalizing symptoms was significant in the theta frequency band, wherein theta activity was weaker for older relative to younger girls (but not boys) with greater internalizing symptoms. This relationship was strongest in the temporoparietal junction, with areas of the cingulate cortex exhibiting a similar relationship. The moderating role of sex in the relationship between age, internalizing symptoms, and spontaneous theta activity predominantly implicated association cortices. The negative relationship between theta and internalizing symptoms may reflect negative rumination with anxiety and depression. The specificity of this effect to older girls may reflect the selective emergence of psychiatric symptoms during adolescence in this subgroup.

Daily Associations Between Sleep and Affect in Youth at Risk for Psychopathology: The Moderating Role of Externalizing Symptoms

Problems with sleep, emotion regulation, and externalizing psychopathology are interrelated, but little is known about their day-to-day associations in youth. We examined self-reported daily sleep quality as a bidirectional predictor of next-day positive and negative affect (PA/NA), with externalizing symptoms as a moderator. Data were drawn from an ecological momentary assessment (EMA) study involving 82 youths (ages 9-13; 50% female; 44% White, 37% Black/African American) at high (n = 41) or low (n = 41) familial risk for psychopathology. Parents rated youths' externalizing symptoms at baseline. Youths then completed a 9-day EMA protocol, reporting sleep quality 1x/day and affect 4-8x/day. Daily means, peaks, and variability in PA and NA were computed. Multilevel models examined bidirectional associations between sleep and affect (between- and within-person), testing externalizing symptoms as a moderator and controlling for age and sex. In models of sleep predicting affect: Within-person, poorer-than-usual sleep quality predicted greater variability and higher peaks in next-day NA, but only for youth with higher levels of externalizing symptoms. Between-person, poor sleep quality and higher levels of externalizing symptoms predicted lower mean and peak PA. In models of affect predicting sleep: Within-person, lower-than-usual mean PA predicted poorer subsequent sleep quality, but only for youth with higher levels of externalizing symptoms. Between-person, youths with higher mean and peak PA had better sleep quality. These findings suggest that affective functioning is bidirectionally linked to daily self-reported sleep quality among high- and low-risk youth. Specific disturbances in daily sleep-affect cycles may be distinctly associated with externalizing psychopathology.

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.

A meta-analysis of longitudinal studies on the interplay between sleep, mental health, and positive well-being in adolescents

Objective

This review aimed to summarize longitudinal research about the interplay between sleep, mental health, and positive well-being in adolescents.

Method

Multiple search strategies were applied until 28th January 2023 to identify relevant research published in peer-reviewed journal articles or available grey literature. A final set of 63 studies were included in the systematic review and 42 in the meta-analysis.

Results

Results highlighted that long sleep duration, good sleep quality, and low insomnia symptoms were bidirectionally related to lower internalizing (Sleep T1 → Internalizing symptoms T2: r = -.20, p < .001; Internalizing symptoms T1 → Sleep T2: r = -.21, p < .001) and externalizing (Sleep T1 → Externalizing symptoms T2: r = -.15, p < .001; Externalizing symptoms T1→ Sleep T2: r = -.17, p < .001) symptoms, and to higher levels of psychological well-being (Sleep T1 → Psychological well-being T2: r = .15, p < .001; Psychological well-being T1 → Sleep T2: r = .15, p < .05). Moreover, good sleep was positively related to higher subjective well-being at a later time point (r = .18, p < .001).

Conclusions

Overall, these findings suggest a bidirectional relation between different aspects of sleep, mental health, and positive well-being.

Children's Sleep and Externalizing Problems: A Day-to-day Multilevel Modeling Approach

BACKGROUND

Sleep problems and externalizing problems tend to be positively associated, but the direction of this association is unclear.

METHOD

Day-to-day associations between sleep and behavior were examined in children (N = 22) ages 3-8 with clinical levels of externalizing problems. These children were enrolled in Parent Management Training and behavioral sleep intervention. During assessments before and after treatment, children wore actigraphs for seven days and parents concurrently completed sleep diaries and daily tallies of noncompliance, aggression, and tantrums. Multilevel modeling was used to account for the nested structure of the data, at the day-to-day level (level 1), within assessment points (level 2), and within children (level 3).

RESULTS

Late sleep timing and fragmentation were predictive of next-day noncompliance and tantrums, respectively. There were fewer associations for a given day's behavior predicting that night's sleep, although children who showed more aggression and noncompliance at baseline tended to have later bedtimes and sleep onset times compared to other children.

Sleep and psychiatric symptoms in young child psychiatric outpatients - a Follow-up study

BACKGROUND

Knowledge of the continuity of sleep problems and the associations between sleep and psychiatric symptoms in child psychiatric patients is scarce.

OBJECTIVES

To investigate the persistency of sleep problems and how sleep at preschool age predicts sleep problems and psychiatric symptoms at school age in child psychiatric patients.

METHODS

Participants (n = 68) were child psychiatry outpatients at Helsinki University Hospital in 2015-2017. Caregivers evaluated sleep with the Sleep Disturbance Scale for Children (SDSC) and psychiatric symptoms with the Child Behavior Checklist (CBCL) at baseline (age 4-7 years) and again at follow-up (age 8-13 years). Family background information was collected at both time points.

RESULTS

Sleep problems at preschool age predicted sleep problems at school age (R2Adjusted = .48, p < .001). Persistent sleep problems associated strongly with the intensity of psychiatric symptoms (p = .001). Internalizing symptoms were predicted by sleep problems (p = .038) even after controlling for age, sex, and psychiatric symptoms at preschool age.

CONCLUSION

Sleep problems are prevalent and persistent and relate to psychiatric symptoms in children treated at child psychiatry clinics. These results emphasize the need for identification and treatment of sleep problems in these children.

How Self-Regulation and Executive Functions Deficits Affect Quality of Life of Children/Adolescents with Emotional Regulation Disorders

BACKGROUND

Deficits in self-regulation and executive functions (EFs) frequently characterize children/adolescents with emotional regulation disorders and restrict their daily function and quality of life (QOL). These deficits are mainly manifested by neuropsychological measures in laboratory settings. This study aimed to compare self-regulation and EFs by ecological measures to reflect the implications in daily life between children with emotional regulation disorders and healthy controls and examine the relations between self-regulation, EFs and QOL in the study group.

METHODS

the participants were 49 children aged 8-18: 25 children/adolescents with emotional regulation disorders and 24 healthy children. The parents completed a socio-demographic questionnaire, the Child Behavior Checklist (CBCL), the Behavior Rating Inventory of Executive Functions (BRIEF) and the Pediatric Quality of Life Inventory (Peds-QL).

RESULTS

The study group had greater self-regulation difficulties (internalization and externalization problems), executive dysfunctions (EFdys) (including metacognition difficulties) and a lower QOL. Their internalization and externalization problems correlated with reduced EFs and QOL. Internalization predicted the physical and emotional QOLs, while metacognition predicted social and school-related QOLs.

CONCLUSIONS

Deficits in self-regulation and EFs are prevalent in children/adolescents with emotional disorders and restrict their daily function and QOL. Therefore, they should be routinely evaluated by ecological instruments to reflect daily restrictions.

Patient-Reported Outcomes Over 24 Months in Pediatric CKD: Findings From the MyKidneyHealth Cohort Study

RATIONALE & OBJECTIVE

The lived experience of children with chronic kidney disease (CKD) is poorly characterized. We examined the associations between patient-reported outcome (PRO) scores measuring their fatigue, sleep health, psychological distress, family relationships, and global health with clinical outcomes over time in children, adolescents, and younger adults with CKD and investigated how the PRO scores of this group compare with those of other children, adolescents, and younger adults.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

212 children, adolescentss, and adults aged 8 to 21 years with CKD and their parents recruited from 16 nephrology programs across North America.

PREDICTORS

CKD stage, disease etiology, and sociodemographic and clinical variables.

OUTCOME

PRO scores over 2 years.

ANALYTICAL APPROACH

We compared PRO scores in the CKD sample with a nationally representative general pediatric population (ages 8 to 17 years). Change of PROs over time and association of sociodemographic and clinical variables with PROs were assessed using multivariable regression models.

RESULTS

For all time points, 84% of the parents and 77% of the children, adolescents, and younger adults completed PRO surveys . The baseline PRO scores for the participants with CKD revealed a higher burden of fatigue, sleep-related impairment, psychological distress, impaired global health, and poorer family relationships compared with the general pediatric population, with median score differences≥1 SD for fatigue and global health. The baseline PRO scores did not differ by CKD stage or glomerular versus nonglomerular etiology. Over 2 years, PROs were stable with a<1-point annual change on average on each measure and intraclass correlation coefficients ranging from 0.53 to 0.79, indicating high stability. Hospitalization and parent-reported sleep problems were associated with worse fatigue, psychological health, and global health scores (all P<0.04).

LIMITATIONS

We were unable to assess responsiveness to change with dialysis or transplant.

CONCLUSIONS

Children with CKD experience a high yet stable burden of impairment across numerous PRO measures, especially fatigue and global health, independent of disease severity. These findings underscore the importance of assessing PROs, including fatigue and sleep measures, in this vulnerable population.

PLAIN-LANGUAGE SUMMARY

Children with chronic kidney disease (CKD) have many treatment demands and experience many systemic effects. How CKD impacts the daily life of a child is poorly understood. We surveyed 212 children, adolescents, and younger adults with CKD and their parents over 24 months to assess the participants' well-being over time. Among children, adolescents, and younger adults with CKD we found a very high and persistent burden of psychological distress that did not differ by degree of CKD or type of kidney disease. The participants with CKD endorsed greater impairment in fatigue and global health compared with healthy children, adolescents, and younger adults, and parent-reported sleep problems were associated with poorer patient-reported outcome (PRO) scores across all domains. These findings emphasize the importance of including PRO measures, including fatigue and sleep measures, into routine clinical care to optimize the lived experience of children with CKD.

Associations of Changes in Sleep and Emotional and Behavioral Problems From Late Childhood to Early Adolescence

Importance

Sleep problems and psychopathology symptoms are highly comorbid and bidirectionally correlated across childhood and adolescence. Whether these associations are specific to discrete profiles of sleep problems and specific internalizing and externalizing phenomena is currently unclear.

Objective

To characterize individual changes in profiles of sleep problems and their prospective associations with psychopathology symptoms across the transition from childhood to adolescence.

Design, Setting, and Participants

This observational cohort study used baseline data (participant age of 9 to 11 years) and 2-year follow-up data (participant age of 11 to 13 years) from the community-setting, multicenter Adolescent Brain Cognitive Development (ABCD) study. Individuals were assessed for a range of sleep problems at both waves and categorized into profiles via latent profile analysis. The stability and change in these profiles over time was assessed via latent transition analysis. Logistic regression models examined whether psychopathology symptoms were cross-sectionally associated with profile membership and whether transitions between profiles were associated with changes psychopathology symptoms over time. Data were collected from September 2016 to January 2020, and data were analyzed from August 2021 to July 2022.

Exposures

Sleep problems were assessed at both baseline and follow-up via the parent-reported Sleep Disturbance Scale for Children (SDSC).

Main Outcomes and Measures

Psychopathology symptoms at both baseline and follow-up were assessed using the internalizing and externalizing dimension scores derived from the parent-reported Child Behavior Checklist.

Results

A total of 10 313 individuals (4913 [47.6%] were female) were categorized into 4 latent profiles of sleep problems at both baseline and follow-up: a low disturbance profile, a sleep onset/maintenance problems profile, a moderate and nonspecific disturbance profile (termed mixed disturbance), and a high disturbance profile. Individuals in the 3 more severe problem profiles displayed greater risk of concurrent internalizing symptoms (sleep onset/maintenance problems: odds ratio [OR], 1.30; 95% CI, 1.25-1.35; P < .001; mixed disturbance: OR, 1.29; 95% CI, 1.25-1.33; P < .001; high disturbance: OR, 1.44; 95% CI, 1.40-1.49; P < .001) and externalizing symptoms (sleep onset/maintenance problems: OR, 1.20; 95% CI, 1.16-1.23; P < .001; mixed disturbance: OR, 1.17; 95% CI, 1.14-1.20; P < .001; high disturbance: OR, 1.24; 95% CI, 1.21-1.28; P < .001). Transitions between sleep profiles over time were associated with prospective internalizing and externalizing symptoms, but not vice versa.

Conclusions and Relevance

There are substantial changes in sleep problems across the transition to adolescence that are associated with later internalizing and externalizing symptoms. Sleep profiles could be targeted in future intervention and treatment programs to improve sleep-related and mental health-related outcomes across development.

Association of emotional and behavioral problems with sleep disturbance among Chinese adolescents: The moderation effect of academic performance

BACKGROUND

This study aimed to explore the association of emotional and behavioral problems with sleep disturbance among Chinese adolescents, and to test whether these associations vary with adolescents' academic performance.

METHODS

Data were from the 2021 School-based Chinese Adolescents Health Survey using a multistage, stratified-cluster, and random-sampling method to collect information from 22,684 middle school students in Guangdong Province, China.

RESULTS

Emotional problems (aOR = 1.34, 95 % CI = 1.32-1.36), conduct problems (aOR = 1.19, 95 % CI = 1.16-1.21), hyperactivity (aOR = 1.35, 95 % CI = 1.33-1.37), and peer problems (aOR = 1.06, 95 % CI = 1.04-1.09) were significantly associated with the increased risk of sleep disturbance among middle school students in Guangdong Province. The prevalence of sleep disturbance among adolescents was 29.4 %. There were significant interactions of emotional problems/conduct problems/peer problems/prosocial behavior with academic performance on sleep disturbance. Further stratification analyses by academic performance showed that adolescents with self-reported good academic performance had a higher risk of sleep disturbance than those students with self-reported average or poor academic performance.

LIMITATIONS

This study only included school students and used the cross-sectional design to preclude causality determination.

CONCLUSIONS

Our findings suggest that emotional and behavioral problems elevate the risk of sleep disturbance in adolescents. Adolescent academic performance plays a modulating role in these above-mentioned significant associations for sleep disturbance.

Clinical applications of artificial intelligence in sleep medicine: a sleep clinician's perspective

BACKGROUND

The past few years have seen a rapid emergence of artificial intelligence (AI)-enabled technology in the field of sleep medicine. AI refers to the capability of computer systems to perform tasks conventionally considered to require human intelligence, such as speech recognition, decision-making, and visual recognition of patterns and objects. The practice of sleep tracking and measuring physiological signals in sleep is widely practiced. Therefore, sleep monitoring in both the laboratory and ambulatory environments results in the accrual of massive amounts of data that uniquely positions the field of sleep medicine to gain from AI.

METHOD

The purpose of this article is to provide a concise overview of relevant terminology, definitions, and use cases of AI in sleep medicine. This was supplemented by a thorough review of relevant published literature.

RESULTS

Artificial intelligence has several applications in sleep medicine including sleep and respiratory event scoring in the sleep laboratory, diagnosing and managing sleep disorders, and population health. While still in its nascent stage, there are several challenges which preclude AI's generalizability and wide-reaching clinical applications. Overcoming these challenges will help integrate AI seamlessly within sleep medicine and augment clinical practice.

CONCLUSION

Artificial intelligence is a powerful tool in healthcare that may improve patient care, enhance diagnostic abilities, and augment the management of sleep disorders. However, there is a need to regulate and standardize existing machine learning algorithms prior to its inclusion in the sleep clinic.

Effect of Sleep Changes on Health-Related Quality of Life in Healthy Children: A Secondary Analysis of the DREAM Crossover Trial

IMPORTANCE

Little is known regarding the effect of poor sleep on health-related quality of life (HRQOL) in healthy children.

OBJECTIVE

To determine the effect of induced mild sleep deprivation on HRQOL in children without major sleep issues.

DESIGN, SETTING, AND PARTICIPANTS

This prespecified secondary analysis focused on HRQOL, a secondary outcome of the Daily Rest, Eating, and Activity Monitoring (DREAM) randomized crossover trial of children who underwent alternating weeks of sleep restriction and sleep extension and a 1-week washout in between. The DREAM trial intervention was administered at participants' homes between October 2018 and March 2020. Participants were 100 children aged 8 to 12 years who lived in Dunedin, New Zealand; had no underlying medical conditions; and had parent- or guardian-reported normal sleep (8-11 hours/night). Data were analyzed between July 4 and September 1, 2022.

INTERVENTIONS

Bedtimes were manipulated to be 1 hour later (sleep restriction) and 1 hour earlier (sleep extension) than usual for 1 week each. Wake times were unchanged.

MAIN OUTCOMES AND MEASURES

All outcome measures were assessed during both intervention weeks. Sleep timing and duration were assessed using 7-night actigraphy. Children and parents rated the child's sleep disturbances (night) and impairment (day) using the 8-item Pediatric Sleep Disturbance and 8-item Sleep-Related Impairment scales of the Patient-Reported Outcomes Measurement Information System questionnaire. Child-reported HRQOL was assessed using the 27-item KIDSCREEN questionnaire with 5 subscale scores and a total score. Both questionnaires assessed the past 7 days at the end of each intervention week. Data were presented as mean differences and 95% CIs between the sleep restriction and extension weeks and were analyzed using intention to treat and an a priori difference in sleep of at least 30 minutes per night.

RESULTS

The final sample comprised 100 children (52 girls [52%]; mean [SD] age, 10.3 [1.4] years). During the sleep restriction week, children went to sleep 64 (95% CI, 58-70) minutes later, and sleep offset (wake time) was 18 (95% CI, 13-24) minutes later, meaning that children received 39 (95% CI, 32-46) minutes less of total sleep per night compared with the sleep extension week in which the total sleep time was 71 (95% CI, 64-78) minutes less in the per-protocol sample analysis. Both parents and children reported significantly less sleep disturbance at night but greater sleep impairment during the day with sleep restriction. Significant standardized reductions in physical well-being (standardized mean difference [SMD], -0.28; 95% CI, -0.49 to -0.08), coping in a school environment (SMD, -0.26; 95% CI, -0.42 to -0.09), and total HRQOL score (SMD, -0.21; 95% CI, -0.34 to -0.08) were reported by children during sleep restriction, with an additional reduction in social and peer support (SMD, -0.24; 95% CI, -0.47 to -0.01) in the per-protocol sample analysis.

CONCLUSIONS AND RELEVANCE

Results of this secondary analysis of the DREAM trial indicated that even 39 minutes less of sleep per night for 1 week significantly reduced several facets of HRQOL in children. This finding shows that ensuring children receive sufficient good-quality sleep is an important child health issue.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12618001671257.

Moderating effects of PER3 gene DNA methylation on the association of sleep quality with mental health in Chinese young adults

BACKGROUND

Poor sleepers have a higher prevalence of mental health problems, and vice versa. However, the mechanisms underlying this association remain unknown. We aimed to examine the bidirectional association between sleep quality and mental health, and further explore the moderating effects of PER3 gene DNA methylation on the association.

METHODS

This prospective longitudinal study was conducted from April 2019 to May 2021, integrated questionnaire and blood sample data from 2 universities in Anhui and Jiangxi Provinces. The current study recruited 1179 young adults at baseline and conducted the follow-up survey among 1135 half a year later. The sleep quality and depressive symptoms, anxiety symptoms, and stress symptoms were assessed using a questionnaire at baseline and follow-up. Blood samples were collected at baseline, and MethyTarget™ was used to detect the PER3 gene DNA methylation level. A cross-lag model was used to examine the bidirectional association between sleep quality and mental health. The PROCESS plug-in of SPSS software was used to analyse the moderating effects of PER3 gene DNA methylation.

RESULTS

Cross-lagged analyses suggested a significant bidirectional relationship between poor sleep quality and depressive symptoms, anxiety symptoms, and stress symptoms. Sleep quality at baseline was a significant predictor of depressive symptoms (β = 0.344, P < 0.001), anxiety symptoms (β = 0.348, P < 0.001), and stress symptoms (β = 0.324, P < 0.001) half a year later. Depressive symptoms (β = 0.049, P < 0.001), anxiety symptoms (β = 0.055, P < 0.001), and stress symptoms (β = 0.063, P < 0.001) at baseline were also significant predictors of poor sleep quality half a year later. Furthermore, PER3 gene DNA methylation has negative moderating effects between sleep quality at baseline and depressive symptoms (β = -11.706, P = 0.012), anxiety symptoms (β = -10.289, P = 0.019), and stress symptoms (β = -10.799, P = 0.024) half a year later and a sex difference. Among boys, PER3 gene DNA methylation has positive moderating effects between anxiety symptoms at baseline and sleep quality (β = 3.337, P = 0.018) half a year later. However, there was no association between mental health at baseline and sleep quality half a year later among girls.

CONCLUSION

Bidirectional relationships were identified between sleep quality and mental health among Chinese young adults during the study period. DNA methylation evidence supports a negative moderating effect of PER3 gene DNA methylation on the relationship between sleep quality at baseline and mental health half a year later and had sex differences. Among boys, PER3 gene DNA methylation had positive moderating effects between anxiety symptoms at baseline and sleep quality half a year later. These findings point to the importance of circadian clock gene DNA methylation in the relationship between sleep quality and mental health.

Experiences of Using Weighted Blankets among Children with ADHD and Sleeping Difficulties

Introduction

Sleeping difficulties are common in children with attention deficit hyperactivity disorder (ADHD). A sleep intervention with weighted blankets was designed to increase current understanding of using weighted blankets to target children's individual needs in connection with sleep and daytime functioning.

Aim

To explore how children with ADHD and sleeping difficulties experience the use of weighted blankets.

Methods

An explorative qualitative design in which 26 children with ADHD and sleeping difficulties, 6-15 years old, were interviewed about a sleep intervention with weighted blankets. Four categories emerged from qualitative content analysis.

Results

Children's experiences revealed that the use of weighted blankets 1) requires a commitment, by adjusting according to needs and preferences and adapting to the environment; 2) improves emotional regulation by feeling calm and feeling safe; 3) changes sleeping patterns by creating new routines for sleep and improving sleep quality; and 4) promotes everyday participation by promoting daily function and balancing activity and sleep.

Conclusions

Using weighted blankets promoted children's management of daily life with ADHD and sleeping difficulties. Occupational therapists can improve the assessment and delivery of weighted blankets tailored to individual needs based on increased knowledge from the children themselves.

The bidirectional relationship between sleep and externalizing behavior: A systematic review

It is well-established that sleep and behavior are interrelated. Although studies have investigated this association, not many have evaluated the bidirectional relationship between the two. To our knowledge this is the first systematic review providing a comprehensive analysis of a reciprocal relationship between sleep and externalizing behavior. Five databases (PsycINFO, PubMed, Web of Science, Scopus, and Google Scholar) were utilized to yield a total of 3,762 studies of which 20 eligible studies, empirical articles examining bidirectionality of sleep and externalizing behavior, were selected for analysis. According to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis, the varying methodological approaches used in these studies were analyzed and synthesized, including examining differences and similarities in outcomes between distinct study designs (longitudinal vs cross-sectional), sleep measures (objective vs subjective vs a combination of both), informants (parents, self-report, teachers), and recruited participants (clinical, subclinical and typical populations). The assessment of risk of bias and quality of studies was guided by the instruments employed in research on sleep and behavior in the past. This review establishes that a bidirectional relationship between sleep problems and externalizing behavior clearly exists, and identifies limitations in the existing literature. Furthermore, the importance of early interventions that target both externalizing behaviors and sleep problems is highlighted as a potentially effective way of breaking the sleep-externalizing behavior relationship. Nonetheless, causality cannot be claimed until more trials that manipulate sleep and evaluate changes in externalizing behavior are conducted.

Translation and adaptation into Brazilian Portuguese and investigation of the psychometric properties of the Children's Sleep Habits Questionnaire (CSHQ-BR)

OBJECTIVES

To translate to Brazilian Portuguese, culturally adapt and confirm the psychometric parameters of validity and reliability of the Children's Sleep Habits Questionnaire (CSHQ-BR) in children.

METHODS

A sample of 314 typically developing children, 51% girls, mean age 7.12 years (SD = 2.04 years) were assessed, comprising 227 from São Paulo and 87 from the Amazon region. Translation, back translation, cultural adaptation, a pilot study and item review were carried out, yielding the final version of the CSHQ. Psychometric parameters were determined based on content validity coefficient (CVC), test-retest, internal consistency, evidence of convergent validity and internal structure.

RESULTS

The final CVC for the scale was 0.88. Intraclass correlation was 0.98 for the overall questionnaire and ranged from 0.88 to 0.98 for subscales. CSHQ-BR internal consistency was α = 0.81 for the CSHQ-BR total score (95% CI) and from 0.51 to 0.75 for subscales. Exploratory factor analysis suggested a novel 4-factor structure. A positive correlation was found between the CSHQ and the Questionnaire on Sleep Behavior. Mean total CSHQ score in Brazilian children was 46.85 (SD = 9.43), and boys had a higher mean total score than girls, although not statistically significant.

CONCLUSION

The CSHQ-BR exhibited satisfactory equivalence for the original English abbreviated form and the Brazilian Portuguese version, proving a useful sleep screening instrument for identifying sleep problems in Brazilian children aged 4-10 years.

The Associations between 24-Hour Movement Behaviours and Quality of Life in Preschoolers: A Compositional Analysis of Cross-Sectional Data from 2018-2021

Studies show that the quality of life (QoL) of preschoolers is closely related to physical activity (PA), sedentary behaviour (SB), and sleep (SL). Yet many researchers looked at these 24-h movement behaviours as behaviours that are independent of one another when examining the association of QoL with these behaviours. The main purpose of the present study was to describe the temporal trends in PA, SB, and SL in preschoolers and the concomitant association with QoL of children. Annual cross-sectional data on QoL and 24-h movement behaviours of 8045 Singaporean preschoolers were collected from 2018 to 2021. Compositional analysis, linear regression, and isotemporal replacement approaches were used to examine changes in PA, SB, and SL from 2018-2021 and how these changes were associated with QoL. Temporal trends in movement behaviours showed that PA and SL decreased after 2020. During 2018-2021, the association of PA and QoL in preschoolers was characterised by a 'U' curve (βPA-2018 = 3.06, p < 0.001; βPA-2019 = 1.43, p < 0.05; βPA-2020 = -0.43, p > 0.05; βPA-2021 = 2.82, p < 0.001), while SL and QoL were characterised by an inverted 'U' curve (βSL-2018 = -2.39, p < 0.001; βSL-2019 = -0.27, p > 0.05; βSL-2020 = 2.00, p < 0.01; βSL-2021 = -0.21, p > 0.05). SB was significantly and negatively associated with QoL after 2020, with 2020 identified as the inflection point for the change in SB (βSB-2018 = 0.67, p > 0.05; βSB-2019 = -1.16, p > 0.05; βSB-2020 = -1.56, p < 0.01; βSB-2021 = -2.61, p < 0.01). Using a time re-allocation technique to treat the 2021 data, reallocating time from SB to PA or to SL predicted improvements in QoL of preschoolers (Pall < 0.05). The study provided useful information on the temporal trends in PA, SB, SL, and QoL of preschoolers over four years. Additionally, these data provided insights into how changes in QoL are predicted by changes in duration in the 24-h movement behaviours.

Bidirectional associations between sleep problems and behavioural difficulties and health-related quality of life in adolescents: Evidence from the SCAMP longitudinal cohort study

Background

Sleep problems show associations with negative outcomes in both physical and mental health in adolescents, but the associations may be reciprocal. We aimed to assess bidirectional associations between sleep problems and mental health symptoms including behavioural difficulties (internalising and externalising difficulties) and low health-related quality of life (HRQoL).

Methods

A total of 6616 adolescents (52.4% females) across Greater London completed baseline assessments when they were aged 11-12 years, and 3803 of them (57.2% females) completed follow-up assessments at aged 13-15 years. Weekday and weekend sleep duration were derived from self-reported bedtime, sleep onset latency and wake time. Sleep disturbance was assessed using a standardized sleep disturbance scale. Internalising and externalising difficulties were assessed using subscales of the Strength and Difficulties Questionnaire. HRQoL was assessed using the KIDSCREEN-10 questionnaire. Cross-lagged structural equation modelling was used with multiple imputation to examine bidirectional associations between sleep problems and mental health symptoms.

Results

Females had greater internalising difficulties, worse HRQoL and more sleep disturbance than males. Persistent insufficient weekday and weekend sleep, and sleep disturbance (i.e., at both baseline and follow-up) were associated with internalising and externalising difficulties and low HRQoL at follow-up (ORs ranged from 1.53 to 3.63). Persistent externalising difficulties and low HRQoL were also associated with insufficient weekend sleep and sleep disturbance at follow-up (ORs ranged from 1.68 to 4.25). Using continuous variables, we found bidirectional associations between weekday sleep duration and HRQoL, weekend sleep duration and externalising score, sleep quality and internalising score, and sleep quality and HRQoL. The association magnitudes were mostly similar in the two directions.

Conclusions

Our study showed bidirectional associations between sleep problems and mental health symptoms during adolescence, indicating that early intervention and treatment on the first-occurring symptom may prevent the development of subsequent problems.

Associations between sleep problems and domains relevant to daytime functioning and clinical symptomatology in autism: A meta-analysis

Autistic individuals experience significantly higher rates of sleep problems compared to the general population, which negatively impacts various aspects of daytime functioning. The strength of associations across domains of functioning has not yet been summarized across studies. The present meta-analysis examined the strength of associations between sleep problems and various domains of daytime functioning in autistic individuals. Searches were conducted in EMBASE, PubMed, Web of Science, and Google Scholar through May 2020. Inclusion criteria were: an index of sleep disturbance in individuals diagnosed with autism spectrum disorder (ASD); data collected prior to any sleep-related intervention; statistical data indicating relations between sleep problems and outcomes relevant to behavior, cognition, and physical or mental health. Exclusion criteria were: statistics characterizing the relationship between sleep disturbance and outcome variables that partialled out covariates; studies examining correlations between different measures of sleep disturbance. Participants totaled 15,074 from 49 published articles and 51 samples, yielding 209 effect sizes. Sleep problems were significantly associated with more clinical symptomatology and worse daytime functioning. Subgroup analyses demonstrated that sleep problems were most strongly associated with internalizing and externalizing symptoms and executive functioning, followed by core autism symptoms, family factors, and adaptive functioning. Findings highlight the far-reaching consequences of sleep problems on daytime functioning for autistic individuals and support the continued prioritization of sleep as a target for intervention through integrated care models to improve wellbeing. LAY SUMMARY: Autistic individuals experience higher rates of sleep problems, such as difficulty falling asleep and staying asleep, compared to the general population. We quantitatively summarized the literature about how sleep problems are related to different aspects of daytime functioning to identify areas that may be most affected by sleep. Sleep problems were related to all areas assessed, with the strongest associations for mood and anxiety symptoms. We recommend prioritizing sleep health in autistic individuals to improve wellbeing and quality of life.

Psychological distress mediates the connection between sleep deprivation and physical fighting in adolescents

Lack of sleep is common in adolescence, and represents an important threat to adolescents' well-being, academic commitment, and general health. It also has significant behavioral consequences through an increased likelihood of interpersonal violence. Previous studies have demonstrated an association between aggressive behavior and lack of sleep, but the psychological mediators remain completely unexplored. Grounded in the General Aggression Model, we investigated the affective pathway as one of the potential mechanisms linking lack of sleep and aggression. We hypothesized and showed that psychological distress is an intermediary phenomenon linking lack of sleep and physical aggression. Based on a school sample of 11,912 participants (median age: 14.5), we observed that 23.7% of the young people admitted having been involved in physical fighting on one or more occasions, and that 25.81% were in sleep debt when referred for medical assessment. We analyzed the relationship between sleep duration and physical fighting and the mediating link of psychological distress by performing multiple regressions in the components' paths. The results showed that the adolescents' amount of sleep appeared to be a significant predictor of physical fighting, and that this relationship was partially mediated by psychological distress. These results are consistent with the General Aggression Model, and represent the first empirical confirmation that psychological distress symptoms partially mediate the connection between lack of sleep and physical aggression.

Adolescents' sleep and adjustment: Reciprocal effects

Reciprocal relations between sleep and adjustment were investigated. Participants included 246 adolescents (M = 15.80 years; 67.5% White, 32.5% Black/African American; 53% female, 47% male) at Time 1 (data collected 2012-2013), 227 at Time 2 (M = 16.78 years) and 215 at Time 3 (M = 17.70 years). Sleep-wake variables were measured with self-reports (sleepiness) and actigraphy (average sleep minutes and efficiency, variability in sleep minutes and efficiency). Adolescents reported on depression and anxiety symptoms, and parents reported on externalizing problems. Greater variability in sleep duration and efficiency as well as sleepiness predicted adjustment problems (range of R² : 36%-60%). Reciprocal relations were supported mostly for sleepiness (range of R² : 16%-32%). Results help understand bidirectional relations between sleep and adjustment.

Sleep in Individuals with ADHD: Prevalence, Impacts, Causes, and Treatments

Sleep problems are common in children and adolescents with ADHD. This chapter covers the basics of sleep and the prevalence and types of sleep problems experienced by children and adolescents with ADHD. The impacts of sleep problems on the day-to-day lives of children with ADHD and their families are covered including impacts on child daily functioning and cognition, as well as family well-being. There is no one cause of sleep problems in children with ADHD with both biological and environmental factors implicated. There are a small number of randomized controlled trials that support the efficacy of treating sleep problems in children with ADHD using behavioral strategies. A small number of studies also have found improvements in sleep onset delay in children with ADHD following treatment with melatonin. Little is known about how to best support adolescents and adults with ADHD with sleep, although a small emerging literature largely in adults with ADHD suggests that bright light therapies could potentially be helpful given the extent of circadian involvement in the sleep problems experienced by individuals with ADHD. This chapter ends with consideration of future research directions largely related to approaches to supporting individuals with ADHD and sleep difficulties.

Predictors of diagnostically defined insomnia in child and adolescent community samples: a literature review

Diagnostically defined insomnia is prevalent, persistent, and associated with a range of negative outcomes in childhood and adolescence. To inform prevention and treatment, we need to identify relevant predictors that can be addressed in such intervention efforts. Therefore, a systematic search for longitudinal studies involving child and adolescent samples (ages 4 to 19) examining predictors of diagnostically defined insomnia adjusted for previous insomnia was conducted. The search identified 6419 studies, resulting in six included papers involving five samples (n = 9949) conducted in five different countries (the US, New Zealand, Norway, China, and Japan). Few longitudinal studies investigated the predictors of diagnostically defined insomnia in children and adolescents, and insomnia is rarely defined according to diagnostic manuals. The results suggested that poor mental health (most notably depression) and female sex may be involved in the etiology of diagnostically defined insomnia. Stress might be the most modifiable factor identified. However, the diversity of the predictors studied in previous reports combined with the lack of replication prevent any firm conclusions from being drawn. This review serves as a summary of the best available evidence.