Potential Role of Sleep Disturbance in the Development of Early Puberty: Past Clinical Evidence for Future Management

The incidence of early puberty in children has been increasing. It has been suspected that both genetic and various environmental factors such as nutrition and hormonal exposure could influence the mechanisms underlying the earlier onset of puberty. Interestingly, several previous studies have reported a strong connection between sleep and puberty. Specifically, it was discovered that luteinizing hormone (LH), a potential marker for the onset of puberty, was increased during the deep sleep period. Furthermore, a high prevalence of early puberty was observed in patients with sleep disorders, especially in those experiencing narcolepsy. In this review article, findings related to the association between sleep disturbance and early puberty have been comprehensively summarized. Any contrary findings are also included and discussed. Advances in the knowledge surrounding sleep disturbance have led to a greater understanding of a correlation between early puberty and sleep disorder and provide alternative therapeutic options for the treatment of central precocious puberty in the future.

Is it time to agree upon a standardised approach to the assessment of contributing factors and impacts of adolescent pelvic pain?

BACKGROUND

A biopsychosocial approach to the understanding of pelvic pain is increasingly acknowledged. However, there is a lack of standardised instruments - or their use - to assess risk factors and their impact on pelvic pain in both clinical and research settings. This review aims to identify validated tools used to assess known contributory factors to pelvic pain, as well as the validated tools to measure the impact of pelvic pain in adolescents and young adults, in order to provide a framework for future standardised, adolescent specific assessment and outcome tools.

METHODS

Literature searches were performed in MEDLINE, PsycInfo and PubMed. Search terms included pelvic pain, dysmenorrhoea, endometriosis, adolescent, pain measurement, quality of life, sleep, mental health, coping strategies and traumatic experience.

RESULTS

We found validated instruments to assess adverse childhood experiences and coping strategies, both known contributing factors to pelvic pain. The impact of pain was measured through validated tools for health-related quality of life, mental health and sleep.

CONCLUSIONS

Pelvic pain evaluation in adolescents should include a multi-factorial assessment of contributing factors, such as childhood adversity and coping strategies, and impacts of pelvic pain on quality of life, mental health and sleep, using validated instruments in this age group. Future research should focus on the development of consensus amongst researchers as well as input from young women to establish a standardised international approach to clinical trials involving the investigation and reporting of pelvic pain in adolescents. This would facilitate comparison between studies and contribute to improved quality of care delivered to patients.

The relationship between sleep and menstrual problems in early adolescent girls

Introduction

Adolescence is marked by hormonal, physical, neural, and behavioral changes, including in sleep patterns and, in females, the onset of menarche. Menstrual problems, such as painful menses, are common and contribute to school absences, and could indicate gynecological conditions impacting reproductive health. While studies in adults have shown associations between sleep disturbances and menstrual problems, this relationship is less understood in adolescents. Our study explores the association between sleep, menstrual problems, and menarche in a diverse sample of early adolescent girls in the U.S.

Methods

We used linear mixed-effect models to analyze associations between sleep behavior (self- and caregiver-reported) and menstrual problems (self-reported cycle irregularity, premenstrual symptom and menstrual pain severity and their impact on daily life) and menstrual characteristics (menstrual flow) in 3,037 post-menarcheal adolescent girls (Mean age:13.03 years) from the ABCD Study®. Covariates included years since menarche, race, ethnicity, parental education, and body mass index. We also used longitudinal data to explore changes in sleep behavior as a function of menarche.

Results

Of the sample, 26.2% reported moderate-severe premenstrual symptoms and 20.8% reported moderate-severe menstrual pain. 23.3% reported irregular menstrual cycles, 15.9% reported heavy menstrual flow. Shorter sleep duration was associated with greater menstrual pain intensity (β =-0.19) and impact on daily activities (β = -0.15), irregular cycles (β = -0.17), and severe premenstrual symptoms (β = -0.04). Higher sleep disturbance scores correlated with greater menstrual pain (β = 0.18) and premenstrual symptom severity (β = 0.03). Later wake-up times were linked to greater menstrual pain intensity (β = 0.14). Shorter time since menarche was associated with lower menstrual flow (β = 0.07) and pain intensity (β = 0.51) and less severe premenstrual symptoms (β = 0.07). Being post-menarche was associated with later bedtimes and shorter sleep duration.

Conclusion

Findings of links between sleep behavior and menstrual problems in early adolescence underscore the importance of addressing sleep and menstrual issues in healthcare screenings and educational initiatives for adolescents. Future research should focus on longitudinal and intervention studies to clarify these relationships.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41606-024-00111-w.

Longitudinal associations of menstrual characteristics with mental health problems among Chinese girls

Cross-sectional studies indicate that menstrual problems are related to poorer mental health; however, longitudinal studies are limited. This longitudinal study aimed to determine whether baseline menstrual characteristics were risk factors for incident and persistent mental health problems. The study was conducted among Chinese adolescent girls. Menstrual characteristics including menarche, menstrual cycle and menstrual pain were assessed at baseline, whereas mental health problems including PTSD, depression, anxiety, ADHD, insomnia, psychotic-like experiences, non-suicidal self-injury, suicide ideation, suicide plan, and suicide attempt were assessed at baseline (n = 1039) and at the 1-year follow-up (n = 946) by self-administered, structured questionnaires. Multiple logistic regressions were performed to examine whether menstrual characteristics were associated with incident (e.g., PTSD at follow-up but not baseline) and persistent (e.g., PTSD at both time points) mental health problems. The results demonstrated that early menarche was related to persistence of psychotic-like experiences; irregular menstruation was associated with higher rates of incident anxiety and insomnia, and persistent depression, anxiety, ADHD, insomnia, non-suicidal self-injury, suicide ideation, and suicide plan; menstrual pain was associated with elevated rates of incident PTSD and depression, and persistent depression, insomnia, psychotic-like experiences, non-suicidal self-injury, suicidal ideation, suicide plan, and suicide attempt. In conclusion, irregular menstruation and menstrual pain specifically contributed to the development of emotional problems and insomnia, and were associated with maintenance of the most mental health problems in early adolescence. The long-term effects of menstrual problems on mental health need further study.

Causal associations between sleep traits and age at natural menopause: A Mendelian randomization study

Observational studies have revealed that several sleep traits can impact ovarian function in women. However, there is no evidence suggesting associations between sleep traits and age at natural menopause (ANM). The objective of this study was to investigate the causal relationship between sleep traits (insomnia, sleep duration, daytime sleepiness) and ANM from the perspective of genetic variation. We selected the single-nucleotide polymorphisms from large-scale genome-wide association studies as instrumental variables and conducted a two-sample Mendelian randomization (MR) analysis on these single-nucleotide polymorphisms, including inverse variance weighting, MR-Egger, weighted median, simple mode and weighted mode. The Steiger test was employed to verify the correct causal directionality. The robustness of the MR analysis was examined through Cochran's Q test, horizontal pleiotropy test, and leave-one-out analysis. The results indicated that insomnia was causally associated with ANM (inverse variance weighting: β = -0.982; 95% CI: -1.852 to -0.111, P = .027), with other analyses confirming the robustness of this finding. Steiger test and reverse MR Analysis validated the absence of a reverse causal association between the two. However, sleep duration and daytime sleepiness did not exhibit a causal effect on ANM. In summary, this study provides initial evidence that insomnia can contribute to an earlier onset of ANM. Nevertheless, further clinical studies are needed to elucidate these findings.

Depression, anxiety, insomnia and dysmenorrhea in stressed fingolimod-treated women with multiple sclerosis

OBJECTIVE

This study examined the prevalence and correlates of depression, anxiety, insomnia, and dysmenorrhea in stressed fingolimod-treated women with multiple sclerosis.

METHODS

This cross-sectional study recruited female patients diagnosed with multiple sclerosis and high stress scores from Al-Bashir Hospital in Jordan. Depression was assessed by the Patient Health Questionnaire (PHQ-9); anxiety by the Generalized Anxiety Disorder (GAD-7) scale; insomnia by the Insomnia Severity Index (ISI-A) scale; and dysmenorrhea severity by a measure assessing working ability, location, intensity, days of pain, and miscellaneous dysmenorrhea symptoms (WaLIDD).

RESULTS

A total of 129 patients were recruited for the study. Severe depression was reported in 55.8%, severe anxiety in 62.0%, severe insomnia in 36.4%, and severe dysmenorrhea in 23.3%. Multivariate analyses revealed that depressive symptoms were associated with dysmenorrhea (OR = 3.55, 95% CI = 1.56-8.12, p = 0.003); anxiety symptoms with "not using dysmenorrhea analgesics" (OR = 2.74, 95% CI = 1.16-6.46, p = 0.02) and dysmenorrhea symptoms (OR = 4.74, 95% CI = 1.94-11.59, p = 0.001); insomnia symptoms with age above 30 years (OR = 4.34, 95% CI = 1.64-11.51, p = 0.003); and dysmenorrhea symptoms with the presence of chronic diseases (OR = 4.21, 95% CI = 1.28-13.92, p = 0.02), anxiety symptoms (OR = 3.03, 95% CI = 1.18-7.73, p = 0.02), and insomnia symptoms (OR = 3.00, 95% CI = 1.18-7.64, p = 0.02).

CONCLUSION

Stressed women with multiple sclerosis in Jordan experience high rates of depression, anxiety, insomnia, and dysmenorrhea. Characteristics related to these conditions may help clinicians to identify those at risk. Longitudinal studies are needed to determine the causal nature of these associations.

Psychometric properties of the Youth Self-rated Insomnia Scale (YSIS) in adolescent psychiatric patients

The 8-item Youth Self-rated Insomnia Scale (YSIS) was developed to assess insomnia severity in the past month among youths. The YSIS has satisfactory psychometric properties in the general adolescent population. This study examined psychometric properties of the YSIS in a large sample of adolescent psychiatric patients. A total of 536 patients aged 10-19 years were consecutively recruited from the outpatient department of Shandong Mental Health Center between December 2021 and March 2022. Patients completed a structured questionnaire consisting of the YSIS scale and questions about sleep duration, nightmares, psychiatric history, depression, psychiatric and sleep medications, and demographics. Patients were diagnosed following the ICD-10 criteria. Of the participants, the mean age was 15.30 years (SD = 1.95), 61.0% were female, 60.9% were diagnosed with mood disorders, 65.7% were on antidepressants, and 49.0% were on anxiolytics or hypnotics. The mean YSIS score was 22.6 (SD = 8.07). Coefficient omega was 0.84. Exploratory factor analysis revealed one factor and two correlated residuals. The YSIS scores were significantly correlated with depression scores (r = 0.68) and significantly increased with sleep onset latency, short sleep duration, nightmare frequency, and sleep medication use. The YSIS demonstrated satisfactory internal consistency reliability, construct validity, and criteria-related validity in adolescent psychiatric patients. The YSIS appears to be a reliable and valid scale for measuring insomnia severity in adolescent psychiatric patients.

Dysmenorrhea and Sleep: A Review

This review encompasses the clinical features and relevance to investigate sleep in women with dysmenorrhea. Dysmenorrhea is a prevalent gynecologic dysfunction that affects the social and professional lives of women. It can occur at every menstrual cycle, depending on the cause and psychologic factors. Studies have reported poor sleep and insomnia symptoms in dysmenorrhea condition, which may intensify the dysmenorrhea manifestation and interfere negatively to its treatment. There is an urgent need to identify the main cause of this dysfunction and provide efficient treatments to minimize the detrimental effects of dysmenorrhea in quality of life of these women.

Premenstrual Syndrome, Anxiety, and Depression Among Menstruating Rural Adolescent Girls: A Community-Based Cross-Sectional Study

Introduction Menstrual periods in young females can add a new challenge to the already difficult adolescent transition period. Menstrual health concerns can have extreme physical and psychosocial impacts on adolescent girls. Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are extremely common yet underestimated. Depression in adolescents is a mental and emotional disorder. The objective of the study was to find out the prevalence of PMS, PMDD, anxiety, and depression among rural menstruating adolescent girls and the factors associated with it. Methods This was a community-based cross-sectional study carried out among 20 rural schools for the period of one year. Sample size was calculated based on previous research. Adolescent females who had menstruated for one year were included and those with primary amenorrhea and previously diagnosed mental health abnormalities were excluded. Becks' Depression Inventory, Hamilton Anxiety Scale, and Premenstrual Symptoms Screening Tool (PSST-A) were used. Data were collected by interview technique and entered in an Excel sheet (Microsoft Corporation, Redmond, Washington, United States), and analyzed using IBM SPSS Statistics for Windows, Version 22.0 (Released 2013; IBM Corp., Armonk, New York, United States). Results Out of 430 rural adolescent girls, 180 (41.9%) were 15 years, 277 (64.4%) belonged to nuclear families, 236 (54.9%) exercised less than 30 minutes, 144 (33.5%) had menarche at the age of 13 years, 288 (67%) had regular cycles, 266 (61.9%) had moderate flow during the menstrual cycle, 302 (70.2%) had a flow duration of less than seven days, and 243 (56.5%) had dysmenorrhea. Thirty-eight (8.8%) girls had PMDD and 75 (17.4%) had PMS. Age, family status, severity of menstrual flow, duration of cycle, and presence of dysmenorrhea, depression, and anxiety had a statistically significant association with PMDD. The class/grade in which studying, cycle regularity, flow during the menstrual cycle, duration of the cycle, dysmenorrhea, anxiety, and depression status had a statistically significant association with PMS. Conclusions The menstrual cycle's impact on the mental health of rural adolescent girls should not be ignored and schools can be instrumental in improving their quality of life. Regular counselling and mental health supervision by school teachers and peer groups can be beneficial.

The Menstrual Cycle and Sleep

Aspects of sleep change across the menstrual cycle in some women. Poorer sleep quality in the premenstrual phase and menstruation is common in women with premenstrual symptoms or painful menstrual cramps. Although objective sleep continuity remains unchanged across the regular, asymptomatic menstrual cycle, activity in the sleep electroencephalogram varies, with a prominent increase in sleep spindle activity in the postovulatory luteal phase, when progesterone is present, relative to the follicular phase. Menstrual cycle phase, reproductive stage, and menstrual-related disorders should be considered when assessing women's sleep complaints.

Associations between insomnia symptom trajectories with depression and self-harm behaviors in Chinese college students before and during the COVID-19 pandemic: A five-wave longitudinal investigation

BACKGROUND

Sleep problems are highly prevalent during COVID-19 pandemic. However, only very limited studies have examined the changing patterns of insomnia symptom before and during the COVID-19 pandemic, and most of these studies were limited to two-wave designs and the variable-centered approach.

METHODS

The data was taken from a large-scale health-related cohort among Chinese college students. This cohort was a five-wave design and 3834 participants who completed at least two waves were included in the present study. Growth mixture modeling (GMM) was used to estimate trajectory classes for insomnia symptoms, followed by binary logistic regression to explore the association between trajectory classes and subsequent mental health problems.

RESULTS

GMM analyses extracted four distinct trajectories of insomnia symptoms: stable-low pattern (n = 2897, 75.6 %), increasing pattern (n = 405, 10.6 %), decreasing pattern (n = 182, 4.7 %), and stable-high pattern (n = 350, 9.1 %). Additionally, we found that individuals in stable-high and increasing patterns were more likely to experience mental health problems after the COVID-19 pandemic even after adjusting significant covariates and outcomes at baseline.

CONCLUSIONS

Appreciable heterogeneity in insomnia symptoms among college students was revealed before and during the COVID-19 pandemic. About 20 % of college students were classified as high-risk patterns of insomnia symptoms. Psychological interventions should target such vulnerable groups to reduce the rates of mental health problems.

Menstrual pain mediated the association between daytime sleepiness and suicidal risk: A prospective study

BACKGROUND

Adolescents with daytime sleepiness have been demonstrated to have a higher level of suicidal risk than those without. Currently, few studies had examined the pathway from daytime sleepiness to suicidal risk among female adolescents. This study aimed to explore the association among menstrual pain, daytime sleepiness, and suicidal risk among female adolescents in China.

METHODS

Of 7072 adolescents who participated in the follow-up survey of Shandong Adolescents Behavior & Health Cohort (SABHC), 3001 were female adolescents who had begun to menstruate and included for the analysis. A structured self-administrated questionnaire was used to measure menstrual pain, daytime sleepiness, suicidal risk and demographic characteristics. Participants were first surveyed in November-December 2015 and resurveyed 1 year later.

RESULTS

Of 3001 participants, 11.43 % had suicidal risk, 79.8 % experienced menstrual pain. Cross-lagged analysis showed that there was cause-and-effect relationship between menstrual pain and daytime sleepiness. Moderate (OR = 1.79, 95%CI: 1.22-2.63) and severe (OR = 2.73, 95%CI: 1.80-4.12) menstrual pain (follow-up) were associated with suicidal risk (follow-up). Daytime sleepiness (baseline: OR = 1.04, 95%CI: 1.02-1.06, follow-up: OR = 1.07, 95%CI: 1.05-1.09) had effects on suicidal risk (follow-up). Mediation analysis showed that menstrual pain played a partially mediating role between daytime sleepiness and suicidal risk, with the indirect effect being 0.002 (95%CI: 0.001-0.004).

LIMITATIONS

All data were self-reported.

CONCLUSIONS

Menstrual pain and daytime sleepiness had effects on each other, and they both were the risk factors of suicidal risk. Among female adolescents, the association between daytime sleepiness and suicidal risk could be partially mediated by menstrual pain. Releasing the menstrual pain of female adolescents with daytime sleepiness could reduce their suicidal risk.

Narrative review of the prevalence and distribution of acute pain in children in the self-care setting

Acute pain among children is common, yet it may be underestimated and undertreated if the pain is not recognized. Assessing and managing pediatric pain can be complicated, and as such, measuring the prevalence of acute pain in children can be challenging. We sought to provide a consolidated review of the available data on the prevalence of commonly occurring acute pain in children in the self-care setting. An extensive literature search was performed to determine the prevalence of acute pain at multiple bodily locations in children aged between 3 months and 18 years. We considered the influence of age, sex, and sociodemographic factors on prevalence estimates. We also sought to identify some of the challenges involved in assessing and managing pediatric pain, thus shedding light on areas where there may be clinical and medical unmet needs. In general, a high prevalence of acute pain in children was detected, particularly headache, menstruation-related pain, and dental and back pain. Older age, female sex, and lower socioeconomic status were associated with increased pain prevalence. Risk factors were identified for all pain types and included psychological issues, stress, and unhealthy lifestyle habits. Owing to the heterogeneity in study populations, the prevalence estimates varied widely; there was also heterogeneity in the pain assessment tools utilized. The paucity of information regarding pain prevalence appears to be out of proportion with the burden of acute pain in children. This could indicate that clinicians may not be equipped with an optimal pain management strategy to guide their practice, especially regarding the use of developmentally appropriate pain assessment tools, without which prevalence data may not be captured. If acute pain is not accurately identified, it cannot be optimally treated. Further investigation is required to determine how the information from prevalence studies translates to the real-world setting.

Associations between Insomnia, Daytime Sleepiness, and Depressive Symptoms in Adolescents: A Three-Wave Longitudinal Study

BACKGROUND

Insomnia, daytime sleepiness, and depressive symptoms are prevalent in adolescents. This three-wave prospective study examined the associations between the three symptoms in adolescents.

METHODS

A total of 6995 schoolchildren in 7th and 10th grades (Mean age = 14.86 years) participated in a longitudinal study of behavior and health in Shandong, China. Standardized rating scales were used to assess symptoms of insomnia, daytime sleepiness, and depression in November-December in 2015, 1 year later, and 2 years later.

RESULTS

Insomnia was cross-sectionally associated with 10-14-fold increased odds of daytime sleepiness and 5-9-fold increased odds of depression. Daytime sleepiness was associated with 4-5-fold increased odds of depression. Insomnia, daytime sleepiness, or depression at a later time point was significantly predicted by itself at earlier time points. Insomnia was a significant predictor of daytime sleepiness and depression and a mediator between depression and daytime sleepiness. Daytime sleepiness was a significant predictor of insomnia and a mediator between depression and insomnia. Depression was a significant predictor of insomnia and daytime sleepiness and a mediator between insomnia and daytime sleepiness.

CONCLUSIONS

Insomnia, daytime sleepiness, and depressive symptoms were highly comorbid in adolescents. The associations of insomnia with daytime sleepiness and depression were bidirectional. Depression predicted daytime sleepiness, but not vice versa. Further research is needed to understand the underlying neurobiological mechanisms between insomnia, daytime sleepiness, and depression during adolescence.

Associations between experienced aggression, poor sleep, and suicide risk among Chinese adolescents

STUDY OBJECTIVES

The physical and mental health of adolescents is an important study area. This study aims to examine the occurrence of aggression, sleep disturbances, and suicide risk among Chinese adolescents, along with the relationships between these factors.

METHODS

This is a cross-sectional study conducted through an online survey. Of the original 7011 Chinese adolescent respondents, the analysis included data from 6122 adolescents, aged between 12 and 18 years, from 23 regions, whose average age was 16.12 (±1.44) years, with 48.8% being male. While the chi-square test and t-test were used for analyzing demographic data and continuous variables, respectively, mediation analysis was used to explore the mechanism of experiencing aggression on suicide risk. The respondents' sleep quality, nightmare distress, daytime sleepiness, fatigue, and suicide risk were assessed using the Pittsburgh Sleep Quality Index (PSQI), Nightmare Distress Questionnaire-Chinese version (NDQ-CV), Chinese Adolescent Daytime Sleepiness Scale (CADSS), Multidimensional Fatigue Inventory (MFI-20), and the suicide risk module of the Mini-International Neuropsychiatric Interview (MINI), respectively. Four items were used to assess adolescents' experiences with aggression.

RESULTS

Of the respondents, 42% reported experiencing aggression by others, especially parental physical maltreatment. Furthermore, 26.9% of adolescents in school, and in particular, 31.8% in senior high school experienced insomnia symptoms. Adolescents who reported experiences of aggression had more severe insomnia symptoms, nightmare distress, fatigue, and a higher risk of suicide when compared with those who did not (all ps < 0.001). Insomnia symptoms, nightmare distress, and fatigue all mediated the relationship between aggression and suicide risk, and there was a chain of mediating effects between these factors [for total indirect effect β = 1.1512, 95% CI (0.9671 to 1.3426), direct effect β = 0.4934, 95% CI (0.1978 to 0.7891), and total effect β = 1.6446, 95% CI (1.3479 to 1.9414)].

CONCLUSIONS

Our findings indicate that among adolescents, experiencing aggression is associated with an increased suicide risk. In addition to the direct effect of aggression on suicide risk, insomnia, nightmare distress, and fatigue mediate the relationship between aggression and suicide risk. More attention should be paid to adolescents experiencing aggression, and interventions should be implemented and strengthened.

Nightmare distress as a mediator between frequent nightmares and depressive symptoms in Chinese adolescents

BACKGROUND

Frequent nightmares are related to depressive symptoms in adolescents. Little is known about pathways from frequent nightmares to depressive symptoms. This study aimed to examine the mediation effect of nightmare distress in the association between frequent nightmares and depressive symptoms in a large sample of Chinese adolescents.

METHODS

A total of 11,831 adolescents who participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort were included in the analysis. A self-administered questionnaire was used to measure nightmare frequency, nightmare distress, depressive symptoms, sleep duration, insomnia, and demographic characteristics. Linear regressions and mediation analyses were performed to examine the associations between frequent nightmares, nightmare distress and depressive symptoms.

RESULTS

Of 11,831 participates, 50.9% were males and the mean age was 14.97 ± 1.45. Adolescents with frequent nightmares scored significantly higher on nightmare distress (t = 29.87, P <  0.001) and depressive symptoms (t = 20.05, P < 0.001) than those adolescents without frequent nightmares. Frequent nightmares (β = 1.04, 95% CI: 0.48-1.60) and nightmare distress (β = 0.30, 95% CI: 0.28-0.32) were associated with depressive symptoms. Mediation analyses showed that nightmare distress accounted for 63.76% of the total effects in the entire sample, 51.17% in males and 80.00% in females, respectively.

LIMITATION

No causality could be made from the cross-sectional data and possible information bias due to self-report.

CONCLUSIONS

The association between frequent nightmares and depressive symptoms appears to be substantially mediated by nightmare distress. Assessing and intervening distress associated with frequent nightmares may have important clinical implications for reducing the risk of depression in adolescents.

Association between Free Sugars Intake and Excessive Daytime Sleepiness among Chinese Adolescents

This study aimed to investigate the prevalence of excessive daytime sleepiness (EDS) and explore the association between free sugars intake and EDS. In this cross-sectional study, a total of 1517 middle school students (808 boys and 707 girls) aged 12~14 years were recruited. The study was conducted in Changsha city, China. Adolescents completed an online questionnaire, including the Epworth Sleepiness Scale (ESS), sleep characteristics, a 12-item Food Frequency Questionnaire (FFQ), and other self-reported information. The ESS score ≥ ten was defined as EDS. The anthropometric indices, including height, weight, and waist circumference, were measured and recorded by uniformly trained assistants. Statistical analyses included the Chi-square test and binary logistic regression model. The mean ESS score and free sugars consumption were 6.8 ± 3.9 points and 53.1 ± 44.7 g/d, respectively. The prevalence of EDS among adolescents was 22.5%, and more girls than boys had EDS (26.1% vs. 19.4%, p < 0.05). An exceeded free sugars intake was positively associated with EDS, with the adjusted Odds Ratio (OR) with its 95% Confident Interval (95% CI) of 1.366 (1.060~1.761, p < 0.05). EDS and excessive consumption of free sugars are commonly found among Chinese adolescents. Further studies are needed to confirm whether free sugars restriction can be meaningful to improve daytime drowsiness in those with EDS.

The mediating role of daytime sleepiness between problematic smartphone use and post-traumatic symptoms in COVID-19 home-refined adolescents

BACKGROUND

COVID-19 was first recognized in late 2019 in China, at which time school closures forced most students to isolate at home or maintain social distance, both of which increased smartphone use, daytime sleepiness and post traumatic disorder (PTSD) risks. However, to date, no research has fully explored these behavioral risks or the consequences.

METHODS

Two thousand and ninety home-confined students from two Chinese high schools participated in an online-based questionnaire battery that assessed their sociodemographic characteristics, COVID-19 related exposures, daytime sleepiness, problematic smartphone use, and PTSD. The subsequent data were subjected to mediation analysis, and structural equation models (SEM) were employed to explore the variable relationships.

RESULTS

The problematic smartphone use, daytime sleepiness and PTSD prevalence were respectively 16.4%, 20.2% and 6.9%. The number of COVID-19 related exposure was directly associated with problematic smartphone use and PTSD symptoms. Problematic smartphone use was found to be a mediator between COVID-19 related exposure and PTSD symptoms, and daytime sleepiness was found to partially mediate the associations between problematic smartphone use and PTSD.

CONCLUSIONS

The more exposure associated with the pandemic, the more psychological and behavioral problems the adolescents had. The relatively high rate of problematic smartphone use in home isolated adolescents possibly increased the risk of daytime sleepiness and psychological problems. Therefore, targeted improvements are needed to reduce the risk of psychological problems and daytime sleepiness in adolescents.

Prospective Associations of Frequent Pain Symptoms With Suicidal Behavior in Adolescents

Chronic pain and suicidal behavior are prevalent in adolescents. This longitudinal study examined the associations between pain symptoms and suicidal behavior in adolescents. A total of 7,072 adolescents participated in a follow-up study of behavior and health in Shandong, China. A self-administered structured questionnaire was used to assess pain symptoms (headache, stomachache, and other nonspecific pain), insomnia, anxiety/depression, substance use, stressful life events, prior suicidal behavior, and family environment in November-December in 2015. One year later, a follow-up survey was conducted. Mean age of the sample was 14.6 years, and half were female. Of the sample, 44.8% and 8.4% reported having one or more pain symptoms "sometimes" and "often", respectively. A total of 22.4% and 10.6% reported having lifetime suicidal behavior at baseline and subsequent suicidal behavior over the 1-year follow-up, respectively. Frequent pain was significantly associated with increased risk of suicidal behavior at baseline (OR=1.64, 95%CI=1.32-2.03) and during the subsequent year (OR=1.50, 95%CI=1.17-1.93) while adjusting for adolescent individual and family covariates. Among adolescents without a history of prior suicidal behavior, frequent pain was significantly associated with an approximately 70% increased risk of incident suicidal behavior (OR= 1.69, 95%CI=1.14-2.51). In conclusion, frequent pain appears to be predictive of adolescent suicidal behavior one year later. PERSPECTIVE: This article presents the prospective associations of frequent pain symptoms with suicidal behavior in adolescents. Frequent pain was associated with a 50-70% increased risk of suicidal behavior 1 year later. The finding underscores the importance of pain assessment and treatment in comprehensive suicide prevention efforts in adolescents.

Associations of frequent pain symptoms with excessive daytime sleepiness in adolescents: a longitudinal study

STUDY OBJECTIVES

Pain symptoms, sleep disturbance, and daytime sleepiness are common in adolescents. This study examined the cross-sectional and prospective associations between pain symptoms and excessive daytime sleepiness (EDS) in a large sample of adolescents.

METHODS

Participants were 7,072 adolescents (mean age = 14.6 years) in a follow-up study of behavior and health in Shandong, China. A self-administered structured questionnaire was used to assess pain symptoms (headache, stomachache, and other general pain), body weight and height, sleep, anxiety/depression, substance use, and family environment in November-December in 2015 and one year later. The Chinese adolescent daytime sleepiness scale (CADSS) was used to measure daytime sleepiness.

RESULTS

Of the sample, 19.8% and 23.2% had moderate or severe EDS at baseline and at 1-year follow-up, respectively. The prevalence and 1-year incidence rates of EDS significantly increased with the frequencies of pain symptoms. Frequent pain was significantly associated with increased risk of EDS at baseline (OR=2.01, 95% CI=1.56-2.59), incident EDS (OR=1.41, 95% CI=1.03-1.93), and persistent EDS (OR=2.17, 95% CI=1.52-3.09) while adjusting for adolescent and family covariates, including anxiety/depression, nocturnal sleep duration, insomnia symptoms, frequent snoring, body mass index, and hypnotic use. Similar associations were observed across headache, stomachache, and other pain.

CONCLUSIONS

Frequent pain is significantly and independently associated with increased risk of EDS. Our findings suggest that assessing and treating pain symptoms is important to improve healthy sleep and reduce risk of EDS in adolescents. Further research is needed to understand the underlying psychological and neurobiological mechanisms between pain and daytime sleepiness in adolescents.

Pathways to adolescents' health: chronotype, bedtime, sleep quality and mental health

The strong relationship between sleep and health is defined in the literature. While the need for sleep increases in adolescence with the effect of physiological and hormonal changes, the studies have highlighted the serious sleeping problems of adolescents compared to childhood and adulthood. This study aimed to examine the relationship between chronotype, bedtime, sleep quality and mental health among adolescents. This research was a descriptive-relational study. A total of 1083 students constituted the group of the research. The data were collected through the Morningness-Eveningness Questionnaire (MEQ) and General Health Questionnaire and a questionnaire consisting of some questions about sleep. In the evaluation of data, multiple regression, mediation and path analysis were performed. Age, having problems affecting sleep, difficulties falling asleep, sharing the room with someone else and lack of leisure activities were related to bedtime. It was found that determinants of sleep quality were the variables related to sleep itself. Being a male student, having problems affecting sleep, difficulties falling at sleep, waking up during the night, getting support in the morning for waking up and lack of leisure activities negatively affected mental health. MEQ scale was interpreted as a determinant of sleep time, sleep quality, and mental health level. Although the MEQ score directly affected sleep quality, bedtime had a partial mediation role between MEQ score and sleep quality. Sleep quality had a full mediation role between MEQ score and mental health score. School health workers, especially nurses, should consider chronotype-focused measures to improve adolescents' sleep quality and psychosocial health.

Longitudinal associations of nightmare frequency and nightmare distress with suicidal behavior in adolescents: mediating role of depressive symptoms

STUDY OBJECTIVES

Nightmares are a significant risk factor of suicidal behavior. This study examined the longitudinal associations of nightmare frequency and distress with suicidal thought (ST), suicide plan (SP), and suicide attempt (SA) and mediating role of depressive symptoms in adolescents.

METHODS

A total of 6,923 adolescents who participated in the 1-year follow-up of Shandong Adolescent Behavior & Health Cohort were included for the analysis. Participants completed a self-administered questionnaire to assess nightmares, sleep duration, insomnia, depressive symptoms, substance use, prior suicidal behavior, and family demographics in November-December in 2015. One year later, a follow-up survey was conducted to ask participants to report their depressive symptoms and suicidal behaviors.

RESULTS

Of the sample, 26.2% reported having frequent nightmares (at least twice/month) at baseline, and 10.0%, 3.6%, and 2.7% reported having ST, SP, and SA over 1-year follow-up. The rates of subsequent ST, SP, and SA all significantly increased with baseline nightmare frequency and distress. Path analyses showed that depressive symptoms played a significant mediating role in the associations of frequent nightmares and elevated nightmare distress with ST, SP, and SA before and after adjusting for adolescent and family covariates and prior suicidal behavior.

CONCLUSIONS

Suicidal risk increased with nightmare frequency and distress among adolescents. The association between nightmares and suicidal behavior was at least partially mediated by depressive symptoms. Assessing and intervening nightmares and depressive symptoms associated with nightmares may have important implications for preventing adolescent suicidal behavior.

Sleep Quality and Duration in European Adolescents (The AdolesHealth Study): A Cross-Sectional, Quantitative Study

Sleep is a vital element of adolescents' overall health; it influences their body and mind and thus affects their quality of life. Adequate sleep quality and duration are essential for maintaining optimal metabolic health and lowering the risk of developing several medical conditions, such as cardiovascular disease. The current study aimed to assess the perceived sleep quality and duration of 1717 European adolescents from three different European countries (Spain, Iceland and Estonia) aged 13- to 16-years (900 boys, 817 girls) using the Pittsburgh Sleep Quality Index (PSQI). A multivariate analysis of variance (MANOVA) was performed to examine differences between groups and two-factor analysis of variance (ANOVA) was used to analyze city and age differences. The probability of having poor sleep quality and duration was calculated by Odd-Ratio (OR). Our study found poor sleep quality in 44% of the boys and 53% of the girls, whereas 68% and 69%, respectively did not get the recommended hours of sleep (i.e., 8-10 h). No difference was found between adolescents from Estonia, Iceland and Spain regarding sleep duration. In contrast, Spanish and Estonian adolescents reported higher probabilities of having poor sleep quality. Finally, girls had a significantly higher probability of poor sleep quality than boys.

Is napping related with health-related behaviors and sleep habits among adolescents? A population-based study

INTRODUCTION

Changes in sleep quality and quantity occur in adolescence and can lead to the compensatory behavior of daytime napping.

OBJECTIVE

Analyze factors related to napping in adolescents.

METHODS

A population-based cross-sectional study was conducted with 1022 adolescents who participated in the 2014-2015 Health Survey of the city of Campinas, state of São Paulo, Brazil. Napping was the dependent variable. Sociodemographic characteristics, living habits, health-related behaviors, feelings of loneliness, satisfaction with life and nocturnal sleep habits were the independent variables. Data analysis was performed using Rao-Scott chi-square test, unpaired Student's t-test and Poisson regression analysis; p < 0.05 was considered significant. The software STATA was used for analysis.

RESULTS

Mean participant age was 14.6 years (SD: 2.7; range: 10 to 19 years). Males accounted for 50.9% of the sample and 55.7% had white skin color. A total of 40.5% reported napping. Napping was more common in females (p = 0.006), the 14-to-17-year-old age group (p = 0.002), those who took medications in the previous 15 days (p = 0.001), those who were insufficiently active (p = 0.036), those who reported little or no satisfaction with life (p = 0.008) and those who woke up in bad mood (p = 0.004). Adolescents who napped also reported shorter sleep during the week (p < 0.001) and a perceived greater need for sleep (p < 0.001).

CONCLUSION

The prevalence of napping among the adolescents was independently associated with shorter average sleep, a perceived greater need for sleep than that obtained and waking up in a bad mood.

Dynamic fluctuations of emotional states in adolescents with delayed sleep phase-A longitudinal network modeling approach

BACKGROUND

Very late sleep rhythms are risks for social adjustment problems in adolescence. Using ecological momentary assessment data, we quantified and visualized temporal and contemporaneous within-persons dynamical relations of sleepiness and emotions in adolescents with and without late sleep rhythms.

METHODS

We analyzed a temporal network via multilevel vector autoregression (mlVAR) modeling and a contemporaneous network through the partial associations between the residuals of temporal and the between-subject multilevel models. We tested whether these networks were different between those with a late circadian rhythm [concurrent delayed sleep phase (DSP) N = 172, 37% boys, 63% girls] and those without (N = 143, 22% boys, 78% girls).

RESULTS

In adolescents without DSP, the temporal networks showed continuity only for low mood from the previous to the following time point. In adolescents with DSP, there were more predictable patterns of emotions. Feelings of depression led to a decrease of positive emotions and increase of irritation and anxiety. The contemporaneous networks showed clusters of positive and negative emotions in both groups and sleepiness decreased the experience of positive emotions concurrently.

LIMITATIONS

DSP in our current study was based only on one out of three diagnostic criteria of the full disorder (DSM-5) and it was assessed only once.

CONCLUSIONS

These findings indicate that the dynamic organization of emotions and sleepiness is different in adolescents with and without DSP. DSP adolescents have more predictable and maladaptive emotional patterns during the day. Results provide new insight about why individuals with DSP are at a heightened risk for decreased emotional adjustment.