Effects of Modifiable Activity-Related Health Behaviors on the Sleep-Pain Relationship in Adolescents.

Poor sleep and chronic pain are commonly related in adolescents. Only 5% of adolescents meet recommendations for physical activity and screen time, both of which impact the experience of sleep and pain disturbances. Research is needed to better understand the sleep-pain relationship in adolescents and to identify potential protective factors, such as activity-related health behaviors. This study examined sleep, behaviors that influence activity (i.e., physical activity, screen time), and their interaction as predictors of pain in a sleep-disordered sample of 105 adolescents aged 12-18 presenting for polysomnography. A hierarchical multiple linear regression was conducted to examine these relationships. Consistent with hypotheses, worse insomnia predicted worse pain. However, other activity-related health behaviors did not influence this relationship, ps > .05. Findings suggest that sleep should be the focus of treatment for adolescents with primary sleep disorders to prevent the onset or exacerbation of pain.

Associations Among Sleep, Emotional Eating, and Body Dissatisfaction in Adolescents.

The literature on adolescent sleep has shown a bidirectional relationship between sleep difficulties and altered eating habits, including emotional eating. However, it is unclear if this relationship is related to preexisting body concerns, or if poor sleep is the prime contributor to emotional eating patterns. This study therefore seeks to examine body dissatisfaction as a moderator of the sleep-emotional eating relationship in an at-risk sample. Adolescents (N = 106) presenting for overnight polysomnography self-reported on time-in-bed, insomnia, body dissatisfaction, and emotional eating. Less time-in-bed was correlated with a greater desire for thinness and greater insomnia severity was related to overall emotional eating and eating in response to anxiety, anger, and frustration and in response to depression. Moderation analyses revealed that the relationships between time-in-bed and eating in response to feeling unsettled (b = -.002, 95% CI[- .003, - .001], p < .005) and eating in response to anxiety, anger, and frustration (b = -.01, 95% CI[- .01, - .001], p < .05) were exacerbated by worse body dissatisfaction. Optimizing sleep may attenuate the risk for disordered eating, particularly for adolescents with high body dissatisfaction.

Exploring Bidirectional Relationships: Child Sleep Duration, Child Behavior Problems, and Parenting Stress in Families of Children with Autism Spectrum Disorder.

Background: Youth with Autism Spectrum Disorder (ASD) are at-risk for sleep and behavior problems, and their parents are at-risk for high stress. Child sleep duration, behavior problems, and parenting stress are interrelated; however, directionality of these associations is unclear and research including youth with ASD is lacking. Using a day-to-day, within-person design, this study explores the directionality of these relationships in families of children with ASD. Method: Twenty-six children (ages 3-5, 73.1% male, 65.4% Hispanic/Latino) with ASD and their mothers participated in a 14-day study. Child sleep duration (parent-report and actigraphy), behavior problems, and parenting stress were measured daily. Constructs were decomposed into their within- and between-person components and analyzed with random intercept cross-lagged panel models. Results: While between-person relationships were directionally expected in that shorter sleep, more behavior problems, and greater parenting stress were associated, within-person relationships were complicated. Better-than-average child behavior was associated with less next-day parenting stress, yet more parenting stress than average was associated with better next-day child behavior. As expected, longer-than-average child sleep was associated with less next-day parenting stress, while greater child behavior problems were associated with less sleep that night. Conclusions: Understanding the directionality of associations between child and parent factors allows for the optimization of interventions to improve the quality of life for families of children with ASD. Interventions that target child behavior and/or help parents manage stress while maintaining effective parenting strategies for sleep and behavior may be useful.

Insight Into the Adolescent Patient Experience With Nonalcoholic Fatty Liver Disease.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is the leading chronic liver disease in youth, yet little is known about the adolescent patient's experience with NAFLD, which is key for treatment engagement. We examined adolescents' experiences with NAFLD diagnosis, thoughts on how NAFLD affects their daily life, understanding and perceptions of diagnosis and treatment, and impressions of how to improve care. METHODS: Utilizing a mixed-method design, adolescents with NAFLD (N = 16; Mean age = 15.8 years; Mean BMI = 37 kg/m 2 ) participated in focus groups. To supplement qualitative data, adolescents and their caregiver completed measures assessing illness perceptions, adolescent quality of life, and eating/activity behaviors. RESULTS: Focus group themes suggested reactions to diagnosis varied from unconcerned to anxious. NAFLD diagnosis occurred within the context of other psychological/medical concerns and was not perceived to affect most adolescents' daily lives. Although adolescents understood general contributors to NAFLD, comprehension of their diagnosis varied. Adolescents were more likely to make lifestyle changes when families were supportive, and they preferred tailored recommendations for health behavior change from the healthcare team. Notably, 62.5% of adolescents were more concerned about their weight than NAFLD. Almost half (43.8%) identified as food insecure. CONCLUSIONS: Adolescents with NAFLD may benefit from personalized treatment. Care could be enhanced by ensuring comprehension of diagnosis, problem-solving personal, and family barriers and increasing family support. Harnessing adolescents' desire for weight loss may be a more salient driver for change in disease status. Interventions should also address systemic barriers such as food insecurity to ensure equitable care.

Prevalence of somatic and pain complaints and associations with sleep disturbance in adolescents with insomnia presenting to a behavioral sleep medicine clinic.

STUDY OBJECTIVES: Sleep problems are highly comorbid with pediatric pain, yet there is a dearth of research on how pain and somatic complaints impact adolescent insomnia presentation and response to cognitive-behavioral therapy for insomnia (CBT-I). This study aims to (1) determine the prevalence of parent-reported somatic/pain complaints in adolescents with insomnia presenting to a behavioral sleep clinic, (2) assess the impact of somatic/pain complaints on initial sleep presentation, and (3) assess the impact of baseline somatic/pain complaints on response to CBT-I. METHODS: Participants included adolescents (n = 375) presenting to a behavioral sleep medicine center with a primary diagnosis of insomnia. As a part of clinical care, pre-evaluation measures were completed including the Pediatric Insomnia Severity Index, Adolescent Sleep Hygiene Scale, Adolescent Sleep Wake Scale, and Child Behavior Checklist. The Somatic Syndrome Scale of the Child Behavior Checklist measured somatic complaints and teens were categorized as endorsing pain if reported to experience aches/pains, headaches, or stomachaches. Adolescents completed the Pediatric Insomnia Severity Index at end of treatment. RESULTS: Most adolescents had parent-reported somatic (61.1%) and/or pain complaints: headaches (66.6%), stomachaches (48.5%), and aches/pains (45.1%). Greater somatic and pain complaints predicted a worse sleep presentation at intake (all P < .05). After controlling for insomnia severity at intake, neither end-of-treatment insomnia severity nor treatment status were predicted by somatic and pain complaints at intake. CONCLUSIONS: Results suggest that parent-reported somatic/pain complaints are prevalent in > 50% of adolescents seeking behavioral insomnia treatment. Although complaints are associated with more severe insomnia at intake, they do not appear to interfere with treatment response. CITATION: Van Dyk TR, Krietsch KN, King CD, Byars KC. Prevalence of somatic and pain complaints and associations with sleep disturbance in adolescents with insomnia presenting to a behavioral sleep medicine clinic. J Clin Sleep Med. 2022;18(1):151-160.

Poor sleep and adolescent obesity risk: a narrative review of potential mechanisms.

Poor sleep is related to increased obesity risk in adolescents, though the mechanisms of this relationship are unclear. This paper presents a conceptual framework of the various pathways that have been proposed to drive this relationship. In this framework, increased food reward, emotional reactivity, decreased inhibitory control, metabolic disturbances, poorer dietary quality, and disrupted meal timings may increase the likelihood of increasing overall energy intake. This paper further notes how poor sleep increases sedentary behavior and screen time, which likely limits overall energy expenditure. The model posits that these mechanisms result in an imbalance of energy intake and expenditure following poor sleep, intensifying the overall risk for obesity. Increases in food reward processes, decreases in insulin sensitivity, disrupted meal timing, and increases in sedentary behavior seem to be the most compelling mechanisms linking poor sleep with increased obesity risk in adolescents. Future directions and clinical implications of this framework are discussed.

Rates of Mental Health Symptoms and Associations With Self-Reported Sleep Quality and Sleep Hygiene in Adolescents Presenting for Insomnia Treatment.

STUDY OBJECTIVES: Despite high prevalence rates of both psychopathology and sleep problems during adolescence, as well as frequent co-occurrence, little is known about the mental health of adolescents presenting for insomnia evaluation and treatment. This study describes (1) rates of mental health symptoms and (2) associations of mental health symptoms with sleep behaviors and schedules in adolescents presenting to a behavioral sleep medicine clinic within an accredited sleep disorders center. METHODS: As a part of routine clinical care, 376 adolescents (ages 11 to 18 years) presenting for insomnia evaluation completed measures of insomnia and sleep behavior. Their caregiver reported on mental health diagnoses and symptoms. RESULTS: Adolescents had high rates of mental health diagnoses (75%) and clinically elevated symptoms (64%). Affective, anxiety, and attention deficit-hyperactivity disorder (ADHD) symptoms were most commonly reported. Mental health symptoms were related to sleep behaviors and insomnia severity, with ADHD symptoms and affective problems most consistently associated with disrupted sleep. CONCLUSIONS: Health providers should assess for mental health problems in youth presenting with sleep-related concerns. Intervening with both sleep and mental health problems should be considered to most effectively improve functioning.

Feasibility and impact on daytime sleepiness of an experimental protocol inducing variable sleep duration in adolescents.

Although most research on sleep and adolescent health has focused on how long each youth sleeps on average, variability in sleep duration may be just as problematic. Existing findings have been inconsistent and unable to address cause-effect relationships. This study piloted an experimental protocol to induce sleep variability and explore its impact on daytime sleepiness in adolescents. Healthy adolescents aged 14-17 participated in a 3-week, at-home protocol. Sleep was monitored by sleep diaries and actigraphy. Following a run-in period to stabilize wake times (set at 6:30am throughout the protocol), participants were randomly counterbalanced across two 5-night experimental conditions. Bedtimes were consistent at 11:00pm during the stable sleep condition (7.5-hour sleep period each night) but changed on alternating nights during the variable sleep condition (ranging from 9:30pm to 12:30am) so that sleep duration averaged 7.5 hours across the condition with a standard deviation of 1.37 hours. Difficulty waking was assessed each morning and daytime sleepiness was assessed by end-of-condition parent- and adolescent-reports. Of the 20 participants who completed the study, 16 met the predetermined adherence definition. For those who were adherent, there were no differences in overall sleep duration between the stable and variable sleep conditions (p>.05) but adolescents had 58.6 minutes greater night-to-night variation in sleep duration in the variable condition (p < .001). Across all nights, youth reported greater difficulty waking following nights of shorter assigned sleep (p = .004) and greater overall sleepiness during the variable condition (p = .03). It is feasible to experimentally vary how long adolescents sleep on a nightly basis while holding average sleep duration constant. Such a protocol will promote tests of the acute effects of day-to-day changes in sleep duration on health.

Mental Health Diagnoses and Symptoms in Preschool and School Age Youth Presenting to Insomnia Evaluation: Prevalence and Associations with Sleep Disruption.

Objective/Background: Sleep problems and emotional and behavioral difficulties are highly correlated in community samples of youth and in youth presenting to mental health treatment. However, fewer studies have characterized the associations between sleep and psychopathology symptoms in youth presenting to pediatric sleep clinics. This retrospective, cross-sectional study examined the prevalence of psychopathology symptoms and their associations with sleep disruption in youth presenting to a behavioral sleep medicine clinic. Participants: Participants were 373 preschoolers (1.5 to 5 years old) and 300 school age youth (6 to 10 years old) presenting to a pediatric behavioral sleep medicine clinic with a primary insomnia diagnosis. Methods: As a part of routine clinical care, parents completed a battery of pre-evaluation measures assessing insomnia severity, sleep disturbance, history of mental health diagnosis, and psychopathology symptoms. Results: Both preschool and school age youth had high rates of parent-reported mental health diagnoses (35% and 74%, respectively) and clinically elevated psychopathology symptoms (69% of preschoolers and 77% of school age youth) at initial insomnia evaluation. These symptoms were significantly associated with sleep disruption, with ADHD and affective problems most consistently associated with sleep problems in preschoolers and symptoms of anxiety, affective, and behavioral problems most consistently associated with sleep problems in school age youth. Conclusions: Psychopathology symptoms should be regularly assessed in youth presenting to behavioral sleep medicine clinics. Further, the role of psychopathology should be considered in insomnia conceptualization and treatment and, when appropriate, psychopathology symptoms should be targeted in treatment or appropriate referrals should be made.

Inducing more sleep on school nights reduces sedentary behavior without affecting physical activity in short-sleeping adolescents.

OBJECTIVES/BACKGROUND: Short sleep duration during adolescence is associated with increased dietary intake and greater risk for overweight/obesity. However, findings are mixed on the relationship between sleep and physical activity (PA) during the school year, when short sleep duration is most common. Furthermore, there is concern that increasing sleep duration may interfere with opportunities for PA, yet this has not been directly tested. This study examined the impact of an at-home experimental sleep extension protocol on PA during the school year among short-sleeping adolescents. PARTICIPANTS/METHODS: Participants included 18 adolescents (67% female, 78% white) who reported regularly sleeping between 5-7 h on school nights. Adolescents completed a five-week, at-home sleep manipulation protocol with an initial baseline week followed in a randomized, counterbalanced order by two experimental conditions, each lasting two weeks. During prescribed habitual sleep (HAB), bedtimes and rise times were set to match the baseline sleep pattern, and during sleep extension (EXT), adolescents were instructed to increase time in bed on school nights by 1.5 h per night relative to baseline. Wrist-mounted actigraphy was employed to monitor sleep and waist-mounted accelerometers were used to measure daytime PA. RESULTS: Adolescents slept for an average duration of 71 min longer on school nights during EXT than during HAB (p < 0.001). During HAB, adolescents spent more time in sedentary behavior (p = 0.002) than during EXT, but there were no cross-condition differences in light activity (p = 0.184) or moderate-to-vigorous PA (p = 0.102). CONCLUSIONS: Extending sleep duration on school nights in short-sleeping adolescents reduces time spent in sedentary behavior, without having a negative impact on health-promoting moderate-to-vigorous PA.

Feasibility and Emotional Impact of Experimentally Extending Sleep in Short-Sleeping Adolescents.

Study Objectives: Published experimental sleep manipulation protocols for adolescents have been limited to the summer, limiting causal conclusions about how short sleep affects them on school nights, when they are most likely to restrict their sleep. This study assesses the feasibility and emotional impact of a school-night sleep manipulation protocol to test the effects of lengthening sleep in habitually short-sleeping adolescents. Methods: High school students aged 14-18 years who habitually slept 5-7 hours on school nights participated in a 5-week experimental sleep manipulation protocol. Participants completed a baseline week followed in randomized counterbalanced order by two experimental conditions lasting 2 weeks each: prescribed habitual sleep (HAB; sleep time set to match baseline) and sleep extension (EXT; 1.5-hour increase in time in bed from HAB). All sleep was obtained at home, monitored with actigraphy. Data on adherence, protocol acceptability, mood and behavior were collected at the end of each condition. Results: Seventy-six adolescents enrolled in the study, with 54 retained through all 5 weeks. Compared to HAB, during EXT, participants averaged an additional 72.6 minutes/night of sleep (p < .001) and had reduced symptoms of sleepiness, anger, vigor, fatigue, and confusion (p < .05). The large majority of parents (98%) and adolescents (100%) said they would "maybe" or "definitely" recommend the study to another family. Conclusions: An experimental, school-night sleep manipulation protocol can be feasibly implemented which directly tests the potential protective effects of lengthening sleep. Many short-sleeping adolescents would benefit emotionally from sleeping longer, supporting public health efforts to promote adolescent sleep on school nights.

Intraindividual variability of sleep/wake patterns in relation to child and adolescent functioning: A systematic review.

Substantial research attention has been devoted to understanding the importance and impact of sleep in children and adolescents. Traditionally, this has focused on mean sleep variables (e.g., a child's "typical" or average sleep duration), yet research increasingly suggests that intraindividual variability (IIV) of sleep/wake patterns (sometimes referred to as sleep variability or night-to-night variability) regularly occurs and may have implications for adjustment. A systematic search of five electronic databases identified 52 empirical studies published between 2000 and 2015 that examined correlates of sleep IIV in children and adolescents, with a recent increase in the publication rate of such studies. Identified studies were often atheoretical and included post hoc analyses, though IIV in select aspects of sleep does appear to be associated with increasing age/pubertal status, non-White race, physical and neurodevelopmental conditions (e.g., attention-deficit/hyperactivity disorder; autism), psychopathology symptoms (e.g., anxiety, depression, inattention), body weight, stress, aspects of cognitive functioning, and poorer sleep functioning/habits. The limited intervention work examining sleep IIV in adolescents is promising, though studies are needed using more rigorous intervention designs. Clinical sleep recommendations may not only need to address overall sleep duration and sleep habits but also the stability of sleep duration and timing. It will be important for future research examining sleep IIV in children and adolescents to use a developmental framework in advancing theory pertaining to the causes, mechanisms, moderators, and outcomes of sleep IIV in youth, and a conceptual model is proposed to help guide such efforts.

Daily Bidirectional Relationships Between Sleep and Mental Health Symptoms in Youth With Emotional and Behavioral Problems.

OBJECTIVE: The present study examined the daily, bidirectional relationships between sleep and mental health symptoms in youth presenting to mental health treatment. METHODS: Youth aged 6 to 11 (36% female, 44% European American) presenting to outpatient behavioral health treatment (N = 25) were recruited to participate in the study. Children and parents completed daily questionnaires regarding the child's sleep, mood, and behavior for a 14-day period, while youth wore an actigraph watch to objectively measure sleep. RESULTS: Examining between- and within-person variance using multilevel models, results indicate that youth had poor sleep duration and quality and that sleep and mental health symptoms were highly related at the daily level. Between-person effects were found to be most important and significant bidirectional relationships exist. CONCLUSIONS: Identifying and addressing sleep problems in the context of mental health treatment is important, as poor sleep is associated with increased symptomology and may contribute to worsened mental health.

The Moderating Role of Dysfunctional Parent-Child Relationships on the Association Between Outward Anger Expression and Physical Health in Youth From Low-Income Families.

OBJECTIVE: The purpose of this study is to examine the role of outward anger expression on physical health outcomes (number of illnesses in the past year, 2-year medical service utilization, and health-related quality of life) while also expanding on previous research by assessing the moderating effect of parent-child dysfunction. METHOD: An ethnically diverse sample of 125 children, ages 8 to 11 years, was recruited from a family medicine practice serving a low-income population. RESULTS: High levels of outward anger expression were related to a greater number of illnesses, greater medical service utilization, and lower health-related quality of life. Additionally, worse parent-child dysfunction exacerbated this relationship for a number of illnesses and medical service utilization. CONCLUSION: Results suggest that health care providers should consider the influence of environmental and familial factors on the physical health of children with anger. Recommendations for identifying at-risk youth and improving anger expression as well as parent-child relationships are provided.

Stimulant Medications and Sleep for Youth With ADHD: A Meta-analysis.

CONTEXT: Mixed findings exist on whether stimulant medications alter youth sleep. OBJECTIVE: To determine the effect of stimulant medications on sleep. DATA STUDIES: Studies published through March 2015 were collected via CINAHL, PsycINFO, and PubMed. References of retrieved articles were reviewed. STUDY SELECTION: Eligibility criteria included studies with children/adolescents who had attention-deficit/hyperactivity disorder (ADHD), random assignment to stimulants, and objective sleep measurement. Studies that did not include information about key variables were excluded. DATA EXTRACTION: Study-level, child-level, and sleep data were extracted by 2 independent coders. Effect sizes were calculated by using random effects models. Potential moderators were examined by using mixed effect models. RESULTS: A total of 9 articles (N = 246) were included. For sleep latency, the adjusted effect size (0.54) was significant, indicating that stimulants produce longer sleep latencies. Frequency of dose per day was a significant moderator. For sleep efficiency, the adjusted effect size (-0.32) was significant. Significant moderators included length of time on medication, number of nights of sleep assessed, polysomnography/actigraphy, and gender. Specifically, the effect of medication was less evident when youth were taking medication longer. For total sleep time, the effect size (-0.59) was significant, such that stimulants led to shorter sleep duration. LIMITATIONS: Limitations include few studies, limited methodologic variability, and lack of unpublished studies. CONCLUSIONS: Stimulant medication led to longer sleep latency, worse sleep efficiency, and shorter sleep duration. Overall, youth had worse sleep on stimulant medications. It is recommended that pediatricians carefully monitor sleep problems and adjust treatment to promote optimal sleep.

A Meta-Analysis of the Effect of Experimental Sleep Restriction on Youth's Attention and Hyperactivity.

This meta-analysis examined the effect experimental sleep restriction has on youth's attention and hyperactivity outcomes. Thirteen published studies containing 17 independent samples were included (N = 496). Random- and fixed-effects models were used to estimate pooled effect sizes and moderator effects, respectively. Results indicate that sleep-restricted youth had significantly worse attention outcomes than youth with extended sleep, but no differences were evident regarding hyperactivity. Significant moderators of this effect included age and sex. These results have important implications for both the prevention and treatment of attention problems, highlighting the need for health professionals to screen for and treat underlying sleep issues.

Peer victimization and child physical health: the moderating role of pessimism.

OBJECTIVE: Involvement in peer victimization has been associated with numerous negative consequences, including poor physical health. The purpose of this study is to improve on previous research evaluating the victimization-health relationship by examining the health (i.e., health-related quality of life [HRQoL], medical service utilization) of both victims and aggressors and examining individual variation in this relationship through the moderating effect of pessimism. METHOD: The sample included 125 ethnically diverse youth aged 8-11 years recruited from a low-income medical practice. Child-report of involvement in peer victimization and pessimism was assessed along with parent-report of HRQoL. 2-year medical service utilization was extracted from medical records. RESULTS: Although not all hypotheses were supported, victims and aggressors were found to be at increased risk for certain poor health outcomes, which were exacerbated by high levels of pessimism. CONCLUSION: Findings expand on research into peer victimization and health and provide important implications for identification, prevention, and intervention strategies with at-risk youth.

Psychosocial stressors and health behaviors: examining sleep, sedentary behaviors, and physical activity in a low-income pediatric sample.

OBJECTIVE: To better understand the relationship between psychosocial stressors and health behaviors in a low-income pediatric sample. METHOD: Participants were 122 children (8-11 years old, 53.3% female) and their parents recruited from a low-income primary care clinic. Measures assessed child stressors and parental financial strain, and child sleep problems, sedentary behaviors, and physical activity. RESULTS: Parental financial strain and child stressors were independently associated with sleep problems and sedentary behaviors, controlling for age and gender. Though stressors in general accounted for significant variance in physical activity, results indicate a complex relationship as parental financial strain predicted more physical activity and child stressors predicted less physical activity. CONCLUSION: Stressors are associated with adverse pediatric health behaviors. Consequently, chronic stressors could negatively affect long-term health, and interventions targeting stressors and health behaviors are indicated. Pediatric health care providers play a key role in promoting health behaviors among youth experiencing significant psychosocial stressors.