Impact of insomnia on future functioning of adolescents
Introduction
Despite the inherent importance of the restorative effects of sleep, there is scant information available on sleep behaviors [1], [2] and sleep disturbances among adolescents [3], [4], [5] and the implications of these disturbances and problems for well-being.
Transition to an earlier school start time, along with pubertal phase delay, significantly affects teenagers' sleep quality, sleep/wake schedule, and daytime behavior. The combination of the phase advance, late-night activities or jobs, and early-morning school demands can significantly constrict hours available to sleep [6], [7]. The available community and school-based studies examining the prevalence of sleep disturbances in youths indicate that symptoms of insomnia and hypersomnia are common. For example, Dahl [8] notes that studies in nonclinical populations have found that 20–30% of children and adolescents have complaints or difficulties related to sleep that are regarded as significant. It is difficult to interpret the prevalence rates reported and reports of factors found to be associated with reports of sleep problems in these studies due to variability in operational definitions, sample populations, and assessment techniques (not to mention differences in methodologies, sample sizes, and statistical analyses). Most of the studies have been school-based rather than community-based.
Ohayon and Guilleminault [9] reviewed all epidemiologic surveys of sleep disorders published over a 20-year period that had focused on insomnia, excessive sleepiness, sleep-disordered breathing, and parasomnia. Not a single one had adolescent sleep problems as a focus. Although not designed as a sleep study per se, a small study (n=304) of 18-year-olds in Spain [10] found the prevalence of any DSM-III-R sleep disorder (13.4%) was higher than the prevalence of affective disorders (7.2%) or anxiety disorders (2.7%). Insomnia was the most prevalent sleep disorder (13.1%). Ohayon et al. [11] have published the most systematic assessment of the prevalence of sleep problems among adolescents (aged 15–18). They found the prevalence of DSM-IV sleep disorders to be relatively low. The prevalence of primary insomnia was 2.2%, primary hypersomnia was 0.2%, and circadian rhythm disorder was 0.5%. Symptoms of sleep disturbance were much more common: difficulties initiating sleep (12.4%), difficulties maintaining sleep (9.2%), early-morning awakening (10.5%), nonrestorative sleep (13.8%), daytime sleepiness (19.9%), nightmares (4.2%), night terrors (2.4%), and sleep walking (5.0%).
Available evidence documents that youths with disturbed sleep also experience a range of deficits in psychological, somatic, and interpersonal functioning [12]. Dahl [4] notes that within groups of children and adolescents with psychiatric, behavioral, or emotional problems, rates of sleep disorders are elevated. He also notes that in nonclinical populations, youth with sleep problems appear to have elevated rates of psychological dysfunction. Recent reviews by Anders and Eiben [3] and Anders [13] conclude that sleep disruption in youths and psychiatric disorders remains controversial, a conclusion shared by Dahl [14]. For example, Johnson et al. [15] found that children with trouble sleeping had significantly increased odds of anxiety/depression based on mother reports but not teacher reports. This association was limited to cross-sectional data, however. In prospective analyses, the association of trouble sleeping at age 6 with incidence of depression at age 11 was not statistically significant. However, there are no community-based, epidemiologic studies that have examined this issue among adolescents in the United States. Even for key disorders such as major depression, ADHD, and substance abuse, results of studies have not been very informative, due in part to small samples, heterogeneous diagnostic subgroups, short-term follow-up periods, and lack of large-scale experimental and epidemiologic investigations.
But evidence on the effects of disturbed sleep on functioning of adolescents is limited, both in amount and scope, as recent reviews document [16], [17], [18]. The evidence that we have indicates that poor sleep is associated with both behavioral and emotional problems among adolescents. For example, adolescents with disturbed sleep report more depression, anxiety, irritability, fearfulness, anger, tenseness, emotional instability, inattention and conduct problems, drug use, and alcohol use [16], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30]. Youths with sleep problems also report more suicidal ideation and attempts [24], [28], [31]. Adolescents with problematic sleep also have been found to have more fatigue [22], less energy, symptoms of headache, stomachache, backache, and worse perceived health [26], [28], [29], [30], [32], [33], [34]. Not all studies find such an association, however [35]. Although studies have rarely directly examined the role of stress in epidemiologic studies of adolescent sleep problems, there is some evidence that youths experiencing stress also experience more sleep problems [30].
For some domains, such as suicidal ideation and attempts as well as somatic health status and interpersonal relations, the evidence is still somewhat limited. For example, only three studies have examined suicidal behaviors and adolescent sleep problems [24], [28], [31]. Disturbed sleep was associated with more suicidal ideation and gestures. Only two studies have examined the effects of disturbed sleep on family relationships [21], [28]. Hauri and Sobel [21] found sleep pathology was not related to various indicators of family functioning, whereas Vignau et al. [28] found adolescent sleep problems were associated with parental marital status (separated or divorced), mental health problems in the parents, and physical health problems in the parents. There is increasing evidence that emotional and behavioral problems among children and adolescents do not occur in isolation. Rather, youths who experience problems or deficits in one domain are at much greater risk of having other deficits or problems. For example, children and adolescents who have one psychiatric disorder are at greater risk of having a second disorder, sometimes more. In some studies, half of those youths with a psychiatric disorder had at least one other disorder [36], [37], [38].
Roberts et al. [39] examined the association between disturbed sleep and the functioning of adolescents, in particular cumulative effects on functioning across multiple life domains. Correlates of insomnia were disturbed mood (odds ratio, OR=5.9), fatigue (OR=7.4), and suicidal ideation (OR=3.4). The same pattern held for hypersomnia, although the associations were not as strong for fatigue (OR=6.8), mood disturbance (OR=3.5), and suicidal ideation (OR=2.8). Youths who experienced both insomnia and hypersomnia had greater odds of psychological, interpersonal, and somatic dysfunction than youths who had experienced only one sleep disturbance. Cumulative effects of sleep problems were pronounced, with 27.6% of those with hypersomnia, 41.7% of those with insomnia, and 59.2% of those with both sleep problems reporting three or more types of dysfunction. The results suggest that adolescents experiencing disturbed sleep also experience a range of deficits in functioning (see also [40], [41]). From the available evidence, however, it is not possible to specify what the causal pathways are. Do sleep disturbances lead to deficits in functioning, or do deficits in functioning lead to disturbed sleep? This is due to the fact that there has been only one longitudinal study of adolescents that has examined this question [42], finding that disturbed sleep among adolescents at baseline did not predict future scores on neuroticism and extraversion. This study did not examine other indicators of functioning.
Clearly there is a paucity of studies that focus on the epidemiology of disordered sleep among adolescents, as our review indicates. In addition, very few of the available studies focus on consequences of disordered sleep, and almost none have used prospective designs to address this issue. Furthermore, definitions of sleep problems have varied enormously. Only one previous study has examined sleep disorders using diagnostic nomenclature [11]. No study that focused on consequences of disordered sleep has done so. Our purpose here is to reexamine the question of the effects of disordered sleep on adolescent functioning. We do so using a large, community sample of adolescents studied prospectively over 12 months, for which data are available on a broad array of measures of functioning, using symptoms of disturbed sleep that operationalize DSM-IV criteria for insomnia.
Section snippets
Methods
Teen Health 2000 was designed as a two-wave, prospective study of the prevalence of psychiatric disorder among adolescents in managed care and use of services for both psychiatric and somatic complaints. The sample was selected from households in the Houston metropolitan area enrolled in local health maintenance organizations. One youth 11–17 years was sampled from each eligible household, oversampling for African and Latino American households. Wave 1 data collection ended in early 2000 and
Results
The prevalences of symptoms of insomnia are presented in Table 1. As can been seen, symptoms of problematic sleep are common. Nearly 18% of the youths 11–17 years of age report nonrestorative sleep almost every day in the past month. Over 6% report difficulty initiating sleep, over 5% waking up frequently during the night, and another 3% early-morning awakening almost every day. Over 7% report daytime fatigue and another 5% daytime sleepiness. Combining “often” and “almost every day” response
Discussion
To summarize, prospective data from Teen Health 2000 provide evidence that insomnia has adverse consequences for the future functioning of adolescents. Multivariate analyses, not adjusting for insomnia at follow-up, show the negative impact is far-ranging, affecting many aspects of adolescents' lives. The average OR across 11 indicators of functioning, by way of example, was 2.5. Furthermore, for 9 of the 11 measures of dysfunction, there was a clear dose–response relation between insomnia and
Acknowledgements
This research was supported in part by Grant No. MH 49764 from the National Institute of Mental Health to the first author. An earlier version of this paper was presented at the Fourth Milano International Symposium on Sleep, “The Epidemiology of Sleep Disorders,” Milan, Italy, September 3–5, 2001.
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