Intolerance of uncertainty and adolescent sleep quality: The mediating role of worry

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Highlights

  • The negative effect of intolerance of uncertainty (IU) on adolescent sleep quality is identified.

  • The relationship between IU and adolescent sleep quality is mediated by worry.

  • Some means of improving adolescent sleep quality is proposed.

Abstract

This study explores the relationship between intolerance of uncertainty (IU) and adolescent sleep quality, and tests whether this relationship is mediated by worry. A total of 2286 Chinese adolescents with a mean age of 15.0 years (SD = 1.7) were recruited; they completed questionnaires relating to IU, worry, and sleep quality. The results showed that greater IU was positively correlated with poorer adolescent sleep quality, and this relationship was mediated by worry. The mediating model of worry showed gender and grade invariances. The implications of this study were discussed.

Introduction

Sleep quality is one of the most important indices of adolescent health (Shochat, Cohen-Zion, & Tzischinsky, 2014). In many countries, however, sleep quality in adolescents has been found to be poor, which have reflected insufficient sleep duration, low sleep efficiency, daytime dysfunction, and more (Gradisar et al., 2011, Lin et al., 2010). Poor sleep quality can seriously affect adolescents' learning capacity, school performance, and neurobehavioral functioning (Shochat et al., 2014, Dewald et al., 2010). Therefore, it is important to determine the potential variables relating to adolescent sleep quality and identify means of improving this situation.

IU refers to a dispositional characteristic that results from a set of negative beliefs about uncertainty and its implications (Dugas & Robichaud, 2007). IU was originally observed in the domain of Generalized Anxiety Disorder (GAD); Dugas, Gagnon, Ladouceur, and Freeston (1998) and Dugas, Marchand, and Ladouceur (2005) defined it as a key factor in causing and maintaining GAD and worry. Studies with adolescent samples support the positive effects of IU on adolescent worry (Dugas et al., 2012, Fialko et al., 2012). In recent years, more and more research has shown that IU is also an important factor in other adolescent health problems, such as cyberchondria (Fergus, 2015, Norr et al., 2015), eating disorders (Renjan et al., 2016, Wheaton et al., 2016), and alcohol abuse (Kraemer, McLeish, & O'Bryan, 2015). It also influences adolescents' behavior-based decisions (Carleton et al., 2016), memory bias (Francis, Dugas, & Ricard, 2016), and personalities (Fergus & Rowatt, 2014).

To our knowledge, although the role of IU in many adolescent health problems has been remarked upon, the relationship between IU and adolescent sleep quality has been infrequently tested. Adolescents with greater IU manifest negative beliefs regarding uncertainty, avoidance or increased vigilance regarding perceived threats, and elevated negative emotional arousal (Meeten, Dash, Scarlet, & Davey, 2012), all of which lead to sleep-related problems (Harvey, 2002). Many studies of GAD patients showed that patients with greater IU suffer from sleep dysfunctions including longer Sleep Latency, decreased Sleep Duration, decreased total sleep efficiency, and increased waking periods during sleep time (Bélanger et al., 2004, Tsypes et al., 2013). Intervention studies have also indicated that when the level of IU is reduced, patients' sleep quality improves (Clementi & Alfano, 2014). This study will explore the relationship between IU and adolescent sleep quality and its mediating mechanism.

In this research, the effect of worry will also be considered, because worry is not only the other important cognitive factor for adolescent sleep difficulties, but also highly correlated with IU. Worry refers to repetitive thinking about future negative events that is both harmful and uncontrollable (Meeten et al., 2012). Worry is also an important cognitive component of anxiety (Dugas et al., 2012, Fialko et al., 2012). Although IU and worry are related to uncertainty, they are independent concepts. IU refers to a low threshold of tolerance for uncertainty, while worry is the repetitive thinking about ambiguous future events (Dugas & Robichaud, 2007). IU is a key factor in causing and maintaining worry; this has been proven to be the case in adults, patients with GAD (e.g., McEvoy and Mahoney, 2013, Norr et al., 2013), and adolescents (e.g., Dugas et al., 2012, Fialko et al., 2012, Thielsch et al., 2015). Previous studies with adolescents have showed that negative beliefs about uncertainty may result in difficulties dealing with ambiguity-inducing situations, which lead to excessive worry (Dugas et al., 2012). IU is also a higher-order vulnerability factor for adolescent worry, predisposing individuals to cognitive avoidance and negative problem orientation (Fialko et al., 2012).

Furthermore, worry is an important cause of poor adolescent sleep quality (Harvey, 2002, Carney et al., 2010, Yan et al., 2014). According to the cognitive model of Sleep Disturbance, worry is a potential underlying cause of sleep-related difficulties (Harvey, 2002). Excessive worry can elevate arousal above a critical threshold, interrupting the natural sequence of relaxation, drowsiness, and onset of sleep (Harvey, 2002). The effects of worry on adolescent Sleep Disturbances have been widely tested via empirical studies (e.g., Akerstedt et al., 2007, Carney et al., 2010, Yan et al., 2014; for a review, see Pillai & Drake, 2015). Excessive worry belongs to cognitive hyperarousal, which directly increases the risk of poor sleep quality (Harvey, 2002). However, IU is a cognitive threshold or filter for an individual's perceptions (Dugas & Robichaud, 2007). Compared to worry, it is less directly associated with sleep difficulties, but may be associated with sleep disturbances via worry (Harvey, 2002). Therefore, the relationship between IU and adolescent sleep quality may be mediated by worry.

In sum, IU appears to be an important element of cognitive vulnerability affecting adolescent sleep quality. From the cognitive perspective, this study will empirically explore the relationship between IU and sleep quality with considering the mediating role of worry. In this study, IU, sleep quality, and worry in adolescents were measured by the short version of the intolerance of uncertainty scale (IUS-12), Pittsburgh Sleep Quality Index (PSQI), and Worry Tendency Questionnaire for Chinese Adolescents (WTQ-CAs), respectively. Two questions will be tested: (1) Is a greater IU positively correlated with poorer adolescent sleep quality? and (2) Is this relationship mediated by worry?

Section snippets

Participants

The participants in this research were recruited via a cluster sampling from six middle schools in Fuzhou, the seaside capital city of Fujian province in China. Because students in the 9th and 12th grades were preparing for the high school and college entrance exams, respectively, they were not recruited for this research. Participants completed their questionnaires in class; the surveys were administered by their psychological health education or head teachers. A total of 2400 participants'

Primary analysis

The mean of the PSQI values was 5.42 (SD = 2.65). Females showed significantly higher than males in PSQI. Older adolescents showed higher values than early adolescents in PSQI ((5.82 ± 2.54) vs (5.01 ± 2.70), t = 7.23, p < 0.001, rpb = 0.15). There were also significant grade differences in PSQI. Older adolescents showed higher values than early adolescents in IU ((34.67 ± 9.38) vs (33.17 ± 9.88), t = 3.58, p < 0.001, rpb = 0.08). There were also statistically significant differences by grade in terms of IU and its

Discussion

The aims of this study were to test the relationship between IU and adolescent sleep quality, and the mediating role of worry for this relationship. The results indicated that a greater IU was positively correlated with poorer adolescent sleep quality, and this relationship was partially mediated by worry. The questions raised in the introduction were validated. This research also found that although gender and grade differences affected adolescent sleep quality, IU, and worry, the mediating

Conclusion

This study suggested that adolescent IU is directly associated with sleep quality but also indirectly correlated through the mediating role of worry. Some approaches targeting in greater IU and excessive worry might be effective for improving adolescent sleep quality.

Funding Acknowledgments

This research was supported by a grant from the Humanities and Social Science Foundation of Ministry of Education, China (No. 13YJA190016).

References (37)

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    Parent-child agreement on the IUSC was only r = .16; disagreement in parent and child report is common in child anxiety disorders, especially for unobservable symptoms (e.g., Comer & Kendall, 2004; De Los Reyes et al., 2012). To date, studies examining IU in youth have utilized the IUSC child and/or parent report (Boulter, Freeston, South, & Rodgers, 2014; Comer et al., 2009; Cowie, Clementi, & Alfano, 2016; Donovan, Holmes, & Farrell, 2016; Donovan, Holmes, Farrell, & Hearn, 2017; Kertz & Woodruff-Borden, 2013; Neil, Olsson, & Pellicano, 2016; Read, Comer, & Kendall, 2013; Sanchez, Kendall, & Comer, 2016, 2017), the IUS or IUS-12 adult measure administered to youth (Aloi & Segura-García, 2016; Barahmand, 2008; Boelen, Vrinssen, & van Tulder, 2010; Dekkers, Jansen, Salemink, & Huizenga, 2017; Dugas, Laugesen, & Bukowski, 2012; Hearn, Donovan, Spence, March, & Holmes, 2017; Krain et al., 2006, 2008; Laugesen, Dugas, & Bukowski, 2003; Lin, Xie, Yan, & Yan, 2017; Thielsch, Andor, & Ehring, 2015; Wright, Lebell, & Carleton, 2016), a 34-item parent and child-report measure of the extent to which uncertainty is unacceptable and aversive (Palitz et al., 2019) or 5 items from the IUS administered to youth (Fialko, Bolton, & Perrin, 2012; see Osmanağaoğlu, Creswell, & Dodd, 2018 for a recent metaanalysis). Some of this research has examined the relationship between IU and anxiety disorders in youth.

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    All studies used a child self-report questionnaire measure for worry. IU was measured using questionnaire measures in all 31 studies; seven studies used the Intolerance of Uncertainty Scale for Children (IUS-C) child report (Cowie et al., 2016; Dodd and Taylor, 2015; Donovan et al., 2016, 2017; Kertz and Woodruff-Borden, 2013; Osmanagaoglu et al., 2017; Read et al., 2013), three studies used the IUS-C parent report (Neil et al., 2016; Sanchez et al., 2017, 2016), three studies used both the parent and child report of IUS-C (Boulter et al., 2014; Comer et al., 2009; Cornacchio et al., under-review), eight studies used the Intolerance of Uncertainty Scale (IUS) which is a standardized adult measure to assess IU (Aloi and Segura-Garcia, 2016; Barahmand, 2008; Dugas et al., 2012; Krain et al., 2008, 2006; Laugesen et al., 2003; Morriss et al., 2014; Thielsch et al., 2015), six studies used the IUS-12 which is a shortened version of the IUS (Boelen et al., 2010; Dekkers et al., 2017; Freeston et al., 2015; Hearn et al., 2017; Lin et al., 2017; Wright et al., 2016), and four studies assessed IU by using only 5 items from the IUS (Cervin et al., under review; Fialko et al., 2012; Lunderg et al., under-review). Where both child and parent reported IU was available, the child report was used in the analysis, as there is poor agreement between parent and child report of IU; and it has been suggested that children are better reporters of their own IU (Comer et al., 2009).

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