Original ArticleAdverse childhood experiences and sleep disturbances in adults☆
Introduction
Sleep problems are very common among US adults. According to the National Sleep Foundation’s 2005 Sleep in America poll, a quarter of respondents reported having a “good night’s sleep” only a few nights per month or less. In addition, one-third reported at least one symptom of insomnia every night or almost every night during the past year [1]. One in ten American adults (11%) in 2008 reported insufficient rest or sleep every night for the past 30 days [2]. Sleepiness has been strongly associated with the risk of driving crashes and near misses [3], [4], falls among older adults [5], and injuries in young children [6]. In adults, insufficient sleep (defined as ⩾14 days in the past 30 days) was significantly correlated with cigarette smoking, heavy drinking in men, physical inactivity, mental distress, depressive symptoms, anxiety, frequent pain, and obesity [7]. Inadequate sleep has also been linked to weight gain in adolescent girls [8] and to increased insulin resistance in obese children [9]. In addition to numerous health risks, work performance, medical errors, and employee absenteeism may also be affected by sleep disturbances [10], [11]. Inadequate sleep is a primary cause of absenteeism and impaired productivity while at work and has an estimated annual overall direct (medical expenses) and indirect (absenteeism and short-term disability) cost impact in excess of $30 billion [11], [12].
Understanding the early life origins of sleep disturbances may be particularly useful in order to prevent and treat this costly phenomenon, given that one in five US children experience child maltreatment [13]. Notably, physically and/or sexually abused children, relative to normal controls or depressed children experienced greater sleep latency and decreased sleep efficiency [14]. Psychological abuse has been similarly associated with deleterious effects on sleep. In a retrospective study of 97 psychologically maltreated children, Martinez-Roig et al. found that children younger than 6 years of age manifested sleep disorders secondary to their treatment [15]. In a study of working age adults (20–54 years), Koskenvuo et al. found that those who reported childhood adversities (e.g., parental separation or divorce, long-term financial difficulties or severe conflicts in the family, frequent fear of a family member, severe illness or alcohol problems in a family member) were more likely to self-report a poorer quality of sleep [16].
Several plausible mechanisms that could link adverse childhood experiences (ACEs) to a lifetime trajectory of sleep disturbances exist. Stress associated with ACEs may result in sleep problems in childhood that may continue into adulthood [17]. ACEs appear to have a long-term negative impact on neurodevelopment and neurobiological functions, which could contribute to sleep disturbances in adults [18]. Further, the ACE score is associated with an increased risk of early initiation of adverse health behaviors [19], [20], [21], [22], [23], which can, in turn, negatively impact sleep.
Prior ACE study articles have shown that ACEs are highly interrelated and frequently co-occur [24]. More than 80% of ACE study wave 1 respondents who reported one ACE reported at least one additional ACE [24]. The interrelatedness has led to the use of the “ACE score”—an integer count of the number of ACEs—to assess the cumulative impact of these childhood stressors on a wide variety of health and social problems [25]. A positive graded relationship of the ACE score to sleep disturbances has previously been briefly described in an overview of the epidemiology and neurobiology of a variety of long-term effects of ACEs [18]. The relationship between ACEs and objective sleep measures obtained from actigraphy and polysomnography has been investigated using the childhood trauma questionnaire in a sample of 59 insomnia subjects [26]. A history of ACEs among insomniacs was associated with a greater number of awakenings and more movement arousals, as measured by polysomnography, and with lower sleep efficiency, as measured by actigraphy.
This study explores the relationship of ACEs to two forms of self-reported sleep disturbances among San Diego members of the Kaiser Health Plan, a large health maintenance organization, who participated in the ACE study. This investigation is a secondary analysis of data collected as part of the larger ACE study. Although ACEs have been found to be associated with an increased risk for alcoholism, smoking, obesity, drug abuse, depression, suicide attempts, lung cancer, and premature mortality, research on the association between ACEs and sleep has not been widely undertaken [27], [28], [29]. In order to address this issue, we studied the relationship between multiple ACEs and the likelihood of reporting sleep disturbances in adulthood.
Section snippets
Methods
The ACE study is an ongoing collaboration between Kaiser Permanente (San Diego, California) and the US Centers for Disease Control and Prevention (Atlanta, Georgia). The ACE study was approved by the institutional review boards of the Southern California Permanente Medical Group (Kaiser Permanente), Emory University, and the US Department of Health and Human Services. The objective of the ACE study is to assess the impact of multiple ACEs on a wide variety of health behaviors and outcomes, as
Characteristics of study population
The study population included 9367 women (54%) and 7970 men (46%). Among participants, 9.9% were aged 19–34 years, 25.9% were 35–49 years, 31.9% were 50–64 years, and 32.2% were aged ⩾65 years. The study population was predominantly white (75%) and educated such that 39% were college graduates, 36% had some college education, 18% were high school graduates, and only 7% had not graduated from high school.
Adverse childhood experiences
The prevalence of each individual ACE is shown in Table 1. A history of physical abuse (28.3%)
Discussion
Each of the eight ACEs increased the likelihood of both types of self-reported sleep disturbance. Thus, these events that occurred during the individual’s first 18 years of life continue to exert harmful effects upon sleep decades later. Moreover, the ACE score showed a graded relationship to both trouble falling or staying asleep and being tired after sleeping. Individuals reporting five or more ACEs were twice as likely as those reporting none to experience both self-reported sleep
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2011.03.013.
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The findings and conclusions in this paper are those of the authors and do not necessarily reflect the views of the Centers for Disease Control and Prevention.