Review ArticleAdverse childhood experiences are associated with adult sleep disorders: a systematic review
Introduction
Adverse childhood experiences (ACEs), typically defined as stressful or traumatic life events that occur during the first 18 years of life (such as emotional, physical, or sexual abuse, emotional or physical neglect, or other forms of family dysfunction) are pervasive and significant public health problems [1], [2], [3]. A 2008 nationally representative telephone survey estimated that about 61% of children and youth in the US experience at least one ACE per year [4]. This figure slightly decreased to 57.7% in 2011 [5]. The 2011 national survey reported that 13.7% of children had experienced maltreatment, 8.0% had experienced emotional abuse, and 3.7% had experienced physical abuse in the year prior to survey [5]. With regard to sexual abuse, 5.6% of children had been sexually victimized in the last year, while 2.2% had been sexually assaulted. These estimates vary greatly by sex; among 14- to 17-year-old girls, 22.8% had experienced sexual victimization in the last year and 10.7% were sexually assaulted [5]. Additionally, the likelihood of lifetime sexual assaults was significantly higher for girls than for boys (17.4% vs. 4.2%) [5]. Because ACEs affect the majority of American children, it is of grave importance to understand the burdens associated with these early-life events.
In addition to their acute effects such as injury and physical trauma, ACEs are associated with an increased risk of several negative health outcomes across the life course, such as mental illness, substance abuse, heart disease, and premature mortality [1], [2], [3], [6], [7], [8], [9], [10], [11], [12], [13]. Among the few studies that have been conducted among women, investigators have identified suicide attempts and revictimization as additional outcomes of ACEs that have been exclusively identified among women [12], [13]. Early detection of a history of ACEs is critical in developing trauma-informed care for subsequent health consequences and in preventing further adverse health outcomes [14]. As a result, there is a pressing need to identify the long-term effects of ACEs.
Current evidence suggests that adult sleep disorders may be one such effect of ACEs. Sleep disorders are highly prevalent health concerns and estimated to affect 50–70 million Americans, and they have cumulative effects over time [15]. Sleep disorders not only contribute to lost work-related productivity but also lead to severe health outcomes such as obesity, hypertension, diabetes, occupational injuries, depression, and premature mortality [16], [17], [18], [19], [20]. Identifying sleep disorders as a consequence of ACEs will inform the development of more effective therapy for survivors of abuse who suffer from sleep disorders. Additionally, an accumulating body of epidemiologic evidence has identified sleep as a common mediator of many of the associations between ACEs and the aforementioned health outcomes. Thus, identifying and treating sleep disorders in patients exposed to an ACE could prevent additional downstream health and social consequences [7], [21], [22], [23]. Understanding the association between ACEs and adult sleep disorders in women is of particular interest because women are disproportionately affected by certain types of ACEs (eg, sexual abuse) and sleep problems (eg, difficulty maintaining sleep and excessive daytime sleepiness), and because women are at a risk of unique health outcomes (eg, revictimization and suicide) as a result of physical and emotional abuse [5], [12], [13], [24]. The following is a review of the literature regarding the association between ACEs and sleep disorders in adulthood. Because of the high burden of victimization and the potential for revictimization among girls and women, we place particular emphasis on summarizing the influences of childhood adversity and sleep disorders among women. Information gleaned from this review will contribute to a research and public health agenda that addresses the needs of survivors of ACEs.
Section snippets
Methods
The literature search for this systematic review included original studies of human subjects with no limitation on the year of publication. The search was open to observational studies, including case series with ≥10 subjects, cross-sectional, prospective cohort, retrospective cohort, and case–control studies, as well as randomized trials. The exposure of interest, ACEs, was limited to adversity- or abuse-related events that occurred before 18 years of age. ACEs could have been assessed using
Results
A total of 887 articles were identified through the electronic database search (87 from MEDLINE, 518 from Embase, and 282 from Web of Science). After the initial screening, based on titles and careful review of the abstracts, a total of 781 articles were excluded. After removing duplicates, 54 unique articles remained and underwent a full-text screen by the two reviewers. Overall, 24 articles were excluded during the full-text screen based on the aforementioned exclusion criteria. Fig. 1
Significance of the association between ACEs and adult sleep
This systematic review found that ACEs are associated with multiple sleep disorders and disturbances in adulthood. Having a better understanding of the relationship between ACEs and sleep in adulthood is of great clinical significance for multiple reasons. First, disturbed sleep in adulthood may serve as an indicator for the assessment of abuse or trauma history and may also be a consequence of more serious underlying health problems. There is a pressing need for identification of symptoms that
Summary and future directions
ACEs are highly prevalent among children growing up in the US and can result in severe long-term health and social consequences [1], [2], [3], [5], [6], [7], [8], [9], [10], [11], [12], [13]. Multiple retrospective studies have identified associations between ACEs and sleep disorders and disturbances measured subjectively [21], [25], [26], [27], [28], [29], [30], [31], [32], [33], [35]. Two studies found a statistically significant association between childhood sexual abuse and sleep paralysis
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: http://dx.doi.org/10.1016/j.sleep.2014.12.013.
Acknowledgments
This research was supported by grants from the National Institutes of Health [the Eunice Kennedy Shriver Institute of Child Health and Human Development (NICHD): R01-HD-059835; and the National Center for Research Resources (NCRR)/National Center for Advancing Translational Sciences (NCATS): 8UL1TR000170-07].
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