Clinical ReviewSleep, emotional and behavioral difficulties in children and adolescents
Introduction
Sleep disturbances in children and adolescents are common (e.g., 1, 2). It is increasingly apparent that sleep disturbances are associated with both emotional (e.g., anxiety and depression) and behavioral (e.g., attention and conduct) difficulties in children and adolescents.3 Understanding more about co-occurring difficulties can facilitate understanding of the developmental progression of difficulties, aid researchers and clinicians in the early identification, prevention and treatment of difficulties as well as inform associated issues such as nosology (the classification of disorders). Given the known importance of sleep in youth,4 as well as the importance of having detailed knowledge of associations with other phenotypes, this review presents a selection of key empirical findings on the links between sleep and emotional and behavioral difficulties in children and adolescents. The review begins with a discussion of issues surrounding the definition and measurement of sleep disturbances. Concurrent links between sleep and emotional and behavioral difficulties are then described – followed by the presentation of longitudinal associations. A selection of possible mechanisms underlying associations is then described. The review ends with a description of future challenges for the field. These include the need to: 1) use multi-methods to assess sleep; 2) measure sleep in large-scale studies; 3) conduct controlled experiments to further establish the effects of sleep variations on emotional and behavioral difficulties; and 4) take an interdisciplinary approach to further understand the links between sleep and associated difficulties.
Section snippets
Defining and measuring sleep disturbances
Perhaps the biggest challenge when assimilating literature on sleep and associated difficulties is the lack of consensus regarding how to assess and define sleep disturbances. Three issues concerning the assessment of sleep disturbances are noteworthy. First, sleep disturbances can take many forms. For example, a distinction can be drawn between dyssomnias (such as insomnia) and parasomnias (such as sleep walking). Furthermore, the classification of such disorders varies, depending on the
Sleep and emotional problems
Links between sleep disturbances, anxiety and depression in adulthood are well established.5 In contrast, only relatively recently has there been a wide interest in these associations within childhood and adolescence. Within this field, as with sleep disturbances, emotional problems have been conceptualized in different ways. While some studies combine symptoms of anxiety and depression into a single variable,3, 13 others distinguish between anxiety subtypes.14
Longitudinal associations
In addition to highlighting concurrent associations, researchers have also investigated longitudinal associations between sleep and other phenotypes. Such studies encompass different time periods spanning a year or so60 to over a decade.61 These studies suggest that sleep disturbances in childhood or adolescence predict a whole host of later difficulties (e.g., 3, 50), with some studies reporting this link even when adjusting for the stability of difficulties over time (e.g., 3, 62).
Summary: sleep and associated difficulties
A review of the literature reveals that the recent increase in interest in the links between sleep difficulties and associated problems in youth is warranted. Indeed, sleep disturbances have been associated with a whole host of other difficulties concurrently and may also represent risk indicators for the emergence of further problems later in life. Additional research is needed to confirm emerging trends (such as developmental changes in the magnitude of associations over time and the precise
Nosology
When explaining the associations between sleep disturbance and other difficulties it is important to reflect on the issue of nosology. Sleep disturbances are considered symptoms of a range of other disorders (including generalized anxiety disorder and major depressive disorder) as well as distinct diagnoses (see DSM-IV5). This topic has been widely discussed and despite symptom overlap, there are strong arguments for not dismissing sleep difficulties as secondary to other difficulties.74
Summary and future challenges
Sleep issues are ubiquitous in children with emotional and behavioral problems. These associations appear when measuring traits in the full range as well as at the extremes – and occur when assessing associations both concurrently and longitudinally. Associations between sleep, emotional and behavioral difficulties are likely bidirectional, with sleep problems or insufficient sleep exacerbating emotional and behavioral difficulties; and, mood disturbances, anxiety and stress compromising sleep
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
Alice M. Gregory is supported by a Leverhulme Trust Fellowship. We thank Liat Tikotzky for her valuable comments.
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