Elsevier

Psychiatry Research

Volume 94, Issue 2, 15 May 2000, Pages 93-102
Psychiatry Research

Trouble sleeping and anxiety/depression in childhood

https://doi.org/10.1016/S0165-1781(00)00145-1Get rights and content

Abstract

The purpose of this report was to estimate the association between children’s trouble sleeping and anxiety/depression at ages 6 and 11, cross-sectionally and prospectively. Data come from a study of the psychiatric sequelae of low birth weight (LBW: <2500 g). LBW and normal birth weight children were randomly selected from the 1983–1985 newborn lists of an urban and a suburban hospital. Eight hundred and twenty-three children participated at age 6 and, of those, 717 (87.1%) participated at age 11. Achenbach’s Child Behavior Checklist (CBCL) and the Teacher Report Form (TRF) were used to obtain ratings of psychiatric problems. The CBCL asked if the child had trouble sleeping during the past 6 months. Children with trouble sleeping had significantly increased odds of anxiety/depression based on mothers’ reports (OR=6.9, 95% CI 4.1–11.4) but not teachers’ reports (OR=1.1, 95% CI 0.4–2.7). There was a greater association between sleep and depression at age 11 than at age 6, and among suburban than among urban children. These findings remained when adjusted for birthweight, sex, and mother’s history of major depressive disorder. Profile analysis indicated a stronger association of trouble sleeping with anxiety/depression than other psychiatric problems. The association of trouble sleeping at age 6 with incidence of depression at age 11 was not statistically significant (suburban children RR=2.22, 95% CI 0.53–9.23; urban children RR=0.92, 95% CI 0.20–4.18).

Introduction

Recent studies of adults indicate that insomnia predicts the development of major depressive disorder (MDD). Using data from the Epidemiologic Catchment Area (ECA) study, Ford and Kamerow (1989) published the first longitudinal general population study of insomnia as a predictor of new episodes of MDD. They reported that the risk of a new episode of major depression was 39.8 times greater for those with insomnia at both baseline and the 1-year follow-up than for those without insomnia. Also analyzing data from the ECA to examine prodromes and precursors to mental disorders, Eaton et al. (1995) calculated that 47% of those with first onset of MDD at the 1-year follow-up had sleep problems at baseline. Sleep problems had the highest attributable risk of any examined precursor of MDD, including ‘had thoughts or wishes for death’ (41%) and ‘sad mood for 2 weeks’ (28%). Weissman et al. (1997) found that among those without a history of psychiatric disorder at baseline, the odds of first onset MDD at the 1-year follow-up were 5.4 times greater for those with insomnia at baseline compared to those without insomnia, using ECA data. Even controlling for other depressive symptoms among those who did not meet criteria for MDD at baseline, Breslau et al. (1996) found that insomnia signaled an increased risk of first onset depression during a 3.5-year follow-up interval (odds ratio=2.1).

Anxiety and depression begin to develop in late childhood and early adolescence (Breslau et al., 1995, Shaffer et al., 1996). Thus examination of a potential precursor, such as sleep problems, during this developmental period may be particularly valuable as a potential indicator of increased risk of early onset of these disorders.

The few studies that have examined difficulty sleeping or insomnia and psychiatric problems in adolescents have found associations between difficulty sleeping and negative mood states and poor social competence (Price et al., 1978, Kirmil-Gray et al., 1984, Morrison et al., 1992). Two studies have examined the association between sleep problems and any psychiatric disorder. Morrison et al. (1992) found that sleep problems (i.e. needing more sleep, difficulty falling asleep, difficulty staying asleep, early awakening, or other sleep problems combined) were associated with multiple DSM-III disorders or anxiety among 15-year-olds. Blader et al. (1997) surveyed parents of children of 5–12 years of age about sleep problems and psychiatric diagnoses in their children. Bedtime resistance was the most common chronic sleep problem reported (27% — three times per week or more). Of parents, 11.3% reported that their children had difficulty falling asleep, once in bed, three or more nights per week. Sleep onset problems were significantly associated with one or more psychiatric disorders, but the study did not report findings for individual diagnoses (Blader et al., 1997).

Prior studies have indicated that mothers’ depression has been associated with increased reports of sleep problems in children (Zuckerman et al., 1987) and mothers’ history of any psychiatric disorder has been associated with an apparent over-reporting of psychiatric and behavioral problems in their children (Chilcoat and Breslau, 1997). To our knowledge, no study of sleep problems has used multiple informants (e.g. parents and teachers) to evaluate psychiatric problems, or controlled for maternal depression in evaluating the relationship between sleep problems and psychopathology. Although the association between sleep problems and depression may result, from a bias that increases reporting of all problems, no study has examined the specificity of the association of sleep problems with anxiety/depression.

To investigate the role of trouble sleeping in children’s anxiety/depression, we estimated the association between children’s trouble sleeping and symptoms of anxiety/depression as reported by mothers and teachers at ages 6 and 11. We address the following questions:

  • 1.

    Is there an association between trouble sleeping and a clinically significant level of anxiety/depression as evaluated by mothers and teachers?

  • 2.

    Is the association with trouble sleeping specific to anxiety/depression?

  • 3.

    Is there an association between trouble sleeping at age 6 and symptoms of anxiety/depression at age 11?

Section snippets

Sample

We identified and assessed a stratified random sample of low birth weight (LBW: <2500 g) and normal birth weight (NBW) 6-year-old children from two socio-economically disparate populations. We targeted the 1983–1985 cohort of newborns who reached age 6 in 1990–1992. Two major hospitals in south-east Michigan were selected, one in the city of Detroit (urban) and the other in a middle-class suburb (suburban). We sampled only inborn children. Neither hospital specialized in high-risk pregnancies

Prevalence estimates of sleep problems and anxiety/depression

According to mothers’ reports, 6.4% of children at age 6, and 8.8% at age 11 had trouble sleeping sometimes or often. Mothers and teachers report similar prevalence of anxiety/depression above a clinically significant cut-off, approximately 4% to 6% across ages 6 and 11 (see Table 2).

Association of trouble sleeping with anxiety/depression

At age 6, 13.2% of children with trouble sleeping compared to 3.1% of children without trouble sleeping scored above the anxious/depressed clinical cut-off, according to their mothers (OR=4.7, 95% CI 1.9–11.5). A

Discussion

In this study we found that mothers’ reports of trouble sleeping in their children were strongly associated with mother’s ratings of clinically significant levels of anxiety/depression at 6 and 11 years of age, adjusting for a number of factors, including the mother’s diagnosis of MDD. The association was significantly greater for suburban than urban children and at age 11 than at age 6. Trouble sleeping was associated with clinical levels of all eight psychiatric domains examined in this study

Acknowledgements

Supported by grant MH44586 from the National Institute of Mental Health.

References (24)

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  • N. Breslau et al.

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