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Volume 15 No. 10
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Scientific Investigations
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Rates of Mental Health Symptoms and Associations With Self-Reported Sleep Quality and Sleep Hygiene in Adolescents Presenting for Insomnia Treatment

Tori R. Van Dyk, PhD1; Stephen P. Becker, PhD2,3; Kelly C. Byars, PsyD2,3,4
1Department of Psychology, Loma Linda University, Loma Linda, California; 2Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; 4Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio

ABSTRACT

Study Objectives:

Despite high prevalence rates of both psychopathology and sleep problems during adolescence, as well as frequent co-occurrence, little is known about the mental health of adolescents presenting for insomnia evaluation and treatment. This study describes (1) rates of mental health symptoms and (2) associations of mental health symptoms with sleep behaviors and schedules in adolescents presenting to a behavioral sleep medicine clinic within an accredited sleep disorders center.

Methods:

As a part of routine clinical care, 376 adolescents (ages 11 to 18 years) presenting for insomnia evaluation completed measures of insomnia and sleep behavior. Their caregiver reported on mental health diagnoses and symptoms.

Results:

Adolescents had high rates of mental health diagnoses (75%) and clinically elevated symptoms (64%). Affective, anxiety, and attention deficit-hyperactivity disorder (ADHD) symptoms were most commonly reported. Mental health symptoms were related to sleep behaviors and insomnia severity, with ADHD symptoms and affective problems most consistently associated with disrupted sleep.

Conclusions:

Health providers should assess for mental health problems in youth presenting with sleep-related concerns. Intervening with both sleep and mental health problems should be considered to most effectively improve functioning.

Citation:

Van Dyk TR, Becker SP, Byars KC. Rates of mental health symptoms and associations with self-reported sleep quality and sleep hygiene in adolescents presenting for insomnia treatment. J Clin Sleep Med. 2019;15(10):1433–1442.


BRIEF SUMMARY

Current Knowledge/Study Rationale: Adolescence is characterized by high rates of both mental health and sleep concerns. Despite the possibility that emotional and behavioral problems may exacerbate issues with sleep, little is known about the mental health of adolescents presenting to sleep treatment. This study describes types and prevalence rates of mental health symptoms, in addition to their associations with sleep behaviors, in adolescents presenting with concerns of insomnia.

Study Impact: Findings indicate these youths have high rates of mental health symptoms and these symptoms are related to increased problems with sleep. To break a potential cycle between worsening sleep and mental health, sleep providers should assess and provide options for treatment of comorbid emotional and behavioral problems.

INTRODUCTION

Sleep problems and psychopathology symptoms frequently co-occur across the lifespan.13 This co-occurrence may be particularly salient for adolescents considering both high rates of mental health disorders4 and sleep problems5,6 during this developmental period.7 The association between sleep problems and psychopathology symptoms has been examined in community samples of adolescents8 and in adolescents presenting for mental health treatment.9 However, relatively little is known about the mental health comorbidities of adolescents presenting specifically for evaluation and treatment of insomnia. Characterizing mental health symptoms and how these symptoms relate to specific aspects of sleep behavior in adolescents is important in considering how providers approach the evaluation and treatment of sleep problems in these youths.

The co-occurrence of sleep problems and mental health symptoms in sleep treatment settings has been explored in youth across the developmental spectrum,10 in preschool and school age samples,11 and in adults.12,13 Rates of mental health problems for those presenting for sleep treatment in all youths, regardless of age, have been estimated to be around 67%,10 with similar rates in preschool (69%) and school-age youths (77%)11 and greater variability in rates reported in adult samples (22% to 75%).12,13 Further, relationships between psychopathology symptoms and sleep have been found in these different groups. In analyses that combine youths of all ages, symptoms of depression were related to longer sleep onset latency.10 However, some differential associations have been identified when examining specific developmental periods among children presenting to insomnia evaluation: attention deficit-hyperactivity disorder (ADHD) and affective problems are uniquely associated with sleep disruption in preschool-aged children whereas anxiety and affective and behavioral problems are associated with sleep disruption in school-aged children.11

Although rates of psychopathology symptoms and associations with sleep problems have been explored in those presenting for sleep treatment, an examination specific to adolescents is lacking. Associations identified in younger youths and/or adults should not be assumed to hold true among adolescents because adolescence is a distinctive developmental period characterized by increases in both psychopathology and sleep problems, changing biology, increasing independence, and unique social and societal demands.7,14 Such critical developmental factors likely influence the unique sleep problems and mental health symptoms experienced during adolescence and, subsequently, the relations between these domains of functioning.

Although clinical sleep medicine settings provide a useful context to understanding mental health comorbidities in adolescents with sleep problems, this knowledge is not just important for providers practicing within sleep disorders centers. Insufficient sleep is the norm during adolescence, with most teens falling below the recommended 8 hours of sleep on school nights.6 Further, although most commonly reported in younger children, adolescents also report sleep problems in pediatric primary care contexts.15 Thus, all health care providers serving teens should be screening for sleep problems and subsequently should be cognizant of mental health comorbidities that may precipitate or exacerbate these concerns. The current literature does not provide a clear picture of the prevalence of specific mental health symptoms characteristic of adolescents presenting to insomnia evaluation nor does it describe the relationship between these symptoms and the specific sleep problems common during adolescence. To address these gaps, the current study aims to describe the prevalence of mental health symptoms in adolescents presenting for insomnia evaluation and to examine associations between mental health symptoms and varying sleep behaviors. It was hypothesized that rates of mental health symptoms would be high in these youths and associated with more severe insomnia and worse sleep.

METHODS

Participants

Participants were 376 youths between the ages of 11 and 18 years presenting with their caregiver for an evaluation at an outpatient pediatric behavioral sleep medicine clinic (BSMC) between July 2009 and April 2017. Participants were included if they had a primary diagnosis of insomnia according to the International Classification of Sleep Disorders (ICSD).16,17 There were no exclusion criteria. Participants were included even if they had a comorbid sleep disorder (eg, obstructive sleep apnea) or a secondary behavioral sleep medicine diagnosis (eg, parasomnia). Participants’ primary diagnosis of insomnia was not better explained by these comorbidities.

Procedures

All participants were either self-referred or referred by a health care provider for primary concerns related to sleep and subsequently were presenting to a pediatric BSMC. The BSMC was housed within an accredited sleep disorders center within a tertiary-care pediatric hospital. A relatively small percent of participants (14.6%) were referred from psychiatrists or behavioral health providers. Participants were most frequently referred from primary care providers (38.6%) or other medical specialties (37.2%), with 9.6% of patients being self-referred. Upon referral to the sleep disorders center, caregivers completed an intake questionnaire and children were subsequently triaged to be seen by a board-certified sleep physician in the sleep disorders center and/or by a licensed psychologist certified in behavioral sleep medicine in the BSMC. Prior to being seen in the BSMC, patients and caregivers completed a battery of pre-evaluation measures that were used in conjunction with a comprehensive clinical interview and a review of a sleep diary (when available) to make diagnoses based on the ICSD.16,17 During the initial evaluation, a verbal and written explanation of the study was provided to the families and all patients were invited to participate. Caregivers provided written informed consent and participants provided written assent. All study procedures were approved by the hospital’s institutional review board.

Demographic Measures

Participant information including age, sex, race/ethnicity, and income were reported by caregivers on the pre-evaluation measures.

Sleep Diagnoses and Symptoms

Sleep-Related Diagnoses

As described previously, participants completed a comprehensive evaluation by a licensed clinical psychologist certified in behavioral sleep medicine. Sleep disorders were diagnosed using ICSD criteria16,17 following this evaluation. All participants had a primary insomnia diagnosis with insomnia subtype characterized according to ICSD-2 nosology. When present, organic sleep disorders were diagnosed by a board-certified sleep physician.

Pediatric Insomnia Severity Index

The Pediatric Insomnia Severity Index (PISI)18,19 is a six-question, self-report measure of insomnia severity that was completed at the initial evaluation session. Participants were asked to think about the past week when answering questions related to difficulty falling asleep, difficulty maintaining sleep, daytime sleepiness, and sleep duration. Scores range from 0 to 30, with higher scores indicating greater severity. The PISI adolescent form has been shown to have acceptable validity through correlation with other validated sleep measures (r = .418) and has also demonstrated high internal consistency (α = .80).18

Adolescent Sleep-Wake Scale

The Adolescent Sleep-Wake Scale (ASWS)20 is a 28-item self-report measure assessing sleep quality across five subscales: going to bed, falling asleep, maintaining sleep, reinitiating sleep, and returning to wakefulness. Table 1 provides a description of subscales with sample items. Adolescents respond to the frequency of sleep behaviors occurring in the past month on a 6-point scale (1 = always to 6 = never). Means are used to calculate subscale scores ranging from 1 to 6 with higher scores indicating better sleep quality. The ASWS is widely used in community and clinical samples and has acceptable internal consistency and concurrent validity with the Adolescent Sleep Hygiene Scale (ASHS).21,22

ASWS and ASHS subscale descriptions.

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Table 1

ASWS and ASHS subscale descriptions.

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Adolescent Sleep Hygiene Scale

The revised version of the ASHS was used to assess sleep-facilitating and sleep-inhibiting practices.23 This measure contains 33 self-report items producing six subscales: physiological, sleep environment, cognitive/emotional, sleep stability, daytime sleep, and behavioral arousal (Table 1). Using a 6-point scale (1 = always to 6 = never), adolescents respond to the frequency of sleep behaviors occurring in the past month. Means are used to compute subscale scores which range from 1 to 6 with higher scores indicating better sleep hygiene. The ASHS has satisfactory psychometric properties with adequate to good internal consistency for subscales and good evidence of concurrent and convergent validity.23

Emotional and Behavioral Functioning

Parent-Report Diagnoses

In the pre-evaluation measures, parents reported any mental health diagnoses given to their child by a health care professional. Parent-reported diagnoses were categorized into the following: anxiety and related disorders (ie, anxiety, obsessive compulsive disorder, posttraumatic stress disorder), depression and mood disorders (ie, depression, mood disorder, bipolar disorder, unspecified mood disorders), ADHD, behavior disorders (ie, oppositional defiant disorder, intermittent explosive disorder), pervasive developmental disorders (ie, autism spectrum disorder, Asperger disorder), adjustment disorder, and an “other” category including psychotic disorder, Tourette disorder, conversion disorder, reactive attachment disorder, and eating disorders.

Child Behavior Checklist

At the initial evaluation appointment, parents completed the Child Behavior Checklist (CBCL), which is a 119-item broadband measure of psychopathology symptoms for youths aged 6 to 18 years.24 To best correspond with parent-reported mental health diagnoses, the current study used the CBCL Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented subscales, which included anxiety problems, affective problems, attention deficit-hyperactivity problems, oppositional defiant problems, and conduct problems. T scores ≥ 70 are considered clinically elevated. In analyses examining the relationship between psychopathology and sleep symptoms, CBCL DSM-oriented subscale raw scores were used with sleep-related items removed. This included removing four items from the affective problems scale: “overtired”, “sleeps less than most kids”, “sleeps more than most kids during day and/or night”, and “trouble sleeping”. The DSM-oriented subscales have strong psychometric properties25 and adequate correspondence with DSM-IV mental health disorders diagnosed using semistructured interviews.26

Analysis Plan

First, descriptive analyses were conducted to characterize participant demographics, sleep diagnoses, and rates of parent-reported mental health diagnoses and clinical elevations (T score ≥ 70) of CBCL DSM-oriented subscales. For subsequent analyses evaluating the unique relationships of different psychopathology symptoms with sleep measures, raw scores for the CBCL DSM-oriented subscales with sleep-related items removed were used. Bivariate analyses were first conducted to determine relationships between CBCL subscales and number of parent-report mental health diagnoses and CBCL elevations with sleep symptoms. Multiple regression was then used to determine whether the five CBCL subscale raw scores (centered to improve interpretability), entered simultaneously, predicted insomnia severity, measured by the PISI. Next, path models were estimated using Mplus Version 7.3 (1998–2014, Muthén & Muthén, Los Angeles, California, United States)27 so that multiple independent and dependent variables could be simultaneously evaluated when assessing the relationship between CBCL subscales and sleep quality and sleep hygiene as measured by the ASWS and the ASHS, respectively. Path models with the five CBCL subscales (affective problems, anxiety problems, ADHD problems, oppositional defiant problems, and conduct problems) were regressed separately onto the five ASWS subscales (going to bed, falling asleep, reinitiating sleep, maintaining sleep, and returning to wakefulness) and the six ASHS subscales (physiological, sleep environment, cognitive/emotional arousal, sleep stability, daytime sleep, and behavioral arousal). Suppressor effects were explored when indicated.

RESULTS

Descriptive Analyses

Table 2 presents descriptive information on participant demographics and sleep diagnoses and Table 3 provides descriptive information for the sleep outcome measures. Regarding insomnia subtype, most adolescents (86.2%) had a diagnosis of psychophysiological insomnia, with the remainder having a diagnosis of behavioral insomnia of childhood. Comorbid sleep disorders included parasomnias, sleep-related movement disorders, sleep-related breathing disorders, and sleep-related medical and neurological disorders.

Demographic information and frequency of sleep diagnoses (n = 376).

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Table 2

Demographic information and frequency of sleep diagnoses (n = 376).

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Descriptive information for adolescent-report sleep outcome measures.

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Table 3

Descriptive information for adolescent-report sleep outcome measures.

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Rates of Psychopathology Symptoms

Rates of parent-reported mental health diagnoses and CBCL DSM-oriented clinical elevations are reported in Table 4. Approximately 75% of adolescents had at least one parent-reported mental health diagnosis with anxiety, mood disorders, and ADHD as the most commonly reported diagnoses. Clinical elevations on the CBCL were similar with 63.8% of adolescents having at least one elevation. Affective problems were the most commonly elevated followed by anxiety problems and attention deficit-hyperactivity problems. However, the presence of sleep-related items on the affective problems subscale may inflate prevalence rates. These items were removed from subsequent analyses predicting sleep behaviors. As an indication of mental health severity, approximately 15% of parents reported that their child sometimes or often “deliberately harms self or attempts suicide” and/or “talks about killing self.”

Prevalence of parent-report mental health diagnoses and CBCL DSM-oriented subscale clinical elevations (T-score ≥ 70).

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Table 4

Prevalence of parent-report mental health diagnoses and CBCL DSM-oriented subscale clinical elevations (T-score ≥ 70).

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Psychopathology Symptoms in Relation to Sleep Behaviors

Before multivariate analyses were conducted, bivariate correlations between CBCL subscales, number of parent-report mental health diagnoses, and number of CBCL subscale elevations with PISI, ASWS, and ASHS subscales were examined (Table 5).

Bivariate correlations for CBCL DSM-oriented subscales, number of mental health diagnoses/elevations, and sleep outcome measures.

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Table 5

Bivariate correlations for CBCL DSM-oriented subscales, number of mental health diagnoses/elevations, and sleep outcome measures.

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Insomnia Severity

In a multiple regression model, CBCL subscale raw scores accounted for a significant amount of variance (3.3%) in predicting insomnia severity as measured by the PISI, F5,369 = 2.54, P = .028. Affective problems were the only significant predictor with increased problems related to greater insomnia severity, when controlling for all other CBCL subscales. Table 6 shows detailed results from the regression analysis.

Regression analysis with CBCL subscale raw scores predicting insomnia severity.

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Table 6

Regression analysis with CBCL subscale raw scores predicting insomnia severity.

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Sleep-Wake Schedule

Figure 1 depicts results from the path model in which the five CBCL DSM-oriented subscales were regressed onto the five ASWS subscales. Results indicated that, after controlling for other psychopathology symptoms, greater symptoms of ADHD were associated with more difficulties in going to bed, falling asleep, maintaining sleep, and reinitiating sleep. Greater oppositional defiant problems and conduct problems were associated with more difficulties going to bed and falling asleep, respectively. Greater reports of anxiety problems were associated with more problems reinitiating sleep. Finally, greater affective problems were associated with more difficulty maintaining sleep and returning to wakefulness in the morning.

Path model for CBCL DSM-oriented subscale raw scores predicting ASWS subscales.

Standardized parameter estimates reported with unstandardized estimates within parentheses. Nonsignificant paths (P > .05) are not shown. † P < .10, * P < .05, ** P < .01, *** P < .001. ASWS = Adolescent Sleep-Wake Scale, CBCL = Child Behavior Checklist, DSM = Diagnostic and Statistical Manual of Mental Disorders.

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Figure 1

Path model for CBCL DSM-oriented subscale raw scores predicting ASWS subscales.

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Sleep Hygiene

Figure 2 depicts results from the path model in which the five CBCL DSM-oriented subscales were regressed onto the six ASWS subscales. ADHD, affective, and anxiety problems were the only psychopathology symptom domains associated with various aspects of sleep hygiene. Greater ADHD problems were associated with worse physiological factors and sleep environment. Greater affective problems were associated with greater cognitive-emotional arousal, poorer sleep stability, and more daytime sleep. Finally, greater anxiety problems were associated with greater cognitive-emotional arousal. Contrary to our hypotheses, greater anxiety problems were also associated with better sleep stability and greater symptoms of ADHD were associated with less cognitive/emotional arousal. These associations were examined for potential suppressor effects. None were found for the relationship between anxiety and sleep stability. However, when internalizing symptoms (ie, affective and anxiety problems) were removed from the model, ADHD symptoms were no longer associated with cognitive-emotional arousal. Given this likely suppressor effect, the relationship between ADHD and cognitive-emotional arousal should be interpreted cautiously until replicated in future research.

Path model for CBCL DSM-oriented subscale raw scores predicting ASHS subscales.

Standardized parameter estimates reported with unstandardized estimates within parentheses. Nonsignificant paths (P > .05) are not shown. Dotted line indicates suppressor effect and association should be interpreted cautiously (see manuscript text). † P < .10, * P < .05, ** P < .01, *** P < .001. ASHS = Adolescent Sleep Hygiene Scale, CBCL = Child Behavior Checklist, DSM = Diagnostic and Statistical Manual of Mental Disorders.

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Figure 2

Path model for CBCL DSM-oriented subscale raw scores predicting ASHS subscales.

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DISCUSSION

Adolescents presenting with sleep-related concerns are clinically complex. Results suggest most of these youths have clinical levels of mental health symptoms, with affective, anxiety, and ADHD problems most frequently reported. Comorbidity of mental health symptoms was also common with almost 40% of adolescents demonstrating more than one clinical elevation. A troubling aspect of the high prevalence of mental health symptoms and mental health comorbidity in this population is the finding that these problems were related to behaviors that can interfere with healthy sleep. Although the directionality of the associations between problems with sleep and mental health is complex and not yet fully understood, it is possible that difficulties in one domain of functioning exacerbate difficulties within the other.7 Consequently, it is imperative that adolescent health providers consider mental health symptoms when addressing concerns with sleep.

It is important to consider the relationship between sleep and mental health symptoms within a developmental context.7 In preschool youths, ADHD and affective problems have been predominantly associated with sleep disruption whereas anxiety, affective, and behavioral problems have been most commonly associated with sleep problems in school-age youths.11 Current results indicate that for adolescents, similar to preschool youths, symptoms of ADHD and affective problems are of most concern in relation to poor sleep behaviors, schedules, and insomnia severity. Affective symptoms consistently emerge across developmental periods as related to sleep problems and therefore should be screened for when any youth presents with sleep-related concerns. However, affective problems during adolescence may manifest differently than in other developmental periods with symptoms of irritability, difficulty with sleep, and fatigue being common.28 Notably, irritability and fatigue are also symptoms of sleep disturbance. Subsequently, in regard to differential diagnosis, adolescent sleep providers should carefully consider the etiology of these symptoms and the possibility they may result from mood-related factors in addition to poor sleep.

Consistent with prior research,29 ADHD symptoms also emerged as frequently related to adolescent sleep behaviors. There has been much consideration regarding how sleep disturbances may influence ADHD symptoms. Just like sleep problems may contribute to the heterogeneity of ADHD symptoms,29 ADHD symptoms may affect the heterogeneity of sleep problems in adolescents. For example, in the current sample, adolescents with increased symptoms of ADHD were more likely to report difficulties settling at night and after awakenings, poor sleep maintenance, problematic sleep environments, and physiologically stimulating behavior. As adolescent health providers target sleep behaviors, it is worth considering potential benefits of intervening with ADHD symptoms with behavioral and/or pharmacologic approaches. Conversely, improving sleep may also improve ADHD symptoms, as a recent experimental sleep restriction/extension study found longer sleep duration to be causally linked to improved ADHD and oppositional behaviors.30

Interestingly, although associated with some negative sleep outcomes (eg, difficulty returning to sleep, greater cognitive-emotional arousal at bedtime), increased anxiety was also associated with better sleep stability. It is possible that common sleep-related worries (eg, preoccupations with the negative consequences of poor sleep) would motivate more anxious adolescents to maintain a consistent sleep-wake schedule. However, considering increased reports of arousal at bedtime for these youths, it is important to assess for actual sleep onset time. A stable bedtime may not be an indication of the actual time youths with anxiety are falling asleep. For adolescents with anxiety, it would be particularly important to assess for time spent in bed worrying before sleep onset.

Clinical Implications

Clinically, adolescent health providers should be aware of the relationships between sleep and psychopathology and should consider how these symptoms may contribute to, or potentially worsen, difficulties with sleep. From an assessment standpoint, adolescents presenting with sleep problems should be screened for comorbid mental health symptoms, particularly depression, anxiety, and ADHD. Furthermore, about 15% of youths in this sample were reported to have engaged in self-harm behavior, talked about killing themselves (suicidal ideation and/or planning), and/or attempted suicide in the past 6 months. These rates are higher compared to those from community samples of adolescents of approximately 10% for self-reports of self-harm31 and 12.1%, 4.0%, and 4.1% for lifetime prevalence rates of suicidal ideation, plans, and attempts, respectively.32 Because youth presenting for insomnia treatment may be even more likely to engage in self-harm behavior or to be suicidal, particular attention should be paid to directly assessing for these high-risk behaviors within the context of behavioral sleep medicine evaluations. Further, when self-harm or suicidality is identified, these behaviors should be addressed first before behavioral sleep treatment is initiated.

Mental health concerns should be included within conceptualizations for treating sleep problems and providers should consider how mental health symptoms may interfere with evidence-based treatments for insomnia. Providers also may make adjustments to sleep interventions to accommodate mental health comorbidities. For example, affective problems were related to cognitive-emotional arousal at bedtime as well as indicators of increased sleepiness (eg, daytime naps, difficulty waking). When treating insomnia in adolescents with comorbid depression, providers could consider addressing broader negative cognitions in addition to sleep-related concerns or could use behavioral activation strategies to decrease daytime napping while also improving mood.

Limitations and Future Directions

Although the large sample size, use of multiple reporters, and varied measurements of sleep are notable strengths, limitations do exist. First, the cross-sectional nature of the study prevents assumptions about causality. It is possible, even likely, that bidirectional relationships between sleep and mental health symptoms exist at the time adolescents present with sleep-related concerns. Longitudinal studies are needed to determine how these symptoms develop for children who eventually go on to seek treatment for disrupted sleep. Second, because all participants were referred to a single, specialty sleep clinic, referral bias should be considered. It is possible that providers tended to refer more complex youth, including those with above- average emotional and behavioral problems, to this clinic. However, there was a broad range of referral sources including primary care providers, neurologists, and sleep medicine providers, among others, suggesting many different kinds of adolescent health providers make contact with these youth and would benefit in recognizing the relationship between sleep problems and mental health symptoms in this population. Further, although it was discovered that many adolescents had a parent-report mental health diagnosis upon presentation to the clinic, fewer than 15% were actually referred from mental health providers. This relatively small percentage does not account for the high rates of mental health symptoms observed in this sample. It is also important to note that this setting is relatively unique and that pediatric behavioral sleep specialists are not available in many areas; thus, the management of sleep problems and related mental health symptoms may fall on these other health providers. This both emphasizes the importance of these findings to adolescent health providers more generally while also highlighting the increasing need for more providers specially trained in treating behavioral sleep problems and comorbid disorders.

Another limitation was that effect sizes were small. This supports the notion that problems with sleep are multifactorial and mental health symptoms do not fully explain the complexity of sleep disturbances. Other elements that may be particularly important to adolescent sleep should be considered such as family factors, social relationships, school functioning, involvement in extracurricular activities, and biologic changes to circadian rhythms.7,14 In addition, effects were cross-informant, which bolsters confidence in the findings not being due to possible monoinformant biases, and cross-informant associations are generally smaller in magnitude than within-informant associations. Finally, although a combination of parent- and adolescent-report measures is a strength, improvements to measurement could be made. The PISI is a useful tool for estimating insomnia severity, particularly within a clinic context, but is only a proxy. Objective measurements of sleep using actigraphy are needed to better assess aspects of insomnia such as sleep duration and wake after sleep onset. In regard to measuring mental health symptoms, both parent and adolescent reports would be ideal, particularly because parents are not always aware of internally experienced symptoms such as anxiety and depression.33 Further, gathering more detailed information regarding mental health and related treatment (eg, psychotropic medication use, participation in mental health treatment) would be useful in understanding the relationship between these constructs. For example, related to the possibility that these constructs are bidirectionally related, it would be helpful to know if participation in mental health treatment has any effect on insomnia severity.

CONCLUSIONS

Mental health symptoms are prevalent in adolescents presenting with sleep-related concerns, with ADHD and affective symptoms found to be most consistently related to insomnia severity and sleep behaviors and schedules. Adolescents present frequently with short and disrupted sleep6,15; thus, health care providers should be prepared to assess for comorbid emotional and behavioral problems in these youths, adjusting treatment recommendations and making referrals when necessary. Although a relationship has been established, future research is needed to determine whether and how mental health comorbidity interferes with the treatment of sleep problems in adolescents.

DISCLOSURE STATEMENT

All authors have seen and approved of the manuscript. Work for this study was performed at Cincinnati Children’s Hospital Medical Center in Cincinnati, Ohio. The authors report no conflicts of interest.

ABBREVIATIONS

ADHD

Attention deficit-hyperactivity disorder

ASHS

Adolescent Sleep Hygiene Scale

ASWS

Adolescent Sleep-Wake Scale

BSMC

Behavioral Sleep Medicine Clinic

CBCL

Child Behavior Checklist

DSM

Diagnostic and Statistical Manual of Mental Disorders

ICSD

International Classification of Sleep Disorders

PISI

Pediatric Insomnia Severity Index

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