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Editorial Perspective: Perils and Promise for Child and Adolescent Sleep and Associated Psychopathology during the COVID-19 Pandemic

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Abstract

It is anticipated that the novel coronavirus disease 2019 (COVID-19) pandemic and associated societal response will have wide-ranging impacts on youth development and mental health. Sleep is crucial for child and adolescent health and well-being, and the potential for sleep problems to emerge or worsen during and following the pandemic is high. This may be particularly true for children and adolescents who are at heightened risk for the onset of sleep and mental health disturbances and for those whom developmental changes impacting sleep are rapidly occurring. Youth with pre-existing psychopathologies (including anxiety and depression) and neurodevelopmental conditions (including attention-deficit/hyperactivity disorder and autism spectrum disorder) could be especially vulnerable to disturbed sleep during this period of change and uncertainty. It is thus imperative that sleep considerations be part of research and clinical initiatives aimed at understanding and mitigating the impact of the COVID-19 pandemic in children and adolescents. This article considers ways in which the pandemic may impact sleep, including research and clinical implications.
Editorial Perspective: Perils and promise for child and
adolescent sleep and associated psychopathology
during the COVID-19 pandemic
Stephen P. Becker,
1,2
and Alice M. Gregory
3
1
Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati,
OH, USA;
2
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA;
3
Department
of Psychology, Goldsmiths, University of London, London, UK
First diagnosed in December 2019, the novel coro-
navirus disease (COVID-19) has quickly spread
across the globe and upended daily life for billions
of people. With the implementation of social distanc-
ing interventions, direct human contact has become
highly restricted, with most activities that typically
occupy youths’ lives schooling, extracurricular
activities, and socialization with peers transition-
ing to electronic-based platforms. It is anticipated
that the COVID-19 pandemic and associated societal
response will have wide-ranging impacts on youth
development and mental health (Golberstein, Wen, &
Miller, 2020). Sleep is crucial for child and adoles-
cent health and well-being (Gregory & Sadeh, 2016),
and while we do not yet know how sleep has been
impacted by the COVID-19 crisis, the potential for
sleep problems to emerge or worsen during this
period is high (Altena et al., 2020). This may be
particularly true for children and adolescents, for
whom developmental changes impacting sleep are
rapidly occurring (such as those transitioning into
adolescence) and for those who are at heightened
risk for the onset of sleep and mental health distur-
bances. Youth with preexisting psychopathologies
(including anxiety and depression) and neurodevel-
opmental conditions (including attention-deficit/hy-
peractivity disorder [ADHD] and autism spectrum
disorder [ASD]) may also be particularly vulnerable
to disturbed sleep during this time of great change
and uncertainty. It is thus imperative that sleep
considerations be part of both clinical and research
initiatives aimed at mitigating and understanding
the impact of the COVID-19 pandemic in children
and adolescents. This discussion is timely, not least
because one of the many benefits of sufficient sleep
of good quality is to support the immune system
(Besedovsky, Lange, & Haack, 2019). Here, we
discuss ways in which sleep may be impacted by
the pandemic and outline a research agenda for
investigating this topic further.
Possible negative consequences of COVID-19
for child and adolescent sleep
While data are needed to help us understand the
impact of COVID-19 on sleep, a wider literature
indicates that the pandemic could have an impact
upon sleep in children and adolescents.
At the center of the pandemic is the virus itself.
While symptoms appear to be relatively mild in the
majority of children and adolescents, they can occur
and include both respiratory difficulties and fever.
Illness or hospitalization can have an impact on
sleep (Besedovsky et al., 2019). Isolation and shield-
ing could result in increased sedentary behaviors
and food consumption, which are likely to impact
weight (Rundle, Park, Herbstman, Kinsey, & Wang,
2020) and consequently health and sleep over time.
Children and adolescents may also experience
increased levels of stress, given widespread changes
in family financial situations, health concerns, and
uncertainty about the future. These too can result in
sleep difficulties (Tsai et al., 2018).
Further, social distancing advice to stay indoors
can reduce exposure to sunlight, which is so central
in establishing a consistent sleep routine. The latter
may also be impacted by more flexibility in wake and
sleep time and increased opportunity for prolonged
daytime naps. Remote learning could increase time
spent working in the bedroom or the bed, which
contradicts widespread guidance to keep bedroom
activity to a minimum so as to avoid associating the
bed and bedroom with arousal. Remote learning and
the absence of in-person social interactions also
make it possible that youth spend more time using
technology, including during the presleep period.
Increased exposure to alerting ‘blue light’ can dis-
rupt melatonin production, meaning that the body
misses out on a biological cue that it is time to fall
asleep (Dijk & Cajochen, 1997). Bringing technology
into the home could also expose some children, some
perhaps for the first time, to cybervictimization and
other online challenges. There is a clear need to
assess and evaluate risk factors that may, indepen-
dently or jointly, impair youths’ sleep during the
COVID-19 pandemic.
Sleep and COVID-19: relevance for child and
adolescent psychopathology
Children and adolescents with preexisting mental
health conditions may be particularly vulnerable to
©2020 Association for Child and Adolescent Mental Health
Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
Journal of Child Psychology and Psychiatry 61:7 (2020), pp 757–759 doi:10.1111/jcpp.13278
PFI_12mmX178mm.pdf + eps format
disturbed sleep during the COVID-19 pandemic or
more prolonged sleep disturbances following the
pandemic. Youth with anxiety or depression may be
especially prone to COVID-related worries and rumi-
nation, which can interfere with sleep onset and
quality. Youth with ASD may have particular diffi-
culty with the extreme changes in routine resulting
from the COVID-19 pandemic, social distancing
measures, and caregivers working from home as well
as engaging in novel home learning. Youth with
neurodevelopmental disorders, including ASD and
ADHD, may be more likely to experience variable
sleep/wake patterns due to possible altered circadian
function, medication use, and co-occurring psy-
chopathologies (Becker, Sidol, Van Dyk, Epstein, &
Beebe, 2017). It is important to understand which
youth are most at risk for COVID-19-related sleep
problems and psychopathologies, why certain sub-
groups may be more likely than others to experience
negative consequences, what factors confer increased
or decreased risk, how sleep and mental health
unfold over time, and the optimal way to address
sleep-related challenges in different populations.
It is also possible that changes in sleep during the
COVID-19 pandemic exacerbate or even contribute
to psychopathology. Worsened sleep may increase
negative affect, resulting in increased susceptibility
to mood and anxiety problems. Shortened or poor
sleep may lead to greater attentional difficulties and
oppositionality for some youth, resulting in behav-
iors that mimic ADHD and commonly co-occurring
symptoms. During and after the COVID-19 pan-
demic, it will be important to assess both sleep
problems and psychopathology, which considered
alongside a developmental and mental health history
should allow for disentangling the emergence, exac-
erbation, and interrelations among these difficulties
(Gregory & Sadeh, 2016).
Adolescent sleep during the COVID-19
pandemic: the perfect storm intensified?
Adolescents may be particularly vulnerable to the
effects of COVID-19-related social isolation. They are
required to physically distance from friends and, for
some, romantic interests while simultaneously expe-
riencing almost 24/7 proximity to caregivers. Adoles-
cents increasingly prioritize peer relationships and
autonomy, and the current situation may result in
both loneliness and unique parentteen challenges or
negotiations (e.g., related to home learning or com-
pliance with COVID-19 public health guidelines). The
COVID-19 crisis likely also impacts activities that are
key to adolescents’ identity (e.g., part-time employ-
ment), physical activity (e.g., sports participation),
and creativity (e.g., arts participation). The loss of
these in-person activities and related peer relation-
ships may contribute to less physical activity,
increased negative affect, more lethargy or napping
behaviors, and greater screen time and online social
networking. These factors have the potential to
directly or jointly impact bedtimes, sleep quality,
and the regularity of sleep/wake patterns.
Potential for a good night’s sleep?
Although children and adolescents may experience
worsened sleep during and as a result of the COVID-
19 crisis, it is also possible that some youth expe-
rience improved sleep in certain domains. First,
strong ‘evening types’ may benefit from greater
flexibility afforded by home learning. Second and
relatedly, there may be more opportunity for obtain-
ing sufficient sleep since less time is spent traveling
to and from school or engaging in social and
extracurricular activities. These considerations may
point to a silver lining for adolescents’ sleep in
particular: in-person schools are closed, meaning
that many adolescents no longer experience early
school start times and may thus be able to establish
and maintain a schedule more aligned to their
endogenous circadian rhythm, in turn also reducing
social jetlag (given more consistency between week-
day and weekend sleep) (Crowley, Wolfson, Tarokh,
& Carskadon, 2018).
Third, youth who experience peer victimization or
academic failure may find the break from in-person
schooling and activities provides a respite from these
stressors. This may, in turn, reduce rumination or
distress around bedtime that can interfere with sleep
onset and quality. However, this respite may only be
temporary, and it will be important to monitor these
youth as the novelty of social distancing wears off.
Finally, youth may experience closer ties to family
during times of crisis, as well as new or renewed
shared activities (e.g., walks, puzzles/games, meals).
These enhanced family bonds may promote feelings of
connection and safety that also promote healthy
sleep. These possible advantages for sleep need to
be considered alongside the multitude of risks
described above meaning that the overall impact of
COVID-19 on sleep is far from clear. It is also possible
that sleep may be improved in certain domains (e.g.,
sleep duration) and not others (e.g., sleep stability).
Considerations for research and practice
There are a number of important implications of
youth sleep during and after the COVID-19 crisis for
research and practice. Perhaps, most fundamen-
tally, studies will be needed to examine whether, and
if so how, the COVID-19 crisis and associated
physical distancing impact child and adolescent
sleep over time. For example, what domains of sleep
are most clearly impacted, for better or for worse?
Are changes in sleep temporary, or will a subset of
youth experience longer-term sleep disturbances
that originated during the COVID-19 pandemic? Will
changes in sleep patterns (such as the possibility of
increasingly late bedtime in adolescents) result in
©2020 Association for Child and Adolescent Mental Health
758 Stephen P. Becker and Alice M. Gregory J Child Psychol Psychiatr 2020; 61(7): 757–9
difficulties once normality starts to return (e.g.,
when schools reopen and early mornings are
required once more)? Is sleep particularly impacted,
in the short or long term, in children and adolescents
experiencing certain risk factors, including mental
health or neurodevelopmental conditions? It will also
be important to evaluate COVID-19-related factors
(e.g., personal loss, family financial strain, stress
uncertainty) that may predict or maintain sleep
disturbances in youth. Some home environments
will have increased risks (e.g., increases in domestic
violence, alcohol/drug use, child abuse/neglect) for
both child sleep disturbances and psychopathology.
Care will need to be made before extrapolating
results to other situations, as the multiplicity of
factors related to COVID-19 will mean that it is
difficult to make direct comparisons to other situa-
tions (such as the impact of social isolation on sleep
under different circumstances). Monitoring access to
existing resources (prescription medication, services
in and outside of the school context) will also be
important as will establishing the best interventions
for those who struggle with their sleep during and
following COVID-19. Insomnia symptoms in children
and adolescents can be treated with cognitive behav-
ioral therapy for insomnia (CBT-I; Dewald-Kauf-
mann, de Bruin, & Michael, 2019) and given the
reduction in face-to-face contact, rigorous studies
need to further establish the extent to which online
delivery systems are effective in youth. Establishing
healthy sleep practices is important, and statutory
guidance to educate about the importance of sleep
comes into UK schools from September 2020 (UK
Department of Education, 2019). This guidance is
quite timely, and its impact needs evaluation. It is
noteworthy that medicines for insomnia in children
are not approved by the US Food and Drug Admin-
istration or the European Medicines Agency for
insomnia in children (Bruni et al., 2018). Studies
should therefore also establish whether there has
been an increase in prescription of medicine for
insomnia in children and to monitor use over time.
In conclusion, as this pandemic unfolds, there
remains great uncertainty and risk to the health
and well-being of children and adolescents. Support-
ing our youth to get a good night’s sleep is just one
way that we can help them cope with the uncertain
days ahead.
Acknowledgements
S.B. is supported by grants from the National Institute of
Mental Health (NIMH; K23MH108603) and the Institute
of Education Science (IES; R305A160064,
R305A160126). The content is solely the responsibility
of the authors and does not necessarily represent the
official views of the National Institutes of Health or the
U.S. Department of Education. The authors have
declared that they have no competing or potential
conflicts of interest.
Correspondence
Stephen P. Becker, Division of Behavioral Medicine
and Clinical Psychology, Cincinnati Children’s
Hospital Medical Center, 3333 Burnet Avenue,
Cincinnati, OH 45229-3039, USA; Email: stephen.
becker@cchmc.org
and
Alice M. Gregory, Department of Psychology, Gold-
smiths, University of London, New Cross, London
SE14 6NW, UK; Email: a.gregory@gold.ac.uk
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Accepted for publication: 6 May 2020
First published online: 31 May 2020
©2020 Association for Child and Adolescent Mental Health
doi:10.1111/jcpp.13278 Child and adolescent sleep during COVID-19 759
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... 47 This is because social distancing has decreased academic pressure and peer conflict, and allowed greater flexibility and more opportunities for obtaining sufficient sleep, as less time is spent commuting to school. 5,14 Nevertheless, Korean adolescents still have poor mental health, and most do not meet the recommended sleep duration. 48,49 This can be attributed to the academic stress caused by excessive homework given to Korean adolescents engaging in extracurricular activities and competitive educational environments. ...
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In the current global home confinement situation due to the COVID‐19 outbreak, most individuals are exposed to an unprecedented stressful situation of unknown duration. This may not only increase daytime stress, anxiety and depression levels but also disrupt sleep. Importantly, because of the fundamental role that sleep plays in emotion regulation, sleep disturbance can have direct consequences upon next day emotional functioning. In this paper we summarize what is known about the stress‐sleep link and confinement as well as effective insomnia treatment. We discuss those effects of the current home confinement situation that can disrupt sleep but also those that could benefit sleep quality. We suggest adaptions of cognitive behavioral therapy elements that are feasible to implement for those facing changed work schedules and requirements, those with health anxiety and those handling childcare and homeschooling, whilst also recognizing the general limitations imposed on physical exercise and social interaction. Managing sleep problems as best as possible during home confinement can limit stress and possibly prevent disruptions of social relationships.
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The COVID‐19 pandemic is causing substantial morbidity and mortality, straining health care systems, shutting down economies, and closing school districts. While it is a priority to mitigate its immediate impact, we want to call attention to the pandemic’s longer‐term effect on children’s health: COVID‐19, via these school closures, may exacerbate the epidemic of childhood obesity and increase disparities in obesity risk. In many areas of the U.S., the COVID‐19 pandemic has closed schools and some of these school systems are not expected to re‐open this school year. The experiences in Hong Kong, Taiwan and Singapore suggest that social distancing orders, if lifted after short periods, will have to be periodically re‐instated to control COVID‐19 flare ups. In short, we anticipate that the COVID‐19 pandemic will likely double out‐of‐school time this year for many children in the U.S. and will exacerbate the risk factors for weight gain associated with summer recess.
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Sleep and immunity are bidirectionally linked. Immune system activation alters sleep, and sleep in turn affects the innate and adaptive arm of our body's defense system. Stimulation of the immune system by microbial challenges triggers an inflammatory response, which, depending on its magnitude and time course, can induce an increase in sleep duration and intensity, but also a disruption of sleep. Enhancement of sleep during an infection is assumed to feedback to the immune system to promote host defense. Indeed, sleep affects various immune parameters, is associated with a reduced infection risk, and can improve infection outcome and vaccination responses. The induction of a hormonal constellation that supports immune functions is one likely mechanism underlying the immune-supporting effects of sleep. In the absence of an infectious challenge, sleep appears to promote inflammatory homeostasis through effects on several inflammatory mediators, such as cytokines. This notion is supported by findings that prolonged sleep deficiency (e.g., short sleep duration, sleep disturbance) can lead to chronic, systemic low-grade inflammation and is associated with various diseases that have an inflammatory component, like diabetes, atherosclerosis, and neurodegeneration. Here, we review available data on this regulatory sleep-immune crosstalk, point out methodological challenges, and suggest questions open for future research.
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Insomnia is one of the most prevalent sleep disorders in school-aged children and adolescents. Although cognitive behavioral therapy for insomnia (CBT-i) is the first-line treatment for adults, and existing studies show promising effects also for children and adolescents, the number of randomized controlled trials in younger age groups is rather small. CBT-i techniques for school-aged children and adolescents include bedtime shifts (including sleep restriction), stimulus control, thought challenging, psychoeducation, and relaxation techniques. The integration of parents, especially in school-aged children with insomnia, is highly recommended. More research is needed to investigate specific characteristics and models of child and adolescent insomnia.
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The maturation of sleep regulatory systems during adolescence in combination with psychosocial and societal pressures culminate in a "Perfect Storm" of short and ill-timed sleep and the associated consequences for many youngsters. This model, first described by Carskadon in 2011, guides our current thinking of adolescent sleep behavior. Since the original description, the field has moved forward with remarkable pace, and this review aims to summarize recent progress and describe how this new work informs our understanding of sleep regulation and sleep behavior during this developmental time frame.
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Background: Sleep disturbances, in particular insomnia, represent a common problem in children with neurodevelopmental disabilities (NDDs). Currently, there are no approved medications for insomnia in children by the US Food and Drug Administration or European Medicines Agency and therefore they are prescribed off-label. We critically reviewed pediatric literature on drugs as well as nonpharmacological (behavioral) interventions used for sleep disturbances in children with NDDs. Methods: PubMed, Ovid (including PsycINFO, Ovid MEDLINE(®) , and Embase), and Web of Knowledge databases were searched through February 12, 2017, with no language restrictions. Two authors independently and blindly performed the screening. Results: Good sleep practices and behavioral interventions, supported by moderate-to-low level evidence, are the first recommended treatments for pediatric insomnia but they are often challenging to implement. Antihistamine agents, such as hydroxyzine or diphenhydramine, are the most widely prescribed sedatives in the pediatric practice but evidence supporting their use is still limited. An increasing body of evidence supports melatonin as the safest choice for children with NDDs. Benzodiazepines are not recommended in children and should only be used for transient insomnia, especially if daytime anxiety is present. Only few studies have been carried out in children's and adolescents' zolpidem, zaleplon, and eszopiclone, with contrasting results. Limited evidence supports the use of alpha-agonists such as clonidine to improve sleep onset latency, especially in attention deficit/hyperactivity disorder subjects. Tricyclic antidepressants, used in adults with insomnia, are not recommended in children because of their safety profile. Trazodone and mirtazapine hold promise but require further studies. Conclusions: Here, we provided a tentative guide for the use of drugs for insomnia in children with NDDs. Well-controlled studies employing both objective polysomnography and subjective sleep measures are needed to determine the efficacy, effectiveness, and safety of the currently prescribed pediatric sleep medicines in children with NDDs.
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The current study examines the association between parental support and adolescent sleep under varying levels of family stress. Participants included 316 adolescents (Mage = 16.40 years, 43% male) and their parents (Mage = 45.67 years, 91% mothers) from diverse ethnic backgrounds. Both adolescents and parents completed questionnaires and adolescents wore wrist actigraphs and completed self-reports on their sleep for 7 consecutive days. Results indicated that under contexts of family stress, more parental support was linked to longer sleep duration, less sleep variability, and less time spent awake during the night. Findings suggest that under contexts of family stress, cohesive family relationships may provide a sense of stability and security that is necessary for healthful sleep.
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Substantial research attention has been devoted to understanding the importance and impact of sleep in children and adolescents. Traditionally, this has focused on mean sleep variables (e.g., a child’s “typical” or average sleep duration), yet research increasingly suggests that intraindividual variability (IIV) of sleep/wake patterns (sometimes referred to as sleep variability or night-to-night variability) regularly occurs and may have implications for adjustment. A systematic search of five electronic databases identified 52 empirical studies published between 2000 and 2015 that examined correlates of sleep IIV in children and adolescents, with a recent increase in the publication rate of such studies. Identified studies were often atheoretical and included post hoc analyses, though IIV in select aspects of sleep does appear to be associated with increasing age/pubertal status, non-White race, physical and neurodevelopmental conditions (e.g., attention-deficit/hyperactivity disorder; autism), psychopathology symptoms (e.g., anxiety, depression, inattention), body weight, stress, aspects of cognitive functioning, and poorer sleep functioning/habits. The limited intervention work examining sleep IIV in adolescents is promising, though studies are needed using more rigorous intervention designs. Clinical sleep recommendations may not only need to address overall sleep duration and sleep habits but also the stability of sleep duration and timing. It will be important for future research examining sleep IIV in children and adolescents to use a developmental framework in advancing theory pertaining to the causes, mechanisms, moderators, and outcomes of sleep IIV in youth, and a conceptual model is proposed to help guide such efforts.
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Background: Hippocrates flagged the value of sleep for good health. Nonetheless, historically, researchers with an interest in developmental psychopathology have largely ignored a possible role for atypical sleep. Recently, however, there has been a surge of interest in this area, perhaps reflecting increased evidence that disturbed or insufficient sleep can result in poor functioning in numerous domains. Aims and scope: This review outlines what is known about sleep in the psychiatric diagnoses most relevant to children and for which associations with sleep are beginning to be understood. While based on a comprehensive survey of the literature, the focus of the current review is on the latest science (largely from 2010). There is a description of both concurrent and longitudinal links as well as possible mechanisms underlying associations. Preliminary treatment research is also considered which suggests that treating sleep difficulties may result in improvements in behavioural areas beyond sleep quality. Findings and conclusion: To maximise progress in this field, there now needs to be: (a) greater attention to the assessment of sleep in children; (b) sleep research on a wider range of psychiatric disorders; (c) a greater focus on and examination of mechanisms underlying associations; (d) a clearer consideration of developmental questions and (e) large-scale well-designed treatment studies. While sleep problems may sometimes be missed by parents and healthcare providers; hence constituting a hidden risk for other psychopathologies - knowing about these difficulties creates unique opportunities. The current excitement in this field from experts in diverse areas including developmental psychology, clinical psychology, genetics and neuropsychology should make these opportunities a reality.