By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
• The Avon Longitudinal Study of Parents and Children (ALSPAC) recruited pregnant woman in the early 1990s and followed their children from birth onward.
• Children were seen at specific ages, and parents were asked each time about children’s sleep habits.
• Depression was assessed at age 10 years via questionnaire; in-person interviews were conducted at 11-12 years of age to determine if symptoms of borderline personality disorder (BPD) were present and between 12-13 years of age to evaluate for psychotic experiences.
• Frequent night awakenings at 18 months and irregular sleep patterns at 6 months, 30 months, and 5.8 years were significantly linked to psychotic experiences by the age of 12-13 years; the significance of frequent night awakenings at 18 months and an irregular sleep routine at 5.8 years appeared to be mediated by depression at age 10 years.
• Shorter nighttime sleep at age 3.5 years was significantly linked to BPD symptoms by age 11-12 years.
SYNOPSIS: This prospective United Kingdom study involving 13,488 children shows an association between specific early childhood sleep problems and symptoms of psychosis in adolescence. Another specified early childhood sleep problem is associated with symptoms of borderline personality disorder in adolescence.
SOURCE: Morales-Muñoz I, Broome MR, Marwaha S. Association of parent-reported sleep problems in early childhood with psychotic and borderline personality disorder symptoms in adolescence. JAMA Psychiatry 2020:e201875 [Epub ahead of print].
The last 10 years have shown an upsurge in research efforts aimed at understanding the etiology of mental health problems. The search for early onset, modifiable risk factors for behavioral and emotional disorders has received particular attention. Studies point toward poor sleep in early childhood as having relevance for the development of later psychopathology.1,2
Several studies have linked early childhood nightmares to psychotic experiences in teenage years, and one study has suggested a similar association between childhood nightmares and borderline personality disorder (BPD) symptoms in pre-adolescence. The relationship remains unclear, and some researchers suspect that poor childhood sleep could be a precursor to depression and, thus, put an child at risk for other mental health disorders.2,3
BPD typically is considered a disorder presenting in adult years. However, there is growing evidence of BPD symptoms in up to 3% of children as young as 11 years of age. Diagnostic criteria are identical to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for BPD in adults — with the caveat that there is at least one year of “immature personality development” with disruption in at least five of the following areas:
- Unstable interpersonal relationships
- Identity disturbance
- Suicidal and/or self-harming behaviors
- Mood instability
- Feelings of emptiness
- Inappropriate and intense anger
- Paranoias under stressful circumstances4
Individuals with BPD often present with psychotic experiences, such as hallucinations or delusions. However, psychosis in adolescence may occur in association with other disorders of mental health, including depression, anxiety, trauma response, substance abuse, as well as schizophrenia.5 Although BPD symptoms are believed to occur in about 3% of adolescents and psychotic symptoms in 7.5% of adolescents, behavioral sleep problems in young children are significantly more common, occurring in 15% to 30% of children under the age of 5 years.6 Thus, it becomes important to clarify what type of sleep problems are higher risk or more likely to be associated with the development of symptoms of mental health problems as children reach their teenage years.
To add to the growing knowledge about this relationship, Morales-Muñoz et al used a data base of participants in the Avon Longitudinal Study of Parents and Children (ALSPAC), a United Kingdom study in the early 1990s that recruited pregnant women and followed their children from birth through the stages of development. From this cohort group, the team was able to obtain data from 7,155 children reporting on psychotic experiences between the ages of 12 and 13 years and 6,333 children evaluated for symptoms of BPD between the ages of 11 and 12 years. These children responded to a questionnaire at age 10 years regarding depressive symptoms.
Psychotic symptoms were evaluated via the Psychosis-Like Symptom Interview (PLSI),7 and BPD symptoms were assessed using the United Kingdom Childhood Interview for DSM-4 Borderline Personality Disorder.4 The Total Mood and Feelings questionnaire (13 items) was used to evaluate degree or presence of depression.8 The behavioral sleep disorders included night sleep duration, bedtime, night awakenings, and regular sleep routine. These were recorded at ages 6 months, 18 months, 30 months, 3.5 years, 4.8 years, and 5.8 years. When adjusted for variables, such as family adversity, child abuse, sex of the child, maternal age, and prematurity, several significant findings emerged. Results were divided into two sections: the first regarding psychotic symptoms at ages 12 to 13 years and the second regarding BPD symptoms at age 11 to 12 years.
Association of behavioral sleep problems of childhood and psychotic symptoms ages 12-13 years as measured by PLSI:
- Frequent night awakenings at age 18 months was associated with psychotic symptoms at age 12-13 years with odds ratio (OR) 1.13 (95% confidence interval [CI], 1.01-1.26); P = 0.03.
- Irregular sleep routine at ages 6 months, 30 months, and 5.8 years was associated with psychotic symptoms at age 12-13 years.
- 6 months: OR 0.68 (95%CI, 0.50-0.93); P = 0.02
- 30 months: OR 0.64 (95%CI, 0.44-0.95); P = 0.02
Association of behavioral sleep problems of childhood and BPD symptoms at age 11-12 years as measured by the United Kingdom Childhood Interview for DSM-4 Borderline Personality Disorder.
- Shorter nighttime sleep duration at age 3.5 years was associated with BPD symptoms by age 11-12 years, with OR 0.78 (95% CI, 0.66-0.92); P = 0.004.
- When adjusted for depression, there appeared to be no mediating effect on this relationship.
In many ways, this Morales-Muñoz et al investigation gives rise to more questions than answers. The results indicate an association between adolescent psychotic symptoms and higher frequency of night awakenings at age 18 months and/or irregular sleep routines at ages 6 months, 30 months, and 5.8 years. Depression at age 10 mediated some of these findings (frequent night awakening at age 18 months and irregular sleep routine at age 5.8 years.) Additionally, BPD symptoms in pre-adolescents were associated with shorter nighttime sleep duration at age 3.5 years. This result was not mediated by depression at age 10 years. These findings clearly point to a role of sleep in psychopathology and suggest that sleep problems may predate mental health symptoms. The disparate results may reflect separate pathways of development for psychosis and BPD.
Perhaps the largest question raised by these findings is in the area of prevention. Although the hope is that modifying sleep patterns early in life can affect later psychopathology, this study simply cannot provide evidence of such a relationship. It may be that the disrupted sleep patterns reflect an early-onset symptom, rather than a cause of a later-emerging mental health disorder. Additionally, it is important to consider that poor sleep in a child can be extremely disruptive to family life, and, likewise, a disruptive family life can trigger poor sleep habits. The question of the “chicken or the egg” most likely has relevance here; clarification via further studies can help delineate treatment pathways. Even considering the limitations, the findings do raise the possibility of correcting sleep disruption early in life to help prevent or mitigate later psychopathology. This is an area of clinical importance, especially in families with a genetic risk of mental health disorders. A primary care physician is well-positioned to discuss sleep hygiene and sleep regulation with families and remind parents of the importance of establishing bedtime routines while children are young. It is worth keeping in mind that children with constitutionally poor sleep may be at higher risk of developing mental health disorders, and individualizing a plan for these children and families may be the best way to proceed.
- Sadeh A, Tikotzky L, Kahn M. Sleep in infancy and childhood: Implications for emotional and behavioral difficulties in adolescence and beyond. Curr Opin Psychiatry 2014;27:453-459.
- Cook F, Conway LJ, Giallo R, et al. Infant sleep and child mental health: A longitudinal investigation. Arch Dis Child 2020;105:655-660.
- Lereya ST, Winsper C, Tang NKY, Wolke D. Sleep problems in childhood and borderline personality disorder symptoms in early adolescence. J Abnorm Child Psychol 2017;45:193-206.
- Guilé JM, Boissel L, Alaux-Cantin S, de La Rivière SG. Borderline personality disorder in adolescents: Prevalence, diagnosis, and treatment strategies. Adolesc Health Med Ther 2018;9:199-210.
- Laurens KR, Tzoumakis S, Dean K, et al. Population profiles of child-reported psychotic-like experiences and their differential association with other psychopathologies. Br J Clin Psychol 2020;59:22-38.
- Kelleher I, Connor D, Clarke DN, et al. Prevalence of psychotic symptoms in childhood and adolescence: A systematic review and meta-analysis of population-based studies. Psychol Med 2012;42:1857-1863.
- Kelleher I, Harley M, Murtagh A, Cannon M. Are screening instruments valid for psychotic-like experiences? A validation study of screening questions for psychotic-like experiences using in-depth clinical interview. Schizophr Bull 2011;37:362-369.
- Mood and Feelings Questionnaire (MFQ). Child Outcomes Research Consortium. https://www.corc.uk.net/outcome-experience-measures/mood-and-feelings-questionnaire/