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Psychosocial Correlates of Insomnia in An Adolescent Population

Article in Child Psychiatry & Human Development · December 2009

DOI: 10.1007/s10578-009-0166-5 · Source: PubMed

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This is a non-final version of an article published in final form in the
Child Psychiatry and Human Development journal.
The original publication is available at
http://www.springerlink.com/index/l24j0ln70817p79w.pdf

Psychosocial correlates of Insomnia in an adolescent population

Konstantinos E Siomos PhD1, Penelope - Alexia Avagianou PhD2,

Georgios D Floros MD3, Nikolaos Skenteris PhD4, Odysseas D Mouzas

PhD1, Kyriaki Theodorou PhD4, Nikiforos V Angelopoulos PhD1.

1. Department of Psychiatry, University of Thessaly Medical School,

Larisa

2. Developmental Psychology & Psychopathology Laboratory, Preschool

Education , Faculty of Human Sciences, University of Thessaly, Volos

3. 2nd Department of Psychiatry, Aristotle University of Thessaloniki

Medical School

4. Medical School, University of Thessaly, Larisa

Correspondence: Konstantinos E. Siomos PhD. University of

Thessaly, Medical School, University Hospital, Department of Psychiatry

Larissa 41222, Greece. E-mail: ksiomos@med.uth.gr

1
 Abstract

Objective‫ ׃‬This study examines the nature of the relationship between

psychosocial factors and insomnia complaints in an adolescent non-clinical

population.

Methods‫ ׃‬A cross-sectional study of a stratified sample of 2195 Greek

adolescent high-school students. Subjects were given the Athens insomnia

scale (AIS), the Symptom Checklist (SCL-90-R) and a questionnaire

concerning demographic characteristics. None of the subjects had received

help for insomnia complaints or other overt psychopathology.

Results‫ ׃‬Adolescents classified as suffering from insomnia presented

higher levels of general psychopathology. Age, tobacco and alcohol use, self-

reported patterns of communication in the family, perceived economic status

and school performance were identified as correlates of the insomnia

complaints.

Conclusion: A significant number of adolescents fail to receive

appropriate treatment for insomnia. Psychosocial correlates are important

factors to consider when faced with insomnia complaints in this age group.

More research is needed in important timelines in the developmental history

of a young adult.

Key words‫ ׃‬adolescent, insomnia, psychosocial, psychopathology

2
 Introduction

Epidemiological data suggest a high rate of comorbidity between

psychopathology and sleep disorders. Sleep complaints are common in the

general population as is a widespread assumption that disruptions in sleep

patterns are a tell-tale sign of an underlying psychiatric disorder. Comorbidity

is to be expected since insomnia is a key diagnostic criterion or clinical feature

of several psychiatric disorders in both the International Classification of

Diseases, 10th edition (ICD-10) and the Diagnostic and Statistical Manual of

Mental Disorders, 4th ed. (DSM-IV).

Between 50% and 80% of psychiatric patients complain of sleep

disturbances during the acute phase of their illness while studies of patients

who seek treatment with a primary complaint of insomnia indicate that 35% to

44% of them suffer from one or more diagnosable psychiatric disorders [1].

The most common diagnoses on Axis I of the DSM are affective, anxiety and

substance abuse disorders while the most common Axis II diagnoses are

those of compulsive and borderline personality disorders [2]. Numerous

studies indicated a high rate of psychiatric patients with secondary insomnia

complaints severe enough to warrant a diagnosis [3] [4]. Psychological

symptoms in randomly selected community samples of adults have indicated

a high incidence of co-existing sleep disturbances [1, 3]. Empirical and

research data have thus established a positive relationship between severity

of sleep disturbances and concurrent psychopathology, yet the direction of

causality remains equivocal [1]. Typically, most of the studies of random

samples have been cross-sectional studies of self-selected patient groups

seeking treatment.

3
 Those individuals seeking treatment for any one disorder display

higher psychological distress and are more likely to meet diagnostic criteria

for another form of psychopathology [5], leaving the question of whether

insomnia precipitated the onset of the Axis I disorder unanswered. The link

between the clinical entities, insomnia on the one hand and, most notably,

depression and anxiety on the other [6], cannot be easily analyzed since the

stress of either one disease on an individual is affected by a large number of

intrinsic biological and extraneous social factors. Certain aspects are certainly

becoming clearer since evidence suggest that impaired sleep can induce and

predict manic episodes [7] and significantly alter the course of affective

disorders in general [4]. Adult populations of poor sleepers readily associate

stressful life events with the onset of their insomnia [8] while the social

stresses associated with living with a mental disorder in a community cannot

be underestimated.

Adolescence is marked by various biological changes including

changes in sleep patterns (e.g., decrease in the amount of delta sleep,

reduced REM latency). According to Carskadon [9], adolescents require more

sleep than prepubertal youths but frequently get less sleep than they need.

Transition to an earlier school start time, along with sleep phase delay,

significantly affects teenagers’ sleep quality, sleep/wake schedule, and

daytime behavior. The combination of the phase advance, late-night activities

or jobs, and early-morning school demands can significantly constrict hours

available for sleep.

Studies have reported a lower prevalence of insomnia disorders in the

adolescent population than in middle-aged or elderly adults [10] but generally

4
higher than younger children. Older children have more delayed sleep onset

times and increased reported daytime sleepiness [11]. Consistent links

between insomnia complaints, poor functioning and behavioral problems have

been established in the younger age group (up to sixth grade) [12-15]. A

recent study has confirmed this link as a susceptibility for anxiety disorders in

those children aged between 5-9 having persistent sleep problems at that

time [16]. Adolescents reporting sleep problems showed more anxious,

depressed, inattentive, and conduct disorder behaviors than those who had

no (or only occasional) sleep problems [17].

This study examines the nature of this relationship in an adolescent

non-clinical population in an attempt to trace the development of a linear

relationship between insomnia symptoms and psychopathology through

adolescence, before any need for specialised treatment arises, taking into

account social components which may play a significant role in the aetiology

of insomnia.

5
 Methods

Study design and setting

A cross-sectional study of a stratified sample of 2195 students from the

four provincial capitals of the region of Thessaly, Greece. Study design

excluded individuals who were receiving treatment of any kind for insomnia

complaints or elements of psychopathology in an attempt to trace the

dynamics of poor sleep as related to psychopathology without external

influences. A dual purpose is served since the study will offer a glimpse of the

needs in a typical adolescent population of small urban centres (population

levels between 30,000 and 120,000) where social stresses inherent in larger

cities are mostly absent.

Measures

Three questionnaires were administered to all students; A

demographics questionnaire, the Athens Insomnia Scale [18] and the general

psychopathology Symptom Checklist Scale (SCL-90-R) [19].

All participants completed a self-report, general demographics

questionnaire concerning gender, age, school grade, school performance,

parental educational level and financial state, the adolescent’s lifestyle

(sporting activities, television watching hours, tobacco and alcohol

consumption), and finally perceived communication with and between the

adolescent’s parents.

All participants completed the Athens Insomnia Scale (AIS), based on

the ICD-10 criteria for insomnia which is a concise self-evaluation tool for the

estimation of the seriousness of insomnia complaints in clinical and general

populations [18]. The eight-item version was used in this study. Each item is

6
evaluated with zero to three points (by zero corresponding to “no problem”

and three to ‘very serious problem’). The initial five elements of AIS (difficulty

in sleep induction, unintended awakenings during the night, earlier than

desired final awakening, total sleep duration, and overall quality of sleep)

correspond to ICD-10 criterion A of the “non-organic insomnia” diagnosis. The

presence of the complaints for at least three times per week for the duration of

a month corresponds to ICD-10 criterion B. The content of the last three

elements of the scale (sense of well-being during the day, overall functioning

and daytime sleepiness) corresponds to ICD-10 criterion C (negative effect

caused by insomnia to the everyday activities of the individual).

The responders are requested to rate an item positively if they had

experienced some difficulty for at least three times a week during the last

month. The scale provides a total score ranging from zero (denoting absence

of any sleep-related problem) to 24 (representing the most severe degree of

insomnia).

The authors suggested the use of a cut-point of ten if we seek to

maximize the positive predictive value to a value of 90% while still retaining an

excellent negative predictive value of 94%. The last three items of the AIS-8

refer to daytime symptoms that often emerge as a consequence of nocturnal

sleep disturbance in patients with insomnia. We should note however that

these symptoms may also be caused by sleep disorders other than insomnia,

such as narcolepsy and obstructive sleep apnea. The scale’s diagnostic value

has been confirmed in various clinical and population studies [20].

The Symptom Checklist Scale 90-R (SCL-90-R) is a multidimensional

self-report symptom inventory [19], and its derived Greek standardized

7
version [21] was also used in this study. The SCL-90-R consists of 90

questions divided into nine symptom dimensions: Somatisation, Obsessive-

compulsiveness, Interpersonal Sensitivity, Depression, Anxiety, Hostility,

Phobic anxiety, Paranoid ideation and Psychoticism. The examinee is asked

to select from ‘0=no problem’ to ‘4=very serious’ to describe the extent of the

symptoms he/she has experienced during the last 7 days. The nine symptom

dimensions are divided into three global indexes: Global Severity Index,

representing the extent or depth of the present psychiatric disturbance,

Positive Symptom Total, representing the number of questions rated above

one point, and Positive Symptom Distress Index representing the intensity of

the symptoms.

The “Statistical Package for the Social Sciences” [22] version 16, was

used for data analysis. Guidelines for the interpretation of effect sizes were

used as described in Cohen [23].

Results

Of the 2195 students who participated in the study, 1077 were male

and 1118 female. Mean age was 15.34 years (S.D 1.662). Sample

characteristics are presented in Table 1, the frequency differences were not

statistically significant, Pearson’s chi-square (5) = 9.063, sig=.107).

The internal consistency of AIS, as measured by the Cronbach’s alpha

was 0.82, a typical value for a short scale. Following the cutoff value of ten,

251 students were classified as suffering from insomnia. Their distribution

among classes and the sexes are displayed in Table 2. The two sexes did not

differ significantly as to their insomnia status, chi-square (1) = 3.607, p>.05.

There was however a statistically significant difference among insomniacs

8
and non-insomniacs as to age, (Mann-Whitney Z=5.489, p<.001), insomniacs

tended to be older than non-insomniacs. Answers to individual questions of

the AIS scale are presented in Table 3. There was a statistically significant

association of responses to AIS question 8 and gender, female sex

associated with more problems than males in daytime sleepiness, chi-square

(1) = 5.396, p=.02.

Several analyses were run to determine possible associations between

demographic characteristics and insomnia status as classified by the AIS cut-

off value (Table 4).

The age effect was demonstrated when comparing individuals in

different grades, a linear relationship with the number of insomnia complaints

was evident, Kendall’s tau-b = .103, SE=.017, Sig <.001. Effect size was

small.

Cigarette and alcohol users were significantly more likely to present

with insomnia complaints than non-users (Chi-square = 64.751, p<.001 for

smoking and chi-square=21.452, p<.001 for alcohol use). A direct dose effect

was evident: Number of cigarettes smoked was positively related to insomnia

complaints, Kendall's tau b (295) =.133, SE=.055, p=.017. Frequency of

alcohol consumption was also positively related to insomnia complaints,

Kendall's tau b (899) =.154, SE=.023, p<.001, both effects were classified as

being small to moderate.

Having a TV set into the child’s room was linked to a higher frequency

of insomnia complaints, chi-square (1) = 7.124, p<.01. A relationship between

the number of hours viewing TV and insomnia complaints could not be

established.

9
 When investigating the relationship between parents' communication

with their children and their children’s insomnia complaints, Kendall's tau-b

analysis indicated a significant negative association, tau (2141) =-.127,

SE=.023, p<.001. This means that the better the communication between

parents and children the less likely were the children to suffer from insomnia.

There was also a significant negative association between communication

within the parents' couple and children insomnia classification, tau (2141) =-

.128, SE=.023, p<.001, meaning that the better the communication between

the parents’ couples, the less likely were their children to suffer from

insomnia. Effect sizes were small to moderate.

Kendall's tau-b analysis indicated a significant negative association

between perceived financial status and children insomnia classification, tau

(2126) =-.079, SE=.021, p<.001. This means that the better the family's

financial status was perceived to be by the children the less likely were the

children to suffer from insomnia. The effect size however was too small to be

considered clinically significant. Likewise, there was an inverse relationship

detected between grades receive during the last 12 and 3 months with

insomnia complaints, however although Kendall's tau-b values were

statistically significant their small size was indicative of clinical insignificance

(.071 and .062 respectively, a small effect)

No relationship was found between birth order, engaging in sport

activities, owning a personal computer, parent’s educational status and the

children’ insomnia complaints.

Comparison of insomniac and no-insomniac students group in relation

to psychiatric symptoms

10
 The insomnia group presented with statistically significantly higher

scores than non-insomniacs in all SCL-90R psychopathology indexes (p<.05).

Comparisons were made by Mann-Whitney analyses with the target

significance level set to .004 or lower, in order to compensate for multiple

comparisons following the stricter Bonferroni correction (Table 5)

Multiple stepwise regression analysis of all variables and correlation

with insomnia

Multiple regression was conducted to determine the best linear

combination of those factors that emerged from the initial examination as

having a statistically significant effect on AIS scores (age, GSI index,

perceived family financial status, self-reported quality of communication with

parents, perceived quality of communication between the parents, school

performance during the last three months, presence of a TV set into the

adolescent's room, tobacco and alcohol use.) Stepwise regression identified

the combination of the GSI index, self-reported communication with parents,

tobacco use, gender, perceived quality of communication between the parents

and age as the optimal one, F(5,1958) = 179.889, p<.001. The beta weights

suggest that having an elevated index of general psychopathological

symptomatology, reporting poor communication with parents, smoking,

reporting a lower quality of communication between one's parents and being

in the late adolescence significantly contribute to a prediction of insomnia. The

adjusted R squared value was .313. This indicates that the model explained

31.3% of the variance in insomnia complaints, a medium to large effect.

Results are presented in Tables 6a and 6b.

11
 Discussion

The present study indicates the significance of social pressure in the

emergence of insomnia complaints on the one hand and the close link

between those complaints and psychopathology on the other. A first striking

result is the high percentage of adolescents which can be classified as

suffering from insomnia using a moderately stringent criterion. It is safe to say

that insomnia complaints are unheeded either because of underreporting to

parents or the lack of a specialised prevention and early detection health

programs, which seem to be of great importance and need. The confidentiality

which marked data gathering made it possible for this need to emerge from

obscurity and it would be important to promote a similar climate in any attempt

to address this kind of problems in the future. Confidentiality is particularly

important for an adolescent, since this age is by definition a time of frailty and

vulnerability of the self, making the adolescent reluctant to accept any

problems which could be perceived as faults and not willing to seek

appropriate help.

The study of the biopsychosocial factors returned some unexpected

results. Age was an important factor, as expected; however a larger effect

size was reported for alcohol and cigarette consumption as was the case for

communication between the adolescent and hi/her parents and

communication between the parents themselves. Those results highlight the

multi-faceted importance of family dynamics in an adolescent’s everyday life

and the value of ascertaining vices as a warning indicator for underlying

pathologies.

12
 The choice made to compare those individuals with a high rate of

insomnia complaints resulted in robust results with regards to their concurrent

psychopathology. All indexes of the SCL-90R questionnaire were significantly

higher in the insomnia group, with large effect sizes, confirming that the link

between insomnia and psychopathology is strong. Results are impressive

given the fact that none of the individuals was so markedly disturbed in any

one domain as to necessitate specialist help. It appears that this age group

(13-18) is at least equally sensitive to the complex dynamics between

insomnia and psychopathology as the older adolescents are quoted to be,

and more sensitive than the young children group. The increase in insomnia

complaints was correlated to age within our group, reflecting biology and

increased social pressure to mature and function efficiently as a young adult.

The dynamics of change from one level of education to the next (12th year of

age) would be a prime research target, ideally with a longitudinal study, taking

into account the social factors listed above as having a meaningful effect to

insomnia complaints (communication patterns at home, vices) as well as any

other events serving as psychological stressors. Since insomnia complaints

and psychological symptomatology can be partly attributed to specific life

events and do not necessarily persist over time a longitudinal study would be

ideal for examining any patterns. Important ethical issues come to play since

any subject that is found to meet criteria for a disorder should be treated

accordingly and not left to suffer the full psychological burden.

Given the fact that the research in the area of developmental

psychopathology suggests that most of the psychological problems are

present from a very early age it would be of great importance to examine

13
those psychosocial correlates of insomnia to a younger age group. In that way

we can create preventing programs before the period of adolescence in an

effort to reduce the percentages of psychopathology in that age group.

14
15
 Tables
Table 1. The grade level and the gender of the sample

School grade level Female (% within Total (% within

Male (% within sex)
(age) sex) sex)
st
1 (13yrs) 233 (21.6%) 234 (20.9%) 467 (21.3%)
2nd (14yrs) 136 (12.6%) 111 (9.9%) 247 (11.3%)
3rd (15yrs) 219 (20.3%) 203 (18.2%) 422 (19.2%)
4th (16yrs) 203 (17.4%) 250 (20.6%) 453 (19%)
5th (17yrs) 161 (16,4%) 180 (17.9%) 341 (17.2%)
6th (18yrs) 125 (11.6%) 140 (12.5%) 265 (12.1%)
total 1077 (100%) 1118 (100%) 2195 (100%)

16
Table 2. Sample classification according to insomnia status

School grade Male Female Total

AIS class
level (age) (% within sex) (% within sex) (% within sex)
1st (13yrs) 222 (22.9%) 221 (22.8%) 443 (22.8%)
2nd (14yrs) 125 (12.9%) 102 (10.5%) 227 (11.7%)
3rd (15yrs) 188 (19.4%) 181 (18.5%) 369 (19%)
Non-
4th (16yrs) 171 (17.7%) 193 (19.8%) 364 (18.7%)
insomniac
5th (17yrs) 151 (15.6%) 165 (16.9%) 316 (18.7%)
6th (18yrs) 111 (11.5%) 114 (11.7%) 225 (11.6%)
total 968 (100%) 976 (100%) 1944 (100%)
st
1 (13yrs) 11 (10.1%) 13 (9.2%) 24 (9.6%)
2nd (14yrs) 11 (10.1%) 9 (6.3%) 20 (8%)
3rd (15yrs) 31 (28.4%) 22 (15.5%) 53 (21.1%)
Insomniac 4th (16yrs) 16 (14.7%) 37 (26.1%) 53 (21.1%)
5th (17yrs) 26 (23.9%) 35 (24.6%) 61 (24.3%)
6th (18yrs) 14 (12.8%) 26 (18.3%) 40 (15.9%)
total 109 (100%) 142 (100%) 251 (100%)

17
 Table 3. Prevalence of sleep complaints in Greek adolescent students in total
and by gender, as reported in the individual AIS questions. Results indicate
the number of responders who claim to have at least some trouble in each
field.
Male Female Total
Sleep Complaints
(% within sex) (% within sex) (% within sex)
Sleep induction 152 (14.1%) 176 (15.7%) 328 (14.9%)
Awakenings during the night 78 (7.3%) 103 (9.2%) 181 (8.2%)
Final awakening earlier than desired 102 (9.5%) 104 (9.3%) 206 (9.4%)
Total sleep duration 176 (16.3%) 199 (17.8%) 375 (17.1%)
Overall quality of sleep 69 (6.4%) 67 (6%) 136 (6.2%)
Sense of well-being during the day 103 (9.6%) 118 (10.6%) 221 (10.1%)
Functioning 74 (6.5%) 69 (6.2%) 143 (6.5%)
Sleepiness during the day 173 (16.3%) 222(19.9%) 395 (16.5%)

18
 Table 4. Socio-demographic variables and their association with insomnia
status

Non-
Variables of the sample Insomniac Total Association measure
insomniac
School grade
Junior 1 443 24 467
high 2 227 20 247
school 3 369 53 422 Kendall’s tau-b (.103),
Senior 4 364 53 417 SE=.017, Sig <.001
high 5 316 61 377
school 6 225 40 265
Cigarette consumption (self-reported)
No 1722 176 1898
On occasion 80 22 102
Up to ten per day 63 14 77
Kendall’s tau-b (.133),
Ten to twenty per day 57 21 78
SE=.055, Sig .017
Up to forty per day 11 6 17
Over forty per day 11 12 23
Total tobacco users 222 75 297
Alcohol consumption (self-reported)
No 1180 114 1294
On occasion 576 78 654
1 to 2 times per week 167 46 213 Kendall’s tau-b (.154),
Every day 10 8 18 SE=.036, Sig <.001
Over 2 drinks per day 11 5 16
Total alcohol users 764 137 901
School performance (grades received in the last 3 months)
Very low 10 11 21
Low 147 30 177
Kendall’s tau-b (-.062),
Moderate 527 68 595
SE=.023, Sig .007
High 1169 138 1307
total 1853 247 2100
Parents' communication with their children (as perceived by adolescents)
Bad 10 5 15
Mediocre 82 27 109
Kendall’s tau-b (-.127),
Good 612 98 710
SE=.023, Sig .<.001
Very good 1203 106 1309
Total 1907 236 2143
Parents' communication with each other (as perceived by adolescents)
Bad 26 14 40
Mediocre 70 15 85
Kendall’s tau-b (-.128),
Good 528 93 621
SE=.023, Sig .<.001
Very good 1268 114 1382
Total 1892 236 2128
Perceived family economic status
Bad 7 5 12
Mediocre 135 27 162
Kendall’s tau-b (-.079),
Good 1142 152 1294
SE=.021, Sig .<.001
Very good 606 54 660
Total 1890 238 2128

19
 Table 5. The comparison of insomniac and no-insomniac students group, in

relation to psychiatric symptoms by Mann-Whitney test, corrected for multiple

comparisons.

Non-insomniacs Insomniacs Mann-Whitney Z, Sig. Effect

SCL-90-R indexes (N=1944) (N=251) (with Bonferroni size
Median (S.D) Median (S.D) correction) (r)
Somatization 0.33 (0.453) 0.92 (0.812) 13.145 (p<0.05) 0.484
Obsessive-compulsiveness 0.7 (0.57) 1.3 (0.75) 12.714 (p<0.05) 0.456
Interpersonal sensitivity 0.666 (0.551) 1.22 (0.77) 11.657 (p<0.05) 0.435
Depression 0.555 (0.511) 1.11 (0.736) 12.344 (p<0.05) 0.456
Anxiety 0.4 (0.539) 1.1 (0.851) 13.04 (p<0.05) 0.533
Hostility 0.67 (0.796) 1.5 (1.03) 11.576 (p<0.05) 0.394
Phobic anxiety 0.29 (0.418) 0.71(0.756) 9.914 (p<0.05) 0.418
Paranoid ideation 0.67 (0.718) 1.5 (0.906) 12.32 (p<0.05) 0.441
Psychoticism 0.4 (0.481) 1 (0.745) 13.177 (p<0.05) 0.38
GSI 0.53 (0.434) 1.2 (0.683) 15.799 (p<0.05) 0.43
PSDI 32 (17.431) 55 (19.511) 15.088 (p<0.05) 0.488
PST 1.51 (.518) 1.986 (.603) 14.209 (p<0.05) 0.398

20
 Table 6a. Means, Standard Deviations, Tolerance values and
intercorrelations for number of insomnia complaints and predictor variables
(N=1964)

Variable M SD 1 2 3 4 5
Insomnia complaints 4.73 3.848 .532** -.244** .195** -.229** .217**
Predictor variable
1.GSI .6836 .492 - -.233** .176** -.206** .235**
2.Communication with parents 3.54 .627 - -.197** .471** -.139**
3.Smoking 1.13 .337 - -.143** .285**
4.Communication between parents 3.58 .651 - -.121**
5.Age 15.42 1.63 -
**p<.001

21
Table 6b. Simultaneous Multiple Regression Analysis Summary for GSI,
communication with parents, smoking, communication between parents and
age, predicting the number of insomnia complaints

Variable B CIs for B SE B β Tolerance

(Lower/Upper)
GSI 3.682 3.378 / 3.986 .155 .471** .889
Communication with -.460 -.721 / -.199 .133 -.075* .746
parents
Smoking .766 .321 / 1.211 .227 .067* .886
Communication between -.465 -.712 / -.217 .126 - .766
parents .079**
Age .16 .067 / .252 .047 .068* .88
Constant 2.185 .911
Note. R=.561, Adjusted R2 = .313; F(5,1958) = 179.889, p < .001
*p=.001; **p<.001.

22
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