Abstract
OBJECTIVE :
To examine associations between adverse childhood experiences (ACEs) and age specific insufficient sleep duration (ISD) in American youth.
METHODS :
Data from the 2016–2017 National Survey of Children’s Health, a sample of 46,209 youth ages 6–17 were analyzed. The main outcome was sleep duration that did not meet the recent recommendations of the American Academy of Sleep Medicine. Nine types of ACEs, as well as a cumulative count of ACEs, were examined as independent variables in unadjusted and adjusted logistic regression models.
RESULTS :
Approximately half of U.S. children and adolescents (ages 6–17) experienced at least one ACE and a third did not get sufficient sleep. Among those exposed to any ACE, 40.3% had ISD. Seven of the nine ACEs examined were significantly associated with a 20–60% increase in odds of not getting sufficient sleep (adjusted ORs between 1.2 and 1.6). Children exposed to two or more ACEs were nearly twice as likely as those exposed to no ACE to have insufficient sleep duration (adjusted OR=1.7, 95% CI: 1.5–1.9). Moreover, each individual ACE, except parental death was significantly associated with more than one hour less sleep than recommended.
CONCLUSIONS :
This study reports the association of specific and cumulative ACEs with ISD in a nationally representative sample of American youth. The study findings underscore the importance of screening for both ACEs and insufficient sleep during primary care encounters and addressing potential sleep problems in those exposed to ACEs.
Keywords: adverse childhood experiences (ACEs), insufficient sleep, National Survey of Children’s Health
Introduction
Adverse childhood experiences (ACEs) are stressful or traumatic events experienced in childhood or adolescence. ACEs include abuse, neglect, family dysfunction, poverty, exposure to domestic violence, neighborhood violence, and many forms of trauma. Substantial evidence has demonstrated that ACEs negatively impact physical, mental, and behavioral health outcomes in childhood 1–3 and throughout the life course.4 Both episodic and chronic stress associated with exposure to childhood adversity can disrupt the development of emerging brain architecture and connectivity, as well as altering biological functions associated with immunity, cardiovascular function, metabolism and sleep. 5 In the absence of powerful counter-measures that support healthy adaptation and resilience, the impact of these adverse events can result in life-long damage and thus diminish well-being. 6
Close to half of American children/adolescents experienced at least one ACE, as reported by their parents in the 2011–2012 National Survey of Children’s Health.7 According to the Behavioral Risk Factor Surveillance System (BRFSS), an annual, nationally representative telephone survey conducted from 2011 to 2014,8 approximately 61.5% of adults reported they had exposure to at least one ACE. This high prevalence of ACEs, together with the severity of their negative health consequences, makes ACEs an urgent public health concern.
There is emerging evidence to suggest the potential role of sleep as a mediator in the association of childhood adversity with poor behavioral and other health consequences 9,10. In fact, the impact that ACEs may have on sleep problems has received increased attention. Studies have examined the relationship between specific types of ACEs and sleep disturbances among children. Examples include: child maltreatment/abuse, 11 parental separation/divorce,12 family dysfunction,13 community violence,14 childhood sexual abuse15 and socio-demographic adversity.16 Other studies have demonstrated that specific and cumulative ACEs can have an impact on sleep in adulthood.17 However, there is a dearth of population-based epidemiologic studies focused on the wide range of ACEs and their association with age specific insufficient sleep duration (ISD) for youth.
Sufficient sleep is increasingly recognized as a vital component of health and general well-being across the life course. Studies consistently report that adequate sleep by children is associated with better attention, behavior, cognitive functioning, emotional regulation, and physical health.18 A large study of 11,788 pupils from different European countries reported the association of reduced sleep hours with mental health problems in adolescents. 19 A recent study reported that insufficient sleep duration and other sleep problems in early childhood were associated with psychiatric symptoms in adolescence.20 It has also been reported that individuals with insufficient sleep duration were more likely to exhibit an array of acute and chronic health risks related to diabetes, cognitive functioning, heart disease 18,21 and early mortality.22 Consequently, the American Academy of Pediatrics (AAP) endorsed a guideline developed by the American Academy of Sleep Medicine, recommending that school-aged children (6–12 years) should have 9–12 hours of sleep and adolescents (13–18 years) should have 8–10 hours of sleep per night for optimal health.18 Thus far, no study has examined associations of exposure to ACEs with ISD, as defined by these AAP endorsed recommendations for these specific age groups.
This study, therefore, examines exposure to nine specific ACEs, as well as the cumulative number of ACEs, and their association with insufficient sleep duration, so defined, in a nationally representative sample of school-aged children and adolescents. Understanding the association of ACEs with insufficient sleep among children and adolescents has clinical, public health, and policy implications. For example, if ACEs and or sleep insufficiency can be identified in youth and early interventions employed to mitigate the negative impact of ACEs, there is potential for reducing both immediate and long-term behavioral, physical and mental health problems.
Methods
Data source and study population
This study analyzed data from the combined 2016 and 2017 National Survey of Children’s Health (NSCH). The NSCH was designed to produce national and state-level data on physical and emotional health of non-institutionalized American children 0–17 years of age. For this study, the subsample of youth ages 6–17 years was utilized to focus on school-aged children. The analyses excluded children with missing data for any of the study variables, which ranged from 0.3% to 3.4% among different variables. A final sample of n=46,209 school-age children (out of N=51,156) were included; demographic characteristics were similar between the included and total populations. This study used publicly accessible data and was exempt from review by Columbia University/New York State Psychiatric Institute’s Institutional Review Board (IRB).
The NSCH was funded by the Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB) and conducted by the U.S. Census Bureau. The survey data for a given child were collected from a parent or a caregiver knowledgeable about the child’s health and healthcare. Detailed information about data collection methods for the 2016 and 2017 NSCH is provided elsewhere. 23 The combined 2016 and 2017 NSCH data were used to produce more stable national estimates.
Measures
Adverse Childhood Experiences (ACEs).
The 2016–2017 NSCH included questions about nine ACEs. Respondents indicated whether their child had ever experienced: financial hardship; parental divorce/separation; parental death; parental imprisonment; domestic violence; neighborhood violence; living with a mentally ill, suicidal, or severely depressed person; living with someone who had a substance use problem; or experienced unfair treatment because of their race/ethnicity. These ACEs were included in the 2016–2017 NSCH as they are considered acceptable measures of ACEs in clinical and community contexts.24 Given the inter-relatedness and co-occurrence of several ACEs,25 a measure of cumulative exposure to ACEs was created by summing the total number of adverse experiences (0, 1, ≥ 2 ACEs). In this study, we examined exposure to each ACE, and their cumulative count as independent variables.
Insufficient sleep among children and adolescents (ages 6–17).
Respondents were asked to report how many hours their child slept on an average weeknight in the past week. Our definition of insufficient sleep duration (ISD) was determined by applying the guidelines developed by the American Academy of Sleep Medicine, which specifies that school-aged children (6–12 years) should receive 9–12 hours, and teenagers (13–18 years) should receive 8–10 hours of sleep nightly.18 Children who slept less than the minimum recommended duration were classified as having ISD. This variable was used as a dependent variable in the analysis. Furthermore, another variable was created to describe the severity of insufficient sleep duration (one hour less than the current recommendations, and over one hour less than current recommendations).
Covariates.
Because demographic variables such as age, gender, race/ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic and others), and poverty have previously been associated with sleep disturbances and ACEs,26 here, we included them as covariates (potential confounders) in the analysis. Household income was classified into four levels: poor (<100% of the Federal Poverty Line (FPL), low-income (100%–199% of the FPL), middle-income (200%–399% of the FPL), and high-income (400% of the FPL). Family structure (two parents currently married, two parents not currently married, single mother or other type) and parental education (less than high school, high school, or more than high school) were also included as covariates. Finally, internalizing disorders, such as anxiety and depression, are often associated with sleep problems, 27 and were, therefore, also included as covariates.
Statistical Analyses
First, we estimated the prevalence of each ACE, the cumulative count of experienced ACEs, and the prevalence of insufficient sleep duration (ISD). Next, we estimated the prevalence of insufficient sleep stratified by child demographics and mental health variables, as well as family income level, family structure and parental education levels. Logistic regression was used to examine the unadjusted and adjusted associations of each ACE and of cumulative ACEs with ISD. To prevent confounding by participant age, we adjusted for a continuous measure of age in years. Considering the potential for overadjustment, the family structure variable was omitted in the analyses of these ACEs: parental divorce, parental death, and parent imprisonment. Similarly, we did not adjust for children’s anxiety and depression in the analysis of the ACE “living with a mentally ill, suicidal, or severely depressed person”.
Finally, to investigate the association of ACEs with severity of sleep insufficiency, we repeated these analyses using multinomial logistic regression models for a 3-category outcome: Sufficient sleep duration, sleep duration of one hour less than recommended, and sleep duration of over one hour less than recommended. The analyses also controlled for the potential confounding effects of a youth’s age, gender, race/ethnicity, anxiety, depression, family income, family structure, and parent/caretaker’s educational achievement. All statistical analyses were performed using SPSS version 24 Complex Samples module or SAS PROC SURVEYLOGISTIC (used for multinomial logistic regression models). All analyses used NSCH sampling weights to account for non-response and sampling procedures. Standard errors were adjusted for the complex survey design using the Taylor series linearization method. The significance level was set at <0.05.
Results
Prevalence of ACEs.
Table 1 presents the prevalence of ACEs. About half of the study population reported to have been exposed to at least one ACE, and nearly 25% were exposed to two or more ACEs. The two most frequently reported ACEs were parental divorce/separation (28.9%) and difficulty getting by on current income (24.5%). While less prevalent, a sizable proportion of youth had been exposed to living with someone with a substance use problem (10.2%), or living with someone who was mentally ill, suicidal, or severely depressed (8.7%), or an incarcerated parent (9%), or had witnessed domestic violence (6.4%), or neighborhood violence (4.8%), or had been treated unfairly due to race/ethnicity (4.8%).
Table 1.
Prevalence of adverse childhood experiences among U.S. children 6–17 years of age, 2016–2017 National Survey of Children’s Health (N=46,209)
| Weighted % | 95% CI | |
|---|---|---|
| Adverse childhood experience | ||
| Divorce/parental separation | 28.9 | (27.9 – 29.8) |
| Difficult to get by on current income | 24.5 | (23.6 – 25.5) |
| Lived with someone with alcohol or drug problem | 10.2 | (9.5 – 10.8) |
| Parent served time in jail | 9.0 | (8.4 – 9.7) |
| Lived with someone mentally ill, suicidal, or severely depressed | 8.7 | (8.1 – 9.2) |
| Domestic violence witness | 6.4 | (5.9 – 6.9) |
| Victim or witnessed neighborhood violence | 4.8 | (4.4 – 5.3) |
| Treated or judged unfairly due to race/ethnicity | 4.8 | (4.3 – 5.2) |
| Death of parent or guardian | 4.2 | (3.8 – 4.7) |
| Number of adverse childhood experiences (ACEs) | ||
| None | 50.2 | (49.1 – 51.3) |
| Only 1 | 25.1 | (24.1 – 26.0) |
| 2+ | 24.7 | (23.8 – 25.7) |
Prevalence of insufficient sleep duration among children/adolescents aged 6–17.
Table 2 presents the prevalence of ISD by demographic and other characteristics. According to parental report, 34% (95 CI:32.9%−35%) of children ages 6–17 years did not have sufficient sleep on an average weeknight, and among those children exposed to any ACE, 40.3% had insufficient sleep. ISD varied by age, race/ethnicity, family income, family structure, parental educational level and mental health status (chi-square tests with p-value <0.0001). Compared to white-non-Hispanic youth, prevalence of ISD for African American and Hispanic youth was significantly greater (28.8% vs 49.3% and 36.6% respectively). ISD was more prevalent among youth from low income families (42.2%) than among those from higher income families (27.1%). Children who lived in non-married households or with parents who had less than a high-school education were reported to have almost the same prevalence of ISD (42.9% and 41.9% respectively) compared with those who lived with married parents (30.2%) or with parents who had at least a high school education (31.1%). In addition, prevalence of ISD was greater among youth with anxiety problems or depression than those without these conditions (42.7% vs 33.9% and 49.5% vs 34.1%, respectively).
Table 2.
Prevalence of insufficient sleep duration among U.S. children 6–17 years of age, overall and by select characteristics, 2016–2017 National Survey of Children’s Health (N=46,209)
| Weighted % | 95% CI | |
|---|---|---|
| Overall | 34.0 | (32.9 – 35.0) |
|
| ||
| Age * | ||
| 6–10 | 31.6 | (29.8 – 33.4) |
| 11–14 | 32.6 | (30.9 – 34.3) |
| 15–17 | 39.7 | (37.8 – 41.7) |
|
| ||
| Sex | ||
| Male | 34.7 | (33.2– 36.2) |
| Female | 33.2 | (31.7 – 34.7) |
|
| ||
| Race/ethnicity * | ||
| Non-Hispanic white | 28.8 | (27.8 – 29.8) |
| Hispanic | 36.6 | (33.7 – 39.7) |
| Non-Hispanic black | 49.3 | (45.8 – 52.7) |
| Other | 34.3 | (31.8 – 36.9) |
|
| ||
| Anxiety * | ||
| Currently have or had | 42.7 | (37.9 – 47.7) |
| Do not have | 33.9 | (32.1 – 35.7) |
|
| ||
| Depression * | ||
| Currently have or had | 49.5 | (42.4 – 56.7) |
| Do not have | 34.1 | (32.4 – 35.8) |
|
| ||
| Household income * | ||
| 0–99% Federal Poverty Level (FPL) | 42.2 | (39.3 – 45.2) |
| 100–199% FPL | 37.5 | (34.8 – 40.3) |
| 200–399% FPL | 33.0 | (31.2 – 34.8) |
| 400 or greater | 27.1 | (25.9 – 28.4) |
|
| ||
| Family structure * | ||
| Two parents currently married | 30.2 | (29.0 – 31.5) |
| Two parents not currently married | 42.9 | (38.7 – 47.1) |
| Single mother | 41.2 | (38.6 – 43.9) |
| Other type | 41.8 | (37.9 – 45.8) |
|
| ||
| Education level of parents/other adults * | ||
| Less than high school | 41.9 | (36.5 – 47.4) |
| High school | 40.1 | (37.3 – 43.0) |
| More than high school | 31.1 | (30.1 – 32.2) |
|
| ||
| Adverse childhood experiences (ACEs) * | ||
| None | 27.6 | (26.2 – 29.0) |
| 1+ | 40.3 | (38.9 – 41.6) |
|
| ||
Insufficient sleep significantly varied by these variables (chi-squared p-value <0.0001).
Association of ACEs with insufficient sleep duration per American Academy of Sleep Medicine’s recommendations.
Table 3 presents the prevalence of ISD for those with/without each type of ACE and by the total number of ACEs. ISD was prevalent among children with ACEs: 48.6% among those who witnessed domestic violence, 46.8% among victims/witnesses of neighborhood violence, and 42.4% among children whose parent(s) had served time in jail. After adjusting for demographic and socioeconomic characteristics, seven ACEs were significantly associated with an increased odds of ISD (p<0.05): domestic violence (AOR=1.6, 95% CI:1.3–1.9), neighborhood violence (AOR=1.4, 95% CI:1.1–1.7), having lived with someone with an alcohol or drug problem (AOR=1.3, 95% CI:1.2–1.4), financial hardship (AOR=1.3, 95% CI:1.2–1.5), parental divorce/separation (AOR=1.3, 95% CI:1.2–1.4), having lived with a mentally ill, suicidal or severely depressed person (AOR=1.2, 95% CI:1.0–1.4), death of parent or guardian (AOR=1.3, 95% CI:1.0–1.6). Compared to youth without ACE exposure, the odds of experiencing ISD increased with the number of ACE exposures (AOR=1.4 for one ACE, AOR=1.7 for 2 or more ACEs).
Table 3.
Association between each adverse childhood experience (ACEs) and insufficient sleep duration, National Survey of Children’s Health, 2016.
| Adverse childhood experiences (ACEs) | Insufficient Sleep duration % (SE) | Unadjusted OR (95% CI) | Adjusted OR* (95% CI) |
|---|---|---|---|
| Exposure to violence | |||
| Domestic violence witness | |||
| Yes | 48.6 (2.1) | 1.9 (1.6–2.3) | 1.6 (1.3–1.9) |
| No | 32.9 (0.6) | ||
|
| |||
| Victim or witnessed neighborhood violence | |||
| Yes | 46.8 (2.4) | 1.8 (1.4–2.1) | 1.4 (1.1–1.7) |
| No | 33.3 (0.5) | ||
|
| |||
| Family dysfunction | |||
|
| |||
| Parent served time in jail | |||
| Yes | 42.4 (1.9) | 1.5 (1.3–1.7) | 1.2 (0.99–1.4)** |
| No | 33.1 (0.6) | ||
|
| |||
| Lived with someone with alcohol or drug problem | |||
| Yes | 41.5 (1.7) | 1.4 (1.2–1.7) | 1.3 (1.2–1.4) |
| No | 33.1 (0.6) | ||
|
| |||
| Divorce/parental separation | |||
| Yes | 40.4 (1.0) | 1.5 (1.3–1.6) | 1.3 (1.2–1.4)** |
| No | 31.3 (0.6) | ||
|
| |||
| Lived with someone mentally ill, suicidal, or severely depressed | |||
| Yes | 38.5 (1.6) | 1.2 (1.1–1.4) | 1.2 (1.0–1.4)*** |
| No | 33.5 (0.6) | ||
|
| |||
| Financial difficulty | |||
|
| |||
| Difficult to get by on current income | |||
| Yes (somewhat/very often) | 42.9 (1.2) | 1.7 (1.5–1.9) | 1.3 (1.2–1.5) |
| No | 31.1 (0.6) | ||
|
| |||
| Discrimination | |||
| Treated or judged unfairly due to race/ethnicity | |||
| Yes | 45.6 (2.5) | 1.7 (1.4–2.0) | 1.2 (0.99–1.5) |
| No | 33.4 (0.5) | ||
|
| |||
| Death | |||
|
| |||
| Death of parent or guardian | |||
| Yes | 44.7 (2.8) | 1.6 (1.3–2.0) | 1.3 (1.0–1.6)*** |
| No | 33.5 (0.5) | ||
|
| |||
| Accumulative exposure | |||
|
| |||
| Number of adverse childhood experiences (ACEs) | |||
| None | 27.6 (0.7) | Reference 1.6 | Reference |
| Only 1 | 37.8 (1.2) | (1.4–1.8) | 1.4 (1.2–1.6) |
| 2+ | 42.8 (1.1) | 2.0 (1.8–2.2) | 1.7 (1.5–1.9) |
Adjusted for youth’s age, gender, race/ethnicity, family poverty, family structure, and caretaker’s level of education, depression and anxiety.
Adjusted for youth’s age, gender, race/ethnicity, family poverty, and caretaker’s level of education, depression and anxiety. Family structure variable was not included due to potential over adjustment considering the nature of these ACEs.
Adjusted for youth’s age, gender, race/ethnicity, family poverty, and caretaker’s level of education and family structure. Depression and anxiety were not adjusted due to potential over adjustment for this ACE.
Association of ACEs with ISD defined as one hour less, or more than one hour less, than recommended by the American Academy of Sleep Medicine.
Table 4 presents the results of multinomial logistic regression analyses examining the association of each ACE and the cumulative number of ACEs with ISD for (a) one hour less or (b) more than one hour less sleep than recommended (vs. sufficient sleep). Joint tests of association of individual ACEs (except for ‘parent served in jail) with each level of insufficient sleep duration were significant (p<0.05). In the cases of domestic violence, financial hardship, parental divorce/separation, parental/guardian death, living with mentally ill, suicidal, or severely depressed person, and exposure to 2 or more ACEs, the association with more severe ISD (slept more than one hour less than recommended) was statistically significantly (p<0.05) stronger than that with ISD of one hour less than recommend.
Table 4.
Association between each ACE and severe level of insufficient sleep duration, NSCH 2016–2017.
| Adverse Childhood Experience (ACE) | 1 hr less vs. sufficient | >1 hr less vs.sufficient | P-value (1 hr less vs >1 hr less |
|---|---|---|---|
| AOR 95% CI | AOR 95% CI | ||
| Domestic violence witness* | 1.4 1.1–1.7 | 2.1 1.6–2.8 | 0.004 |
| Neighborhood violence | 1.2 0.9–1.5 | 1.6 1.2–2.2 | 0.07 |
| witness/victims* | |||
| Parent served time in jail | 1.1 0.99–1.3 | 1.3 1.04–1.7 | 0.13 |
| Living with someone who had a substance use problem* | 1.2 1.04–1.5 | 1.4 1.1–1.7 | 0.41 |
| Parental divorce/separation* | 1.2 1.1–1.4 | 1.5 1.3–1.9 | 0.01 |
| Living with a mentally ill, suicidal, or severely depressed person* | 1.1 0.9–1.3 | 1.5 1.2–1.9 | 0.004 |
| Financial hardship* | 1.1 0.99–1.3 | 2.1 1.8–2.6 | <0.001 |
| Unfair treatment because of one’s race/ethnicity* | 1.2 0.9–1.5 | 1.4 1.1–1.9 | 0.24 |
| Parental/guardian death* | 1.4 1.1–1.8 | 1.0 0.7–1.3 | 0.047 |
| Number of ACEs* | |||
| 0 | 1.0 Reference | 1.0 Reference | |
| 1 | 1.3 1.1–1.5 | 1.4 1.2–1.6 | 0.06 |
| 2+ | 1.6 1.3–2.0 | 2.2 1.7–2.7 | <0.001 |
AOR= Adjusted odds ratios from multinomial logistic regression models adjusted for youth’s age in years, gender, race/ethnicity, family poverty, family structure, depression, and anxiety; and caretaker’s level of education. Models for parent served time in jail, parental divorce/separation, and parental/guardian death omitted adjustment for family structure; model for living with mentally ill, suicidal, or severely depressed person omitted adjustment for depression and anxiety.
p<0.05, joint test of association of the ACE with each level of insufficient sleep duration.
Discussion
To the best of our knowledge, this is the first epidemiologic study to report the association of specific and cumulative ACEs with age specific ISD in a nationally representative sample of American youth, and to examine sleep insufficiency by the level of severity (i.e., one hour less versus more than one hour less than recommended). Nearly half of U.S. children and adolescents (ages 6–17) experienced at least one ACE, with nearly one in four experiencing two or more ACEs. One out of three children/adolescents did not get sufficient sleep as defined by guidelines endorsed by the AAP. Furthermore, the prevalence of insufficient sleep duration varied by youth’s age and mental health condition, family structure and income, and parents’ education. These findings support a framework of insufficient sleep that is/has been socially patterned.28 It underscores the importance of addressing individual and social level factors to improve sleep health among children/adolescents, especially among those who have experienced ACEs.
The study findings regarding the association of specific and cumulative ACEs with ISD among children and adolescents add to the growing evidence implicating sleep as another dimention of health consequences from ACEs. The categorization of ACEs into threat and deprivation domains 29 can be used as a framework to explore the more subtle aspects of the association of specific ACEs and sleep health. For example, exposure to violence can be considered as belonging to the threat domain as ISD was more prevalent among children and adolescents who witnessed domestic violence or were victims of, or witnessed, neighborhood violence. Acute threat can have effects on the developing neurobiology of the fear-learning and stress-response systems, potentially leading to lifelong biological arousal and hypervigilance, which in turn, can trigger insomnia and disrupt sleep patterns.30,31 On the other hand, in the deprivation domain, experiences such as extreme economic hardship may contribute to chronic stress that impacts sleep through an entirely different pathway. Future longitudinal studies are warranted to identify biological, psychological, and social mechanisms underlying the specific associations of different types of ACEs with ISD.
Importantly, this study also reports a dose-response effect, in that an increased count of ACEs is associated with increased odds of ISD. Children with exposure to multiple ACEs (having ≥2) are the most vulnerable. Moreover, the association of six specific ACEs was stronger with more severe ISD (slept more than one hour less than recommended). This indicates that ACEs not only have a statistically significant association with ISD but also a clinically significant association.
The study findings suggest that ideally all children should be screened for ACEs, for ISD and other sleep problems. At a minimum, children presenting with ACEs should be evaluated for ISD and other sleep problems, and children presenting with sleep problems should be evaluated carefully for the presence of ACEs, in addition to the other known factors (such as medical conditions, screen time and diet/physical activity) that may influence sleep duration and quality.
Screening for childhood adversities in real-time and providing timely trauma informed care to reduce the negative impact of ACEs is a vital strategy to mitigate the negative impact of ACEs on health outcomes. The American Academy of Pediatrics already supports routine screening for interpersonal violence during well-child visits. 32 Given the current debate about whether adults or children who have experienced ACEs should be screened in primary care practice settings 33,34 more studies are needed to determine whether a broad screen of other ACEs in primary care visits is feasible and effective.
Because sleep has been implicated as a potential pathway by which ACEs may impact health consequences,9,10 the interplay between ACEs, sleep, and long-term health outcomes clearly warrants further investigation. In particular, more studies are needed to examine the potential mediating role of sleep in the association of ACEs with other life-long health outcomes and to investigate if intervening to improve sleep mitigates the long-term effects of ACEs on overall health across the life course.
Strengths and Limitations
This is one of the few studies to examine prevalence of different types of ACEs and their cumulative count, using a large, nationally representative sample of youth in the U.S. Since 2016, the National Survey of Children’s Health has included a variable about sleep duration among children and adolescents. This important addition facilitated our analyses of the association of ACEs with ISD, as defined by recommendations from the American Academy of Sleep Medicine and should be analyzed in future data to identify trends.
Our study has important, unavoidable imitations. First, the NSCH survey may underestimate childhood adversity, as the survey data did not include emotional, physical or sexual abuse because the information was based on the report by a parent or caregiver. Also, the measure of sleep duration, derived from reports of the average sleep in the last week, was based on parent or caregiver’s responses. Parents or care givers may have overestimated sleep duration 35. Children’s sleep hours can be different on weekends and the NSCH data do not allow for the differentiation of sleep hours on school days versus on weekends. The NSCH study also excluded institutionalized children and adolescents who may have increased exposure to ACEs (more diverse types, more chronic duration and/or more severe forms). Therefore, the results may not generalize to this group. Second, the cross-sectional character of these data did not allow for an examination of the temporal nature of the associations. Finally, the measure of insufficient sleep duration used here reflects only one dimension of sleep health. More nuanced measures of sleep disturbances, for example those captured using an actigraph should be included in future studies to better unpack the impact of ACEs on sleep.
Conclusions
Seven ACEs and exposure to more than one ACEs are significantly associated with ISD among American youth, and they are also associated with severe ISD, i.e., more than one hour less sleep than recommended. These findings reinforce the public health need to prevent ACEs, underscore the importance of intervening to reduce ACEs and to improve sleep among children with such a history. Longitudinal research is needed to investigate the potential mediating role of sleep on overall health, as sleep may sit on the well-established trajectory from ACEs to short-term and long-term health outcomes.
What is New?
This study reports the association of adverse childhood experiences (ACEs) with age specific insufficient sleep among youth. The study findings demonstrate the importance of addressing both ACES and the associated sleep problems in youth.
Funding
National Heart, Lung, and Blood Institute (R01HL134856, PI Christina Hoven). The funding agency was not involved in the study design, analysis and interpretation of data and the writing of this manuscript.
Footnotes
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Declaration of Competing Interest
There are no conflicts of interest to declare.
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