Significant rise in sleep disturbances among children and adolescents worldwide

In a recent study published in Translational Psychiatry, researchers assessed the global prevalence of sleep disturbances in children and adolescents during the coronavirus disease 2019 (COVID-19) pandemic through a systematic literature review and meta-analysis.

Study: Prevalence of sleep disturbances in children and adolescents during COVID-19 pandemic: a meta-analysis and systematic review of epidemiological surveys. Image Credit: fizkes/Shutterstock.com

Background 

Declared a pandemic in March 2020, COVID-19 has led to over 230 million cases and 4 million deaths by September 2020. Its impact extends beyond physical health, notably affecting mental health, especially in children and adolescents.

Lockdowns and social distancing have increased anxiety, Post-Traumatic Stress Disorder (PTSD), depression, and sleep disturbances among the young. Studies show depression and anxiety prevalence in youth at about 25.2% and 20.5%, respectively, during the pandemic.

Sleep disturbances, influenced by stress and disrupted routines, vary in prevalence from 35.7% to 54%. These findings highlight the critical need for comprehensive analysis and further research into the pandemic’s enduring impact on youth mental health and sleep patterns.

About the study

The meta-analysis on the prevalence of sleep disturbances in children and adults during the COVID-19 pandemic adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocol (INPLASY).

Investigators independently searched major international and Chinese databases, including Web of Science, Chinese Nation Knowledge Infrastructure (CNKI), PubMed, PsycINFO, and WANFANG, from their inception until December 27, 2022. The search terms included various combinations related to sleep disturbances and COVID-19.

Inclusion criteria were framed using the Participants: Intervention: Control: Outcomes: Study design (PICOS) approach focusing on children and adolescents, with no specific interventions or controls, and considering studies that provided prevalence data of sleep disturbances during the pandemic.

The study designs included epidemiological surveys, both cross-sectional and baseline data from cohort studies. There were no restrictions on the measures used for sleep disturbances, and in cases of multiple publications from the same dataset, the one with the largest sample size was selected.

For study selection and data extraction, the same investigators independently screened titles and abstracts, followed by full-text reviews for eligibility. Reference lists of relevant reviews were also manually checked for additional studies.

Discrepancies were resolved through discussions with a third investigator. Data extraction was performed using a standardized form, capturing details like author, publication year, country, survey time, study design, sampling method, mean age, total and male sample sizes, and the scale for assessing sleep disturbances.

Study quality was evaluated using an 8-item instrument for epidemiological studies, with scores ranging from 0 to 8. High-quality studies scored 7–8, moderate quality 4–6, and low quality 0–3. Disagreements in quality assessment were resolved through discussion.

Statistical analysis involved using R software and comprehensive meta-analysis (CMA) version 2.0.

A random-effects model was employed due to varying study characteristics to calculate the pooled prevalence of sleep disturbances with their 95% confidence intervals (CI). Heterogeneity was assessed using the I² statistic, with I² > 50% indicating high heterogeneity. 

Subgroup and meta-regression analyses examined the moderating effects of categorical and continuous variables on the results. Sensitivity analyses identified outlying studies, and publication bias was assessed using funnel plots and Begg tests, with a p-value < 0.05 denoting statistical significance.

Study results 

The results of the meta-analysis, which included 57 articles covering 206,601 participants, revealed important insights into sleep disturbances among children and adolescents during the COVID-19 pandemic.

These studies had a broad range of sample sizes, from 28 to 42,077 participants, with the mean age of participants varying from 6.78 to 17.4 years. The study quality assessments showed a range of scores from 3 to 7, with the majority being of moderate quality.

The pooled prevalence of sleep disturbance was 34% (95% CI: 28–41%, I² = 100%, τ² = 0.071). This result is particularly significant as it indicates substantial sleep disturbances among youth during the pandemic.

The sensitivity analysis revealed no outlying studies that significantly altered this prevalence. Additionally, the analysis for publication bias, including a Funnel plot and Begg test, did not indicate any significant bias in reporting sleep disturbance prevalence.

Subgroup and meta-regression analyses shed light on various factors influencing sleep disturbances. Notably, the prevalence of parent-reported sleep disturbances was significantly higher than self-reported cases.

Studies conducted across Asia and Europe reported a higher prevalence than in other regions. Interestingly, children showed a higher prevalence of sleep disturbances than adolescents or mixed groups.

Factors like mean age, study quality assessment, and the percentage of men showed negative associations with sleep disturbance prevalence, whereas the survey time showed a positive association.

These findings present a lower prevalence rate than some previous meta-analyses, which reported rates as high as 54% and 44%. However, it is important to consider the specificities of each study, including the inclusion of children with neurobehavioral disorders in some and the focus on sleep disorders rather than sleep disturbances in others.

Moreover, the current findings indicate a higher prevalence of sleep disturbances than pre-pandemic figures among adolescents and the general population in China.

The study also found that parent-reported sleep disturbances were more common than self-reported ones.

This discrepancy could be due to parents being more attuned to the objective symptoms and disturbances in their children’s sleep patterns, especially during the pandemic and home isolation.

Additionally, younger children were found to be at a higher risk of sleep disturbances than pre-pandemic times, possibly due to their greater need for outdoor and social activities, which were restricted during the pandemic.

This contrasted with previous findings and highlighted the unique impact of the pandemic on different age groups.