Higher Rates of Sleep Disturbance Among Offspring of Parents With Recurrent Depression Compared to Offspring of Nondepressed Parents

Jessica L. Hamilton, PHD; Cecile D. Ladouceur, PHD; Jennifer S. Silk, PHD; Peter L. Franzen, PHD; Lauren M. Bylsma, PHD


J Pediatr Psychol. 2020;45(1):1-11. 

In This Article


Study Recruitment and Participants

Participants included 82 youth (aged 9–13, 46% female) determined to be at high or low risk based on having at least one biological parent with recurrent depression (2 or more episodes; 88% were mothers). Participants were recruited as part of a larger study on neurobehavioral indices of emotional functioning and depression risk (K01MH104325). Exclusion criteria for all participants included parental history of bipolar disorder, mania, or psychosis. Low-risk youth had parents without a lifetime history of any psychopathology. Youth exclusion criteria included a lifetime diagnosis of a depressive disorder, pervasive developmental disorder, intellectual disability, history of substance abuse/dependence, or a serious head injury or neurological condition. High- and low-risk youth and parents were recruited through local advertising methods online and in print (e.g., websites, research registries, psychiatric clinics, and email listservs). All procedures were approved by the local Institutional Review Board. Parents and youth gave consent and assent prior to the study procedures and received compensation for their time and participation.

Parents completed a screening by phone, which included questions about parental and child mental health history. Participants (parent and child) were then scheduled for their first laboratory visit to participate in a clinical diagnostic assessment with the child and one of his or her parents by trained clinical interviewers (Kiddie Schedule for Affective Disorders and Schizophrenia [K-SADS-PL]; Kaufman et al., 1997 and Structured Clinical Interview for DSM-IV [SCID]; Spitzer, Williams, Gibbon, & First, 1992). In the current study, interviewer reliability for depression diagnosis was excellent (kappa > .9). See Supplementary Table 1 for a summary of sample recruitment and procedures. The final sample included 41 (46% female) high-risk and 41 (49% female) low-risk youth with at least one sleep diary completed and valid data for sleep onset and offset times. Table I includes demographic information for the overall sample and by youth high- and low-risk status. There were no significant differences between participants included in the present study and those in the larger sample.


Following the clinical interview to confirm eligibility, parents and youth completed questionnaires, including youth sleep disturbance (completed by parent and child) and youth internalizing symptoms. Youth then completed a 9-day ecological momentary assessment battery for five weekdays and four weekend days, which included a morning sleep diary. The protocol was administered using a custom app installed on study-provided Android smartphones. Participants were instructed on how to use the devices and the study application. Sleep items were completed at the morning battery, which youth were instructed to complete within 1 hr of waking on weekdays (mean completion time = 7: 39 a.m.) and weekend days (mean = 8: 49 a.m.). On average, youth completed 7.65 sleep diaries (85%) out of 9 possible diaries, of which 4.58 days (out of 5) were weekdays. Total number of sleep diaries was not correlated with study outcomes (r's < .15).


Sleep Disturbance. Parents and youth each completed measures assessing youth sleep disturbance. Parents completed the abbreviated version of the Children's Sleep Habits Questionnaire (CSHQ-A; Bonuck, Goodlin-Jones, Schechter, & Owens, 2017; Owens, Spirito, & McGuinn, 2000), which is a 22-item questionnaire assessing behavioral sleep problems. It includes a total score, which is comprised of 6 subscales: bedtime resistance, sleep duration, sleep anxiety, sleep onset latency, daytime sleepiness, and behaviors around sleep and night awakenings. The modified short-form version has been validated and demonstrated excellent psychometric properties (Bonuck et al., 2017). Item responses range from 1 (never) to 5 (always), with total scores ranging in the current study from 25 to 61. Youth completed the Sleep Self Report (SSR; Owens, Spirito, McGuinn, & Nobile, 2000). Similar to the CSHQ, the SSR includes 26-items assessing common behavioral sleep problems, including bedtime sleep behaviors, nighttime sleep behaviors, and daytime sleepiness. Item responses range from 1 (rarely) to 3 (usually), with total scores ranging in the current study from 27 to 64. In the current study, we used the total score of the CSHQ and SSR to assess overall sleep disturbance rather than individual subscales due to lower, inadequate reliability among several subscales (α =.42–.76). Higher total scores indicate more sleep disturbance for both measures. Internal reliability for the total scale for both measures was adequate (α > .80).

Sleep Duration and Midpoint. On morning sleep diaries, youth reported the timing of sleep onset ("About what time did you go to sleep last night?") and sleep offset ("About what time did you wake up this morning?"), which is standard for sleep diaries. These scores were used to calculate a proxy of sleep duration (e.g., difference between sleep offset and onset times). The middle clock time between sleep on and offset times was used to defined the midpoint of sleep cycle, which correlates with chronotype and dim light melatonin onset (Kantermann, Sung, & Burgess, 2015). Self-reported sleep has demonstrated modest to strong correlations with actigraphy-derived sleep parameters among youth (Wolfson et al., 2003).

Youth Internalizing Symptoms. Youth reported their depression symptoms using the 33-item Mood and Feelings Questionnaire (MFQ)-Long Form (Angold et al., 1995) and anxiety symptoms using the 41-item Screen for Child Anxiety-Related Emotional Disorders (SCARED; Birmaher et al., 1997, 1999). The sleep items were removed from the total scores of both measures to avoid confounds in assessing their association. Item responses range from 0 to 2. Scores ranged from 0 to 47 for the SCARED and 0 to 61 for the MFQ, with higher scores indicating higher levels of anxiety and depressive symptoms. Though these measures were treated as continuous variables in the current study, we included the percentages of clinical cutoffs for the SCARED (≥ 30; Birmaher et al., 1999) and MFQ (≥ 27; Daviss et al., 2006). Internal reliability for the MFQ (α = .96) and SCARED scales with the sleep items removed was excellent (α = .92).

Puberty. The Pubertal Development Scale (PDS; Petersen, Crockett, Richards, & Boxer, 1988) assessed youth pubertal maturation, which is a well-validated measure of self-reported pubertal development. Scores were calculated using a coding system that parallels the Tanner Stages and converts the PDS to a 5-point scale (Shirtcliff, Dahl, & Pollak, 2009), with higher scores indicative of more pubertal maturation. Pubertal development is linked with sleep (Colrain & Baker, 2011), thus, pubertal maturation was covaried in analyses.

Parent-set Bedtime. Given links between parent-set bedtime and youth sleep patterns (Short et al., 2011), we covaried for parent-set bedtime. Using a single-item on the youth sleep measure (SSR; "Who in your family sets the rules about when you go to bed?"), responses were dichotomized to reflect parent-set or child-set bedtimes (Short et al., 2011).

Statistical Analyses

First, descriptive statistics and bivariate correlations between the primary variables were examined, and t-tests were conducted to examine demographic differences by risk status for sex, age, and race. We also examined sleep variables by timing of when they were assessed (school-break/school year), and conducted paired samples t-tests to examine weekday-weekend differences for sleep duration and midpoint. In analyses, we covaried pubertal development, age, sex, SES (indicated by receipt of public assistance), youth depression and anxiety symptoms, and whether parents set youth bedtimes, which are biological and environmental factors that can impact youth sleep (Hagenauer et al., 2009; Short et al., 2011). We also covaried completion of the study during the school-break or school-year for analyses predicting sleep duration and midpoint. For analyses that examined whether sleep disturbance was associated with youth risk status, we conducted path analysis with parent and child-reported sleep disturbance as the primary outcomes in Mplus 7.0 (Muthén & Muthén, 2007). Sleep disturbance reported by parents and youth were endogenous variables, allowed to covary to determine correlations.

To determine whether youth risk status predicted sleep midpoint and duration reported on the sleep diary, we conducted two-level multilevel modeling in Mplus 7.0 with Full Information Maximum Likelihood to estimate parameters for missing data to maximize data. Sleep was reported daily (within-person data) and predictors were between-person. Fixed effects were entered for all covariates and risk status (group) predicting sleep parameters. For a parsimonious model, sleep midpoint and duration were estimated simultaneously and allowed to covary. Random effects were included for the intercept of sleep parameters. Supplementary analyses were conducted for weekdays and weekends (results provided in Supplementary Table 2 and Supplementary Table 3). For exploratory analyses examining sex differences, we added an interaction term between risk status and sex to path and multilevel models. When there was evidence of a significant interaction, we probed the interaction for girls and boys by risk status and plotted the results.

Supplementary Figure 1.

Recruitment and Sampling Procedures
Note: Study procedures are bolded. Approximately 1–2 weeks elapsed between the first and second study visits (pending participant availability). HR and LR= High and Low Risk. Reasons for dropout included scheduling difficulties, interest, perceived study burden, or other (undisclosed).There were no differences between participants included in the current study and those in the larger study sample.