Association of parent-reported sleep problems in early childhood with psychotic and borderline personality disorder symptoms in adolescence

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Colleges, School and Institutes


Importance: Persistent nightmares in childhood have been prospectively associated with psychosis and borderline personality disorder (BPD) in adolescence. However, the extent to which this association is also true for behavioral sleep problems is still unknown, and the potential mechanisms are unexplored.

Objective: To examine the prospective associations between several parent-reported sleep problems in early childhood and psychotic and BPD symptoms at 11 to 13 years of age and the potential mediation of the associations by depression at 10 years of age.

Design, Setting, and Participants: This cohort study assessed 13 488 participants in the Avon Longitudinal Study of Parents and Children birth cohort who were followed up for more than 13 years. Pregnant women from Avon, United Kingdom, with expected dates of delivery from April 1, 1991, to December 31, 1992, were invited to take part in the study. Data analysis was conducted from May 1 to December 31, 2019.

Main Outcomes and Measures: Psychotic experiences at 12 to 13 years of age were assessed using the Psychosis-Like Symptom Interview, and BPD symptoms at 11 to 12 years of age were tested using the UK Childhood Interview for DSM-IV Borderline Personality Disorder. Parent-reported nighttime sleep duration, night awakening frequency, bedtime, and regularity of sleep routines were assessed when the child was 6, 18, and 30 months and 3.5, 4.8, and 5.8 years of age.

Results: Data were available on 7155 participants (3718 girls [52%]) who reported on BPD symptoms and 6333 (3280 boys [52%]) who reported on BPD symptoms. Higher night awakening frequency at 18 months of age (odds ratio [OR], 1.13; 95% CI, 1.01-1.26) and less regular sleep routines at 6 months (OR, 0.68; 95% CI, 0.50-0.93), 30 months (OR, 0.64; 95% CI, 0.44-0.95), and 5.8 years (OR, 0.32; 95% CI, 0.19-0.53) of age were significantly associated with psychotic experiences in adolescence, whereas shorter nighttime sleep duration (OR, 0.78; 95% CI, 0.66-0.92) and later bedtime at 3.5 years of age (OR, 1.32; 95% CI, 1.09-1.60) were significantly associated with BPD symptoms. Results of mediation analysis were consistent with all these associations, except for later bedtime at 3.5 years and BPD in adolescence, which had no association. Depression at 10 years of age mediated the associations between frequent night awakenings at 18 months of age (bias-corrected estimate, −0.005; 95% CI, −0.008 to −0.002; P = .002) and irregular sleep routines at 5.8 years of age (bias-corrected estimate, −0.006; 95% CI, −0.010 to −0.003; P = .003) with psychosis.

Conclusions and Relevance: The findings suggest that some behavioral sleep problems in childhood are distinctively associated with the onset of psychosis and BPD in adolescence, following different pathways. Furthermore, depression at 10 years of age may mediate only the association with psychosis. These findings contribute to the design of more personalized interventions in psychosis and BPD.

Bibliographic note

Funding Information: reported receiving funding from Oxford University Press and the National Institute for Health Research Clinical Research Network and personal fees from Medical Defence Union outside the submitted work. Dr Marwaha reported attending and education event sponsored by Janssen. No other disclosures were reported. Funding Information: Funding/Support: This study was supported by grant 102215/2/13/2 from the UK Medical Research Council and Wellcome. The University of Bristol provided core support for the Avon Longitudinal Study of Parents and Children (ALSPAC). Publisher Copyright: © 2020 American Medical Association. All rights reserved. Copyright: Copyright 2020 Elsevier B.V., All rights reserved.


Original languageEnglish
Article numbere201875
Pages (from-to)1256-1265
Number of pages10
JournalJAMA psychiatry
Issue number12
Early online date1 Jul 2020
Publication statusPublished - Dec 2020

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