Associations of sleep disturbance with depression, anxiety, and irritability in youth

Associations of sleep disturbance with depression, anxiety, and irritability in youth | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Associations of sleep disturbance with depression, anxiety, and irritability in youth Kate Simmons, Ashley Karlovich, Spencer Evans This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4558662/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract In children and adolescents, symptoms of depression, anxiety, and irritability frequently co-occur, and many of these affective problems are associated with sleep disturbance. However, the extent to which sleep disturbance is specifically linked to any one of these affective problems over and above the others remains unclear. Therefore, the current study investigated the unique associations of sleep disturbance with depression, anxiety, and irritability. A community sample of 526 parents/caregivers of youths ages 6–14 ( M age = 9.51; 53.6% female) completed measures assessing their child’s symptoms of sleep disturbance, depression, anxiety, and irritability. Hierarchical multiple regression analyses were conducted to examine sleep disturbance as predicted by depression, anxiety, and irritability, with age and gender as covariates and moderators. Zero-order correlations showed that sleep disturbance was significantly and positively associated with depressive symptoms, anxiety, and irritability. Hierarchical multiple regression analyses showed that sleep disturbance was uniquely associated with depression and anxiety, but not irritability, when all three emotional variables were included in the same model. Further, exploratory moderation analyses suggested that the association between sleep disturbance and irritability may be moderated by child age and gender. Findings shed light on the role of sleep disturbance as a transdiagnostic feature in youth psychopathology, with particularly strong and unique links to depression and anxiety (less so for irritability). Additional research is needed examine these relationships across diverse samples, in clinical settings, and using multi-method, multi-informant, and longitudinal approaches. sleep disturbance depression anxiety irritability transdiagnostic youth Figures Figure 1 Introduction Sleep has become increasingly studied in relation to development and maintenance of emotional symptoms across the lifespan, with significant implications for mental and physical health (Dahl, 1996 ; Gregory & Sadeh, 2012 ; Kortesoja et al., 2020 ). In particular, sleep disturbance is a transdiagnostic construct, listed as a symptom of various mental health disorders in the DSM-5-TR (American Psychiatric Association, 2022 ) and often appearing as part of the clinical presentation of several psychiatric disorders (Dahl & Harvey, 2007 ; Harvey et al., 2011 ). Sleep disturbance includes difficulties falling asleep and staying asleep throughout the night (Forrest et al., 2018 ). In youth specifically, sleep disturbance contributes to increased risk for depression, anxiety, and suicidality, and are often present among youth with other physical and mental health conditions as well (Chorney et al., 2007 ; Kearns et al., 2020 ). Sleep disturbance is also associated with irritability (Rubens et al., 2017 ), both of which are extremely common in adolescents (Karlovich et al., 2023 ). Yet there is limited research on the interplay between sleep and emotions, particularly on the unique associations of sleep disturbance with depression, anxiety, and irritability in youth. Despite prior research on single affective variables (e.g., links between sleep disturbance and anxiety), these associations have yet to be examined across a full range of emotional problems affecting youth. Given the transdiagnostic nature of sleep disturbance and frequent co-occurrence with mental health concerns, examining these unique associations is crucial to understanding the role of sleep in youth psychopathology. Sleep Disturbance and Emotional Symptoms Sleep-related symptoms are central features of major depressive disorders in DSM-5-TR (American Psychiatric Association, 2022 ). Sleep disturbance strongly contributes to the development and expression of depressive disorders in adults (Fang et al., 2019 ; Franzen & Buysse, 2008 ). Although much of the research on this topic has focused on adults, studies among children have found that sleep disturbance is associated with depression (Alvaro et al., 2013 ; Goldstone et al., 2020 ). Up to 73% of youth with Major Depressive Disorder have been found to experience sleep disturbance (Ivanenko & Johnson, 2008 ). Sleep disturbance has been found to predict depressive symptoms in youth, even after controlling for social anxiety (Armstead et al., 2019 ). Given the limited research on sleep disturbance and depression in youth, and their high prevalence in this period, more research is needed to understand their association. Sleep and its relation to anxiety has become an important area of study. Young children with anxiety may be at a greater risk of experiencing problems related to sleep compared to their non-anxious peers (Alfano et al., 2010 ; Weiner et al., 2015 ). This includes sleep disturbance, which, when assessed on its own, has been found to be highly associated with anxiety (Brown et al., 2018 ; Cox & Olatunji, 2016 ). In clinical samples, up to 85% of parents of anxious youth have reported that their child also experiences clinically significant sleep disturbances (Alfano et al., 2010 ; Kendall & Pimentel, 2003 ). However, these studies generally do not account for the presence of comorbidities between anxiety and other affective variables, and the precise nature of the relationship between sleep disturbance and anxiety remains unclear. Similar to sleep disturbance, irritability is a transdiagnostic nonspecific feature that is a primary or secondary symptom of numerous disorders (e.g., anxiety, depressive, and trauma and stressor-related disorders; Karlovich et al., 2023 ). Despite this commonality, there is limited research on the relationship between sleep and irritability. Several disorders characterized by severe irritability (e.g., bipolar disorders, Disruptive Mood Dysregulation Disorder) are also commonly linked to sleep disturbance (Delaplace et al., 2018 ; Harvey et al., 2015 ). Poorer sleep quality is associated with higher levels of irritability, as well as other emotional and behavioral problems (Rubens et al., 2017 ). Additionally, related bodies of research indicate that sleep disturbance predicts higher levels of aggression, violence, and delinquency (Clinkinbeard et al., 2011 ; Kamphuis et al., 2012 ). However, there has been limited research on the unique, specific association between sleep disturbance and irritability. It is important to note that youth affective problems frequently co-occur (Ezpeleta et al., 2020 ). Particularly high comorbidity rates have been documented between anxiety and depressive disorders (for a review, see Cummings et al., 2014 ). The 2016 National Survey of Children’s Health showed that around 74% of youth with depression also had an anxiety disorder (Ghandour et al., 2019 ). Although researchers have examined sleep disturbance in relation to both anxiety and depression, many of these studies do not take into account the high correlations between these two problem areas (Chorney et al., 2007 ; Chu et al., 2019 ). Similarly, irritability is a transdiagnostic construct implicated in a range of mental health disorders in youth. Depression and irritability have also been found to be specifically associated with one another through various pathways, such as genetic and environmental risk factors (Vidal-Ribas Belil & Stringaris, 2021 ). Anxiety and irritability have been found to be uniquely linked (Cornacchio et al., 2016 ). It has been proposed that sleep problems play a key role in accounting for this association (Poznanski et al., 2018 ), although more research is needed. Current Study As summarized above, sleep disturbance has been found to be generally associated with depressed mood, anxiety, and irritability; however, there is also a significant amount of overlap between each of these variables. Given these patterns of high co-occurrence and correlation, the extent to which sleep disturbance is uniquely associated with these particular affective problems in youth remains unclear. It is important to identify these unique associations to better understand the specific role of each variable when controlling for co-occurring concerns. Research in this area could have important implications for the understanding, assessment, and treatment of sleep disturbance, depression, anxiety, and irritability in youth. Accordingly, the current study seeks to fill this gap. We conducted a community-based study of youths ages 5–14 to examine associations among parent/caregiver-rated measures of child sleep disturbance, depression, anxiety, and irritability. We hypothesized that (a) sleep disturbance would be positively correlated with depression, anxiety, and irritability at the zero-order level; and that (b) sleep disturbance’s unique associations with depression and anxiety would be greater than its association with irritability in multiple linear regression analysis. The first hypothesis was made considering research reviewed above documenting sleep disturbances association with all three affective problems. The second hypothesis was made given that there appears to be relatively more evidence for sleep’s associations with depression and anxiety, and less for irritability; and given that the transdiagnostic nature of irritability (i.e., linked to anxiety and depression) may mean there is relatively little remaining variance associated with irritability through which it could be specifically associated with sleep disturbance. Finally, given the variations related to age (e.g., Solmi et al., 2022 ) and gender (e.g., Zahn-Waxler et al., 2008 ) in the development of emotional disorders, we examined these variables as covariates and moderators; however, considering the limited research on how these factors affect sleep’s associations with specific emotional problems, these analyses were considered exploratory. Methods Participants and Procedures Participants were a community sample of 526 parents/caregivers ( M age = 38.23, SD = 8.57), who completed parent-report measures on their child between the ages of 6 and 14 ( M age = 9.51, SD = 2.67). As summarized in Table 1 , caregivers and youths were mostly identified as White and non-Hispanic. Caregivers were predominantly female, while youths were more evenly balanced between male and female. See Table 1 for a comprehensive overview of participant demographic characteristic. Table 1 Sample Demographics Caregiver Child Characteristic n % n % Gender Male 225 42.8 244 46.4 Female 296 56.3 282 53.6 Non-Binary, Transgender, or Other 5 1.0 - - Race White or Caucasian 410 77.9 394 74.9 Black or African American 51 9.7 54 10.3 Asian 39 7.4 35 6.7 Multiracial 12 2.3 35 6.7 American Indian or Alaska Native, Pacific Islander, or Other 14 2.7 8 1.5 Ethnicity Hispanic/Latino/a/x 120 22.8 133 25.3 Not Hispanic/Latino/a/x 392 74.5 375 71.3 No Response 14 2.7 18 3.4 These data were collected as part of an online survey study developed to explore the mental health needs of youth and families in the community. Caregiver participants were recruited and data were collected using multiple platforms including Amazon’s Mechanical Turk (MTurk), Qualtrics Panels, and Prolific. Recruitment was largely focused on caregivers in the South Florida area, but with some platforms we also recruited nationally in order to obtain a larger sample. Participants were eligible if they were at least 18 years of age, the parent or caregiver of a child or adolescent between 6 and 14 years of age, and able to complete informed consent and study surveys in English or Spanish. Potential participants were excluded if they were under 18 years of age, did not have a child in the target age range, or if they were unable to consent to the study. All participants were required to complete an online consent form to participate in the study. Upon completion of the surveys, participants were compensated for their time (usually $ 4–5, with exact amounts varying by platform). The [masked for review] Institutional Review Board approved all recruitment and survey procedures for this study. Measures (summarized below) were administered via Qualtrics. We used partial randomization of survey blocks to help prevent order effects, and “request response” prompts to minimize missing data. Attention check items were used to verify that participants were paying attention to question wording and support the validity of the data. Specifically, these items were embedded at the end of selected measures and they instructed the participant to choose a specific response (e.g., “For this item, please select ‘Very Rarely’”). Of the 687 participants who completed the survey, for the present analyses we excluded those who participated in Spanish ( n = 26); failed one ( n = 1) or both ( n = 24) attention check questions; did not complete the survey ( n = 72); or completed the survey in < 10 minutes (i.e., less than half the expected response time of 20–30 minutes; n = 38). Consequently, the final sample consisted of N = 526 caregivers ( M age = 38.23, SD = 8.57) of children between the ages of 6 and 14 ( M age = 9.51, SD = 2.67). As summarized in Table 1 , the caregivers and youths in this sample were mostly identified as White and non-Hispanic. Caregivers were predominantly female, while youths were more evenly balanced between male and female. Measures Sleep Disturbance. Sleep disturbance was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Sleep Disturbance-Parent Proxy, 4-item short form version (PROMIS-SD-P-4; Forrest et al., 2018 ). This scale asks caregivers to report on their child’s sleep from the past week (e.g., “In the past 7 days...My child had difficulty falling asleep”), using a 5-point Likert scale ranging from 1 (Never) to 5 (Always) . This measure has been validated for use in child and adolescent samples (Forrest et al., 2018 ). Items are summed, with a total score range of 4 to 20, and higher scores indicating greater levels of sleep disturbance. A raw score of 10 or above indicates elevated sleep symptoms, with scores of 12 + and 15 + indicating great and severe sleep impairment, respectively (Forrest et al., 2018 ). For this sample, internal consistency was acceptable (α = .64), particularly considering that alpha tends to be lower for briefer measures (Tavakol & Dennick, 2011 ). Depression. Depression was measured using the Short Mood and Feelings Questionnaire, parent-report form (SMFQ-P; Angold et al., 1995 ). This 13-item form asks caregivers to rate how their child has been feeling or acting over the past two weeks (e.g., “S/he felt miserable or unhappy”) and includes a 3-point scale with the following response options: 0 (Not True) , 1 (Sometimes) , or 2 (True). Item totals are summed, with a score range of 0 to 26 and higher scores indicating greater levels of depression. The SMFQ-P has shown good reliability and discriminant validity in both clinical and community samples (Angold et al., 1995 ; Rhew et al., 2010 ). However, the SMFQ-P does not have an established clinical cut-off score, with some studies suggesting a clinical cut-off score of 4 (Rhew et al., 2010 ) and others suggesting a clinical cut-off score of 8 (Cardamone-Breen et al., 2017 ). Previous research has also shown differences in cut-off scores between genders (Jarbin et al., 2020 ). For the purpose of this study, scores greater than 4 are considered as having elevated symptoms, as this cut-off score has been used in younger adolescent populations in prior research (Liu & Adrian, 2019 ; Rhew et al., 2010 ). In the present sample, internal consistency was excellent (α = .94). Anxiety. Anxiety was measured using the Spence Children’s Anxiety Scale, 8-item short form, parent-report (SCAS-P-8; Reardon et al., 2018 ). Caregivers are asked to indicate the extent to which each statement (e.g., “My child worries about things”) is applicable to their child using a 4-point Likert scale, with responses ranging from 0 (Never) to 3 (Always) . The SCAS-P-8 has shown good internal consistency and both convergent and discriminant validity in community and clinical samples of youth. Additionally, the 8-item version of this measure has shown similar capacity as the full-length Spence Children’s Anxiety Scale to identify youths with anxiety disorders, with a suggested total clinical cut-off score of 7.5 (Reardon et al., 2018 ). For the purpose of this study, the total anxiety score was calculated and used in analyses. Item totals are summed, with a score range of 0 to 24 and higher scores indicating greater levels of anxiety. In this sample, internal consistency was excellent (α = .92). Irritability. Irritability was measured using the parent-report version of the Affective Reactivity Index (ARI; Stringaris et al., 2012 ). This 7-item form includes 6 items relating to total irritability symptoms (e.g., “Is easily annoyed by others”) and 1 impairment item that is not used in scoring (i.e., “Overall, irritability causes him/her problems”). The response options are 0 (Not True) , 1 (Somewhat True) , or 2 (Certainly True). The ARI has shown good internal consistency and both convergent and discriminant validity in clinical and community samples (Evans et al., 2021 ; Mulraney et al., 2014 ). Additionally, parent-report ARI scores greater than 3 have been used to classify children with DMDD (Haller et al., 2020 ), indicating an establish clinical cut-off score of 3. Item totals are summed, with a score range of 0 to 12 and higher scores indicating greater levels of irritability. In this sample, internal consistency was excellent (α = .90). Data Analysis Plan First, we examined descriptive statistics of the data on all study measures, including means, standard deviations, range, and percent with elevated symptoms. The two main study hypotheses were tested via linear correlation and regression analyses. These analyses used a standard alpha of 0.05 and 95% confidence intervals (CIs) for significance. Specifically, we first examined zero-order correlations to characterize the associations and shared variance among sleep disturbance, depression, anxiety, and irritability. Next, hierarchical multiple regression models were estimated examining sleep disturbance as predicted by anxiety, depression, and irritability. To check the robustness of effects, these analyses were conducted with and without age and gender as covariates. Effect sizes for linear correlations was interpreted using established guidelines (Cohen, 1988 ), where negligible, small, medium, and large absolute values of roughly < .1, ≥.1, ≥ .3, and ≥ .5, respectively. Finally, exploratory moderator analyses were conducted to generate hypotheses about how findings might vary across development or gender. Specifically, we estimated separate models for each affective and demographic variable and their product (e.g., anxiety, age, and age*anxiety) as predictors of sleep disturbance. All variables were mean-centered prior computing product terms and conducting analyses. Because these analyses were exploratory and entailed several additional statistical tests, we applied a familywise Bonferroni correction to reduce the risk of false positives. That is, for these results in particular, the standard alpha 0.05 was divided by the number of tests for each moderator (3 [anxiety, depression, irritability] for age, and same 3 for gender), resulting in a Bonferroni adjusted alpha of .0167. Results Descriptive Statistics and Correlations As summarized in Table 2 , sleep and emotion variables were roughly normally distributed with a slight right skew. Using the clinical thresholds from these measures, sizable minorities of the sample had elevated sleep problems (38%), depressive symptoms (45%), anxiety (39%) or irritability (35%). The Pearson’s correlations (see Table 3 ) among depression, anxiety, irritability, and sleep were all significant ( p s < .001) with large effect sizes. Of specific interest, sleep disturbance was positively associated with depression, ( r = .63, 95% CI [58, .68], anxiety ( r = .66, 95% CI [.60, .70]), and irritability r = .55, 95% CI [.49, .61]. In other words, depression, anxiety, and irritability could each be said to explain about 30–44% of the variance in sleep disturbance. The confidence intervals suggest that these correlations of depression and anxiety with sleep disturbance are roughly equivalent with one another, and both greater than the corresponding correlation for irritability. These associations were then examined further through hierarchical multiple regression analyses. Table 2 Descriptive Statistics Measure M SD Range Percent with Elevated Levels Sleep Disturbance (PROMIS-S) 10.65 3.20 4–20 37.6% Depression (SMFQ-P) 5.88 6.38 0–26 45.1% Anxiety (SCAS-P-8) 6.88 5.67 0–24 39.0% Irritability (ARI) 2.93 3.34 0–12 34.6% Caregiver Age (years) 38.23 8.57 20–84 - Child Age (years) 9.51 2.67 6–14 - Note . Elevated levels are defined by score thresholds suggested by prior research, as summarized in the measures section: ≥10 for sleep, ≥ 4 for depression, ≥ 8 for anxiety, ≥ 3 for irritability. PROMIS-S = Patient-Reported Outcomes Measurement Information System (PROMIS). Pediatric Sleep Disturbance-Parent Proxy, 4-item short form. SMFQ-P = Short Mood and Feelings Questionnaire, parent-report form. SCAS-P-8 = Spence Children’s Anxiety Scale, 8-item short form, parent-report. ARI = Affective Reactivity Index, parent report version. Table 3 Zero-Order Correlations 1 2 3 4 5 1. Sleep Disturbance - 2. Depression .63*** - 3. Anxiety .66*** .84*** - 4. Irritability .55*** .81*** .75*** - 5. Age .002 − .006 .01 .01 - 6. Gender .002 .01 .-.04 .03 .07 Note. Correlations with gender are presented as point-biserial correlations, all others are Pearson’s r correlations. * p < .05, ** p < .01, *** p < .001 Hierarchical Multiple Regression Analyses Given high correlations among depression, anxiety, and irritability, we examined the multicollinearity among these variables in the regression model. Results showed that Variance Inflation Factor (VIF) was 4.6 for depression, 3.5 for anxiety, 3.0 for irritability, and 1.0 for age and gender. In other words, based on established guidelines (Hair et al., 2006 ), depression, anxiety, and irritability fell in the 1.0–5.0 range, suggesting a moderate but acceptable levels of multicollinearity, which was taken into account in subsequent analyses Results of hierarchical multiple regression analyses are presented in Table 4 . As shown, sleep disturbance was significantly predicted by anxiety ( B = 0.24, 95% CI [0.17, 0.30], p < .001) and depression ( B = 0.13, 95% CI [0.06, 0.20], p < .001) when controlling for all other predictor variables in the model; however, the association between sleep disturbance and irritability was attenuated to nonsignificance ( B = 0.03, 95% CI [-0.08, 0.14], p = .61). Standardized beta coefficients indicate these effects were medium for anxiety, small for depression, and negligible for all other variables. Age and gender were added as covariates. The overall model was significant, ( F (5, 520) = 85.99, p < .001), accounting for about 45% of the variance in sleep problems ( R 2 = 0.45); therefore, results stood after controlling for child age and gender, which were not significantly associated with sleep disturbance. Table 4 Hierarchical Multiple Regression Analysis Predictor B 95% CI SE β t R 2 ( ΔR 2 ) adj.R 2 Model F (Change F ) Step 1 .452 (.452) .449 143.74*** (143.74)*** Intercept 8.18 [7.86, 8.50] 0.16 - 49.86*** Anxiety 0.24 [0.17, 0.30] 0.03 0.42 6.90*** Depression 0.13 [0.06, 0.20] 0.04 0.26 3.69*** Irritability 0.03 [-0.08, 0.14] 0.05 0.03 0.52 Step 2 .453 (.000) .447 85.99*** (0.11) Intercept 8.15 [7.33, 8.96] 0.41 - 19.68*** Anxiety 0.24 [0.17, 0.31] 0.04 0.42 6.90*** Depression 0.13 [0.06, 0.20] 0.04 0.25 3.66*** Irritability 0.03 [-0.08, 0.13] 0.05 0.03 0.49 Age -0.002 [-0.08, 0.08] 0.04 -0.002 -0.05 Female 0.10 [-0.31, 0.51] 0.21 0.02 0.47 Note. Multiple regression analysis results for affective variables predicting sleep disturbance. * p < .05, ** p < .01, *** p < .001 Given the moderate multicollinearity levels noted above, we conducted sensitivity analyses by re-estimating these models in various ways. The results reported above remained robust and consistent even after we removed each affective variable one at a time (e.g., removing anxiety had a negligible effect on the regression coefficients for depression [ p < .001], and irritability [ p = .10]). Similarly, results did not change when we added predictors to the model in a different order. Notably, adding the irritability term last resulted in negligible change in R 2 ( ΔR 2 < .01), meaning that irritability accounted for less than 1% of the unique variance in sleep disturbance not already accounted for by anxiety and/or depression. Across all sensitivity analyses (8 models in total), terms that were previously significant remained significant ( p s < .001) sensitivity analyses, while nonsignificant results remained nonsignificant ( p s = .10 to .70). Exploratory Moderation Analyses Lastly, we examined age and gender as moderators of the associations between emotional variables and sleep. These results showed that the associations of sleep disturbance with depression and anxiety, as described above, were not moderated by child age and gender as moderators (interaction term p s = .139 to .507). These effects fell above the Bonferroni-corrected alpha (as well as the standard alpha). Thus, all results for depression and anxiety in relation to sleep can be interpreted as applying similarly across boys and girls, younger and older. However, the relationship between sleep disturbance and irritability was moderated by child age ( B = -0.03, 95% CI [-0.06, -0.01], p = .0117) and gender ( B = -0.17, 95% CI [-0.31, -0.03], p = .0156). These results were significant even after applying the Bonferroni correction, indicating statistical significance (not likely a Type I error). To better understand the nature of these associations, we probed the associations between irritability and sleep separately for boys vs. girls, and at estimated levels at approximately 7, 10, and 13 years of age (close to the sample M ± SD = 9.51 ± 2.67 years of age). These results, plotted in Fig. 1 , show that the association between sleep disturbance and irritability is higher for females as opposed to males, and for children at younger ages (i.e., the association is stronger for 7-year-olds compared to 13-year-olds). Discussion This study is the first to our knowledge that examines the unique associations of sleep disturbance with depression, anxiety, and irritability in youth. In line with our first hypothesis, results suggest that sleep disturbance is positively and significantly correlated with depressed mood, anxiety, and irritability. This finding is consistent with prior studies that have shown that sleep disturbance is associated with each of these three constructs (Brown et al., 2018 ; Delaplace et al., 2018 ; Goldstone et al., 2020 ). Additionally, hierarchical multiple regression analyses indicated that sleep disturbance was uniquely predicted by depression and anxiety; however, the prior correlation between irritability and sleep disturbance was attenuated to nonsignificance. These results provide support for the second hypothesis, showing that depression and anxiety are perhaps more directly and specifically associated with sleep disturbance than irritability. Moreover, these results remained consistent across sensitivity analyses and after controlling for demographic covariates, which speaks to the robustness of these findings. Beyond these primary findings, exploratory moderator analyses yielded some interesting results. The associations of sleep disturbance with depression and anxiety were found to be unconditional across age and gender, whereas the relationship of sleep disturbance with irritability was moderated by both of these demographic variables. This finding aligns with our observation of the literature—i.e., that much more work has been done on internalizing problems and sleep than on irritability and sleep. Nonetheless, the present moderator findings accord with a growing body of research showing that irritability’s correlates appear to be at least somewhat influenced by age and/or gender (Humphreys et al., 2019 ; Khurana et al., 2023 ). For example, Humphreys et al. ( 2019 ) found that irritability was more particularly associated with externalizing problems in boys and with internalizing problems in girls. And Khurana et al. ( 2023 ) found that the link between irritability and suicidality was moderated by age, such that irritability was a risk factor in adolescence but not in childhood. These conditional aspects of irritability warrant further research attention. Overall, our primary findings suggest that youth sleep disturbance is associated with all three dimensions of emotional problems, but results shift when controlling for the covariation among these emotional concerns, potentially underscoring the importance of anxiety and depression. This is also concurrent with the existing literature that suggests that overlap and pathways may be present between these variables (Cummings et al., 2014 ; Ezpeleta et al., 2020 ; Poznanski et al., 2018 ). One possibility is that sleep disturbance is fundamentally more central to problems (or disorders) of anxiety and depression, whereas for irritability it may be more peripheral or correlated. Indeed, the centrality of sleep to emotional disorders can perhaps be seen in their diagnostic criteria (e.g., insomnia/hypersomnia for major depression, sleep disturbance for generalized anxiety disorder; American Psychiatric Association, 2022 ). In contrast, sleep disturbance is not directly reflected in disorders of irritability (e.g., Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder). Regarding the anxiety and depression findings, it is possible that sleep disturbance is associated with anxiety in a different way (e.g., physiological arousal) than it is with depression (e.g., low energy and activity levels). Such a pattern could explain why anxiety and depression explained distinct portions of the variance in sleep disturbance, raising additional questions for future research. Implications Our results underscore the degree to which depression, anxiety, and irritability are related to one another. Clinically, when a youth is referred for concerns in any one of these areas, it would be important to conduct an assessment that covers all the others. The finding that irritability is not a uniquely significant predictor of sleep disturbance, while important from a research perspective, should not be interpreted to mean that irritability and sleep are unrelated clinically. Rather the zero-order findings (that irritability, anxiety, and depression are all correlated with sleep disturbance, r s = .55 to .66) are most relevant to practice at this time. Regarding anxiety and depression, there are effective treatments available, such as cognitive-behavioral therapy (Creswell et al., 2021 ; Higa-McMillan et al., 2016 ; Weersing et al., 2017 ). There are also well-established interventions, such as behavioral parent training, which show moderate to large effects in reducing youth irritability (Breaux et al., 2022 ; Evans et al., 2023 ; Kalvin et al., 2024 ; Leibenluft et al., 2024 ), although there is still a paucity of irritability-specific treatments. Further, the present findings shed light on sleep as a transdiagnostic risk factor. Because sleep disturbance is found to be present across disorders, it is important to attend to sleep in the assessment, prevention, and treatment of youth emotional concerns, perhaps especially when comorbidities are present. By addressing sleep disturbance, the clinical presentation of the two or more co-occurring disorders may decrease, without having to address multiple concerns at once (Harvey, 2009 ). This conclusion coincides with current research that points to the importance of addressing sleep disturbance when trying to reduce mental health difficulties (Freeman et al., 2020 ). More broadly, intervention research in the areas of anxiety, depression, and irritability may benefit from considering incorporating elements to address sleep concerns. Limitations and Future Directions This study has several limitations. First, this was a community sample, and participants were predominantly White and non-Hispanic. Additional work is needed to investigate these relationships in clinical populations and in more diverse samples. Second, we observed moderate levels of multicollinearity among emotion variables as predictors. Although our VIF estimates are considered acceptable (Hair et al., 2006 ) and sensitivity analyses supported the stability of our results, the field would benefit from replication via different methods and samples that are likely to show greater independence between variables. Third, the current study relied solely on parent-report measures, which may have contributed to multi-collinearity as well as mono-informant/ method bias. While parents are considered to be reliable reporters of their child’s symptoms and sleep (Creswell et al., 2020 ; Van Meter & Anderson, 2020 ), future work would benefit from incorporating multiple informants (e.g., youth-report) and additional methods (e.g., actigraphy for sleep). Finally, this study used cross-sectional rather than longitudinal data. Thus, determinations cannot be made about the development or change of these relationships over time; nor can conclusions be drawn about the causal relationship between these constructs. Longitudinal research is needed to obtain a clearer picture of irritability, anxiety, depression, and sleep disturbance over development and time. Declarations Author Contribution K.S. and A.K. wrote the main manuscript text and K.S. and S.E. wrote the Results section. K.S. prepared tables 1-4 and S.E. prepared figure 1. All authors reviewed the manuscript. Acknowledgement This manuscript was adapted from the first author’s senior honors thesis, completed in the Department of Psychology at the University of Miami in May 2023. Portions of these results were presented at the 2023 Miami International Child & Adolescent Mental Health Conference in Miami, FL. The authors would like to thank Dr. Jill Ehrenreich-May and Dr. Arlener Turner for their feedback on earlier versions of this project. References Alfano CA, Pina AA, Zerr AA, Villalta IK (2010) Pre-sleep arousal and sleep problems of anxiety-disordered youth. Child Psychiatry Hum Dev 41(2):156–167. https://doi.org/10.1007/s10578-009-0158-5 Alvaro PK, Roberts RM, Harris JK (2013) A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep 36(7):1059–1068. https://doi.org/10.5665/sleep.2810 American Psychiatric Association (2022) Diagnostic and Statistical Manual of Mental Disorders (5th-TR ed.) Angold A, Costello EJ, Messer SC (1995) Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. Int J Methods Psychiatr Res 5:237–249 Armstead EA, Votta CM, Deldin PJ (2019) Examining rumination and sleep: A transdiagnostic approach to depression and social anxiety. Neurol Psychiatry Brain Res 32:99–103. https://doi.org/10.1016/j.npbr.2019.05.003 Breaux R, Baweja R, Eadeh H-M, Shroff DM, Cash AR, Swanson CS, Knehans A, Waxmonsky JG (2022) Systematic Review and Meta-analysis: Pharmacological and Non-pharmacological Interventions for Persistent Non-episodic Irritability. J Am Acad Child Adolesc Psychiatry S0890856722003033. https://doi.org/10.1016/j.jaac.2022.05.012 Brown WJ, Wilkerson AK, Boyd SJ, Dewey D, Mesa F, Bunnell BE (2018) A review of sleep disturbance in children and adolescents with anxiety. J Sleep Res 27(3):1–18. https://doi.org/10.1111/jsr.12635 Cardamone-Breen MC, Jorm AF, Lawrence KA, Mackinnon AJ, Yap MBH (2017) The Parenting to Reduce Adolescent Depression and Anxiety Scale: Assessing parental concordance with parenting guidelines for the prevention of adolescent depression and anxiety disorders. PeerJ 5:e3825. https://doi.org/10.7717/peerj.3825 Chorney DB, Detweiler MF, Morris TL, Kuhn BR (2007) The interplay of sleep disturbance, anxiety, and depression in children. J Pediatr Psychol 33(4):339–348. https://doi.org/10.1093/jpepsy/jsm105 Chu C, Nota JA, Silverman AL, Beard C, Björgvinsson T (2019) Pathways among sleep onset latency, relationship functioning, and negative affect differentiate patients with suicide attempt history from patients with suicidal ideation. Psychiatry Res 273:788–797. https://doi.org/10.1016/j.psychres.2018.11.014 Clinkinbeard SS, Simi P, Evans MK, Anderson AL (2011) Sleep and delinquency: Does the amount of sleep matter? J Youth Adolesc 40(7):916–930. https://doi.org/10.1007/s10964-010-9594-6 Cohen J (1988) Statistical power analysis for the behavioral sciences, 2nd edn. Lawrence Erlbaum Associates Cornacchio D, Crum KI, Coxe S, Pincus DB, Comer JS (2016) Irritability and anxiety severity among youth with anxiety. J Am Acad Child Adolesc Psychiatry 55(1):54–61. https://doi.org/10.1016/j.jaac.2015.10.007 Cox RC, Olatunji BO (2016) A systematic review of sleep disturbance in anxiety and related disorders. J Anxiety Disord 37:104–129. https://doi.org/10.1016/j.janxdis.2015.12.001 Creswell C, Nauta MH, Hudson JL, March S, Reardon T, Arendt K, Bodden D, Cobham VE, Donovan C, Halldorsson B, In-Albon T, Ishikawa S, Johnsen DB, Jolstedt M, de Jong R, Kreuze L, Mobach L, Rapee RM, Spence SH, Kendall PC (2021) Research Review: Recommendations for reporting on treatment trials for child and adolescent anxiety disorders – an international consensus statement. J Child Psychol Psychiatry 62(3):255–269. https://doi.org/10.1111/jcpp.13283 Creswell C, Waite P, Hudson J (2020) Practitioner Review: Anxiety disorders in children and young people – assessment and treatment. J Child Psychol Psychiatry 61(6):628–643. https://doi.org/10.1111/jcpp.13186 Cummings CM, Caporino NE, Kendall PC (2014) Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull 140(3):816–845. https://doi.org/10.1037/a0034733 Dahl RE (1996) The regulation of sleep and arousal. Dev Psychopathol 8(1):3–27. https://doi.org/10.1017/S0954579400006945 Dahl RE, Harvey AG (2007) Sleep in Children and Adolescents with Behavioral and Emotional Disorders. Sleep Med Clin 2(3):501–511. https://doi.org/10.1016/j.jsmc.2007.05.002 Delaplace R, Garny de La Rivière S, Bon Saint Come M, Lahaye H, Popov I, Rey N, Visticot A, Guilé J-M (2018) Sleep and disruptive mood dysregulation disorder: A pilot actigraphy study. Archives de Pédiatrie 25(5):303–308. https://doi.org/10.1016/j.arcped.2018.05.003 Evans SC, Abel MR, Doyle RL, Skov H, Harmon SL (2021) Measurement and correlates of irritability in clinically referred youth: Further examination of the Affective Reactivity Index. J Affect Disord 283:420–429. https://doi.org/10.1016/j.jad.2020.11.002 Evans SC, Shaughnessy S, Karlovich AR (2023) Future Directions in Youth Irritability Research. J Clin Child Adolesc Psychol 52(5):716–734. https://doi.org/10.1080/15374416.2023.2209180 Ezpeleta L, Penelo E, Navarro JB, Osa N, de la, Trepat E (2020) Transdiagnostic trajectories of irritability and oppositional, depression and anxiety problems from preschool to early adolescence. Behav Res Ther 134:103727. https://doi.org/10.1016/j.brat.2020.103727 Fang H, Tu S, Sheng J, Shao A (2019) Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med 23(4):2324–2332. https://doi.org/10.1111/jcmm.14170 Forrest CB, Meltzer LJ, Marcus CL, de la Motte A, Kratchman A, Buysse DJ, Pilkonis PA, Becker BD, Bevans KB (2018) Development and validation of the PROMIS Pediatric Sleep Disturbance and Sleep-Related Impairment item banks. Sleep 41(6):1–13. https://doi.org/10.1093/sleep/zsy054 Franzen PL, Buysse DJ (2008) Sleep disturbances and depression: Risk relationships for subsequent depression and therapeutic implications. Dialog Clin Neurosci 10(4):473–481. https://doi.org/10.31887/DCNS.2008.10.4/plfranzen Freeman D, Sheaves B, Waite F, Harvey AG, Harrison PJ (2020) Sleep disturbance and psychiatric disorders. Lancet Psychiatry 7(7):628–637. https://doi.org/10.1016/S2215-0366(20)30136-X Ghandour RM, Sherman LJ, Vladutiu CJ, Ali MM, Lynch SE, Bitsko RH, Blumberg SJ (2019) Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children. J Pediatr 206:256–267e3. https://doi.org/10.1016/j.jpeds.2018.09.021 Goldstone A, Javitz HS, Claudatos SA, Buysse DJ, Hasler BP, de Zambotti M, Clark DB, Franzen PL, Prouty DE, Colrain IM, Baker FC (2020) Sleep disturbance predicts depression symptoms in early adolescence: Initial findings from the adolescent brain cognitive development study. J Adolesc Health 66(5):567–574. https://doi.org/10.1016/j.jadohealth.2019.12.005 Gregory AM, Sadeh A (2012) Sleep, emotional and behavioral difficulties in children and adolescents. Sleep Med Rev 16(2):129–136. https://doi.org/10.1016/j.smrv.2011.03.007 Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL (2006) Multivariate data analysis. Prentice-Hall Haller SP, Kircanski K, Stringaris A, Clayton M, Bui H, Agorsor C, Cardenas SI, Towbin KE, Pine DS, Leibenluft E, Brotman MA (2020) The Clinician Affective Reactivity Index: Validity and Reliability of a Clinician-Rated Assessment of Irritability. Behav Ther 51(2):283–293. https://doi.org/10.1016/j.beth.2019.10.005 Harvey AG (2009) A Transdiagnostic Approach to Treating Sleep Disturbance in Psychiatric Disorders. Cogn Behav Ther 38(sup1):35–42. https://doi.org/10.1080/16506070903033825 Harvey AG, Kaplan KA, Soehner AM (2015) Interventions for sleep disturbance in Bipolar Disorder. Sleep Med Clin 10(1):101–105. https://doi.org/10.1016/j.jsmc.2014.11.005 Harvey AG, Murray G, Chandler RA, Soehner A (2011) Sleep disturbance as transdiagnostic: Consideration of neurobiological mechanisms. Clin Psychol Rev 31(2):225–235. https://doi.org/10.1016/j.cpr.2010.04.003 Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF (2016) Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety. J Clin Child Adolesc Psychol 45(2):91–113. https://doi.org/10.1080/15374416.2015.1046177 Humphreys KL, Schouboe SNF, Kircanski K, Leibenluft E, Stringaris A, Gotlib IH (2019) Irritability, Externalizing, and Internalizing Psychopathology in Adolescence: Cross-Sectional and Longitudinal Associations and Moderation by Sex. J Clin Child Adolesc Psychol 48(5):781–789. https://doi.org/10.1080/15374416.2018.1460847 Ivanenko A, Johnson K (2008) Sleep Disturbances in Children With Psychiatric Disorders. Semin Pediatr Neurol 15(2):70–78. https://doi.org/10.1016/j.spen.2008.03.008 Jarbin H, Ivarsson T, Andersson M, Bergman H, Skarphedinsson G (2020) Screening efficiency of the Mood and Feelings Questionnaire (MFQ) and Short Mood and Feelings Questionnaire (SMFQ) in Swedish help seeking outpatients. PLoS ONE 15(3):e0230623. https://doi.org/10.1371/journal.pone.0230623 Kalvin CB, Zhong J, Rutten MR, Ibrahim K, Sukhodolsky DG (2024) Review: Evidence-Based Psychosocial Treatments for Childhood Irritability and Aggressive Behavior. JAACAP Open. https://doi.org/10.1016/j.jaacop.2024.01.009 Kamphuis J, Meerlo P, Koolhaas JM, Lancel M (2012) Poor sleep as a potential causal factor in aggression and violence. Sleep Med 13(4):327–334. https://doi.org/10.1016/j.sleep.2011.12.006 Karlovich AR, Shaughnessy S, Simmons K, Evans SC (2023) Toward greater specificity in the nonspecific: Estimating the prevalence of diagnostic irritability and sleep symptoms in adolescents. J Psychopathol Clin Sci 132(7):820–832. https://doi.org/10.1037/abn0000870 Kearns JC, Coppersmith DDL, Santee AC, Insel C, Pigeon WR, Glenn CR (2020) Sleep problems and suicide risk in youth: A systematic review, developmental framework, and implications for hospital treatment. Gen Hosp Psychiatry 63:141–151. https://doi.org/10.1016/j.genhosppsych.2018.09.011 Kendall PC, Pimentel SS (2003) On the physiological symptom constellation in youth with Generalized Anxiety Disorder (GAD). J Anxiety Disord 17(2):211–221. https://doi.org/10.1016/S0887-6185(02)00196-2 Khurana S, Wei MA, Karlovich AR, Evans SC (2023) Irritability and Suicidality in Clinically Referred Youth: Clarifying the Link by Examining the Roles of Age and Hope. J Psychopathol Behav Assess 45(3). https://doi.org/10.1007/s10862-023-10049-5 Kortesoja L, Vainikainen M-P, Hotulainen R, Rimpelä A, Dobewall H, Lindfors P, Karvonen S, Merikanto I (2020) Bidirectional relationship of sleep with emotional and behavioral difficulties: A five-year follow-up of Finnish adolescents. J Youth Adolesc 49(6):1277–1291. https://doi.org/10.1007/s10964-020-01203-3 Leibenluft E, Allen LE, Althoff RR, Brotman MA, Burke JD, Carlson GA, Dickstein DP, Dougherty LR, Evans SC, Kircanski K, Klein DN, Malone EP, Mazefsky CA, Nigg J, Perlman SB, Pine DS, Roy AK, Salum GA, Shakeshaft A, Stringaris A (2024) Irritability in Youths: A Critical Integrative Review. Am J Psychiatry 181(4):275–290. https://doi.org/10.1176/appi.ajp.20230256 Liu FF, Adrian MC (2019) Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression. J Am Acad Child Adolesc Psychiatry 58(12):1157–1164. https://doi.org/10.1016/j.jaac.2019.02.011 Mulraney MA, Melvin GA, Tonge BJ (2014) Psychometric properties of the Affective Reactivity Index in Australian adults and adolescents. Psychol Assess 26(1):148–155. https://doi.org/10.1037/a0034891 Poznanski B, Cornacchio D, Coxe S, Pincus DB, McMakin DL, Comer JS (2018) The link between anxiety severity and irritability among anxious youth: Evaluating the mediating role of sleep problems. Child Psychiatry Hum Dev 49(3):352–359. https://doi.org/10.1007/s10578-017-0769-1 Reardon T, Spence SH, Hesse J, Shakir A, Creswell C (2018) Identifying children with anxiety disorders using brief versions of the Spence Children’s Anxiety Scale for Children, Parents, and Teachers. Psychol Assess 30(10):1342–1355. https://doi.org/10.1037/pas0000570 Rhew IC, Simpson K, Tracy M, Lymp J, McCauley E, Tsuang D, Stoep AV (2010) Criterion validity of the Short Mood and Feelings Questionnaire and one- and two-item depression screens in young adolescents. Child Adolesc Psychiatry Mental Health 4(1):8. https://doi.org/10.1186/1753-2000-4-8 Rubens SL, Evans SC, Becker SP, Fite PJ, Tountas AM (2017) Self-Reported Time in Bed and Sleep Quality in Association with Internalizing and Externalizing Symptoms in School-Age Youth. Child Psychiatry Hum Dev 48(3):455–467 Solmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar de Pablo G, Il Shin J, Kirkbride JB, Jones P, Kim JH, Kim JY, Carvalho AF, Seeman MV, Correll CU, Fusar-Poli P (2022) Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 27(1):281–295. https://doi.org/10.1038/s41380-021-01161-7 Stringaris A, Goodman R, Ferdinando S, Razdan V, Muhrer E, Leibenluft E, Brotman MA (2012) The Affective Reactivity Index: A concise irritability scale for clinical and research settings. J Child Psychol Psychiatry Allied Discip 53(11):1109–1117. https://doi.org/10.1111/j.1469-7610.2012.02561.x Tavakol M, Dennick R (2011) Making sense of Cronbach’s alpha. Int J Med Educ 2:53–55. https://doi.org/10.5116/ijme.4dfb.8dfd Van Meter AR, Anderson EA (2020) Evidence Base Update on Assessing Sleep in Youth. J Clin Child Adolesc Psychol 49(6):701–736. https://doi.org/10.1080/15374416.2020.1802735 Vidal-Ribas Belil P, Stringaris A (2021) How and why are irritability and depression linked? Child Adolesc Psychiatr Clin N Am 30:401–414. https://doi.org/10.1016/j.chc.2020.10.009 Weersing VR, Jeffreys M, Do M-CT, Schwartz KTG, Bolano C (2017) Evidence Base Update of Psychosocial Treatments for Child and Adolescent Depression. J Clin Child Adolesc Psychol 46(1):11–43. https://doi.org/10.1080/15374416.2016.1220310 Weiner CL, Elkins M, Pincus R, D., Comer J (2015) Anxiety sensitivity and sleep-related problems in anxious youth. J Anxiety Disord 32:66–72. https://doi.org/10.1016/j.janxdis.2015.03.009 Zahn-Waxler C, Shirtcliff EA, Marceau K (2008) Disorders of childhood and adolescence: Gender and psychopathology. Annu Rev Clin Psychol 4:275–303 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4558662","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317150627,"identity":"260b9513-30a7-4882-8ca5-3e48cc507a0f","order_by":0,"name":"Kate Simmons","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBACCQYGxgcfDGwY2ICcAwwMzERpYTacUZBGmhY2aZ4Ph2F8IrRItrc/kOAxOB/Nx3468QBDhXViAyEt0jxnDAwkDG7ntvHkbjjAcCadsBY5iRyGBAOQFgagFsa2w0RokX/+4ECCwbncNv63QC3/iNAiLcFg2HDA4EBumwTIlgYitEj25BgzNhgkA7UAbUk4lm5MUIvE8ePPf//5Y5c7vz9384cPNdayBLWgggTSlI+CUTAKRsEowAUAThlDJ53BmcMAAAAASUVORK5CYII=","orcid":"","institution":"University of Miami","correspondingAuthor":true,"prefix":"","firstName":"Kate","middleName":"","lastName":"Simmons","suffix":""},{"id":317150628,"identity":"8d1bfab8-476b-4a47-9670-eb6075b3d6d9","order_by":1,"name":"Ashley Karlovich","email":"","orcid":"","institution":"University of Miami","correspondingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"","lastName":"Karlovich","suffix":""},{"id":317150629,"identity":"0abfcd51-a7e8-467e-bc83-ebbaa4b5d078","order_by":2,"name":"Spencer Evans","email":"","orcid":"","institution":"University of Miami","correspondingAuthor":false,"prefix":"","firstName":"Spencer","middleName":"","lastName":"Evans","suffix":""}],"badges":[],"createdAt":"2024-06-10 14:31:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4558662/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4558662/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59871303,"identity":"b5c03b76-e391-468f-942f-645243c15243","added_by":"auto","created_at":"2024-07-08 17:05:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":65069,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSleep Disturbance and Irritability by Age and Gender\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e (a) The link between irritability and sleep disturbance was moderated by age, such that the association was stronger at younger ages. (b) The link between irritability and sleep disturbance was also moderated by gender, such that the association was stronger among females.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4558662/v1/dbc1af1fcd1473e29a748269.png"},{"id":63860133,"identity":"f0cb596e-3ffb-4bb1-a348-26e9b21d9761","added_by":"auto","created_at":"2024-09-03 06:13:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":702872,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4558662/v1/242e7c17-0576-4d85-ab57-fe6906b30c1f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations of sleep disturbance with depression, anxiety, and irritability in youth","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSleep has become increasingly studied in relation to development and maintenance of emotional symptoms across the lifespan, with significant implications for mental and physical health (Dahl, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Gregory \u0026amp; Sadeh, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Kortesoja et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In particular, \u003cem\u003esleep disturbance\u003c/em\u003e is a transdiagnostic construct, listed as a symptom of various mental health disorders in the DSM-5-TR (American Psychiatric Association, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and often appearing as part of the clinical presentation of several psychiatric disorders (Dahl \u0026amp; Harvey, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Harvey et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Sleep disturbance includes difficulties falling asleep and staying asleep throughout the night (Forrest et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In youth specifically, sleep disturbance contributes to increased risk for depression, anxiety, and suicidality, and are often present among youth with other physical and mental health conditions as well (Chorney et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Kearns et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Sleep disturbance is also associated with irritability (Rubens et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), both of which are extremely common in adolescents (Karlovich et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Yet there is limited research on the interplay between sleep and emotions, particularly on the \u003cem\u003eunique\u003c/em\u003e associations of sleep disturbance with depression, anxiety, and irritability in youth. Despite prior research on single affective variables (e.g., links between sleep disturbance and anxiety), these associations have yet to be examined across a full range of emotional problems affecting youth. Given the transdiagnostic nature of sleep disturbance and frequent co-occurrence with mental health concerns, examining these unique associations is crucial to understanding the role of sleep in youth psychopathology.\u003c/p\u003e\n\u003ch3\u003eSleep Disturbance and Emotional Symptoms\u003c/h3\u003e\n\u003cp\u003eSleep-related symptoms are central features of major depressive disorders in DSM-5-TR (American Psychiatric Association, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Sleep disturbance strongly contributes to the development and expression of depressive disorders in adults (Fang et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Franzen \u0026amp; Buysse, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Although much of the research on this topic has focused on adults, studies among children have found that sleep disturbance is associated with depression (Alvaro et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Goldstone et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Up to 73% of youth with Major Depressive Disorder have been found to experience sleep disturbance (Ivanenko \u0026amp; Johnson, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Sleep disturbance has been found to predict depressive symptoms in youth, even after controlling for social anxiety (Armstead et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Given the limited research on sleep disturbance and depression in youth, and their high prevalence in this period, more research is needed to understand their association.\u003c/p\u003e \u003cp\u003eSleep and its relation to anxiety has become an important area of study. Young children with anxiety may be at a greater risk of experiencing problems related to sleep compared to their non-anxious peers (Alfano et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Weiner et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This includes sleep disturbance, which, when assessed on its own, has been found to be highly associated with anxiety (Brown et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Cox \u0026amp; Olatunji, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In clinical samples, up to 85% of parents of anxious youth have reported that their child also experiences clinically significant sleep disturbances (Alfano et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Kendall \u0026amp; Pimentel, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). However, these studies generally do not account for the presence of comorbidities between anxiety and other affective variables, and the precise nature of the relationship between sleep disturbance and anxiety remains unclear.\u003c/p\u003e \u003cp\u003eSimilar to sleep disturbance, irritability is a transdiagnostic nonspecific feature that is a primary or secondary symptom of numerous disorders (e.g., anxiety, depressive, and trauma and stressor-related disorders; Karlovich et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Despite this commonality, there is limited research on the relationship between sleep and irritability. Several disorders characterized by severe irritability (e.g., bipolar disorders, Disruptive Mood Dysregulation Disorder) are also commonly linked to sleep disturbance (Delaplace et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Harvey et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Poorer sleep quality is associated with higher levels of irritability, as well as other emotional and behavioral problems (Rubens et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Additionally, related bodies of research indicate that sleep disturbance predicts higher levels of aggression, violence, and delinquency (Clinkinbeard et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Kamphuis et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). However, there has been limited research on the unique, specific association between sleep disturbance and irritability.\u003c/p\u003e \u003cp\u003eIt is important to note that youth affective problems frequently co-occur (Ezpeleta et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Particularly high comorbidity rates have been documented between anxiety and depressive disorders (for a review, see Cummings et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The 2016 National Survey of Children\u0026rsquo;s Health showed that around 74% of youth with depression also had an anxiety disorder (Ghandour et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Although researchers have examined sleep disturbance in relation to both anxiety and depression, many of these studies do not take into account the high correlations between these two problem areas (Chorney et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Chu et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Similarly, irritability is a transdiagnostic construct implicated in a range of mental health disorders in youth. Depression and irritability have also been found to be specifically associated with one another through various pathways, such as genetic and environmental risk factors (Vidal-Ribas Belil \u0026amp; Stringaris, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Anxiety and irritability have been found to be uniquely linked (Cornacchio et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). It has been proposed that sleep problems play a key role in accounting for this association (Poznanski et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), although more research is needed.\u003c/p\u003e\n\u003ch3\u003eCurrent Study\u003c/h3\u003e\n\u003cp\u003eAs summarized above, sleep disturbance has been found to be generally associated with depressed mood, anxiety, and irritability; however, there is also a significant amount of overlap between each of these variables. Given these patterns of high co-occurrence and correlation, the extent to which sleep disturbance is uniquely associated with these particular affective problems in youth remains unclear. It is important to identify these unique associations to better understand the specific role of each variable when controlling for co-occurring concerns. Research in this area could have important implications for the understanding, assessment, and treatment of sleep disturbance, depression, anxiety, and irritability in youth.\u003c/p\u003e \u003cp\u003eAccordingly, the current study seeks to fill this gap. We conducted a community-based study of youths ages 5\u0026ndash;14 to examine associations among parent/caregiver-rated measures of child sleep disturbance, depression, anxiety, and irritability. We hypothesized that (a) sleep disturbance would be positively correlated with depression, anxiety, and irritability at the zero-order level; and that (b) sleep disturbance\u0026rsquo;s unique associations with depression and anxiety would be greater than its association with irritability in multiple linear regression analysis. The first hypothesis was made considering research reviewed above documenting sleep disturbances association with all three affective problems. The second hypothesis was made given that there appears to be relatively more evidence for sleep\u0026rsquo;s associations with depression and anxiety, and less for irritability; and given that the transdiagnostic nature of irritability (i.e., linked to anxiety and depression) may mean there is relatively little remaining variance associated with irritability through which it could be specifically associated with sleep disturbance. Finally, given the variations related to age (e.g., Solmi et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and gender (e.g., Zahn-Waxler et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) in the development of emotional disorders, we examined these variables as covariates and moderators; however, considering the limited research on how these factors affect sleep\u0026rsquo;s associations with specific emotional problems, these analyses were considered exploratory.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and Procedures\u003c/h2\u003e \u003cp\u003eParticipants were a community sample of 526 parents/caregivers (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eage\u003c/em\u003e\u003c/sub\u003e = 38.23, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8.57), who completed parent-report measures on their child between the ages of 6 and 14 (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eage\u003c/em\u003e\u003c/sub\u003e = 9.51, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.67). As summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, caregivers and youths were mostly identified as White and non-Hispanic. Caregivers were predominantly female, while youths were more evenly balanced between male and female. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for a comprehensive overview of participant demographic characteristic.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSample Demographics\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCaregiver\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eChild\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Binary, Transgender, or Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite or Caucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e394\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiracial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmerican Indian or Alaska Native, Pacific Islander, or Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic/Latino/a/x\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Hispanic/Latino/a/x\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThese data were collected as part of an online survey study developed to explore the mental health needs of youth and families in the community. Caregiver participants were recruited and data were collected using multiple platforms including Amazon\u0026rsquo;s Mechanical Turk (MTurk), Qualtrics Panels, and Prolific. Recruitment was largely focused on caregivers in the South Florida area, but with some platforms we also recruited nationally in order to obtain a larger sample. Participants were eligible if they were at least 18 years of age, the parent or caregiver of a child or adolescent between 6 and 14 years of age, and able to complete informed consent and study surveys in English or Spanish. Potential participants were excluded if they were under 18 years of age, did not have a child in the target age range, or if they were unable to consent to the study. All participants were required to complete an online consent form to participate in the study. Upon completion of the surveys, participants were compensated for their time (usually \u003cspan\u003e$\u003c/span\u003e4\u0026ndash;5, with exact amounts varying by platform). The [masked for review] Institutional Review Board approved all recruitment and survey procedures for this study.\u003c/p\u003e \u003cp\u003eMeasures (summarized below) were administered via Qualtrics. We used partial randomization of survey blocks to help prevent order effects, and \u0026ldquo;request response\u0026rdquo; prompts to minimize missing data. Attention check items were used to verify that participants were paying attention to question wording and support the validity of the data. Specifically, these items were embedded at the end of selected measures and they instructed the participant to choose a specific response (e.g., \u0026ldquo;For this item, please select \u0026lsquo;Very Rarely\u0026rsquo;\u0026rdquo;). Of the 687 participants who completed the survey, for the present analyses we excluded those who participated in Spanish (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26); failed one (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1) or both (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;24) attention check questions; did not complete the survey (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72); or completed the survey in \u0026lt;\u0026thinsp;10 minutes (i.e., less than half the expected response time of 20\u0026ndash;30 minutes; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;38). Consequently, the final sample consisted of \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;526 caregivers (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eage\u003c/em\u003e\u003c/sub\u003e = 38.23, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8.57) of children between the ages of 6 and 14 (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eage\u003c/em\u003e\u003c/sub\u003e = 9.51, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.67). As summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the caregivers and youths in this sample were mostly identified as White and non-Hispanic. Caregivers were predominantly female, while youths were more evenly balanced between male and female.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003e \u003cb\u003eSleep Disturbance.\u003c/b\u003e Sleep disturbance was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Sleep Disturbance-Parent Proxy, 4-item short form version (PROMIS-SD-P-4; Forrest et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This scale asks caregivers to report on their child\u0026rsquo;s sleep from the past week (e.g., \u0026ldquo;In the past 7 days...My child had difficulty falling asleep\u0026rdquo;), using a 5-point Likert scale ranging from 1 \u003cem\u003e(Never)\u003c/em\u003e to 5 \u003cem\u003e(Always)\u003c/em\u003e. This measure has been validated for use in child and adolescent samples (Forrest et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Items are summed, with a total score range of 4 to 20, and higher scores indicating greater levels of sleep disturbance. A raw score of 10 or above indicates elevated sleep symptoms, with scores of 12\u0026thinsp;+\u0026thinsp;and 15\u0026thinsp;+\u0026thinsp;indicating great and severe sleep impairment, respectively (Forrest et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). For this sample, internal consistency was acceptable (α\u0026thinsp;=\u0026thinsp;.64), particularly considering that alpha tends to be lower for briefer measures (Tavakol \u0026amp; Dennick, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eDepression.\u003c/b\u003e Depression was measured using the Short Mood and Feelings Questionnaire, parent-report form (SMFQ-P; Angold et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). This 13-item form asks caregivers to rate how their child has been feeling or acting over the past two weeks (e.g., \u0026ldquo;S/he felt miserable or unhappy\u0026rdquo;) and includes a 3-point scale with the following response options: 0 \u003cem\u003e(Not True)\u003c/em\u003e, 1 \u003cem\u003e(Sometimes)\u003c/em\u003e, or 2 \u003cem\u003e(True).\u003c/em\u003e Item totals are summed, with a score range of 0 to 26 and higher scores indicating greater levels of depression. The SMFQ-P has shown good reliability and discriminant validity in both clinical and community samples (Angold et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1995\u003c/span\u003e; Rhew et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). However, the SMFQ-P does not have an established clinical cut-off score, with some studies suggesting a clinical cut-off score of 4 (Rhew et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) and others suggesting a clinical cut-off score of 8 (Cardamone-Breen et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Previous research has also shown differences in cut-off scores between genders (Jarbin et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). For the purpose of this study, scores greater than 4 are considered as having elevated symptoms, as this cut-off score has been used in younger adolescent populations in prior research (Liu \u0026amp; Adrian, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Rhew et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). In the present sample, internal consistency was excellent (α\u0026thinsp;=\u0026thinsp;.94).\u003c/p\u003e \u003cp\u003e \u003cb\u003eAnxiety.\u003c/b\u003e Anxiety was measured using the Spence Children\u0026rsquo;s Anxiety Scale, 8-item short form, parent-report (SCAS-P-8; Reardon et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Caregivers are asked to indicate the extent to which each statement (e.g., \u0026ldquo;My child worries about things\u0026rdquo;) is applicable to their child using a 4-point Likert scale, with responses ranging from 0 \u003cem\u003e(Never)\u003c/em\u003e to 3 \u003cem\u003e(Always)\u003c/em\u003e. The SCAS-P-8 has shown good internal consistency and both convergent and discriminant validity in community and clinical samples of youth. Additionally, the 8-item version of this measure has shown similar capacity as the full-length Spence Children\u0026rsquo;s Anxiety Scale to identify youths with anxiety disorders, with a suggested total clinical cut-off score of 7.5 (Reardon et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). For the purpose of this study, the total anxiety score was calculated and used in analyses. Item totals are summed, with a score range of 0 to 24 and higher scores indicating greater levels of anxiety. In this sample, internal consistency was excellent (α\u0026thinsp;=\u0026thinsp;.92).\u003c/p\u003e \u003cp\u003e \u003cb\u003eIrritability.\u003c/b\u003e Irritability was measured using the parent-report version of the Affective Reactivity Index (ARI; Stringaris et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). This 7-item form includes 6 items relating to total irritability symptoms (e.g., \u0026ldquo;Is easily annoyed by others\u0026rdquo;) and 1 impairment item that is not used in scoring (i.e., \u0026ldquo;Overall, irritability causes him/her problems\u0026rdquo;). The response options are 0 \u003cem\u003e(Not True)\u003c/em\u003e, 1 \u003cem\u003e(Somewhat True)\u003c/em\u003e, or 2 \u003cem\u003e(Certainly True).\u003c/em\u003e The ARI has shown good internal consistency and both convergent and discriminant validity in clinical and community samples (Evans et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Mulraney et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Additionally, parent-report ARI scores greater than 3 have been used to classify children with DMDD (Haller et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), indicating an establish clinical cut-off score of 3. Item totals are summed, with a score range of 0 to 12 and higher scores indicating greater levels of irritability. In this sample, internal consistency was excellent (α\u0026thinsp;=\u0026thinsp;.90).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis Plan\u003c/h2\u003e \u003cp\u003eFirst, we examined descriptive statistics of the data on all study measures, including means, standard deviations, range, and percent with elevated symptoms. The two main study hypotheses were tested via linear correlation and regression analyses. These analyses used a standard alpha of 0.05 and 95% confidence intervals (CIs) for significance. Specifically, we first examined zero-order correlations to characterize the associations and shared variance among sleep disturbance, depression, anxiety, and irritability. Next, hierarchical multiple regression models were estimated examining sleep disturbance as predicted by anxiety, depression, and irritability. To check the robustness of effects, these analyses were conducted with and without age and gender as covariates. Effect sizes for linear correlations was interpreted using established guidelines (Cohen, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e1988\u003c/span\u003e), where negligible, small, medium, and large absolute values of roughly\u0026thinsp;\u0026lt;\u0026thinsp;.1, \u0026ge;.1, \u0026ge;\u0026thinsp;.3, and \u0026ge;\u0026thinsp;.5, respectively.\u003c/p\u003e \u003cp\u003eFinally, exploratory moderator analyses were conducted to generate hypotheses about how findings might vary across development or gender. Specifically, we estimated separate models for each affective and demographic variable and their product (e.g., anxiety, age, and age*anxiety) as predictors of sleep disturbance. All variables were mean-centered prior computing product terms and conducting analyses. Because these analyses were exploratory and entailed several additional statistical tests, we applied a familywise Bonferroni correction to reduce the risk of false positives. That is, for these results in particular, the standard alpha 0.05 was divided by the number of tests for each moderator (3 [anxiety, depression, irritability] for age, and same 3 for gender), resulting in a Bonferroni adjusted alpha of .0167.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive Statistics and Correlations\u003c/h2\u003e \u003cp\u003eAs summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, sleep and emotion variables were roughly normally distributed with a slight right skew. Using the clinical thresholds from these measures, sizable minorities of the sample had elevated sleep problems (38%), depressive symptoms (45%), anxiety (39%) or irritability (35%). The Pearson\u0026rsquo;s correlations (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) among depression, anxiety, irritability, and sleep were all significant (\u003cem\u003ep\u003c/em\u003es\u0026thinsp;\u0026lt;\u0026thinsp;.001) with large effect sizes. Of specific interest, sleep disturbance was positively associated with depression, (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.63, 95% CI [58, .68], anxiety (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.66, 95% CI [.60, .70]), and irritability \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.55, 95% CI [.49, .61]. In other words, depression, anxiety, and irritability could each be said to explain about 30\u0026ndash;44% of the variance in sleep disturbance. The confidence intervals suggest that these correlations of depression and anxiety with sleep disturbance are roughly equivalent with one another, and both greater than the corresponding correlation for irritability. These associations were then examined further through hierarchical multiple regression analyses.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescriptive Statistics\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePercent with\u003c/p\u003e \u003cp\u003eElevated Levels\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep Disturbance\u003c/p\u003e \u003cp\u003e(PROMIS-S)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003cp\u003e(SMFQ-P)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003cp\u003e(SCAS-P-8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritability\u003c/p\u003e \u003cp\u003e(ARI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiver Age\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild Age\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote\u003c/em\u003e. Elevated levels are defined by score thresholds suggested by prior research, as summarized in the \u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003emeasures\u003c/span\u003e section: \u0026ge;10 for sleep, \u0026ge;\u0026thinsp;4 for depression, \u0026ge;\u0026thinsp;8 for anxiety, \u0026ge;\u0026thinsp;3 for irritability. PROMIS-S\u0026thinsp;=\u0026thinsp;Patient-Reported Outcomes Measurement Information System (PROMIS). Pediatric Sleep Disturbance-Parent Proxy, 4-item short form. SMFQ-P\u0026thinsp;=\u0026thinsp;Short Mood and Feelings Questionnaire, parent-report form. SCAS-P-8\u0026thinsp;=\u0026thinsp;Spence Children\u0026rsquo;s Anxiety Scale, 8-item short form, parent-report. ARI\u0026thinsp;=\u0026thinsp;Affective Reactivity Index, parent report version.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eZero-Order Correlations\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Sleep Disturbance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.63***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.66***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.84***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Irritability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.55***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.81***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.75***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.-.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote.\u003c/em\u003e Correlations with gender are presented as point-biserial correlations, all others are Pearson\u0026rsquo;s \u003cem\u003er\u003c/em\u003e correlations. *\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01, ***\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eHierarchical Multiple Regression Analyses\u003c/h2\u003e \u003cp\u003eGiven high correlations among depression, anxiety, and irritability, we examined the multicollinearity among these variables in the regression model. Results showed that Variance Inflation Factor (VIF) was 4.6 for depression, 3.5 for anxiety, 3.0 for irritability, and 1.0 for age and gender. In other words, based on established guidelines (Hair et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), depression, anxiety, and irritability fell in the 1.0\u0026ndash;5.0 range, suggesting a moderate but acceptable levels of multicollinearity, which was taken into account in subsequent analyses\u003c/p\u003e \u003cp\u003eResults of hierarchical multiple regression analyses are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. As shown, sleep disturbance was significantly predicted by anxiety (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.24, 95% CI [0.17, 0.30], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and depression (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.13, 95% CI [0.06, 0.20], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) when controlling for all other predictor variables in the model; however, the association between sleep disturbance and irritability was attenuated to nonsignificance (\u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03, 95% CI [-0.08, 0.14], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.61). Standardized beta coefficients indicate these effects were medium for anxiety, small for depression, and negligible for all other variables. Age and gender were added as covariates. The overall model was significant, (\u003cem\u003eF\u003c/em\u003e(5, 520)\u0026thinsp;=\u0026thinsp;85.99, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), accounting for about 45% of the variance in sleep problems (\u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.45); therefore, results stood after controlling for child age and gender, which were not significantly associated with sleep disturbance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eHierarchical Multiple Regression Analysis\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eB\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(\u003cem\u003eΔR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eadj.R\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eModel \u003cem\u003eF\u003c/em\u003e\u003c/p\u003e \u003cp\u003e(Change \u003cem\u003eF\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStep 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.452\u003c/p\u003e \u003cp\u003e(.452)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.449\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e143.74***\u003c/p\u003e \u003cp\u003e(143.74)***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[7.86, 8.50]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e49.86***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[0.17, 0.30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.90***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[0.06, 0.20]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.69***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[-0.08, 0.14]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStep 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.453\u003c/p\u003e \u003cp\u003e(.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e85.99***\u003c/p\u003e \u003cp\u003e(0.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[7.33, 8.96]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19.68***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[0.17, 0.31]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.90***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[0.06, 0.20]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.66***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrritability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[-0.08, 0.13]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[-0.08, 0.08]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e[-0.31, 0.51]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eNote.\u003c/em\u003e Multiple regression analysis results for affective variables predicting sleep disturbance.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01, ***\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eGiven the moderate multicollinearity levels noted above, we conducted sensitivity analyses by re-estimating these models in various ways. The results reported above remained robust and consistent even after we removed each affective variable one at a time (e.g., removing anxiety had a negligible effect on the regression coefficients for depression [\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001], and irritability [\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.10]). Similarly, results did not change when we added predictors to the model in a different order. Notably, adding the irritability term last resulted in negligible change in \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (\u003cem\u003eΔR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01), meaning that irritability accounted for less than 1% of the unique variance in sleep disturbance not already accounted for by anxiety and/or depression. Across all sensitivity analyses (8 models in total), terms that were previously significant remained significant (\u003cem\u003ep\u003c/em\u003es\u0026thinsp;\u0026lt;\u0026thinsp;.001) sensitivity analyses, while nonsignificant results remained nonsignificant (\u003cem\u003ep\u003c/em\u003es\u0026thinsp;=\u0026thinsp;.10 to .70).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eExploratory Moderation Analyses\u003c/h2\u003e \u003cp\u003eLastly, we examined age and gender as moderators of the associations between emotional variables and sleep. These results showed that the associations of sleep disturbance with depression and anxiety, as described above, were not moderated by child age and gender as moderators (interaction term \u003cem\u003ep\u003c/em\u003es\u0026thinsp;=\u0026thinsp;.139 to .507). These effects fell above the Bonferroni-corrected alpha (as well as the standard alpha). Thus, all results for depression and anxiety in relation to sleep can be interpreted as applying similarly across boys and girls, younger and older. However, the relationship between sleep disturbance and irritability was moderated by child age (\u003cem\u003eB\u003c/em\u003e = -0.03, 95% CI [-0.06, -0.01], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.0117) and gender (\u003cem\u003eB\u003c/em\u003e = -0.17, 95% CI [-0.31, -0.03], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.0156). These results were significant even after applying the Bonferroni correction, indicating statistical significance (not likely a Type I error). To better understand the nature of these associations, we probed the associations between irritability and sleep separately for boys vs. girls, and at estimated levels at approximately 7, 10, and 13 years of age (close to the sample \u003cem\u003eM\u003c/em\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2.67 years of age). These results, plotted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, show that the association between sleep disturbance and irritability is higher for females as opposed to males, and for children at younger ages (i.e., the association is stronger for 7-year-olds compared to 13-year-olds).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to our knowledge that examines the unique associations of sleep disturbance with depression, anxiety, and irritability in youth. In line with our first hypothesis, results suggest that sleep disturbance is positively and significantly correlated with depressed mood, anxiety, and irritability. This finding is consistent with prior studies that have shown that sleep disturbance is associated with each of these three constructs (Brown et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Delaplace et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Goldstone et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Additionally, hierarchical multiple regression analyses indicated that sleep disturbance was uniquely predicted by depression and anxiety; however, the prior correlation between irritability and sleep disturbance was attenuated to nonsignificance. These results provide support for the second hypothesis, showing that depression and anxiety are perhaps more directly and specifically associated with sleep disturbance than irritability. Moreover, these results remained consistent across sensitivity analyses and after controlling for demographic covariates, which speaks to the robustness of these findings.\u003c/p\u003e \u003cp\u003eBeyond these primary findings, exploratory moderator analyses yielded some interesting results. The associations of sleep disturbance with depression and anxiety were found to be unconditional across age and gender, whereas the relationship of sleep disturbance with irritability was moderated by both of these demographic variables. This finding aligns with our observation of the literature\u0026mdash;i.e., that much more work has been done on internalizing problems and sleep than on irritability and sleep. Nonetheless, the present moderator findings accord with a growing body of research showing that irritability\u0026rsquo;s correlates appear to be at least somewhat influenced by age and/or gender (Humphreys et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Khurana et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). For example, Humphreys et al. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) found that irritability was more particularly associated with externalizing problems in boys and with internalizing problems in girls. And Khurana et al. (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) found that the link between irritability and suicidality was moderated by age, such that irritability was a risk factor in adolescence but not in childhood. These conditional aspects of irritability warrant further research attention.\u003c/p\u003e \u003cp\u003eOverall, our primary findings suggest that youth sleep disturbance is associated with all three dimensions of emotional problems, but results shift when controlling for the covariation among these emotional concerns, potentially underscoring the importance of anxiety and depression. This is also concurrent with the existing literature that suggests that overlap and pathways may be present between these variables (Cummings et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Ezpeleta et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Poznanski et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). One possibility is that sleep disturbance is fundamentally more central to problems (or disorders) of anxiety and depression, whereas for irritability it may be more peripheral or correlated. Indeed, the centrality of sleep to emotional disorders can perhaps be seen in their diagnostic criteria (e.g., insomnia/hypersomnia for major depression, sleep disturbance for generalized anxiety disorder; American Psychiatric Association, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In contrast, sleep disturbance is not directly reflected in disorders of irritability (e.g., Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder). Regarding the anxiety and depression findings, it is possible that sleep disturbance is associated with anxiety in a different way (e.g., physiological arousal) than it is with depression (e.g., low energy and activity levels). Such a pattern could explain why anxiety and depression explained distinct portions of the variance in sleep disturbance, raising additional questions for future research.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eOur results underscore the degree to which depression, anxiety, and irritability are related to one another. Clinically, when a youth is referred for concerns in any one of these areas, it would be important to conduct an assessment that covers all the others. The finding that irritability is not a \u003cem\u003euniquely\u003c/em\u003e significant predictor of sleep disturbance, while important from a research perspective, should not be interpreted to mean that irritability and sleep are unrelated clinically. Rather the zero-order findings (that irritability, anxiety, and depression are all correlated with sleep disturbance, \u003cem\u003er\u003c/em\u003es\u0026thinsp;=\u0026thinsp;.55 to .66) are most relevant to practice at this time. Regarding anxiety and depression, there are effective treatments available, such as cognitive-behavioral therapy (Creswell et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Higa-McMillan et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Weersing et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). There are also well-established interventions, such as behavioral parent training, which show moderate to large effects in reducing youth irritability (Breaux et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Evans et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kalvin et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Leibenluft et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), although there is still a paucity of irritability-specific treatments.\u003c/p\u003e \u003cp\u003eFurther, the present findings shed light on sleep as a transdiagnostic risk factor. Because sleep disturbance is found to be present across disorders, it is important to attend to sleep in the assessment, prevention, and treatment of youth emotional concerns, perhaps especially when comorbidities are present. By addressing sleep disturbance, the clinical presentation of the two or more co-occurring disorders may decrease, without having to address multiple concerns at once (Harvey, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). This conclusion coincides with current research that points to the importance of addressing sleep disturbance when trying to reduce mental health difficulties (Freeman et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). More broadly, intervention research in the areas of anxiety, depression, and irritability may benefit from considering incorporating elements to address sleep concerns.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, this was a community sample, and participants were predominantly White and non-Hispanic. Additional work is needed to investigate these relationships in clinical populations and in more diverse samples. Second, we observed moderate levels of multicollinearity among emotion variables as predictors. Although our VIF estimates are considered acceptable (Hair et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) and sensitivity analyses supported the stability of our results, the field would benefit from replication via different methods and samples that are likely to show greater independence between variables. Third, the current study relied solely on parent-report measures, which may have contributed to multi-collinearity as well as mono-informant/ method bias. While parents are considered to be reliable reporters of their child\u0026rsquo;s symptoms and sleep (Creswell et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Van Meter \u0026amp; Anderson, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), future work would benefit from incorporating multiple informants (e.g., youth-report) and additional methods (e.g., actigraphy for sleep). Finally, this study used cross-sectional rather than longitudinal data. Thus, determinations cannot be made about the development or change of these relationships over time; nor can conclusions be drawn about the causal relationship between these constructs. Longitudinal research is needed to obtain a clearer picture of irritability, anxiety, depression, and sleep disturbance over development and time.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.S. and A.K. wrote the main manuscript text and K.S. and S.E. wrote the Results section. K.S. prepared tables 1-4 and S.E. prepared figure 1. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis manuscript was adapted from the first author\u0026rsquo;s senior honors thesis, completed in the Department of Psychology at the University of Miami in May 2023. Portions of these results were presented at the 2023 Miami International Child \u0026amp; Adolescent Mental Health Conference in Miami, FL. The authors would like to thank Dr. Jill Ehrenreich-May and Dr. Arlener Turner for their feedback on earlier versions of this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlfano CA, Pina AA, Zerr AA, Villalta IK (2010) Pre-sleep arousal and sleep problems of anxiety-disordered youth. Child Psychiatry Hum Dev 41(2):156\u0026ndash;167. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10578-009-0158-5\u003c/span\u003e\u003cspan address=\"10.1007/s10578-009-0158-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlvaro PK, Roberts RM, Harris JK (2013) A systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression. Sleep 36(7):1059\u0026ndash;1068. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5665/sleep.2810\u003c/span\u003e\u003cspan address=\"10.5665/sleep.2810\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2022) \u003cem\u003eDiagnostic and Statistical Manual of Mental Disorders\u003c/em\u003e (5th-TR ed.)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngold A, Costello EJ, Messer SC (1995) Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. Int J Methods Psychiatr Res 5:237\u0026ndash;249\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArmstead EA, Votta CM, Deldin PJ (2019) Examining rumination and sleep: A transdiagnostic approach to depression and social anxiety. Neurol Psychiatry Brain Res 32:99\u0026ndash;103. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.npbr.2019.05.003\u003c/span\u003e\u003cspan address=\"10.1016/j.npbr.2019.05.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBreaux R, Baweja R, Eadeh H-M, Shroff DM, Cash AR, Swanson CS, Knehans A, Waxmonsky JG (2022) Systematic Review and Meta-analysis: Pharmacological and Non-pharmacological Interventions for Persistent Non-episodic Irritability. J Am Acad Child Adolesc Psychiatry S0890856722003033. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaac.2022.05.012\u003c/span\u003e\u003cspan address=\"10.1016/j.jaac.2022.05.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown WJ, Wilkerson AK, Boyd SJ, Dewey D, Mesa F, Bunnell BE (2018) A review of sleep disturbance in children and adolescents with anxiety. J Sleep Res 27(3):1\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jsr.12635\u003c/span\u003e\u003cspan address=\"10.1111/jsr.12635\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardamone-Breen MC, Jorm AF, Lawrence KA, Mackinnon AJ, Yap MBH (2017) The Parenting to Reduce Adolescent Depression and Anxiety Scale: Assessing parental concordance with parenting guidelines for the prevention of adolescent depression and anxiety disorders. PeerJ 5:e3825. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7717/peerj.3825\u003c/span\u003e\u003cspan address=\"10.7717/peerj.3825\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChorney DB, Detweiler MF, Morris TL, Kuhn BR (2007) The interplay of sleep disturbance, anxiety, and depression in children. J Pediatr Psychol 33(4):339\u0026ndash;348. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/jpepsy/jsm105\u003c/span\u003e\u003cspan address=\"10.1093/jpepsy/jsm105\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChu C, Nota JA, Silverman AL, Beard C, Bj\u0026ouml;rgvinsson T (2019) Pathways among sleep onset latency, relationship functioning, and negative affect differentiate patients with suicide attempt history from patients with suicidal ideation. Psychiatry Res 273:788\u0026ndash;797. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.psychres.2018.11.014\u003c/span\u003e\u003cspan address=\"10.1016/j.psychres.2018.11.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClinkinbeard SS, Simi P, Evans MK, Anderson AL (2011) Sleep and delinquency: Does the amount of sleep matter? J Youth Adolesc 40(7):916\u0026ndash;930. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10964-010-9594-6\u003c/span\u003e\u003cspan address=\"10.1007/s10964-010-9594-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen J (1988) Statistical power analysis for the behavioral sciences, 2nd edn. Lawrence Erlbaum Associates\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCornacchio D, Crum KI, Coxe S, Pincus DB, Comer JS (2016) Irritability and anxiety severity among youth with anxiety. J Am Acad Child Adolesc Psychiatry 55(1):54\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaac.2015.10.007\u003c/span\u003e\u003cspan address=\"10.1016/j.jaac.2015.10.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCox RC, Olatunji BO (2016) A systematic review of sleep disturbance in anxiety and related disorders. J Anxiety Disord 37:104\u0026ndash;129. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.janxdis.2015.12.001\u003c/span\u003e\u003cspan address=\"10.1016/j.janxdis.2015.12.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell C, Nauta MH, Hudson JL, March S, Reardon T, Arendt K, Bodden D, Cobham VE, Donovan C, Halldorsson B, In-Albon T, Ishikawa S, Johnsen DB, Jolstedt M, de Jong R, Kreuze L, Mobach L, Rapee RM, Spence SH, Kendall PC (2021) Research Review: Recommendations for reporting on treatment trials for child and adolescent anxiety disorders \u0026ndash; an international consensus statement. J Child Psychol Psychiatry 62(3):255\u0026ndash;269. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpp.13283\u003c/span\u003e\u003cspan address=\"10.1111/jcpp.13283\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell C, Waite P, Hudson J (2020) Practitioner Review: Anxiety disorders in children and young people \u0026ndash; assessment and treatment. J Child Psychol Psychiatry 61(6):628\u0026ndash;643. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcpp.13186\u003c/span\u003e\u003cspan address=\"10.1111/jcpp.13186\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCummings CM, Caporino NE, Kendall PC (2014) Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull 140(3):816\u0026ndash;845. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/a0034733\u003c/span\u003e\u003cspan address=\"10.1037/a0034733\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahl RE (1996) The regulation of sleep and arousal. Dev Psychopathol 8(1):3\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1017/S0954579400006945\u003c/span\u003e\u003cspan address=\"10.1017/S0954579400006945\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahl RE, Harvey AG (2007) Sleep in Children and Adolescents with Behavioral and Emotional Disorders. Sleep Med Clin 2(3):501\u0026ndash;511. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jsmc.2007.05.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jsmc.2007.05.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelaplace R, Garny de La Rivi\u0026egrave;re S, Bon Saint Come M, Lahaye H, Popov I, Rey N, Visticot A, Guil\u0026eacute; J-M (2018) Sleep and disruptive mood dysregulation disorder: A pilot actigraphy study. Archives de P\u0026eacute;diatrie 25(5):303\u0026ndash;308. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arcped.2018.05.003\u003c/span\u003e\u003cspan address=\"10.1016/j.arcped.2018.05.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans SC, Abel MR, Doyle RL, Skov H, Harmon SL (2021) Measurement and correlates of irritability in clinically referred youth: Further examination of the Affective Reactivity Index. J Affect Disord 283:420\u0026ndash;429. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jad.2020.11.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jad.2020.11.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEvans SC, Shaughnessy S, Karlovich AR (2023) Future Directions in Youth Irritability Research. J Clin Child Adolesc Psychol 52(5):716\u0026ndash;734. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15374416.2023.2209180\u003c/span\u003e\u003cspan address=\"10.1080/15374416.2023.2209180\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzpeleta L, Penelo E, Navarro JB, Osa N, de la, Trepat E (2020) Transdiagnostic trajectories of irritability and oppositional, depression and anxiety problems from preschool to early adolescence. Behav Res Ther 134:103727. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.brat.2020.103727\u003c/span\u003e\u003cspan address=\"10.1016/j.brat.2020.103727\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang H, Tu S, Sheng J, Shao A (2019) Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med 23(4):2324\u0026ndash;2332. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jcmm.14170\u003c/span\u003e\u003cspan address=\"10.1111/jcmm.14170\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForrest CB, Meltzer LJ, Marcus CL, de la Motte A, Kratchman A, Buysse DJ, Pilkonis PA, Becker BD, Bevans KB (2018) Development and validation of the PROMIS Pediatric Sleep Disturbance and Sleep-Related Impairment item banks. Sleep 41(6):1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/sleep/zsy054\u003c/span\u003e\u003cspan address=\"10.1093/sleep/zsy054\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFranzen PL, Buysse DJ (2008) Sleep disturbances and depression: Risk relationships for subsequent depression and therapeutic implications. Dialog Clin Neurosci 10(4):473\u0026ndash;481. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.31887/DCNS.2008.10.4/plfranzen\u003c/span\u003e\u003cspan address=\"10.31887/DCNS.2008.10.4/plfranzen\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreeman D, Sheaves B, Waite F, Harvey AG, Harrison PJ (2020) Sleep disturbance and psychiatric disorders. Lancet Psychiatry 7(7):628\u0026ndash;637. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S2215-0366(20)30136-X\u003c/span\u003e\u003cspan address=\"10.1016/S2215-0366(20)30136-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhandour RM, Sherman LJ, Vladutiu CJ, Ali MM, Lynch SE, Bitsko RH, Blumberg SJ (2019) Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children. J Pediatr 206:256\u0026ndash;267e3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpeds.2018.09.021\u003c/span\u003e\u003cspan address=\"10.1016/j.jpeds.2018.09.021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldstone A, Javitz HS, Claudatos SA, Buysse DJ, Hasler BP, de Zambotti M, Clark DB, Franzen PL, Prouty DE, Colrain IM, Baker FC (2020) Sleep disturbance predicts depression symptoms in early adolescence: Initial findings from the adolescent brain cognitive development study. J Adolesc Health 66(5):567\u0026ndash;574. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jadohealth.2019.12.005\u003c/span\u003e\u003cspan address=\"10.1016/j.jadohealth.2019.12.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGregory AM, Sadeh A (2012) Sleep, emotional and behavioral difficulties in children and adolescents. Sleep Med Rev 16(2):129\u0026ndash;136. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.smrv.2011.03.007\u003c/span\u003e\u003cspan address=\"10.1016/j.smrv.2011.03.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHair JF, Black WC, Babin BJ, Anderson RE, Tatham RL (2006) Multivariate data analysis. Prentice-Hall\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaller SP, Kircanski K, Stringaris A, Clayton M, Bui H, Agorsor C, Cardenas SI, Towbin KE, Pine DS, Leibenluft E, Brotman MA (2020) The Clinician Affective Reactivity Index: Validity and Reliability of a Clinician-Rated Assessment of Irritability. Behav Ther 51(2):283\u0026ndash;293. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.beth.2019.10.005\u003c/span\u003e\u003cspan address=\"10.1016/j.beth.2019.10.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvey AG (2009) A Transdiagnostic Approach to Treating Sleep Disturbance in Psychiatric Disorders. Cogn Behav Ther 38(sup1):35\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/16506070903033825\u003c/span\u003e\u003cspan address=\"10.1080/16506070903033825\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvey AG, Kaplan KA, Soehner AM (2015) Interventions for sleep disturbance in Bipolar Disorder. Sleep Med Clin 10(1):101\u0026ndash;105. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jsmc.2014.11.005\u003c/span\u003e\u003cspan address=\"10.1016/j.jsmc.2014.11.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvey AG, Murray G, Chandler RA, Soehner A (2011) Sleep disturbance as transdiagnostic: Consideration of neurobiological mechanisms. Clin Psychol Rev 31(2):225\u0026ndash;235. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.cpr.2010.04.003\u003c/span\u003e\u003cspan address=\"10.1016/j.cpr.2010.04.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiga-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF (2016) Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety. J Clin Child Adolesc Psychol 45(2):91\u0026ndash;113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15374416.2015.1046177\u003c/span\u003e\u003cspan address=\"10.1080/15374416.2015.1046177\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHumphreys KL, Schouboe SNF, Kircanski K, Leibenluft E, Stringaris A, Gotlib IH (2019) Irritability, Externalizing, and Internalizing Psychopathology in Adolescence: Cross-Sectional and Longitudinal Associations and Moderation by Sex. J Clin Child Adolesc Psychol 48(5):781\u0026ndash;789. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15374416.2018.1460847\u003c/span\u003e\u003cspan address=\"10.1080/15374416.2018.1460847\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvanenko A, Johnson K (2008) Sleep Disturbances in Children With Psychiatric Disorders. Semin Pediatr Neurol 15(2):70\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.spen.2008.03.008\u003c/span\u003e\u003cspan address=\"10.1016/j.spen.2008.03.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJarbin H, Ivarsson T, Andersson M, Bergman H, Skarphedinsson G (2020) Screening efficiency of the Mood and Feelings Questionnaire (MFQ) and Short Mood and Feelings Questionnaire (SMFQ) in Swedish help seeking outpatients. PLoS ONE 15(3):e0230623. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0230623\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0230623\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalvin CB, Zhong J, Rutten MR, Ibrahim K, Sukhodolsky DG (2024) Review: Evidence-Based Psychosocial Treatments for Childhood Irritability and Aggressive Behavior. JAACAP Open. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaacop.2024.01.009\u003c/span\u003e\u003cspan address=\"10.1016/j.jaacop.2024.01.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamphuis J, Meerlo P, Koolhaas JM, Lancel M (2012) Poor sleep as a potential causal factor in aggression and violence. Sleep Med 13(4):327\u0026ndash;334. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.sleep.2011.12.006\u003c/span\u003e\u003cspan address=\"10.1016/j.sleep.2011.12.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarlovich AR, Shaughnessy S, Simmons K, Evans SC (2023) Toward greater specificity in the nonspecific: Estimating the prevalence of diagnostic irritability and sleep symptoms in adolescents. J Psychopathol Clin Sci 132(7):820\u0026ndash;832. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/abn0000870\u003c/span\u003e\u003cspan address=\"10.1037/abn0000870\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKearns JC, Coppersmith DDL, Santee AC, Insel C, Pigeon WR, Glenn CR (2020) Sleep problems and suicide risk in youth: A systematic review, developmental framework, and implications for hospital treatment. Gen Hosp Psychiatry 63:141\u0026ndash;151. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.genhosppsych.2018.09.011\u003c/span\u003e\u003cspan address=\"10.1016/j.genhosppsych.2018.09.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKendall PC, Pimentel SS (2003) On the physiological symptom constellation in youth with Generalized Anxiety Disorder (GAD). J Anxiety Disord 17(2):211\u0026ndash;221. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0887-6185(02)00196-2\u003c/span\u003e\u003cspan address=\"10.1016/S0887-6185(02)00196-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhurana S, Wei MA, Karlovich AR, Evans SC (2023) Irritability and Suicidality in Clinically Referred Youth: Clarifying the Link by Examining the Roles of Age and Hope. J Psychopathol Behav Assess 45(3). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10862-023-10049-5\u003c/span\u003e\u003cspan address=\"10.1007/s10862-023-10049-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKortesoja L, Vainikainen M-P, Hotulainen R, Rimpel\u0026auml; A, Dobewall H, Lindfors P, Karvonen S, Merikanto I (2020) Bidirectional relationship of sleep with emotional and behavioral difficulties: A five-year follow-up of Finnish adolescents. J Youth Adolesc 49(6):1277\u0026ndash;1291. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10964-020-01203-3\u003c/span\u003e\u003cspan address=\"10.1007/s10964-020-01203-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeibenluft E, Allen LE, Althoff RR, Brotman MA, Burke JD, Carlson GA, Dickstein DP, Dougherty LR, Evans SC, Kircanski K, Klein DN, Malone EP, Mazefsky CA, Nigg J, Perlman SB, Pine DS, Roy AK, Salum GA, Shakeshaft A, Stringaris A (2024) Irritability in Youths: A Critical Integrative Review. Am J Psychiatry 181(4):275\u0026ndash;290. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1176/appi.ajp.20230256\u003c/span\u003e\u003cspan address=\"10.1176/appi.ajp.20230256\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu FF, Adrian MC (2019) Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression. J Am Acad Child Adolesc Psychiatry 58(12):1157\u0026ndash;1164. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaac.2019.02.011\u003c/span\u003e\u003cspan address=\"10.1016/j.jaac.2019.02.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMulraney MA, Melvin GA, Tonge BJ (2014) Psychometric properties of the Affective Reactivity Index in Australian adults and adolescents. Psychol Assess 26(1):148\u0026ndash;155. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/a0034891\u003c/span\u003e\u003cspan address=\"10.1037/a0034891\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoznanski B, Cornacchio D, Coxe S, Pincus DB, McMakin DL, Comer JS (2018) The link between anxiety severity and irritability among anxious youth: Evaluating the mediating role of sleep problems. Child Psychiatry Hum Dev 49(3):352\u0026ndash;359. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10578-017-0769-1\u003c/span\u003e\u003cspan address=\"10.1007/s10578-017-0769-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReardon T, Spence SH, Hesse J, Shakir A, Creswell C (2018) Identifying children with anxiety disorders using brief versions of the Spence Children\u0026rsquo;s Anxiety Scale for Children, Parents, and Teachers. Psychol Assess 30(10):1342\u0026ndash;1355. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/pas0000570\u003c/span\u003e\u003cspan address=\"10.1037/pas0000570\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRhew IC, Simpson K, Tracy M, Lymp J, McCauley E, Tsuang D, Stoep AV (2010) Criterion validity of the Short Mood and Feelings Questionnaire and one- and two-item depression screens in young adolescents. Child Adolesc Psychiatry Mental Health 4(1):8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1753-2000-4-8\u003c/span\u003e\u003cspan address=\"10.1186/1753-2000-4-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRubens SL, Evans SC, Becker SP, Fite PJ, Tountas AM (2017) Self-Reported Time in Bed and Sleep Quality in Association with Internalizing and Externalizing Symptoms in School-Age Youth. Child Psychiatry Hum Dev 48(3):455\u0026ndash;467\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSolmi M, Radua J, Olivola M, Croce E, Soardo L, Salazar de Pablo G, Il Shin J, Kirkbride JB, Jones P, Kim JH, Kim JY, Carvalho AF, Seeman MV, Correll CU, Fusar-Poli P (2022) Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 27(1):281\u0026ndash;295. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s41380-021-01161-7\u003c/span\u003e\u003cspan address=\"10.1038/s41380-021-01161-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStringaris A, Goodman R, Ferdinando S, Razdan V, Muhrer E, Leibenluft E, Brotman MA (2012) The Affective Reactivity Index: A concise irritability scale for clinical and research settings. J Child Psychol Psychiatry Allied Discip 53(11):1109\u0026ndash;1117. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1469-7610.2012.02561.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1469-7610.2012.02561.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTavakol M, Dennick R (2011) Making sense of Cronbach\u0026rsquo;s alpha. Int J Med Educ 2:53\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5116/ijme.4dfb.8dfd\u003c/span\u003e\u003cspan address=\"10.5116/ijme.4dfb.8dfd\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Meter AR, Anderson EA (2020) Evidence Base Update on Assessing Sleep in Youth. J Clin Child Adolesc Psychol 49(6):701\u0026ndash;736. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15374416.2020.1802735\u003c/span\u003e\u003cspan address=\"10.1080/15374416.2020.1802735\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVidal-Ribas Belil P, Stringaris A (2021) How and why are irritability and depression linked? Child Adolesc Psychiatr Clin N Am 30:401\u0026ndash;414. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.chc.2020.10.009\u003c/span\u003e\u003cspan address=\"10.1016/j.chc.2020.10.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeersing VR, Jeffreys M, Do M-CT, Schwartz KTG, Bolano C (2017) Evidence Base Update of Psychosocial Treatments for Child and Adolescent Depression. J Clin Child Adolesc Psychol 46(1):11\u0026ndash;43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/15374416.2016.1220310\u003c/span\u003e\u003cspan address=\"10.1080/15374416.2016.1220310\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner CL, Elkins M, Pincus R, D., Comer J (2015) Anxiety sensitivity and sleep-related problems in anxious youth. J Anxiety Disord 32:66\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.janxdis.2015.03.009\u003c/span\u003e\u003cspan address=\"10.1016/j.janxdis.2015.03.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZahn-Waxler C, Shirtcliff EA, Marceau K (2008) Disorders of childhood and adolescence: Gender and psychopathology. Annu Rev Clin Psychol 4:275\u0026ndash;303\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"sleep disturbance, depression, anxiety, irritability, transdiagnostic, youth","lastPublishedDoi":"10.21203/rs.3.rs-4558662/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4558662/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn children and adolescents, symptoms of depression, anxiety, and irritability frequently co-occur, and many of these affective problems are associated with sleep disturbance. However, the extent to which sleep disturbance is specifically linked to any one of these affective problems over and above the others remains unclear. Therefore, the current study investigated the unique associations of sleep disturbance with depression, anxiety, and irritability. A community sample of 526 parents/caregivers of youths ages 6\u0026ndash;14 (\u003cem\u003eM\u003c/em\u003e\u003csub\u003eage\u003c/sub\u003e = 9.51; 53.6% female) completed measures assessing their child\u0026rsquo;s symptoms of sleep disturbance, depression, anxiety, and irritability. Hierarchical multiple regression analyses were conducted to examine sleep disturbance as predicted by depression, anxiety, and irritability, with age and gender as covariates and moderators. Zero-order correlations showed that sleep disturbance was significantly and positively associated with depressive symptoms, anxiety, and irritability. Hierarchical multiple regression analyses showed that sleep disturbance was uniquely associated with depression and anxiety, but not irritability, when all three emotional variables were included in the same model. Further, exploratory moderation analyses suggested that the association between sleep disturbance and irritability may be moderated by child age and gender. Findings shed light on the role of sleep disturbance as a transdiagnostic feature in youth psychopathology, with particularly strong and unique links to depression and anxiety (less so for irritability). Additional research is needed examine these relationships across diverse samples, in clinical settings, and using multi-method, multi-informant, and longitudinal approaches.\u003c/p\u003e","manuscriptTitle":"Associations of sleep disturbance with depression, anxiety, and irritability in youth","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-08 17:05:04","doi":"10.21203/rs.3.rs-4558662/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a1f3368e-191f-4c03-b086-26120e29ca4f","owner":[],"postedDate":"July 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-03T06:05:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-08 17:05:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4558662","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4558662","identity":"rs-4558662","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}