Association of Emotional Mental Status With Sleep Quality in Adolescents With Systemic Lupus Erythematosus

Association of Emotional Mental Status With Sleep Quality in Adolescents With Systemic Lupus Erythematosus | 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 Short Report Association of Emotional Mental Status With Sleep Quality in Adolescents With Systemic Lupus Erythematosus Sonya Mar‘atusalihat, Reni Ghrahani, Rodman Tarigan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8043142/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Childhood-onset systemic lupus erythematosus (cSLE) is a chronic autoimmune illness. The nature of cSLE and long-term usage of corticosteroids put adolescents at risk of emotional and mental issues, as well as poor sleep quality. This study assessed the correlation between this population's emotional and mental health and the quality of their sleep. Methods Sixty inpatient and outpatient teenagers (10–18 years old) with cSLE participated in this cross-sectional observational study. The Indonesian version of the Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality, while the Pediatric Symptom Checklist-17 (PSC-17) was used to measure emotional mental health. The data were analyzed using Chi-squared or Fisher's exact tests as appropriate and Spearman correlations. A p-value less than or equal to 0.05 was deemed significant. Results Emotional mental problems were found in 18.3% of participants, predominantly within the internalizing domain (16.7%). Nearly half of the teenagers (41.7%) reported having poor quality sleep. Having a bad night's sleep was significantly associated with having an emotional or mental health issue (p = 0.039; PR = 2.10, 95% CI: 1.24–3.55). There was a small but statistically significant positive relationship between emotional mental state scores and overall PSQI scores (r = 0.301, p = 0.019), especially for daytime dysfunction (r = 0.365, p = 0.004). Conclusion Adolescents with cSLE have a high prevalence of emotional and mental problems and poor sleep quality, with a significant but weak correlation between the two. Routine mental health and sleep quality screening using simple tools such as PSC-17 and PSQI, along with psychosocial support and sleep hygiene education, are recommended for the clinical management of cSLE. childhood-onset systemic lupus erythematosus adolescents emotional mental status depression sleep quality Background Adequate sleep is vital for physical and mental health, and essential for growth and development in adolescents. 1 Sleep is associated with reduced motor activity, less engagement with the external world, a particular posture (e.g., lying down with closed eyes), and easy reversibility. 2 During adolescence, hormonal changes and pubertal maturation may affect sleep patterns, making this phase vulnerable to poor sleep quality. 3 , 4 Social pressures and modern lifestyle factors also contribute to sleep deprivation in adolescents. 5 Moreover, adolescents with chronic illnesses, such as cSLE, are specifically at an increased risk of having poor sleep quality due to the disease's progression, recurrent symptoms, and prolonged management. 6 SLE is characterized by the overproduction of autoantibodies and the creation of immune complexes that harm numerous organ systems. 7 cSLE is more progressive than that of adult-onset SLE 7 – 10 and accounts for 15–20% of all SLE patients, with an incidence of 0.36 to 2.5 per 100,000 children and a prevalence ranging from 1.89 to 34.1 per 100,000 children. 7 , 8 Sleep disorders and poor sleep quality are frequently reported in the adult SLE population, 6,11,12 but the causes of poor sleep quality have not been identified and are highly complex, modulated by various factors. 6 , 12 Behavioural and psychosocial factors, such as physical activity, depression, and stress, influence sleep quality, 12,13 with the relationship between sleep quality and its causative factors considered bidirectional. 6 , 12 Cytokine dysregulation and SLE treatment, such as the use of long-term steroids and immunomodulators, are thought to contribute to poor sleep quality in SLE patients. 11 – 13 Corticosteroids, the main SLE treatment, are suspected to trigger depression and sleep disorders. 1 , 2 Depression is an emotional mental disorder frequently reported among SLE patients, 6 with an estimated 50–90% of patients with emotional mental disorders experiencing sleep quality problems. 12 To date, most studies on poor sleep quality in SLE have been conducted in adults; therefore, this study was designed to evaluate the relationship between mental and emotional status and sleep quality in cSLE adolescents. Method Patient selection This cross-sectional observational study of inpatients and outpatients from the Division of Allergy, Immunology, and Rheumatology, Hasan Sadikin Hospital, Bandung, Indonesia, was conducted from July to August 2025. Patients diagnosed with SLE according to the 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria, the 2019 European Alliance of Associations for Rheumatology (EULAR)/ACR criteria, or the 1997 American College of Rheumatology (ACR) criteria were eligible for inclusion. Patients had a mild to moderate disease activity level at the time of assessment, and they were required to complete the Pediatric Symptom Checklist-17 (PSC-17) and the Pittsburgh Sleep Quality Index (PSQI) questionnaires. Patients were excluded if they exhibited signs of severe illness activity or had a reduced level of awareness. All patients and parents were provided with the study information and the opportunity to ask questions before providing written informed consent for participation. The research was authorized by the Director of Dr. Hasan Sadikin General Hospital, and ethically approved by the Ethics Committee of Dr. Hasan Sadikin General Hospital. Emotional Mental Status Measurement Emotional mental status was assessed using the PSC-17 questionnaire, which is a screening instrument for the early detection of emotional and behavioral problems in children and adolescents. 14 The PSC-17 questionnaire consists of 17 items designed to help identify and evaluate changes in emotional and behavioral issues among children and adolescents. The questionnaire comprises three domains: internalizing, externalizing, and attention, and is scored using a Likert scale, where 0 means never, 1 means sometimes, and 2 means often experiencing the symptom. The internalizing domain included feelings of sadness, hopelessness, low self-esteem, moodiness, and anxiety. The externalizing domain included not liking to share, lacking empathy, fighting, blaming others, disobeying rules, bothering other children, and taking others’ belongings. The attention domain included restlessness, daydreaming, difficulty concentrating, acting without thinking, and being easily distracted. A patient was considered to have emotional mental problems if they had a score > 5 on the internalizing subscale, > 7 on the externalizing subscale, > 7 on the attention subscale, or a total score of > 15. This questionnaire had previously been translated into Indonesian and demonstrated good validity and reliability. It can be self-administered among adolescents, thereby minimizing observer bias. 14 , 15 Sleep Quality Measurement The sleep quality was assessed using the Indonesian version of the PSQI questionnaire, which was validated for adolescents in Indonesia in 2018. 16 This sleep measurement tool, containing 19 items, is often used in studies on healthy adolescents and adults with SLE to evaluate sleep latency, length, subjective quality, efficiency, disruptions, medication use, and daytime dysfunction. It is scored using a 5-point Likert scale, with a total PSQI score ranging from 0 (excellent) to 21 (poor), to determine the respondent's sleep experience and quality during the last month. Good sleep is defined as a PSQI score of 5 or less, while poor sleep is defined as a score of 5 or more. 11 , 16 Patient Characteristics All 60 patients underwent clinical and laboratory evaluation. The data collected included age, sex, nutritional status, height status, family income, quality of life, duration of schoolwork, duration of screen time, disease duration, duration of steroid use, and steroid dose. Nutritional status and height status were classified based on the World Health Organization (WHO) Growth Reference. Family income was categorized as either low or sufficient based on the minimum wage of Bandung City. Quality of life was assessed using the Indonesian version of the Pediatric Quality of Life Inventory (PedsQL) questionnaire. The steroid dosage was based on the prednisone dose and divided into three categories: no use or low dose (0.1 − 0.2 mg/kg), moderate dose (0.2 − 0.5 mg/kg), and high dose (0.5 − 1 mg/kg). Disease activity was assessed using the MEX-SLEDAI and classified as mild or moderate. Statistical Analysis The number of teenagers with chronic SLE (n = 60) was used to calculate the power to detect a difference in the prevalence of a possible risk factor between 20% and 55% exposure. With a 2-sided significance level of 5%, this study would be able to detect this difference with around 80% power. The data were analyzed using SPSS for Windows, version 25.0, and normality was assessed using the Kolmogorov-Smirnov test. The participants' emotional and mental health, as well as the quality of their sleep, were represented by descriptive statistics. Bivariate analysis using Fisher's exact test or Chi-Square tests was conducted to determine how emotional mental state relates to sleep quality. The relationship between emotional mental state and the characteristics of sleep quality (PSQI) was assessed using Spearman's rank correlations. A p-value < 0.05 was considered statistically significant. Results Patient Characteristics This study involved 60 cSLE adolescents, aged 10.3 to 17.9 years, with a median age of 15.5 years. The study population was predominantly female (85%; 51 adolescents). Based on anthropometric data, most of the adolescents had good nutritional status (70%; 42 adolescents) and normal height (70%; 42 adolescents). Most patients were from low-income families (73.3%; 44 adolescents), spent ≤ 3 hours/day on schoolwork or studying at home (91.7%; 55 adolescents), and had a screen time of > 2 hours/day for 43 adolescents (71.7%). The majority of patients had a disease duration of ≤ 1 year (66.7%; 40 adolescents) and were on high-dose steroids (28 adolescents; 46.7%). Most patients had mild disease activity according to the MEX-SLEDAI (76.7%; 46 adolescents). Most adolescents had a poor quality of life (75%; 45 individuals), with the most affected domains being school and physical functioning (Table 1 ). The relationship with sleep quality is shown in Table 2 . Table 1 Patient Characteristics Variable Total (N = 60) Age (years), Median (min–max) 15.5 (10.3–17.9) Age category, N (%) 10–12 years 8 (13.4) 13–15 years 32 (53.3) 16–18 years 20 (33.3) Sex, N (%) Male 9 (15.0) Female 51 (85.0) Nutritional status, N (%) Good 42 (70.0) Low 4 (6.7) Over 14 (23.3) Height, N (%) Stunted 18 (30.0) Normal 42 (70.0) Family income, N (%) Low 44 (73.3) Sufficient 16 (26.7) Homework duration, N (%) ≤ 3 hours 55 (91.7) > 3 hours 5 (8.3) Screen time duration, N (%) ≤ 2 hours 17 (28.3) > 2 hours 43 (71.7) Disease duration, N (%) ≤ 1 year 40 (66.7) > 1 year 20 (33.3) MEX SLEDAI score, N (%) Mild 46 (76.7) Moderate 14 (23.3) Steroid dose, N (%) Low 22 (36.6) Moderate 10 (16.7) High 28 (46.7) Steroid treatment duration, N (%) ≤ 1 year 40 (66.7) > 1 year 20 (33.3) Quality of Life Good 15 (25.0) Bad 45 (75.0) Physical Domain Good 29 (48.3) Bad 31 (51.7) Emotional Domain Good 36 (60.0) Bad 24 (40.0) Social Domain Good 51 (85.0) Bad 9 (15.0) School Domain Good 23 (38.3) Bad 37 (61.7) Table 2 Association between patients’ characteristics and sleep quality Variable Sleep Quality p-value Bad (PSQI ≥ 5) Good (PSQI < 5) Age category, N (%) 0.922 a 10–12 years 3 (37.5) 5 (62.5) 13–15 years 13 (40.6) 19 (59.4) 16–18 years 9 (45.0) 11 (55.0) Sex, N (%) 0.722 b Male 3 (33.3) 6 (66.7) Female 22 (43.1) 29 (56.9) Nutritional status, N (%) 0.783 a Good 18 (42.9) 24 (57.1) Low 1 (25.0) 3 (75.0) Over 6 (42.9) 8 (57.1) Height, N (%) 0.391 a Stunted 6 (33.3) 12 (66.7) Normal 19 (45.2) 23 (54.8) Family income, N (%) 0.430 a Low 17 (38.6) 27 (61.4) Sufficient 8 (50) 8 (50) Homework duration, N (%) 0.64 b ≤ 3 hours 22 (40.0) 33 (60.0) > 3 hours 3 (60.0) 2 (40.0) Screen time duration, N (%) 0.265 a ≤ 2 hours 9 (52.9) 8 (47.1) > 2 hours 16 (37.2) 27 (62.8) Disease duration, N (%) 0.711 a ≤ 1 year 16 (40.0) 24 (60.0) > 1 year 9 (45.0) 11 (55.0) MEX SLEDAI Score, N (%) 0.470 a Mild 18 (39.1) 28 (60.9) Moderate 7 (50.0) 7 (50.0) Steroid dose, n (%) 0.062 a Low 7 (31.8) 15 (68.2) Moderate 2 (20.0) 8 (80.0) High 16 (57.1) 12 (42.9) Steroid treatment duration, n (%) 0.853 a ≤ 1 year 17 (42.5) 23 (57.5) > 1 year 8 (40.0) 12 (60.0) Note: a Chi-squared, b Fisher’s exact, *p < 0.05 Emotional Mental Status The PSC-17 scores ranged from 0 to 16, with a median of 7. The prevalence of cSLE adolescents who had emotional and mental problems was 18.3% (11 individuals) (Table 3 ). Among cSLE adolescents who showed a tendency toward emotional mental problems, the internalizing domain was the most commonly affected. Table 3 Emotional Mental Status Variable N = 60 PSC 17 Score, median (min–max) 7 (0–16) Emotional mental status, N (%) Emotional mental problems 11 (18.3) Normal 49 (81.7) Internalizing Domain, N (%) Internalizing problems 10 (16.7) Normal 50 (83.3) Attention Domain, N (%) Attention problems 1 (1.7) Normal 59 (98.3) Externalizing Domain, N (%) Externalizing problems 0 (0.0) Normal 60 (100.0) Sleep Quality The PSQI score ranged from 0 to 12, with a median score of 4, and 25 adolescents (41.7%) experienced poor sleep quality. The results in sleep quality is shown in Table 4 . Table 4 Sleep Quality Variable N = 60 PSQI Score, median (min–max) 4 (0–12) Sleep quality, N (%) Poor 25 (41.7) Good 35 (58.3) Emotional Mental Status and Sleep Quality The relationship between emotional mental status and sleep quality in cSLE adolescents was statistically significant (p = 0.039). Adolescents who were having emotional mental problems had a higher proportion of poor sleep quality (72.7%) compared to those with a normal emotional mental status (34.7%). Prevalence ratio analysis indicated that adolescents with emotional mental problems had a 2.10 times higher risk of poor sleep quality compared to the normal group (95% CI: 1.24–3.55) (Table 5 ). Table 5 Association between emotional mental status and sleep quality Variable Sleep Quality P-value PR (95% CI) Bad PSQI ≥ 5 Good PSQI < 5 Emotional Mental Status Emotional mental problems 8 (72.7) 3 (27.3) 0.039 b * 2.10 (1.24–3.55) Normal 17 (34.7) 32 (65.3) Note: b Fisher’s exact test, *p < 0.05 There was a positive correlation between emotional mental status scores and total PSQI scores (r = 0.301; p = 0.019), indicating that higher PSC-17 scores, reflecting a tendency toward emotional mental problems, were associated with poorer sleep quality (Table 6 ). In the analysis of PSQI dimensions, emotional mental status scores were only significantly associated with the daytime dysfunction dimension (r = 0.365; p = 0.004). Table 6 Correlation between emotional mental status and sleep quality Variable Emotional Mental (PSC-17) r-coefficient p Value Sleep quality (PSQI) 0.301 0.019* Component Subjective sleep quality 0.182 0.164 Sleep latency 0.171 0.192 Sleep duration 0.189 0.148 Sleep efficiency 0.235 0.070 Sleep disturbances 0.199 0.127 The use of sleeping medication - - Daytime dysfunction 0.365 0.004* Note: Spearman’s rank correlations, *p < 0.05 Discussion The Indonesian version of PSC-17 is a valid and highly reliable instrument for detecting mental and emotional problems in adolescents, 14 and indicated that 18.3% of cSLE adolescents in this study had mental and emotional problems. It has been reported that children with rheumatologic diseases in children often experience mental health issues such as anxiety and depression compared to their healthy peers. 17 A high prevalence of depression has also been reported in cSLE patients. 18 However, studies conducted in Southeast Asia reported that a third of cSLE patients had a risk of depression, 11,19,20 more than observed in the present study. Internalizing problems were found to be more predominant and are one of the symptoms of mental and emotional problems in children and adolescents identified by the PSC-17. 14 Internalizing problems are described as a tendency towards anxiety, depression, nervousness, and social withdrawal. 14 Neufeld also reported that a cSLE population had a high frequency of symptoms of depression (35%) and anxiety (35%). 21 The stress of living with a chronic condition is one of the contributing factors to anxiety and depression symptoms in cSLE, as they found no relationship between factors related to SLE, such as disease duration, disease activity, or steroid use, and anxiety and depressive symptoms. 21 Chronic psychosocial stress can cause sub-threshold symptoms to develop into diagnostic symptoms in vulnerable individuals, increasing the risk of future mental health disorders, especially in developing adolescents. 21 In contrast, Puspitanza reported that disease activity and low physical activity were related to depression. 19 Low physical activity in SLE patients is linked to an increase in pro-inflammatory cytokines and an imbalance of hormones and neurotransmitters in the brain, such as serotonin and dopamine, which can cause mood disorders, especially depression, in cSLE patients. 19 The high prevalence of poor sleep quality among SLE patients (56–60%) is often underrecognized, undertreated, and understudied. 12 In the SLE adult population, complaints of difficulty initiating or maintaining sleep, as well as poor sleep quality, are frequently reported. 11 – 13 In the present study, nearly half of the adolescents reported poor sleep quality based on their PSQI scores. 16 According to Wi et al., cSLE adolescents have poorer sleep quality compared to healthy adolescents, measured by both objective actigraphy and subjective sleep measurements, supporting the current findings regarding poor sleep quality in cSLE adolescents. 22 Many factors influence sleep quality in SLE patients, including disease duration, medication side effects, and comorbidities conditions like arthralgia, pain, fatigue, and depression. 23 Yottasan et al. reported a relationship between poor sleep quality and a high body mass index, which differs from the current study, in which the anthropometric status of adolescents was not related to sleep quality; however, their study sample contained more overweight adolescents (38.6% vs. 23.3%). 11 Short sleep duration affects body weight, especially in adolescents who are in a crucial period of life, obtaining independence, enhancing their social life, and having a high desire to adapt to a modern lifestyle. 24 Additionally, they may experience pressure due to a high study load and homework, all cumulatively resulting in reduced sleep time, fatigue, and physical activity, and ultimately increasing the consumption of energy-dense food during waking hours. 24 These social and behavioral factors complement previously hypothesized mechanisms, such as hormonal dysregulation, changes in body metabolism, daytime sleepiness, and fatigue, which lead to lack of sleep, resulting in increased energy consumption. 24 Yottasan et al. also reported that steroid exposure did not affect sleep quality, similar to the current study, which found no significant relationship between steroid dose and duration of use and sleep quality. 11 This is in contrast to observations in the adult SLE population, in which SLE medication is related to sleep quality. 13 The drugs used have serious side effects and can increase disease symptoms or other symptoms, which will affect sleep quality. 13 Özer et al. also reported that poor sleep quality worsened in patients with a longer disease duration. 13 This differs from the current results, where disease duration did not have a significant relationship with sleep quality. In SLE, an increase in the duration of the disease increases the possibility of the number of organs involved, aggravating symptoms, and thus affecting the patient's sleep quality. 13 The average good sleep quality in the first year of the disease was a finding in Özer's study. 13 In the present study, there was a correlation between mental-emotional status and sleep quality, in line with Yin's comprehensive research, which discovered a modest association between the quality of sleep and depression in individuals with SLE. 6 Mental health issues, including depression, have been linked to issues with subjective sleep quality, latency, disruption, and daytime functioning. 6 Other aspects of sleep, including the amount of time spent sleeping, sleep quality, and whether or not medicine was used to aid with sleep, did not show any association. 6 Slightly different from the present study results, the findings show that only the daytime dysfunction component was significantly correlated with mental-emotional status. The underlying mechanism of poor sleep quality is not clear. However, sleep deprivation may disrupt the circadian rhythm by impacting the brain regions responsible for emotions, the amygdala and the anterior cortex, which are also involved in sleep regulation. This dysregulation occurs during depressive episodes. 6 Tangkittiwet et al. used the Patient Health Questionnaire for Adolescents (PHQ-A) and the Generalized Anxiety Disorders Scale (GAD-7) to evaluate symptoms of anxiety and sadness, suggesting that there is a link between cSLE patients' anxiety and depressive symptoms and the quality of their sleep. 20 The correlation in their study was moderate, while the current study's correlation was weak. Wi et al. further reinforced the relationship between depression and poor sleep in the cSLE population. 22 Functional connectivity in many brain areas, such as the lateral orbitofrontal cortex, dorsolateral prefrontal cortex, cingulate cortex, and precuneus, is positively correlated with poor sleep quality and depressive symptoms. 25 Functional connectivity between these areas contributes significantly to the relationship between depressive disorder and poor sleep quality, 25 as sleep-wake homeostasis is mediated by the nervous system in the brainstem and hypothalamus with the cerebral cortex. This study has several limitations. First, only bivariate relationships were examined with a minimal sample size, which limited the multivariate analysis between the existing variables. The second limitation is that social factors, such as family support and parental parenting styles, and environmental factors, such as home location, the influence of neighbors, and access to health services, that can affect sleep quality, were not evaluated. The third limitation is the possibility of interviewer bias, as the interviews were conducted by a team. Finally, there was no further evaluation to determine the definitive diagnosis of patients with mental-emotional problems. Conclusion This study demonstrates that cSLE adolescents have a relatively high prevalence of emotional-mental problems, particularly in the internalizing domain, as well as poor sleep quality. There was a weak correlation between emotional mental status and sleep quality, highlighting that cSLE adolescents are at risk of experiencing psychological and sleep disturbances. Therefore, routine screening of mental health and sleep quality using simple instruments such as the PSC-17 and PSQI is important in clinical practice, accompanied by psychosocial interventions and sleep hygiene education. Future studies should involve larger populations with longitudinal designs and explore additional factors to gain a deeper understanding of the relationship between mental health and sleep quality in cSLE adolescents. Abbreviations cSLE Childhood-onset Systemic Lupus Erythematosus PSQI Pittsburgh Sleep Quality Index PSC-17 Pediatric Symptom Checklist-17 SLICC Systemic Lupus International Collaborating Clinics EULAR European Alliance of Associations for Rheumatology ACR American College of Rheumatology WHO World Health Organization PedsQL Pediatric Quality of Life Inventory PHQ-A Patient Health Questionnaire for Adolescents GAD-7 Generalized Anxiety Disorder Scale Declarations Acknowledgments All authors thank the patients’ parents for consenting to this article's publication. We thank all doctors in Dr. Hasan Sadikin General Hospital, Bandung, who contributed to patient management and examination. Author Contributions All authors contributed to the study’s conception and design. SM collected and analyzed the data and drafted the initial manuscript. All authors read and approved the final manuscript. Funding This study did not receive any funding, and the authors declare no conflicts of interest. Data Availability No data other than what is included in this article will be shared. Etics approval and consent to participate The study was approved by Director of Dr. Hasan Sadikin General Hospital, and ethically approved by the Ethics Committee of Dr. Hasan Sadikin General Hospital. This study was preformed in line with the principles of th Declaration of Helsinki. Written informed consent and assent were obtained from all individual participants included in the study Consent for publication Not applicable. Competing interests The authors have no relevant financial or non-financial interest to disclose. References Phillips SR, Johnson A, Shirey MR, Rice M. Sleep quality in school-aged children: a concept analysis. J Pediatr Nurs. 2020;52:54. Jiang F. Sleep and early brain development. Annals Nutr Metabolism. 2019;75(Suppl 1):44–54. Organization WH. Adolescent mental health. 2020. Gruber R, Carrey N, Weiss SK, Frappier JY, Rourke L, Brouillette RT, et al. Position statement on pediatric sleep for psychiatrists. J Can Acad child Adolesc psychiatry. 2014;23(3):174. Paruthi S, Brooks LJ, D'Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549–61. Yin R, Li L, Xu L, Sui W, Niu ME, Xu R, Srirat C. Association between depression and sleep quality in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Sleep Breath. 2022;26(1):429–41. Sapartini G, Ghrahani R, Setiabudiawan B. Lymphopenia as an independent marker of disease activity in children with systemic lupus erythematosus. Children. 2025;12(4):486. Blamires J, Foster M, Napier S, Dickinson A. Experiences and perspectives of children and young people living with childhood-onset systemic lupus erythematosus—an integrative review. Children. 2023;10(6):1006. Smith EM, Lythgoe H, Midgley A, Beresford MW, Hedrich CM. Juvenile-onset systemic lupus erythematosus: update on clinical presentation, pathophysiology, and treatment options. Clin Immunol. 2019;209:108274. Trindade VC, Carneiro-Sampaio M, Bonfa E, Silva CA. An update on the management of childhood-onset systemic lupus erythematosus. Pediatr Drugs. 2021;23(4):331–47. Yottasan P, Kerr SJ, Veeravigrom M, Siripen N, Rianthavorn P. Sleep impairments and quality of life in Thai adolescents with systemic lupus erythematosus. J Pediatr Nurs. 2022;67:e58–64. Costa DD. Sleep and Systemic Lupus Erythematosus. In: Verster JC, Pandi-Perumal SR, Streiner DL, editors. Sleep and quality of life in clinical medicine. Totowa, NJ: Humana; 2008. pp. 433–43. Özer S, Kankaya H, Gün R, Yeler N, Marangoz Ö, Bozça H. Factors affecting sleep quality in patients with systemic lupus erythematosus. Lupus. 2022;31(1):39–44. Irwanto MNAD, Ikhtiar I, Nurmala I. Internal reliability and validity of Pediatric Symptom Checklist-17 Indonesian version for behavioral problem identification in adolescent population. Sapporo Med J. 2020;54(08):1–11. Pujiastuti E, Fadlyana E, Garna H. Comparison of Psychosocial Problems in Obese and Normal-Weight Adolescents Using the Pediatric Symptom Checklist (PSC)-17. Sari Pediatri. 2016;15(4):201–6. Setyowati A, Chung M. Validity and reliability of the Indonesian version of the Pittsburgh Sleep Quality Index in adolescents. Int J Nurs Pract. 2021;27(5):e12856. Treemarcki EB, Danguecan AN, Cunningham NR, Knight AM. Mental health in pediatric rheumatology: an opportunity to improve outcomes. Rheumatic Disease Clin. 2022;48(1):67–90. Davis AM, Graham TB, Zhu Y, McPheeters ML. Depression and medication nonadherence in childhood-onset systemic lupus erythematosus. Lupus. 2018;27(9):1532–41. Puspitanza ID, Alia M, Kesuma Y, Rismarini R, Novery E, Bahar E. Prevalence and risk factors of depression in juvenile systemic lupus erythematosus. Paediatr Indonesiana. 2024;64(4):293–9. Tangkittiwet N, Charuvanij S, Manaboriboon B, Chantaratin S, Pattaragarn A, Piyaphanee N. Illness perception and psychological distress in adolescents with systemic lupus erythematosus. Lupus. 2025;34(4):395–404. Neufeld KM, Moaf P, Quilter M, Danguecan AN, Couture J, Dominguez D, Hendrikx O, Ng L, Schachter R, Korczak DD, Levy DM. Evaluation of depressive and anxiety symptoms in childhood-onset systemic lupus erythematosus: Frequency, course, and associated risk factors. Lupus. 2024;33(8):874–85. Wi D, Palermo TM, Stevens A, Ward TM. Sleep deficiency and symptoms of pain, fatigue, and depressed mood in youth with and without childhood systemic lupus erythematosus. J Clin Sleep Med. 2024;20(10):1607–14. Mason L, Connolly J, Devenney LE, Lacey K, O’Donovan J, Doherty R. Sleep, nutrition, and injury risk in adolescent athletes: a narrative review. Nutrients. 2023;15(24):5101. Anam MR, Akter S, Hossain F, Bonny SQ, Akter J, Zhang C, Rahman MM, Mian MA. Association of sleep duration and sleep quality with overweight/obesity among adolescents of Bangladesh: a multilevel analysis. BMC Public Health. 2022;22(1):374. Cheng W, Rolls ET, Ruan H, Feng J. Functional connectivities in the brain that mediate the association between depressive problems and sleep quality. JAMA Psychiatry. 2018;75(10):1052–61. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Jan, 2026 Reviews received at journal 08 Jan, 2026 Reviews received at journal 07 Jan, 2026 Reviews received at journal 03 Jan, 2026 Reviews received at journal 30 Dec, 2025 Reviewers agreed at journal 23 Dec, 2025 Reviewers agreed at journal 20 Dec, 2025 Reviewers agreed at journal 17 Dec, 2025 Reviewers agreed at journal 17 Dec, 2025 Reviewers agreed at journal 25 Nov, 2025 Reviewers invited by journal 19 Nov, 2025 Editor assigned by journal 10 Nov, 2025 Submission checks completed at journal 10 Nov, 2025 First submitted to journal 05 Nov, 2025 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. 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Ghrahani","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYJCCA2AkAWQlVIAFDEAED0iQCC1niNTCANfC2IbQwoBLi3l778EDDL/u5PPPbn724OG8w3nm7Ic3MPyoYZDhw6FF5sy5hAOMfc8sZ9w5Zm6QuO1wsWVPWgFjzzEGHkkcWiQkcgwOMPYcNmC4kWAmAdSSuOFAjgEDbwMDjwEuLfJvIFrkb6R/k0icA9Ry/o0B4198WiRAUj8OGxjcyAHa0gDUciPHgBmvLTxAhwFVGhjeyCmTSDiWnrhzxrOCwzLHJHD7hf2M8YcPfw4byN1I3yb5o8Y6cTt/8saHb2ps7HGFGBgktiFxQJFyABJN+MAfNC2jYBSMglEwCpABAIgHZef5OMHXAAAAAElFTkSuQmCC","orcid":"","institution":"Padjadjaran University","correspondingAuthor":true,"prefix":"","firstName":"Reni","middleName":"","lastName":"Ghrahani","suffix":""},{"id":550359635,"identity":"c2b7ff98-4517-49ce-b6ea-5ba98ccef540","order_by":2,"name":"Rodman Tarigan","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Rodman","middleName":"","lastName":"Tarigan","suffix":""}],"badges":[],"createdAt":"2025-11-06 03:23:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8043142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8043142/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96944124,"identity":"7d7c46cd-b6ff-49d5-a368-206f9b9d03fd","added_by":"auto","created_at":"2025-11-27 19:19:43","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61928,"visible":true,"origin":"","legend":"","description":"","filename":"ManuskriptEmotionalMentalStatusSonya.docx","url":"https://assets-eu.researchsquare.com/files/rs-8043142/v1/b17eef413bebacd2b5ba3668.docx"},{"id":96944122,"identity":"0aec4528-7c04-49c7-ae38-e909e62e0b9a","added_by":"auto","created_at":"2025-11-27 19:19:43","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5296,"visible":true,"origin":"","legend":"","description":"","filename":"c281f8fa12be4efbaa976bd01454eedf.json","url":"https://assets-eu.researchsquare.com/files/rs-8043142/v1/2e232d924905086d76e98622.json"},{"id":96944125,"identity":"d6e63c70-c3c1-4a39-9778-42eaf837f445","added_by":"auto","created_at":"2025-11-27 19:19:43","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96364,"visible":true,"origin":"","legend":"","description":"","filename":"c281f8fa12be4efbaa976bd01454eedf1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8043142/v1/62b180e3bea4c882fde1236d.xml"},{"id":96944123,"identity":"cc9ff55e-4960-4d96-a66f-005c386da440","added_by":"auto","created_at":"2025-11-27 19:19:43","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96106,"visible":true,"origin":"","legend":"","description":"","filename":"c281f8fa12be4efbaa976bd01454eedf1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8043142/v1/a9a3d78dc6936cc266adda3c.xml"},{"id":96944126,"identity":"cc151f88-12cb-4793-89eb-7f83cabb20d5","added_by":"auto","created_at":"2025-11-27 19:19:43","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":100350,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8043142/v1/c4e9a64bc802c70664093dbf.html"},{"id":97136043,"identity":"ff9f510c-c1af-4b0d-8cf2-95854c0e63b1","added_by":"auto","created_at":"2025-12-01 09:55:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":883374,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8043142/v1/89534cf4-90f7-4fce-96c6-e830a2d7f771.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAssociation of Emotional Mental Status With Sleep Quality in Adolescents With Systemic Lupus Erythematosus\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAdequate sleep is vital for physical and mental health, and essential for growth and development in adolescents.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Sleep is associated with reduced motor activity, less engagement with the external world, a particular posture (e.g., lying down with closed eyes), and easy reversibility.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e During adolescence, hormonal changes and pubertal maturation may affect sleep patterns, making this phase vulnerable to poor sleep quality.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Social pressures and modern lifestyle factors also contribute to sleep deprivation in adolescents.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Moreover, adolescents with chronic illnesses, such as cSLE, are specifically at an increased risk of having poor sleep quality due to the disease's progression, recurrent symptoms, and prolonged management.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eSLE is characterized by the overproduction of autoantibodies and the creation of immune complexes that harm numerous organ systems.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e cSLE is more progressive than that of adult-onset SLE\u003csup\u003e\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and accounts for 15\u0026ndash;20% of all SLE patients, with an incidence of 0.36 to 2.5 per 100,000 children and a prevalence ranging from 1.89 to 34.1 per 100,000 children.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Sleep disorders and poor sleep quality are frequently reported in the adult SLE population, \u003csup\u003e6,11,12\u003c/sup\u003e but the causes of poor sleep quality have not been identified and are highly complex, modulated by various factors.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Behavioural and psychosocial factors, such as physical activity, depression, and stress, influence sleep quality,\u003csup\u003e12,13\u003c/sup\u003e with the relationship between sleep quality and its causative factors considered bidirectional.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Cytokine dysregulation and SLE treatment, such as the use of long-term steroids and immunomodulators, are thought to contribute to poor sleep quality in SLE patients.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Corticosteroids, the main SLE treatment, are suspected to trigger depression and sleep disorders.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Depression is an emotional mental disorder frequently reported among SLE patients,\u003csup\u003e6\u003c/sup\u003e with an estimated 50\u0026ndash;90% of patients with emotional mental disorders experiencing sleep quality problems.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTo date, most studies on poor sleep quality in SLE have been conducted in adults; therefore, this study was designed to evaluate the relationship between mental and emotional status and sleep quality in cSLE adolescents.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient selection\u003c/h2\u003e\u003cp\u003eThis cross-sectional observational study of inpatients and outpatients from the Division of Allergy, Immunology, and Rheumatology, Hasan Sadikin Hospital, Bandung, Indonesia, was conducted from July to August 2025. Patients diagnosed with SLE according to the 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria, the 2019 European Alliance of Associations for Rheumatology (EULAR)/ACR criteria, or the 1997 American College of Rheumatology (ACR) criteria were eligible for inclusion. Patients had a mild to moderate disease activity level at the time of assessment, and they were required to complete the Pediatric Symptom Checklist-17 (PSC-17) and the Pittsburgh Sleep Quality Index (PSQI) questionnaires. Patients were excluded if they exhibited signs of severe illness activity or had a reduced level of awareness. All patients and parents were provided with the study information and the opportunity to ask questions before providing written informed consent for participation. The research was authorized by the Director of Dr. Hasan Sadikin General Hospital, and ethically approved by the Ethics Committee of Dr. Hasan Sadikin General Hospital.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEmotional Mental Status Measurement\u003c/h3\u003e\n\u003cp\u003eEmotional mental status was assessed using the PSC-17 questionnaire, which is a screening instrument for the early detection of emotional and behavioral problems in children and adolescents.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The PSC-17 questionnaire consists of 17 items designed to help identify and evaluate changes in emotional and behavioral issues among children and adolescents. The questionnaire comprises three domains: internalizing, externalizing, and attention, and is scored using a Likert scale, where 0 means never, 1 means sometimes, and 2 means often experiencing the symptom. The internalizing domain included feelings of sadness, hopelessness, low self-esteem, moodiness, and anxiety. The externalizing domain included not liking to share, lacking empathy, fighting, blaming others, disobeying rules, bothering other children, and taking others\u0026rsquo; belongings. The attention domain included restlessness, daydreaming, difficulty concentrating, acting without thinking, and being easily distracted. A patient was considered to have emotional mental problems if they had a score\u0026thinsp;\u0026gt;\u0026thinsp;5 on the internalizing subscale, \u0026gt;\u0026thinsp;7 on the externalizing subscale, \u0026gt;\u0026thinsp;7 on the attention subscale, or a total score of \u0026gt;\u0026thinsp;15. This questionnaire had previously been translated into Indonesian and demonstrated good validity and reliability. It can be self-administered among adolescents, thereby minimizing observer bias.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003eSleep Quality Measurement\u003c/h3\u003e\n\u003cp\u003eThe sleep quality was assessed using the Indonesian version of the PSQI questionnaire, which was validated for adolescents in Indonesia in 2018.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e This sleep measurement tool, containing 19 items, is often used in studies on healthy adolescents and adults with SLE to evaluate sleep latency, length, subjective quality, efficiency, disruptions, medication use, and daytime dysfunction. It is scored using a 5-point Likert scale, with a total PSQI score ranging from 0 (excellent) to 21 (poor), to determine the respondent's sleep experience and quality during the last month. Good sleep is defined as a PSQI score of 5 or less, while poor sleep is defined as a score of 5 or more.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003ch3\u003ePatient Characteristics\u003c/h3\u003e\n\u003cp\u003eAll 60 patients underwent clinical and laboratory evaluation. The data collected included age, sex, nutritional status, height status, family income, quality of life, duration of schoolwork, duration of screen time, disease duration, duration of steroid use, and steroid dose. Nutritional status and height status were classified based on the World Health Organization (WHO) Growth Reference. Family income was categorized as either low or sufficient based on the minimum wage of Bandung City. Quality of life was assessed using the Indonesian version of the Pediatric Quality of Life Inventory (PedsQL) questionnaire. The steroid dosage was based on the prednisone dose and divided into three categories: no use or low dose (0.1\u0026thinsp;\u0026minus;\u0026thinsp;0.2 mg/kg), moderate dose (0.2\u0026thinsp;\u0026minus;\u0026thinsp;0.5 mg/kg), and high dose (0.5\u0026thinsp;\u0026minus;\u0026thinsp;1 mg/kg). Disease activity was assessed using the MEX-SLEDAI and classified as mild or moderate.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe number of teenagers with chronic SLE (n\u0026thinsp;=\u0026thinsp;60) was used to calculate the power to detect a difference in the prevalence of a possible risk factor between 20% and 55% exposure. With a 2-sided significance level of 5%, this study would be able to detect this difference with around 80% power.\u003c/p\u003e\u003cp\u003eThe data were analyzed using SPSS for Windows, version 25.0, and normality was assessed using the Kolmogorov-Smirnov test. The participants' emotional and mental health, as well as the quality of their sleep, were represented by descriptive statistics. Bivariate analysis using Fisher's exact test or Chi-Square tests was conducted to determine how emotional mental state relates to sleep quality. The relationship between emotional mental state and the characteristics of sleep quality (PSQI) was assessed using Spearman's rank correlations. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003ePatient Characteristics\u003c/h2\u003e\u003cp\u003eThis study involved 60 cSLE adolescents, aged 10.3 to 17.9 years, with a median age of 15.5 years. The study population was predominantly female (85%; 51 adolescents). Based on anthropometric data, most of the adolescents had good nutritional status (70%; 42 adolescents) and normal height (70%; 42 adolescents). Most patients were from low-income families (73.3%; 44 adolescents), spent\u0026thinsp;\u0026le;\u0026thinsp;3 hours/day on schoolwork or studying at home (91.7%; 55 adolescents), and had a screen time of \u0026gt;\u0026thinsp;2 hours/day for 43 adolescents (71.7%). The majority of patients had a disease duration of \u0026le;\u0026thinsp;1 year (66.7%; 40 adolescents) and were on high-dose steroids (28 adolescents; 46.7%). Most patients had mild disease activity according to the MEX-SLEDAI (76.7%; 46 adolescents). Most adolescents had a poor quality of life (75%; 45 individuals), with the most affected domains being school and physical functioning (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The relationship with sleep quality is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\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\u003ePatient Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years), Median (min\u0026ndash;max)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15.5 (10.3\u0026ndash;17.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge category, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;12 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (13.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u0026ndash;15 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32 (53.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u0026ndash;18 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20 (33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\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=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9 (15.0)\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=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51 (85.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNutritional status, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42 (70.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (6.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14 (23.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStunted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (30.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42 (70.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily income, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44 (73.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSufficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16 (26.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHomework duration, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;3 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55 (91.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (8.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScreen time duration, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;2 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (28.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43 (71.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease duration, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40 (66.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20 (33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMEX SLEDAI score, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46 (76.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14 (23.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSteroid dose, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (36.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10 (16.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28 (46.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSteroid treatment duration, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40 (66.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20 (33.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (25.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e45 (75.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical Domain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29 (48.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31 (51.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional Domain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36 (60.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24 (40.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Domain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51 (85.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9 (15.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool Domain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23 (38.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37 (61.7)\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\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\u003eAssociation between patients\u0026rsquo; characteristics and sleep quality\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSleep Quality\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003cp\u003e(PSQI\u0026thinsp;\u0026ge;\u0026thinsp;5)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003cp\u003e(PSQI\u0026thinsp;\u0026lt;\u0026thinsp;5)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge category, N (%)\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\u003cp\u003e0.922\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;12 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (62.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u0026ndash;15 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (40.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (59.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u0026ndash;18 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (45.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (55.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, N (%)\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\u003cp\u003e0.722\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\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\u003e3 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\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=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (43.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 (56.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNutritional status, N (%)\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\u003cp\u003e0.783\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (42.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (75.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (42.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight, N (%)\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\u003cp\u003e0.391\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStunted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (45.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (54.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily income, N (%)\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\u003cp\u003e0.430\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (38.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (61.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSufficient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHomework duration, N (%)\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\u003cp\u003e0.64\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;3 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScreen time duration, N (%)\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\u003cp\u003e0.265\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;2 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (52.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (47.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;2 hours\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (37.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (62.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease duration, N (%)\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\u003cp\u003e0.711\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (45.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (55.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMEX SLEDAI Score, N (%)\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\u003cp\u003e0.470\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (39.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (60.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSteroid dose, n (%)\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\u003cp\u003e0.062\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (31.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (68.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (80.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (57.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (42.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSteroid treatment duration, n (%)\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\u003cp\u003e0.853\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (42.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (57.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (40.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: \u003csup\u003ea\u003c/sup\u003eChi-squared, \u003csup\u003eb\u003c/sup\u003eFisher\u0026rsquo;s exact, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEmotional Mental Status\u003c/h3\u003e\n\u003cp\u003eThe PSC-17 scores ranged from 0 to 16, with a median of 7. The prevalence of cSLE adolescents who had emotional and mental problems was 18.3% (11 individuals) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Among cSLE adolescents who showed a tendency toward emotional mental problems, the internalizing domain was the most commonly affected.\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\u003eEmotional Mental Status\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;60\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePSC 17 Score, median (min\u0026ndash;max)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (0\u0026ndash;16)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional mental status, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional mental problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (18.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49 (81.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternalizing Domain, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInternalizing problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (16.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (83.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttention Domain, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttention problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (98.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExternalizing Domain, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExternalizing problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSleep Quality\u003c/h2\u003e\u003cp\u003eThe PSQI score ranged from 0 to 12, with a median score of 4, and 25 adolescents (41.7%) experienced poor sleep quality. The results in sleep quality is shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\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\u003eSleep Quality\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;60\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePSQI Score, median (min\u0026ndash;max)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (0\u0026ndash;12)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSleep quality, N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (41.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (58.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eEmotional Mental Status and Sleep Quality\u003c/h2\u003e\u003cp\u003eThe relationship between emotional mental status and sleep quality in cSLE adolescents was statistically significant (p\u0026thinsp;=\u0026thinsp;0.039). Adolescents who were having emotional mental problems had a higher proportion of poor sleep quality (72.7%) compared to those with a normal emotional mental status (34.7%). Prevalence ratio analysis indicated that adolescents with emotional mental problems had a 2.10 times higher risk of poor sleep quality compared to the normal group (95% CI: 1.24\u0026ndash;3.55) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation between emotional mental status and sleep quality\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\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSleep Quality\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003cp\u003ePSQI\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003cp\u003ePSQI\u0026thinsp;\u0026lt;\u0026thinsp;5\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional Mental Status\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional mental problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (72.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (27.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.039\u003csup\u003eb\u003c/sup\u003e*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2.10 (1.24\u0026ndash;3.55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (34.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32 (65.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: \u003csup\u003eb\u003c/sup\u003eFisher\u0026rsquo;s exact test, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere was a positive correlation between emotional mental status scores and total PSQI scores (r\u0026thinsp;=\u0026thinsp;0.301; p\u0026thinsp;=\u0026thinsp;0.019), indicating that higher PSC-17 scores, reflecting a tendency toward emotional mental problems, were associated with poorer sleep quality (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). In the analysis of PSQI dimensions, emotional mental status scores were only significantly associated with the daytime dysfunction dimension (r\u0026thinsp;=\u0026thinsp;0.365; p\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation between emotional mental status and sleep quality\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eEmotional Mental\u003c/p\u003e\u003cp\u003e(PSC-17)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003er-coefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSleep quality (PSQI)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.301\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.019*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComponent\u003c/b\u003e\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubjective sleep quality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.164\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSleep latency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.192\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSleep duration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.189\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.148\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSleep efficiency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.070\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSleep disturbances\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.127\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe use of sleeping medication\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\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDaytime dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.004*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: Spearman\u0026rsquo;s rank correlations, *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe Indonesian version of PSC-17 is a valid and highly reliable instrument for detecting mental and emotional problems in adolescents,\u003csup\u003e14\u003c/sup\u003e and indicated that 18.3% of cSLE adolescents in this study had mental and emotional problems. It has been reported that children with rheumatologic diseases in children often experience mental health issues such as anxiety and depression compared to their healthy peers.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e A high prevalence of depression has also been reported in cSLE patients.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e However, studies conducted in Southeast Asia reported that a third of cSLE patients had a risk of depression,\u003csup\u003e11,19,20\u003c/sup\u003e more than observed in the present study. Internalizing problems were found to be more predominant and are one of the symptoms of mental and emotional problems in children and adolescents identified by the PSC-17.\u003csup\u003e14\u003c/sup\u003e Internalizing problems are described as a tendency towards anxiety, depression, nervousness, and social withdrawal.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eNeufeld also reported that a cSLE population had a high frequency of symptoms of depression (35%) and anxiety (35%).\u003csup\u003e21\u003c/sup\u003e The stress of living with a chronic condition is one of the contributing factors to anxiety and depression symptoms in cSLE, as they found no relationship between factors related to SLE, such as disease duration, disease activity, or steroid use, and anxiety and depressive symptoms.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Chronic psychosocial stress can cause sub-threshold symptoms to develop into diagnostic symptoms in vulnerable individuals, increasing the risk of future mental health disorders, especially in developing adolescents.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e In contrast, Puspitanza reported that disease activity and low physical activity were related to depression.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Low physical activity in SLE patients is linked to an increase in pro-inflammatory cytokines and an imbalance of hormones and neurotransmitters in the brain, such as serotonin and dopamine, which can cause mood disorders, especially depression, in cSLE patients.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe high prevalence of poor sleep quality among SLE patients (56\u0026ndash;60%) is often underrecognized, undertreated, and understudied.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e In the SLE adult population, complaints of difficulty initiating or maintaining sleep, as well as poor sleep quality, are frequently reported.\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e In the present study, nearly half of the adolescents reported poor sleep quality based on their PSQI scores.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e According to Wi et al., cSLE adolescents have poorer sleep quality compared to healthy adolescents, measured by both objective actigraphy and subjective sleep measurements, supporting the current findings regarding poor sleep quality in cSLE adolescents.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMany factors influence sleep quality in SLE patients, including disease duration, medication side effects, and comorbidities conditions like arthralgia, pain, fatigue, and depression.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Yottasan et al. reported a relationship between poor sleep quality and a high body mass index, which differs from the current study, in which the anthropometric status of adolescents was not related to sleep quality; however, their study sample contained more overweight adolescents (38.6% vs. 23.3%).\u003csup\u003e11\u003c/sup\u003e Short sleep duration affects body weight, especially in adolescents who are in a crucial period of life, obtaining independence, enhancing their social life, and having a high desire to adapt to a modern lifestyle.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Additionally, they may experience pressure due to a high study load and homework, all cumulatively resulting in reduced sleep time, fatigue, and physical activity, and ultimately increasing the consumption of energy-dense food during waking hours.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e These social and behavioral factors complement previously hypothesized mechanisms, such as hormonal dysregulation, changes in body metabolism, daytime sleepiness, and fatigue, which lead to lack of sleep, resulting in increased energy consumption.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eYottasan et al. also reported that steroid exposure did not affect sleep quality, similar to the current study, which found no significant relationship between steroid dose and duration of use and sleep quality.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e This is in contrast to observations in the adult SLE population, in which SLE medication is related to sleep quality.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The drugs used have serious side effects and can increase disease symptoms or other symptoms, which will affect sleep quality.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e \u0026Ouml;zer et al. also reported that poor sleep quality worsened in patients with a longer disease duration.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e This differs from the current results, where disease duration did not have a significant relationship with sleep quality. In SLE, an increase in the duration of the disease increases the possibility of the number of organs involved, aggravating symptoms, and thus affecting the patient's sleep quality.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e The average good sleep quality in the first year of the disease was a finding in \u0026Ouml;zer's study.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn the present study, there was a correlation between mental-emotional status and sleep quality, in line with Yin's comprehensive research, which discovered a modest association between the quality of sleep and depression in individuals with SLE.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Mental health issues, including depression, have been linked to issues with subjective sleep quality, latency, disruption, and daytime functioning.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Other aspects of sleep, including the amount of time spent sleeping, sleep quality, and whether or not medicine was used to aid with sleep, did not show any association.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Slightly different from the present study results, the findings show that only the daytime dysfunction component was significantly correlated with mental-emotional status. The underlying mechanism of poor sleep quality is not clear. However, sleep deprivation may disrupt the circadian rhythm by impacting the brain regions responsible for emotions, the amygdala and the anterior cortex, which are also involved in sleep regulation. This dysregulation occurs during depressive episodes.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTangkittiwet et al. used the Patient Health Questionnaire for Adolescents (PHQ-A) and the Generalized Anxiety Disorders Scale (GAD-7) to evaluate symptoms of anxiety and sadness, suggesting that there is a link between cSLE patients' anxiety and depressive symptoms and the quality of their sleep.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e The correlation in their study was moderate, while the current study's correlation was weak. Wi et al. further reinforced the relationship between depression and poor sleep in the cSLE population.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Functional connectivity in many brain areas, such as the lateral orbitofrontal cortex, dorsolateral prefrontal cortex, cingulate cortex, and precuneus, is positively correlated with poor sleep quality and depressive symptoms.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Functional connectivity between these areas contributes significantly to the relationship between depressive disorder and poor sleep quality,\u003csup\u003e25\u003c/sup\u003e as sleep-wake homeostasis is mediated by the nervous system in the brainstem and hypothalamus with the cerebral cortex.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, only bivariate relationships were examined with a minimal sample size, which limited the multivariate analysis between the existing variables. The second limitation is that social factors, such as family support and parental parenting styles, and environmental factors, such as home location, the influence of neighbors, and access to health services, that can affect sleep quality, were not evaluated. The third limitation is the possibility of interviewer bias, as the interviews were conducted by a team. Finally, there was no further evaluation to determine the definitive diagnosis of patients with mental-emotional problems.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that cSLE adolescents have a relatively high prevalence of emotional-mental problems, particularly in the internalizing domain, as well as poor sleep quality. There was a weak correlation between emotional mental status and sleep quality, highlighting that cSLE adolescents are at risk of experiencing psychological and sleep disturbances. Therefore, routine screening of mental health and sleep quality using simple instruments such as the PSC-17 and PSQI is important in clinical practice, accompanied by psychosocial interventions and sleep hygiene education. Future studies should involve larger populations with longitudinal designs and explore additional factors to gain a deeper understanding of the relationship between mental health and sleep quality in cSLE adolescents.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ecSLE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Childhood-onset Systemic Lupus Erythematosus\u003c/p\u003e\n\u003cp\u003ePSQI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pittsburgh Sleep Quality Index\u003c/p\u003e\n\u003cp\u003ePSC-17\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pediatric Symptom Checklist-17\u003c/p\u003e\n\u003cp\u003eSLICC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Systemic Lupus International Collaborating Clinics\u003c/p\u003e\n\u003cp\u003eEULAR\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;European Alliance of Associations for Rheumatology\u003c/p\u003e\n\u003cp\u003eACR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;American College of Rheumatology\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;World Health Organization\u003c/p\u003e\n\u003cp\u003ePedsQL\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Pediatric Quality of Life Inventory\u003c/p\u003e\n\u003cp\u003ePHQ-A \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Patient Health Questionnaire for Adolescents\u003c/p\u003e\n\u003cp\u003eGAD-7 \u0026nbsp; \u0026nbsp; \u0026nbsp; Generalized Anxiety Disorder Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors thank the patients\u0026rsquo; parents for consenting to this article\u0026apos;s publication. We thank all doctors in Dr. Hasan Sadikin General Hospital, Bandung, who contributed to patient management and examination.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study\u0026rsquo;s conception and design. SM collected and analyzed the data and drafted the initial manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any funding, and the authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo data other than what is included in this article will be shared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEtics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by Director of Dr. Hasan Sadikin General Hospital, and ethically approved by the Ethics Committee of Dr. Hasan Sadikin General Hospital. This study was preformed in line with the principles of th Declaration of Helsinki. Written informed consent and assent were obtained from all individual participants included in the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interest to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePhillips SR, Johnson A, Shirey MR, Rice M. Sleep quality in school-aged children: a concept analysis. J Pediatr Nurs. 2020;52:54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJiang F. Sleep and early brain development. Annals Nutr Metabolism. 2019;75(Suppl 1):44\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrganization WH. Adolescent mental health. 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGruber R, Carrey N, Weiss SK, Frappier JY, Rourke L, Brouillette RT, et al. Position statement on pediatric sleep for psychiatrists. J Can Acad child Adolesc psychiatry. 2014;23(3):174.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParuthi S, Brooks LJ, D'Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYin R, Li L, Xu L, Sui W, Niu ME, Xu R, Srirat C. Association between depression and sleep quality in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Sleep Breath. 2022;26(1):429\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSapartini G, Ghrahani R, Setiabudiawan B. Lymphopenia as an independent marker of disease activity in children with systemic lupus erythematosus. Children. 2025;12(4):486.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlamires J, Foster M, Napier S, Dickinson A. Experiences and perspectives of children and young people living with childhood-onset systemic lupus erythematosus\u0026mdash;an integrative review. Children. 2023;10(6):1006.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith EM, Lythgoe H, Midgley A, Beresford MW, Hedrich CM. Juvenile-onset systemic lupus erythematosus: update on clinical presentation, pathophysiology, and treatment options. Clin Immunol. 2019;209:108274.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTrindade VC, Carneiro-Sampaio M, Bonfa E, Silva CA. An update on the management of childhood-onset systemic lupus erythematosus. Pediatr Drugs. 2021;23(4):331\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYottasan P, Kerr SJ, Veeravigrom M, Siripen N, Rianthavorn P. Sleep impairments and quality of life in Thai adolescents with systemic lupus erythematosus. J Pediatr Nurs. 2022;67:e58\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCosta DD. Sleep and Systemic Lupus Erythematosus. In: Verster JC, Pandi-Perumal SR, Streiner DL, editors. Sleep and quality of life in clinical medicine. Totowa, NJ: Humana; 2008. pp. 433\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u0026Ouml;zer S, Kankaya H, G\u0026uuml;n R, Yeler N, Marangoz \u0026Ouml;, Boz\u0026ccedil;a H. Factors affecting sleep quality in patients with systemic lupus erythematosus. Lupus. 2022;31(1):39\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIrwanto MNAD, Ikhtiar I, Nurmala I. Internal reliability and validity of Pediatric Symptom Checklist-17 Indonesian version for behavioral problem identification in adolescent population. Sapporo Med J. 2020;54(08):1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePujiastuti E, Fadlyana E, Garna H. Comparison of Psychosocial Problems in Obese and Normal-Weight Adolescents Using the Pediatric Symptom Checklist (PSC)-17. Sari Pediatri. 2016;15(4):201\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSetyowati A, Chung M. Validity and reliability of the Indonesian version of the Pittsburgh Sleep Quality Index in adolescents. Int J Nurs Pract. 2021;27(5):e12856.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTreemarcki EB, Danguecan AN, Cunningham NR, Knight AM. Mental health in pediatric rheumatology: an opportunity to improve outcomes. Rheumatic Disease Clin. 2022;48(1):67\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavis AM, Graham TB, Zhu Y, McPheeters ML. Depression and medication nonadherence in childhood-onset systemic lupus erythematosus. Lupus. 2018;27(9):1532\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePuspitanza ID, Alia M, Kesuma Y, Rismarini R, Novery E, Bahar E. Prevalence and risk factors of depression in juvenile systemic lupus erythematosus. Paediatr Indonesiana. 2024;64(4):293\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTangkittiwet N, Charuvanij S, Manaboriboon B, Chantaratin S, Pattaragarn A, Piyaphanee N. Illness perception and psychological distress in adolescents with systemic lupus erythematosus. Lupus. 2025;34(4):395\u0026ndash;404.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNeufeld KM, Moaf P, Quilter M, Danguecan AN, Couture J, Dominguez D, Hendrikx O, Ng L, Schachter R, Korczak DD, Levy DM. Evaluation of depressive and anxiety symptoms in childhood-onset systemic lupus erythematosus: Frequency, course, and associated risk factors. Lupus. 2024;33(8):874\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWi D, Palermo TM, Stevens A, Ward TM. Sleep deficiency and symptoms of pain, fatigue, and depressed mood in youth with and without childhood systemic lupus erythematosus. J Clin Sleep Med. 2024;20(10):1607\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMason L, Connolly J, Devenney LE, Lacey K, O\u0026rsquo;Donovan J, Doherty R. Sleep, nutrition, and injury risk in adolescent athletes: a narrative review. Nutrients. 2023;15(24):5101.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnam MR, Akter S, Hossain F, Bonny SQ, Akter J, Zhang C, Rahman MM, Mian MA. Association of sleep duration and sleep quality with overweight/obesity among adolescents of Bangladesh: a multilevel analysis. BMC Public Health. 2022;22(1):374.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng W, Rolls ET, Ruan H, Feng J. Functional connectivities in the brain that mediate the association between depressive problems and sleep quality. JAMA Psychiatry. 2018;75(10):1052\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"proj","sideBox":"Learn more about [Pediatric Rheumatology](http://ped-rheum.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/proj/default.aspx","title":"Pediatric Rheumatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"childhood-onset systemic lupus erythematosus, adolescents, emotional mental status, depression, sleep quality","lastPublishedDoi":"10.21203/rs.3.rs-8043142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8043142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eChildhood-onset systemic lupus erythematosus (cSLE) is a chronic autoimmune illness. The nature of cSLE and long-term usage of corticosteroids put adolescents at risk of emotional and mental issues, as well as poor sleep quality. This study assessed the correlation between this population's emotional and mental health and the quality of their sleep.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eSixty inpatient and outpatient teenagers (10\u0026ndash;18 years old) with cSLE participated in this cross-sectional observational study. The Indonesian version of the Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality, while the Pediatric Symptom Checklist-17 (PSC-17) was used to measure emotional mental health. The data were analyzed using Chi-squared or Fisher's exact tests as appropriate and Spearman correlations. A p-value less than or equal to 0.05 was deemed significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eEmotional mental problems were found in 18.3% of participants, predominantly within the internalizing domain (16.7%). Nearly half of the teenagers (41.7%) reported having poor quality sleep. Having a bad night's sleep was significantly associated with having an emotional or mental health issue (p\u0026thinsp;=\u0026thinsp;0.039; PR\u0026thinsp;=\u0026thinsp;2.10, 95% CI: 1.24\u0026ndash;3.55). There was a small but statistically significant positive relationship between emotional mental state scores and overall PSQI scores (r\u0026thinsp;=\u0026thinsp;0.301, p\u0026thinsp;=\u0026thinsp;0.019), especially for daytime dysfunction (r\u0026thinsp;=\u0026thinsp;0.365, p\u0026thinsp;=\u0026thinsp;0.004).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eAdolescents with cSLE have a high prevalence of emotional and mental problems and poor sleep quality, with a significant but weak correlation between the two. Routine mental health and sleep quality screening using simple tools such as PSC-17 and PSQI, along with psychosocial support and sleep hygiene education, are recommended for the clinical management of cSLE.\u003c/p\u003e","manuscriptTitle":"Association of Emotional Mental Status With Sleep Quality in Adolescents With Systemic Lupus Erythematosus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-27 19:19:38","doi":"10.21203/rs.3.rs-8043142/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-22T16:21:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-08T23:28:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-07T19:59:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-03T05:16:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-30T07:14:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102662041254205920296894515347819003758","date":"2025-12-23T16:36:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86803301411923595613202432439763437978","date":"2025-12-20T22:50:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283217768912140660271130321824820815718","date":"2025-12-17T18:47:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234479966393164539747669747133857656958","date":"2025-12-17T14:35:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230868135107502075771363942773415754388","date":"2025-11-25T06:44:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-19T13:06:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-10T09:35:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-10T09:34:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Rheumatology","date":"2025-11-06T03:07:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-rheumatology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"proj","sideBox":"Learn more about [Pediatric Rheumatology](http://ped-rheum.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/proj/default.aspx","title":"Pediatric Rheumatology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4190f0ce-4e17-494b-a35f-d5391bcb36ca","owner":[],"postedDate":"November 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-04T13:55:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-27 19:19:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8043142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8043142","identity":"rs-8043142","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}