715315

research-article2017
JAPXXX10.1177/1078390317715315Journal of the American Psychiatric Nurses AssociationZhang et al.

Research Paper
Journal of the American Psychiatric

Sleep Habits, Sleep Problems, Sleep

Nurses Association
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Mental Health Problems Among DOI: 10.1177/1078390317715315

https://doi.org/10.1177/1078390317715315
japna.sagepub.com

Adolescents

Jinwen Zhang, MD1, Zhiwei Xu, MD, PhD2, Kena Zhao, MD3, Ting Chen, MD4,
Xiuxia Ye, MD, PhD5, Zhifei Shen, MD, PhD6, Zengjiang Wu, MD, PhD7,
Jun Zhang, MD, PhD8, Xiaoming Shen, MD, PhD9, and Shenghui Li, MD, PhD10

Abstract
BACKGROUND: Studies in adults suggested that sleep could be a significant contributor to mental health. However,
little is known about their relationship in adolescents. OBJECTIVE: The present study aimed to examine the overall
associations of full-spectrum sleep behaviors, including sleep habits, sleep problems, and sleep hygiene, with mental health
problems among adolescents in Shanghai, China. DESIGN: A stratified, cluster random sample of 4,823 adolescents aged
11 to 20 years participated in a cross-sectional survey. The Adolescent Sleep Disturbance Questionnaire and the modified
Adolescent Sleep Hygiene Scale were used to examine sleep behaviors. The Strengths and Difficulties Questionnaire was
used to evaluate mental health problems. RESULTS: Five sleep variables were found to be associated with adolescents’
mental health. The five factors covered three sleep domains: sleep habits (later bedtime during weekdays), sleep problems
(maintaining sleep difficulties, disorders of arousal), and sleep hygiene (poor emotion at bedtime, unstable sleep schedule).
CONCLUSIONS: The clinical significance of the findings lies in the emphasis of comprehensive screening of sleep in
the predicting, diagnosis, nursing, and intervention of adolescents’ mental health problems.

Keywords
adolescents, mental health problems, sleep habits, sleep problems, sleep hygiene

Background contributor to mental health (Gehrman et al., 2013;

Hashizume, 2014; Seib, Anderson, Lee, & Humphreys,
There has been an increasing recognition of the impor-
tance of mental health in adolescents’ growth and devel-
1
opment (Costello, Egger, & Angold, 2005; Patel, Flisher, Jinwen Zhang, MD, Shanghai Jiao Tong University, Shanghai, China
2
Zhiwei Xu, MD, PhD, Queensland University of Technology,
Hetrick, & McGorry, 2007). Mental health problems are Brisbane, Australia
strongly related to lower educational achievements, poor 3
Kena Zhao, MD, Shanghai Jiao Tong University, Shanghai, China
executive function, higher risky behaviors, and therefore, 4
Ting Chen, MD, Shanghai Jiao Tong University, Shanghai, China
5
account for a large proportion of disease burden among Xiuxia Ye, MD, PhD, Shanghai Jiao Tong University, Shanghai, China
6
adolescents (Patel et al., 2007). The prevalence of mental Zhifei Shen, MD, PhD, Shanghai Academy of Educational Sciences,
Shanghai, China
health problems in children and adolescents worldwide 7
Zengjiang Wu, MD, PhD, Shanghai Academy of Educational Sciences,
ranged from 10% to 20% (Kieling et al., 2011). Shanghai, China
Due to the complex interaction of multiple biological 8
Jun Zhang, MD, PhD, Shanghai Jiao Tong University, Shanghai, China
9
and social factors, adolescents represent a susceptible Xiaoming Shen, MD, PhD, Shanghai Jiao Tong University, Shanghai,
population for mental health problems (Patel et al., China
10
Shenghui Li, MD, PhD, Shanghai Jiao Tong University, Shanghai,
2007). A number of studies have indicated that the most China
marked reduction in sleep duration and the highest prev-
alence of daytime sleepiness occur in adolescents (Leger, Corresponding Author:
Shenghui Li, School of Public Health, Shanghai Jiao Tong University,
Beck, Richard, & Godeau, 2012; Mitchell, Rodriguez, 227 South Chongqing Road, Huangpu District, Shanghai 200027,
Schmitz, & Audrain-McGovern, 2013). Studies among China.
children and adults suggested that sleep could be a major Email: lsh9907@163.com
2 Journal of the American Psychiatric Nurses Association 00(0)
2013). In contrast to children and adults, less is known
about the association of sleep with mental health among
adolescents. Since adolescence represents a vulnerable
window for both mental health problem and sleep restric-
tion, it is important to investigate the association between
sleep and mental health among adolescents. A few stud-
ies have explored the topic. For example, a cross-sec-
tional study among 11,788 adolescents found that short
sleep duration was significantly associated with mental
health problems (Sarchiapone et al., 2014). Another
study, which adopted the prospective cohort study
design, suggested the existence of a causal relationship
between sleep duration and mental health status in ado-
lescents, after controlling for the influence of genetic and
environmental factors (Matamura et al., 2014). Sleep
problems and sleep hygiene may also be involved in the
initiation and development of psychological problems
among adolescents (Roberts, Roberts, & Duong, 2008;
Storfer-Isser, LeBourgeois, Harsh, Tompsett, & Redline,
2013). Based on the limited literature, the understanding
of the association of sleep with mental health among
adolescents is still far away from clear. In addition, sleep
is a multidimensional condition, including sleep habits,
sleep problems, and sleep hygiene (de Bruin, van
Kampen, van Kooten, & Meijer, 2014; Storfer-Isser
et al., 2013; Sun et al., 2014). However, nearly all of the
studies mentioned above only focused on specific single
perspective.
This study was designed to conduct a comprehensive
evaluation on the associations of different sleep domains,
such as sleep habits, sleep problems, and sleep hygiene,
with mental health problems among adolescents.
Method
Subjects and Procedures
A cross-sectional survey was conducted in Shanghai dur-
ing November 2009. Detailed description of the study
was described elsewhere (Chen et al., 2014). Briefly, a
stratified, cluster sampling method was used to recruit
participants. Among 17 districts in Shanghai, 9 districts
are located in urban area and 8 in suburban/rural area.
Four in urban area and two in suburban/rural area were
randomly sampled. Then, two junior high schools and
two senior high schools were randomly sampled from
each district. All students in the target schools were
potential candidates. Among 5,159 students eligible for
the study, 4,966 (96.25%) returned the qualified ques-
tionnaires. Among those, 143 students with missing data
on mental health status were excluded. The final sample
consisted of 4,823 adolescents (49.3% boys vs. 50.7%
girls). The mean age was 15.59 years (SD = 2.04 years,
range = 11.0-20.0 years).
The aims of the survey were explained to school prin-
cipals and teachers in the target schools, and the permis-
sion was obtained to conduct the survey, which is a
common practice in China. Researchers explained the
study purpose to the students and emphasized that the
participation was voluntary and anonymous. The children
who agreed to participate in the survey were asked to take
a questionnaire and an informed consent form to their
parents. The parents were also told that participation in
the survey was voluntary and anonymous. Only those stu-
dents who and whose parents both agreed to participate in
the study entered the survey.
Measures
Sleep Problems and Sleep Habits.  The Chinese version of
Adolescent Sleep Disturbance Questionnaire (ASDQ)
was used to assess sleep problems of adolescents in this
study. The ASDQ is a self-administrated questionnaire,
which was developed based on the literature review, qual-
itative research, pilot studies, and a reliability assessment
(Bruni et al., 1996; Chung & Cheung, 2008; LeBourgeois,
Giannotti, Cortesi, Wolfson, & Harsh, 2005; Liu, Hub-
bard, Fabes, & Adam, 2006; Liu, Zhao, Jia, & Buysse,
2008; Russo, Bruni, Lucidi, Ferri, & Violani, 2007). The
final Chinese version of the questionnaire was conceptu-
ally grouped into the following six subscales: difficulties
in falling asleep (5 items), difficulties in maintaining sleep
(7 items), difficulties in reinitiating sleep (5 items), diffi-
culties in returning to wakefulness (3 items), sleep disor-
dered breathing (3 items), and disorders of arousal (3
items) (Yang, 2016b). The ASDQ has been proved to
have excellent reliability (Cronbach’s alpha coefficients
for the internal consistency were 0.71 for the overall ques-
tionnaire and ranged from 0.61-0.73 for subscales; intra-
class correlation coefficients for the test–retest reliability
were 0.85 for the overall questionnaire and ranged from
0.64 to 0.82 for subscales; Yang, 2016b).
For each item of ASDQ, the response was assessed
using a 5-point Likert-type scale (4 = always, 3 = quite
often, 2 = sometimes, 1 = occasionally, and 0 = never). An
individual sleep problem was defined as the sleep behav-
ior occurring sometimes or more often. Based on the
scoring system, the prevalence of each subscale problem
was calculated. In the present study, a subscale sleep
problem was defined as having at least one individual
sleep problem within a respective subscale. The defini-
tion and cutoff were established with reference to clinical
relevance and previous literature (Liu, Liu, Owens, &
Kaplan, 2005; Spruyt, O’Brien, Cluydts, Verleye, &
Ferri, 2005).
The respondents were also requested to indicate their
sleep habits during the previous month. Sleep habit mea-
sures included bedtime, wake-up time, and sleep duration
Zhang et al. 3
on weekdays (Monday-Friday) and on weekends
(Saturday and Sunday), respectively. For the statistical
analysis, the number of minutes was divided by 60 and
added to the number of hours to obtain a metric variable.
Sleep Hygiene. The Adolescent Sleep Hygiene Scale
(ASHS) is a widely used instrument to evaluate sleep
hygiene among adolescents (LeBourgeois et al., 2005).
For the purpose of the present study, the original version
of ASHS was slightly modified based on literature review
(Ka-Fai & Miao-Miao, 2008; LeBourgeois et al., 2005),
qualitative research, and a pilot study. The modified Chi-
nese version of ASHS (M-ASHS) included 24 items, and
the 24 items were conceptually grouped into five sub-
scales: physiological, cognitive, emotional, sleep envi-
ronment, and sleep stability (Yang, 2016a). For each item
of M-ASHS, the response was assessed on a 5-point Lik-
ert-type scale (1 = always, 5 = never). The total score for
each subscale was then calculated with the higher the
score, the better sleep hygiene.
The reliability of the Chinese version of M-ASHS was
assessed and proved to be excellent (Cronbach’s alpha
coefficients for the internal consistency were 0.89 for the
overall questionnaire and ranged from 0.88 to 0.91 for
subscales; intraclass correlation coefficients for the test–
retest reliability were 0.85 for the overall questionnaire
and ranged from 0.60 to 0.88 for subscales; Yang, 2016a).
To analyze the impact of sleep hygiene on mental
health, each subscale score was recoded into two catego-
ries: “0” for the score ≥75th percentile and “1” for the
score <25th percentile, representing good and poor sleep
hygiene, respectively.
Measures for Mental Health Problems. The self-reported
version of the Strengths and Difficulties Questionnaire
(SDQ) was used to examine mental health status (Good-
man, 1997; Goodman, Meltzer, & Bailey, 2003). The
SDQ consists of 25 items. The short form makes it more
suitable in large epidemiological study. For the best of
our knowledge, it has now been translated into more than
60 different languages and has become an internationally
recognized research instrument to measure mental health
problems (Vostanis, 2006).
The 25 items of the SDQ were grouped into five sub-
scales: emotional symptom, conduct problem, hyperac-
tivity, peer problem, and prosocial behavior. Each
subscale consisted of five items and each item was coded
as certainly true, somewhat true, or not true. Scores for
each subscale ranged from 5 to 15. The total difficulties
score was calculated by summing the scores from emo-
tional symptom, conduct problem, hyperactivity, and
peer problem subscales (Goodman, 1997). Lower scores
indicated more problems on the total difficulties score
and all subscales, except for the prosocial behavior sub-
scale where lower scores indicated better prosocial
behavior.
The reliability of the Chinese version of the SDQ was
0.79 by Cronbach’s alpha coefficients. The association
coefficient between the items and subscales varied from
0.39 to 0.74. The test–retest reliability was 0.72 for the
overall questionnaire and ranged from 0.48 to 0.74 for
subscales by the reassessed association coefficient with
an interval of 6 weeks (Kou, Du, & Xia, 2007).
In this study, the overall mental health problem was
defined by total difficulties score lower than the 10th per-
centile (Goodman, 1997; Goodman et al., 2003). Subscale
mental health problems, including emotional symptom,
conduct problem, hyperactivity, and peer problem, were
defined by corresponding subscale difficulties scores
lower than the 10th percentile, whereas prosocial behav-
ioral problem was regarded as the score of prosocial
behavior subscale higher than the 90th percentile
Confounding Factors. The possible confounding factors
were grouped into four domains:
1. Demographic characteristics included age and
gender.
2. Socioeconomic status included household income
(<1,800, 1,800-3,000, and ≥3,000 Renminbi
[RMB; yuan]/person/month), family structure
(single parent family, nuclear family, and extended
family [a family with grandparents, parents, and
child]), and parents’ educational levels (middle
school or below, high school, and college or
above).
3. Adolescent biological chronic health problems
included overweight/obesity status (yes/no; Cole,
Bellizzi, Flegal, & Dietz, 2000), chronic respira-
tory condition (yes/no, defined as being ever
diagnosed with allergic rhinitis and bronchitis,
asthma, or tonsil/adenoidal hypertrophy by pedia-
tricians), and chronic pain (yes/no).
4. Routine behaviors and activities included psycho-
tropic medications use in the past month (yes/no),
active or passive smoking (yes/no), drinking (yes/
no), television viewing per day during weekdays
and at weekends (≥2 hours/day [h/d] vs. <2 h/d),
computer games playing/computer use (usually/
often and no/occasionally), and physical activity
during weekdays and at weekends (<1 h/d vs. ≥1
h/d).
The recording of each factor is shown in the supple-
mentary materials (available online at http://jap.sagepub.
com/supplemental; see Supplementary Table S1).
4 Journal of the American Psychiatric Nurses Association 00(0)
Ethics Statement
The ethical application and consent procedure of this
study were approved by the Ethics Committee of
Shanghai Jiao Tong University School of Medicine.
Statistical Analysis
Statistical descriptions were made by use of the mean and
standard deviation for continuous variables and the per-
centage for categorical variables. Chi-square test was
used to compare differences between groups where
appropriate.
To examine the associations between sleep behaviors
and mental health problems, logistic regression analyses
were performed, with ‘‘1” for adolescents with mental
health problems and ‘‘0” for healthy adolescents.
Unadjusted odds ratios (OR) and 95% confidence inter-
vals (CI) were calculated using univariate logistic regres-
sion. Adjustments were further made by the multivariate
regression models following a five-step procedure. Each
model included additional variables to assess increas-
ingly proximate determinants of mental health problems.
First, a simple model (Model I) was established only after
adjustment for demographic and socioeconomic charac-
teristics. Second, variables regarding biological chronic
health problems were further controlled (Model II).
Third, routine behaviors and activities were further con-
trolled (Model III). Fourth, sleep behaviors within the
respective subscale were further controlled (Model IV).
Finally, a full model (Model V) was established by adjust-
ing for all possible confounders and all sleep behaviors
simultaneously.
All analyses were performed using the Statistical
Package for Social Sciences (SPSS) for Windows, ver-
sion 15.0 (SPSS Inc., Chicago, IL, USA). In the presenta-
tion of the results, the statistical significance was set at
p < .05 (two tailed).
Results
The Prevalence of Mental Health Problems
and Descriptive Analyses of Possible Influential
Factors
The prevalence of mental health problems was 8.7% in
the sampled adolescents. There was no significant gender
difference in the prevalence (χ2 = 2.07, p = .150; Figure
1). However, the prevalence significantly increased with
increasing age (χ2 = 26.72, p < .001).
Table 1 presents the descriptive analyses of all possi-
ble influential factors for mental health problems. A total
of 25 variables were significantly associated with mental
health problems in the univariate regression models.
Figure 1.  The prevalence of mental health problems by age
and gender.
The Associations of Sleep Behaviors With
Mental Health Problems
To assess the associations between mental health prob-
lems and sleep behaviors, the following analyses were
conducted:
Comparative Analysis of Mental Health Problems Between
Different Sleep Groups. Supplementary Table S2 shows
the comparative analyses of the prevalence of mental
health problems with different sleep groups. The majority
of mental health problems were significantly associated
with sleep behaviors. Generally, short sleep duration,
later bedtime, sleep problems, and poor sleep hygiene
were associated with the higher prevalence of mental
health problems.
Crude and Adjusted Associations of Sleep Behaviors With
Mental Health Problems. Table 1 shows that, except for
wake time during weekdays, all other sleep parameters
were related to mental health problems in the univariate
regression models. Short sleep duration both in weekdays
and at weekends, later bedtime both in weekdays and at
weekends, later wake time at weekends, sleep problems,
and poor sleep hygiene were associated with an increased
likelihood of mental health problems.
As shown in Table 2, through a five-step controlling in
the multivariate regression models, five sleep variables
remained to be significantly related to the increased like-
lihood of mental health problems: later bedtime during
weekdays (OR = 1.65, CI [1.14, 2.39], p = .008), main-
taining sleep difficulties (OR = 2.73, CI [1.69, 4.41], p <
.001), disorders of arousal (OR = 1.48, CI [1.08, 2.02],
p = .014), poor emotion at bedtime (OR = 2.52,
CI [1.81, 3.50], p < .001), and unstable sleep schedule
(OR = 2.04, CI [1.49, 2.80], p < .001).
Zhang et al. 5

Table 1.  The Descriptive Analyses and Univariate Logistical Analyses of Mental Health Problems (N = 4,823).
Prevalence of mental
health problems Univariate regression models

Variables (n, %) N (%) OR [95% CI] p

Demographic characteristics
  Age (years) <.001
   <13 (634, 13.2%) 37 (5.8%) 1.00  
   13 (675, 14.1%) 50 (7.4%) 1.29 [0.83, 2.00] .255
   14 (703, 14.6%) 49 (7.0%) 1.21 [0.78, 1.88] .399
   15 (696, 14.5%) 70 (10.1%) 1.80 [1.19, 2.73] .005
   16 (684, 14.2%) 52 (7.6%) 1.33 [0.86, 2.05] .203
   17 (673, 14.0%) 80 (11.9%) 2.18 [1.45, 3.27] <.001
  ≥18 (736, 15.3%) 81 (11.0%) 2.00 [1.33, 2.99] .001
Gender
   Boys (2,371, 49.3%) 193 (8.1%) 0.86 [0.71, 1.06] .151
   Girls (2,438, 50.7%) 227 (9.3%) 1.00  
Socioeconomic characteristics
  Family income .424
   <1,800 (1,195, 25.5%) 114 (9.5%) 1.10 [0.86, 1.41] .437
   1,800-3,000 (1,434, 30.6%) 116 (8.1%) 0.92 [0.72, 1.17] .504
  ≥3,000 (2,062, 44.0%) 180 (8.7%) 1.00  
  Family structure .090
   Single parent family (267, 5.6%) 32 (12.0%) 1.39 [0.93, 2.08] .108
   Nuclear family (2,575, 54.4%) 209 (8.1%) 0.90 [0.73, 1.12] .339
   Extended family (1,894, 40.0%) 169 (8.9%) 1.00  
  Mother’s educational levels .006
   Middle school and below (1,186, 26.3%) 105 (8.9%) 1.32 [1.00, 1.74] .050
   High school (1,640, 36.4%) 163 (9.9%) 1.50 [1.17, 1.92] .001
   College and above (1,675, 37.2%) 115 (6.9%) 1.00  
  Father’s educational levels .137
   Middle school and below (995, 21.5%) 99 (9.9%) 1.31 [1.00, 1.70] .049
   High school (1,694, 36.6%) 150 (8.9%) 1.15 [0.91, 1.45] .250
   College and above (1,936, 41.9%) 151 (7.8%) 1.00  
Biological chronic health problems
 Overweight/obesity
   Yes (644, 14.1%) 58 (9.0%) 1.07 [0.80, 1.43] .665
   No (3,922, 85.9%) 333 (8.5%) 1.00  
  Chronic respiratory condition
   Yes (1,265, 26.5%) 148 (11.7%) 1.61 [1.30, 1.99] <.001
   No (3,517, 73.5%) 268 (7.6%) 1.00  
  Chronic pain
   Yes (1,756, 36.8%) 269 (15.3%) 3.56 [2.89, 4.40] <.001
   No (3,021, 63.2%) 146 (4.8%) 1.00  
Routine behaviors and activities
  Psychotropic medications using in recent 1 month
   Yes (244, 5.1%) 42 (17.2%) 2.32 [1.63, 3.28] <.001
   No (4,539, 94.9%) 374 (8.2%) 1.00  
  Active or passive smoking
   Yes (897, 19.0%) 100 (11.1%) 1.42 [1.12, 1.80] .004
   No (3,821, 81.0%) 311 (8.1%) 1.00  
 Drink
   Yes (43, 0.9%) 9 (20.9%) 2.83 [1.35, 5.93] .006
   No (4,763, 99.1%) 408 (8.6%) 1.00  
  Television viewing during weekdays (h/d)
  ≥2 (223, 4.6%) 27 (12.1%) 1.47 [0.97, 2.23] .069
   <2 (4,576, 95.4%) 392 (8.6%) 1.00  
  Television viewing during weekends (h/d)
  ≥2 (1,906, 39.7%) 177 (9.3%) 1.12 [0.91, 1.37] .275
   <2 (2,901, 60.3%) 243 (8.4%) 1.00  
  Playing computer games or computer use
   Usually/often (1,120, 23.3%) 134 (12.0%) 1.61 [1.30, 2.00] <.001
   No/occasionally (3,691, 76.7%) 287 (7.8%) 1.00  
  Physical activity during weekdays (h/d)
   <1 (3,960, 82.9%) 346 (8.7%) 1.06 [0.81, 1.39] .694
  ≥1 (818, 17.1%) 68 (8.3%) 1.00  

(continued)
6 Journal of the American Psychiatric Nurses Association 00(0)

Table 1. (continued)

Prevalence of mental
health problems Univariate regression models

Variables (n, %) N (%) OR [95% CI] p

Physical activity during weekends (h/d)

   <1 (3,335, 70.0%) 307 (9.2%) 1.30 [1.03, 1.63] .029
  ≥1 (1,432, 30.0%) 104 (7.3%) 1.00  
Sleep habits
  Sleep duration during weekdays (h/d) <.001
   <8 (2,236, 48.5%) 244 (10.9%) 2.35 [1.66, 3.35] <.001
   8-9 (1,604, 34.8%) 124 (7.7%) 1.61 [1.11, 2.34] .013
  ≥9 (768, 16.7%) 38 (4.9%) 1.00  
  Sleep duration during weekends (h/d) .001
   <8 (363, 7.9%) 51 (14.0%) 1.86 [1.35, 2.57] <.001
   8-9 (876, 19.0%) 81 (9.2%) 1.16 [0.89, 1.51] .263
  ≥9 (3,369, 73.1%) 272 (8.1%) 1.00  
  Bedtime during weekdays
   Later than 10 p.m. (2,293, 48.2%) 259 (11.3%) 1.95 [1.58, 2.41] <.001
   Earlier than 10 p.m. (2 466, 51.8%) 151 (6.1%) 1.00  
  Bedtime during weekends
   Later than 10.30 p.m. (1,927, 40.3%) 219 (11.4%) 1.71 [1.40, 2.09] <.001
   Earlier than 10.30 p.m. (2,850, 59.7%) 199 (7.0%) 1.00  
  Wake time during weekdays
   Later than 6.15 a.m. (2,209, 46.2%) 187 (8.5%) 0.94 [0.77, 1.15] .524
   Earlier than 6.15 a.m. (2570, 53.8%) 231 (9.0%) 1.00  
  Wake time during weekends
   Later than 8 a.m. (2,176, 45.6%) 216 (9.9%) 1.32 (1.08, 1.61) .007
   Earlier than 08 a.m. (2,593, 54.4%) 200 (7.7%) 1.00  
Sleep problems
  Falling asleep difficulties
   Yes (3,256, 68.2%) 333 (10.2%) 1.90 [1.48, 2.42] <.001
   None (1,517, 31.8%) 86 (5.7%) 1.00  
  Maintaining sleep difficulties
   Yes (3,241, 68.5%) 376 (11.6%) 5.29 [3.74, 7.49] <.001
   None (1,488, 31.5%) 36 (2.4%) 1.00  
  Reinitiating sleep difficulties
   Yes (1,995, 42.0%) 278 (13.9%) 3.22 [2.60, 4.00] <.001
   None (2,757, 58.0%) 132 (4.8%) 1.00  
  Returning to wakefulness difficulties
   Yes (4,322, 90.7%) 409 (9.5%) 6.51 [3.06, 13.83] <.001
   None (443, 9.3%) 7 (1.6%) 1.00  
  Sleep disordered breathing
   Yes (654, 13.6%) 122 (18.7%) 3.02 [2.40, 3.80] <.001
   None (4,148, 86.4%) 293 (7.1%) 1.00  
  Disorders of arousal
   Yes (1,209, 25.2%) 206 (17.0%) 3.30 [2.69, 4.05] <.001
   None (3,586, 74.8%) 210 (5.9%) 1.00  
Sleep hygiene
 Physiological
   Bad (1,139, 23.9%) 198 (17.4%) 3.33 [2.71, 4.09] <.001
   Good (3,629, 76.1%) 216 (6.0%) 1.00  
 Cognitive
   Bad (964, 20.4%) 191 (19.8%) 3.99 [3.24, 4.92] <.001
   Good (3,755, 79.6%) 219 (5.8%) 1.00  
 Emotional
   Bad (994, 20.7%) 236 (23.7%) 6.14 [4.98, 7.55] <.001
   Good (3,810, 79.3%) 184 (4.8%) 1.00  
  Sleep environment
   Bad (893, 18.6%) 156 (17.5%) 2.96 [2.39, 3.67] <.001
   Good (3,912, 81.4%) 261 (6.7%) 1.00  
  Sleep stability
   Bad (1,053, 22.5%) 183 (17.4%) 3.19 [2.59, 3.94] <.001
   Good (3,625, 77.5%) 224 (6.2%) 1.00  

Note. OR = odds ratio; CI = confidence interval; h/d = hours/day. Family income was expressed in RMB (yuan)/person/month.
 Table 2.  Associations of Sleep Habits, Sleep Problems, Sleep Hygiene With Mental Health Problems by Multivariate Logistical Regression (N = 4,823).
Model I Model II Model III Model IV Model V

Adjusted OR Adjusted OR Adjusted OR Adjusted OR

Variables Adjusted OR (95% CI) p (95% CI) p (95% CI) p (95% CI) p (95% CI) p

Sleep habits
  Sleep duration during weekdays (h/d) .004 .030 .033 .421a .272
  <8 vs. ≥9 1.91 [1.28, 2.87] .002 1.74 [1.14, 2.67] .011 1.77 [1.13, 2.76] .012 1.30 [0.80, 2.12] .296a 1.12 [0.63, 1.99] .692
  8-9 vs. ≥9 1.42 [0.96, 2.11] .080 1.38 [0.91, 2.09] .131 1.40 [0.91, 2.17] .125 1.36 [0.86, 2.13] .189a 1.42 [0.83, 2.41] .197
  Sleep duration during weekends (h/d) .018 .030 .034 .060a .335
  <8 vs. ≥9 1.67 [1.17, 2.39] .005 1.65 [1.13, 2.41] .010 1.65 [1.12, 2.43] .011 1.65 [1.07, 2.54] .023a 1.39 [0.84, 2.30] .195
  8-9 vs. ≥9 1.04 [0.78, 1.38] .799 0.99 [0.73, 1.35] .941 0.99 [0.73, 1.36] .966 1.00 [0.71, 1.41] .996a 0.94 [0.63, 1.40] .766
  Bedtime during weekdays
   Later than 10 p.m. vs. earlier 1.96 [1.50, 2.56] <.001 1.84 [1.38, 2.43] <.001 1.73 [1.30, 2.31] <.001 1.62 [1.17, 2.25] .004a 1.65 [1.14, 2.39] .008
  Bedtime during weekends
   Later than 10.30 p.m. vs. earlier 1.56 [1.24, 1.97] <.001 1.48 [1.16, 1.89] .002 1.37 [1.07, 1.77] .014 1.12 [0.84, 1.48] .447a 0.96 [0.69, 1.34] .829
  Wake time during weekdays
Later than 6.15 a.m. vs. earlier 1.09 [0.86, 1.38] .474 1.06 [0.83, 1.35] .661 1.06 [0.83, 1.37] .635 0.98 [0.74, 1.28] .860a 0.96 [0.70, 1.31] .784
  Wake time during weekends
   Later than 8 a.m. vs. earlier 1.34 [1.08, 1.67] .009 1.39 [1.10, 1.76] .006 1.30 [1.02, 1.66] .032 1.29 [0.98, 1.71] .074a 1.07 [0.77, 1.49] .692
Sleep problems
  Falling asleep difficulties vs. none 1.88 [1.44, 2.45] <.001 1.66 [1.26, 2.20] <.001 1.65 [1.24, 2.19] .001 1.27 [0.93, 1.72] .131b 1.20 [0.84, 1.71] .320
  Maintaining sleep difficulties vs. none 5.70 [3.87, 8.39] <.001 4.70 [3.14, 7.04] <.001 4.73 [3.13, 7.15] <.001 3.42 [2.21, 5.30] <0.001b 2.73 [1.69, 4.41] <.001
  Reinitiating sleep difficulties vs. none 2.96 [2.35, 3.73] <.001 2.58 [2.02, 3.30] <.001 2.50 [1.95, 3.21] <.001 1.74 [1.32, 2.28] <.001b 1.25 [0.91, 1.72] .168
  Returning to wakefulness difficulties vs. none 6.22 [2.75, 14.11] <.001 5.72 [2.33, 14.05] <.001 5.33 [2.16, 13.12] <.001 3.65 [1.47, 9.10] .005b 1.92 [0.76, 4.86] .172
  Sleep disordered breathing vs. none 2.97 [2.30, 3.84] <.001 2.48 [1.88, 3.28] <.001 2.40 [1.80, 3.18] <.001 1.56 [1.15, 2.14] .005b 1.22 [0.84, 1.76] .294
  Disorders of arousal vs. none 3.15 [2.52, 3.94] <.001 2.60 [2.05, 3.31] <.001 2.65 [2.07, 3.38] <.001 1.81 [1.38, 2.37] <.001b 1.48 [1.08, 2.02] .014
Sleep hygiene
 Physiological
   Bad vs. good 3.13 [2.49, 3.93] <.001 2.78 [2.18, 3.55] <.001 2.75 [2.15, 3.53] <.001 1.54 [1.14, 2.08] .005c 1.31 [0.94, 1.82] .109
 Cognitive
   Bad vs. good 3.75 [2.98, 4.73] <.001 3.11 [2.43, 3.98] <.001 3.03 [2.35, 3.92] <.001 1.31 [0.95, 1.81] .105c 1.06 [0.75, 1.52] .737
 Emotional
   Bad vs. good 5.73 [4.57, 7.19] <.001 4.38 [3.44, 5.59] <.001 4.49 [3.50, 5.76] <.001 3.08 [2.30, 4.12] <.001c 2.52 [1.81, 3.50] <.001
  Sleep environment
   Bad vs. good 3.00 [2.38, 3.79] <.001 2.47 [1.93, 3.18] <.001 2.46 [1.90, 3.19] <.001 1.31 [0.97, 1.78] .081c 1.19 [0.85, 1.68] .314
  Sleep stability
   Bad vs. good 3.27 [2.59, 4.11] <.001 3.20 [2.50, 4.09] <.001 3.11 [2.41, 4.01] <.001 2.21 [1.67, 2.92] <.001c 2.04 [1.49, 2.80] <.001

Note. OR = odds ratio; CI = confidence interval; h/d = hours/day.

Model I: Adjusted for demographic and socioeconomic characteristics. Model II: Model I adjustments plus biological chronic health problems. Model III: Model II adjustments plus routine behaviors and activities. Model IVa: Model
III adjustments plus sleep habits. Model IVb: Model III adjustments plus sleep problems. Model IVc: Model III adjustments plus sleep hygiene. Model V: model III adjustments plus sleep habits, sleep problems, and sleep hygiene.

7
8 Journal of the American Psychiatric Nurses Association 00(0)
In addition to the overall relationships between sleep
behaviors and mental health problems, we examined the
associations of sleep behaviors with each subscale mental
health problem in SDQ, such as emotional symptom,
conduct problem, hyperactivity, peer problem, and proso-
cial behavioral problem (Table 3 and Supplementary
Tables S3 to S7). It can be seen that emotional symptom
was associated with sleep problems, especially insomnia
symptoms, and sleep hygiene. Conduct problem was
linked to sleep problems and sleep hygiene, especially
sleep stability. Hyperactivity was related to sleep disor-
dered breathing and sleep stability. Peer problem was
associated with falling asleep difficulties. Prosocial
behavioral problem was associated with later bedtime
during weekends, falling asleep difficulties, maintaining
sleep difficulties, and unstable sleep.
Discussion
This study evaluated the associations of sleep behaviors,
including sleep habits, sleep problems, and sleep hygiene,
with mental health problems among Chinese adolescents.
Sleep variables, such as later bedtime during weekdays,
maintaining sleep difficulties, disorders of arousal, poor
emotions at bedtime, and unstable sleep schedules were
found to be independently associated with increased
mental health problems.
Sleep Duration, Bed/Wake Time, and Mental
Health Problems
The findings of the present study did not establish a rela-
tionship between short sleep duration and mental health
problems, which is similar to the result of a study among
247 American adolescents (Moore et al., 2009). However,
several other studies found that adolescents with short
sleep duration appeared to have more mental and behav-
ioral problems (Matamura et al., 2014; Meijer, Reitz,
Deković, van den Wittenboer, & Stoel, 2010; Sarchiapone
et al., 2014). Different sample characteristics and different
instruments used to examine sleep behaviors and mental
health problems may have led to the inconsistent results.
In addition, the inconsistency of the findings across differ-
ent studies may also be partly explained by different ana-
lytic strategies (Matamura et al., 2014; Meijer et al., 2010;
Moore et al., 2009; Sarchiapone et al., 2014). In the pres-
ent study, a five-step modeling procedure was adopted.
Short sleep duration was found to be associated with
increased mental health problems through Model I to
Model IV in multivariate regression models. The signifi-
cance did not disappear until further adjusting for sleep
problems and sleep hygiene in Model V. It has been found
that sleep duration was strongly associated with sleep
hygiene (de Bruin et al., 2014; Sun et al., 2014) and sleep
problems (Liu et al., 2005). Therefore, it is possible that
sleep quality (Pilcher, Ginter, & Sadowsky, 1997) and
sleep hygiene are more important than sleep duration to
adolescents’ mental health. Based on the findings, this
study calls for a full consideration of different aspects of
sleep in the evaluation of association between sleep and
mental health, especially in clinical and nursing practice.
By contrast to sleep duration, this study found that
later bedtime was significantly associated with mental
health problems among Chinese adolescents. This find-
ing is similar to a prospective study, which established a
longitudinal causal relationship between later bedtime
and poor mental health status in adolescents (Matamura
et al., 2014). In addition to later bedtime, there is evi-
dence that later wake time is also associated with behav-
ior problems (Wada et al., 2013; Yokomaku et al., 2008).
A recent review concludes that there is a particularly high
comorbidity between delayed sleep phase type and men-
tal health problems among both children and adolescents
(Abbott, Reid, & Zee, 2015). Therefore, more attention
should be paid to sleep rhythm in the intervention and
promotion of mental health among adolescents.
Sleep Problems and Mental Health Problems
In this study, maintaining sleep difficulties and disorders
of arousal were found to be independently associated
with an increased likelihood of mental health problems.
Consistent with the finding of the present study, several
previous studies among children and adolescents have
found that mental health problems were related to insom-
nia symptoms, especially maintaining sleep difficulties
(American Sleep Disorders Association Atlas Task Force,
1993; Casement, Keenan, Hipwell, Guyer, & Forbes,
2016; Cheung & Wong, 2011; Luo, Zhang, & Pan, 2013;
Roberts & Duong, 2013; Singareddy et al., 2013). The
findings also indicate that disorders of arousal were asso-
ciated with an increased likelihood of mental health prob-
lems. Nightmares, the most common complaint within
the domain of disorders of arousal, were found to be
linked to mental health problems in youth (Munezawa
et al., 2011; Sheaves et al., 2015). Although the potential
mechanism is still unclear, the relationship between dis-
orders of arousal and mental health problems is impress-
ing and should be further explored in the future.
Previous studies have demonstrated that subjects with
mental health problems usually complained about sleep
problems and poor sleep quality (Morin & Ware, 1996;
Tsuno, Besset, & Ritchie, 2005). Recent studies further
suggested that sleep problems may increase the risk of,
and even directly contribute to, the development of some
mental health problems (Alfano & Gamble, 2009;
Casement et al., 2016; Gehrman et al., 2013). Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition,
 Table 3.  The Associations of Sleep Behaviors With Subscales of Mental Health by Multivariate Logistical Regression (N = 4,823).
Prosocial behavioral
Emotional symptom Conduct problem Hyperactivity Peer problem problem

Adjusted OR Adjusted OR Adjusted OR Adjusted OR Adjusted OR

Variables (95% CI) p (95% CI) p (95% CI) p (95% CI) p (95% CI) p

Sleep habits
  Sleep duration during weekdays (h/d) .343 .134 .579 .437 .726
  <8 vs. ≥9 1.48 [0.88, 2.50] .144 1.42 [0.74, 2.73] .295 1.31 [0.79, 2.18] .296 1.38 [0.79, 2.42] .262 0.86 [0.55, 1.33] .489
  8-9 vs. ≥9 1.33 [0.82, 2.16] .251 1.77 [0.97, 3.25] .064 1.21 [0.76, 1.92] .427 1.07 [0.65, 1.76] .780 0.86 [0.58, 1.27] .439
  Sleep duration during weekends (h/d) .535 .148 .183 .646 .690
  <8 vs. ≥9 0.95 [0.57, 1.57] .827 1.48 [0.88, 2.50] .141 1.44 [0.91, 2.29] .120 1.26 [0.70, 2.27] .443 1.21 [0.77, 1.89] .416
  8-9 vs. ≥9 0.81 [0.56, 1.17] .265 0.84 [0.55, 1.30] .434 0.90 [0.62, 1.31] .595 1.18 [0.76, 1.83] .466 0.99 [0.71, 1.39] .966
  Bedtime during weekdays
   Later than 10 p.m. vs. earlier 1.20 [0.85, 1.70] .299 1.07 [0.72, 1.60] .727 1.05 [0.74, 1.48] .793 1.07 [0.69, 1.66] .770 1.20 [0.87, 1.67] .264
  Bedtime during weekends
   Later than 10.30 p.m. vs. earlier 0.81 [0.59, 1.10] .178 1.20 [0.84, 1.70] .314 0.99 [0.73, 1.34] .930 0.88 [0.60, 1.31] .536 1.53 [1.15, 2.03] .003
  Wake time during weekdays
   Later than 6.15 a.m. vs. earlier 1.06 [0.79, 1.42] .685 1.32 [0.95, 1.85] .100 1.08 [0.81, 1.44] .625 1.12 [0.79, 1.59] .537 0.95 [0.73, 1.24] .684
  Wake time during weekends
   Later than 8 a.m. vs. earlier 1.06 [0.78, 1.43] .726 1.04 [0.73, 1.48] .828 0.96 [0.71, 1.30] .787 1.01 [0.70, 1.46] .970 0.95 [0.72, 1.26] .736
Sleep problems
  Falling asleep difficulties vs. none 1.17 [0.84, 1.62] .359 0.93 [0.64, 1.34] .686 0.76 [0.57, 1.02] .067 1.60 [1.07, 2.39] .023 1.43 [1.07, 1.91] .015
  Maintaining sleep difficulties vs. none 2.43 [1.60, 3.69] <.001 1.57 [1.01, 2.42] .044 1.27 [0.91, 1.76] .154 1.04 [0.70, 1.53] .856 1.63 [1.20, 2.21] .002
  Reinitiating sleep difficulties vs. none 1.72 [1.28, 2.32] <.001 1.34 [0.95, 1.89] .091 0.85 [0.63, 1.14] .273 1.05 [0.74, 1.51] .776 0.92 [0.70, 1.21] .541
  Returning to wakefulness difficulties vs. none 1.19 [0.60, 2.37] .615 1.45 [0.61, 3.44] .399 1.86 [0.95, 3.63] .071 1.54 [0.80, 2.97] .197 1.30 [0.78, 2.17] .312
  Sleep disordered breathing vs. none 1.77 [1.26, 2.47] .001 1.16 [0.77, 1.73] .485 1.50 [1.06, 2.14] .023 1.02 [0.63, 1.64] .948 1.20 [0.84, 1.70] .323
  Disorders of arousal vs. none 1.48 [1.10, 1.97] .009 1.52 [1.09, 2.14] .015 1.16 [0.85, 1.59] .352 1.45 [0.99, 2.13] 0.055 1.09 [0.80, 1.48] .589
Sleep hygiene
 Physiological
   Bad vs. good 1.15 [0.84, 1.57] .385 1.02 [0.71, 1.46] .929 1.32 [0.95, 1.82] .099 1.04 [0.68, 1.60] .854 1.00 [0.73, 1.39] .982
 Cognitive
   Bad vs. good 1.22 [0.87, 1.71] .246 1.68 [1.15, 2.46] .008 0.98 [0.67, 1.41] .899 0.96 [0.59, 1.54] .848 1.08 [0.76, 1.55] .658
 Emotional
   Bad vs. good 2.23 [1.64, 3.04] <.001 1.99 [1.38, 2.85] <.001 1.30 [0.92, 1.85] .136 1.37 [0.90, 2.09] .146 0.82 [0.58, 1.16] .260
  Sleep environment
   Bad vs. good 0.93 [0.67, 1.30] .663 1.17 [0.82, 1.69] .389 1.07 [0.75, 1.52] .701 1.14 [0.73, 1.78] .567 0.97 [0.69, 1.38] .878
  Sleep stability
   Bad vs. good 1.77 [1.31, 2.39] <.001 2.14 [1.53, 2.98] <.001 1.75 [1.29, 2.37] <.001 0.91 [0.59, 1.39] .652 1.39 [1.04, 1.87] .027

Note. OR = odds ratio; CI = confidence interval; h/d = hours/day. Adjusted for demographic and socioeconomic characteristics, biological chronic health problems, routine behaviors and activities, sleep habits, sleep problems,
and sleep hygiene.

9
10 Journal of the American Psychiatric Nurses Association 00(0)
has acknowledged the bidirectional nature of the interre-
lationships between sleep disorders and psychiatric disor-
ders (Winokur, 2015). The overlap and bidirectional
associations between sleep problems and mental health
problems may be due to a shared biological root (Winokur,
2015). These findings further suggest the importance to
screen sleep problems in clinical and nursing practice
when coping with adolescents’ mental health problems.
Sleep Hygiene and Mental Health Problems
Previous studies have shown that poor sleep hygiene
practices can affect daily functioning in many areas
(Witcher et al., 2012). However, few studies have exam-
ined the association of sleep hygiene with mental health
problems. In the present study, findings indicated that
poor emotion and unstable sleep schedule were indepen-
dently associated with mental health problems. Similarly,
a study in adolescents found that after adjusting for age
and sex, cognitive/emotional condition at bedtime was
correlated with internalizing behaviors (Storfer-Isser
et al., 2013). The results of this study support the previous
finding, and further confirm that the relationship of sleep
hygiene with mental health problems, even taking sleep
habits and sleep problems into account, still existed.
Another study in preschool children demonstrated that
children with unstable sleep schedule were more likely to
show problematic behaviors (Yokomaku et al., 2008).
Studies found that circadian disruption, through environ-
mental and behavioral manipulations, can affect not only
the quality and quantity of sleep but also mental health
(Abbott et al., 2015). The finding, along with the existing
evidences, supports that sleep hygiene is involved in the
development of mental health. Since previous studies
have demonstrated that there were complicated interac-
tions among sleep habits, sleep hygiene, and sleep prob-
lems (de Bruin et al., 2014; Storfer-Isser et al., 2013; Sun
et al., 2014), more research is needed to interpret the pos-
sible differential impacts of different aspects of sleep.
Limitations
The present study is limited by the reliance on a subjec-
tive measure of sleep variables, which may increase the
possibility of rater biases. However, the previous study
has shown acceptable agreement between self-reports
and actigraphic measures of sleep parameters (Cespedes
et al., 2016). Moreover, the use of self-report question-
naire for assessment of mental health problems was an
additional limitation of the study. Furthermore, although
this study tried to control for many potential confounding
factors that could affect adolescents’ mental health status,
residual confounding was possible. Finally, this is an
observational study. Associations reported in the analysis
may not necessarily be causal. Further clinical trials are
needed to make a definitive conclusion on any of the
findings.
Conclusions
This study found the significant associations between
sleep behaviors and mental health problems among
Chinese adolescents. Data on sleep behaviors were col-
lected from three aspects of sleep, covering sleep habits,
sleep problems, and sleep hygiene, which enabled us to
better understand the independent associations between
sleep behaviors and mental health problems. The findings
suggested that five sleep variables such as later bedtime
during weekdays, maintaining sleep difficulties, disor-
ders of arousal, poor emotions at bedtime, and unstable
sleep schedules were independently associated with an
increased likelihood of mental health problems. The five
variables covered all three aspects of sleep. The findings
highlight the importance of multiple dimension screening
and surveillance of sleep in mental health promotion and
intervention.
Author Roles
Study concept and design: SL. Statistical analysis: SL, JZ, and
TC. Drafting of the manuscript: JZ. Critical revision of the man-
uscript: SL, ZX, and JZ. Survey and data collection: JZ, KZ,
XY, ZS, ZW, and XS.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this arti-
cle: The study was funded by grants from National Natural
Science Foundation of China (81072314), Innovation Program
of Shanghai Municipal Education Commission (13YZ034),
2012 Shanghai Public Health Academic Leader Project
(GWDTR201222), and Shanghai Jiao Tong University Medicine
and Engineering Cross Fund Project (YG2013MS13).
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