Kids who have a lot of difficulty sleeping are at heightened risk for developing suicidal thoughts and behaviors as they enter adolescence, a new Stanford Medicine-led study found.

The research, published recently in JAMA Network Open, tracked more than 8,800 youth ages 9 and 10, none of whom had suicidal thoughts or behaviors at the start of the study. Children with high or severe levels of sleep disturbance were more than twice as likely as solid sleepers to develop suicidal thoughts and behaviors over the following two years, the data showed. Frequent nightmares conferred especially high risk.

Understanding the connections between poor sleep and suicide is important because sleep problems offer a golden opportunity for parents and physicians to intervene, according to Stanford Medicine suicidologist and founder of the Stanford Suicide Prevention Research Laboratory, Rebecca Bernert, PhD, the study’s senior author.

Although the relationship between sleep and suicide risk is likely complex, and it’s difficult to tell whether sleep problems lead to suicidal thoughts and behaviors or simply expose a preexisting vulnerability, sleep nevertheless offers a uniquely useful window into mental health.

Sleep issues are easy to spot, aren’t stigmatized in the way that many mental health problems are and are very treatable, Bernert said. Plus, improving someone’s sleep has a variety of benefits.

“This risk factor provides a gateway to treatment, whether for overall well-being, to prevent or improve depression, or to specifically reduce risk of suicide,” said Bernert, an assistant professor of psychiatry and behavioral sciences. “In this way, I see so much hope in sleep for a lifesaving opportunity.”

Perfect storm of sleep changes

As adolescence begins, sleep patterns change. Brain and physical development accelerates, launching the body into an aggressive growth spurt – increasing kids’ need to sleep nine or more hours per night.

At the same time, puberty shifts the body clock toward “night owl” patterns, causing teens to fall asleep and wake up later. Adolescents also face new responsibilities that can interfere with sleep: more homework; a busier social life; and, perhaps, early-morning sports practices or classes.

“It’s a perfect storm,” Bernert said.

While these changes are normal and not a cause for alarm, Bernert’s team wanted to investigate whether sleep patterns predict mental health risks as youth transition from late childhood into early adolescence, where research remains relatively rare. The researchers had established links between sleep problems and suicide risk among young and older adults, as well as among high-risk groups, including military veterans. Sleep can also be disrupted in mental health conditions connected to suicide risk, such as post-traumatic stress disorder, anxiety, and depression, but studies had not evaluated the relationship between disturbed sleep and suicidal behavior in late childhood.

The researchers used data from an ongoing national investigation, the Adolescent Brain Cognitive Development Study, which is funded by the National Institutes of Health and is tracking the maturation of more than 10,000 U.S. children starting at age 9 or 10. Bernert’s team analyzed data from 8,807 young people who had completed a two-year follow-up around age 12.

The baseline data included information provided by participants’ parents on a brief survey designed to index overall sleep disturbances. Investigators also evaluated different types of sleep issues – including difficulty falling asleep or staying asleep; sleep breathing problems, such as sleep apnea; nightmares; and daytime sleepiness – as a few examples.

Parents also answered questions at the beginning of the study about their family’s demographics, the child’s levels of anxiety and depressive symptoms, and factors such as family history of depression and the amount of conflict in the family. Children answered questions about parental monitoring, such as how much parents knew about their whereabouts and how often the family had dinner together.

At baseline and the two-year follow-up, the child and parent completed a detailed questionnaire about the child’s mental health that included questions about four levels of suicidal thoughts and behaviors, ranging from passive thoughts (thinking one would be better dead) to having made a suicide attempt. Because the study was intended to evaluate emerging suicidal ideation, the analysis did not include children who had suicidal thoughts or behaviors at baseline.

Nightmares raise risk

More than half of the children had minimal sleep disturbances when the study began. Two years in, 91% of children in the study had no suicidal thoughts or behaviors.

Children with high levels of sleep disturbance at baseline were 39% more likely than those with minimal sleep disturbance to have suicidal ideation or behavior two years later, and those with severe sleep disturbance were more than two and a half times as likely (268% more likely) to report suicidal thoughts or a suicide attempt by age 12. In total, nearly a third of children who had severe sleep disturbance at the start of the study had some level of suicidal thoughts or behavior two years later.

A child’s baseline levels of anxiety and depression, family history of depression, and family conflict all were linked to higher odds of suicidal thoughts and behavior at age 12. By comparison, more parental monitoring was protective and linked to lower odds of suicidal thoughts and behavior.

“Parentally set earlier bedtimes are helpful,” Bernert said, adding that the study suggests that other simple parenting practices – checking in regularly with your kids, knowing where they are, having regular family dinners – may offer meaningful benefits to children’s mental health.

The sleep problems with the strongest connection to suicide risk were nightmares, excessive daytime sleepiness, and difficulty falling asleep and maintaining sleep. Among these risk factors, nightmares stood out: Children with severe, daily nightmares at the start of the study were five times more likely to have suicidal thoughts or behaviors two years later.

“There’s a reason for this,” Bernert said. “One of the fundamental functions of REM sleep – or dreaming – has to do with emotion regulation and emotional information processing. Though occasional disturbing dreams or nightmares are normal and considered adaptive, nightmares that are intense, distressing, and highly repetitive may disrupt this processing. We also believe they can serve as a unique opportunity for intervention.”

The good news is that there are effective, medication-free treatments for insomnia and nightmares, Bernert said. For instance, “dream re-scripting” treatment (imagery rehearsal therapy) has been shown to be an effective treatment for nightmares. The treatment starts with sleep education – patients learn that we all have nightmares on occasion, and that frequent nightmares are a behavior we can un-learn. The clinician then engages the patient in guided imagery exercises to rescript the dream, by way of a better story or new ending for their dream. Likewise, insomnia is easily treatable among children and adolescents using a brief behavioral intervention (cognitive behavioral therapy for insomnia).

Better screening tools for pediatricians

In addition to forming the foundation for more research on the connections between sleep and suicide risk, Bernert hopes her team’s findings can help pediatricians look for early signs of mental health problems in their young patients. Simple tools already exist to help doctors and parents check for sleep problems in kids, she noted, such as a brief questionnaire that uses the acronym BEARS (for bedtime, excessive daytime sleepiness, awakening during the night, regularity and duration of sleep, and snoring) to remind people which facets of sleep disturbance to look for – and to prioritize for overall sleep health.

“Sleep problems are unique in terms of their visibility,” she said, noting the usefulness of a risk factor for mental health problems that lacks stigma compared with other known risk factors for suicide. “Sleep is visible to a parent, a loved one, or a pediatrician. A developing teen may be willing to speak about their sleep even if they are less comfortable speaking about their mood or depression. This makes sleep a potential gateway to treatment and overall well-being – while offering hope for prevention.”