UK Children’s Sleep and Anxiety During the COVID-19 Pandemic

doi:10.21203/rs.3.rs-418388/v1

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Research Article

UK Children’s Sleep and Anxiety During the COVID-19 Pandemic

https://doi.org/10.21203/rs.3.rs-418388/v1

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Background: Sleep and mental wellbeing are intimately linked. This relationship is particularly important to understand as it emerges over childhood. Here we take the opportunity that the COVID-19 pandemic, and resulting lockdown in the UK, presented to study sleep-related behaviour and anxiety in school-aged children.

Method: Parents and children were asked to complete questionnaires towards the start of the UK lockdown in April-to-May of 2020, then again in August of that year (when many of the restrictions had been lifted). We explored children’s emotional responses to the pandemic, daytime behaviours and sleep patterns at both time points, with responses from both parents and children themselves.

Results: Children’s bedtime anxiety increased at the start of the lockdown as compared to a typical week; however, by August, bedtime anxiety had decreased along with children’s COVID-19 related anxiety. Bedtime anxiety predicted how long it took children to fall asleep at night at both time points. Bedtime and wake-up time shifted at the onset of lockdown, but interestingly total sleep time was resilient (likely owing to an absence of early school start times) and was not predicted by child anxiety.

Conclusions: These findings further support calls for sleep quality (e.g., time taken to fall asleep) to be taken as a key indicator of mental health in children, particularly under normal circumstances when schools are open and sleep duration may be less resilient.

Psychology

Sleep

Anxiety

Childhood

COVID-19

Sleep is closely tied to mental health. Sleep-related problems are experienced by individuals with high levels of anxiety across the lifespan^1,2, and poor sleep impacts negatively on emotional regulation³. Here we aimed to better understand the relationship between anxiety and children’s sleep behaviour by examining how a potentially stressful environmental event (namely, the UK lockdown necessitated by the COVID-19 pandemic in 2020) influenced sleep behaviour and anxiety in children. Utilising parent- and child-reports, we ask if and how anxiety and sleep behaviour changed from the height of lockdown (in the Spring) to later in the year when many of the restrictions on social interaction and daily activities had been lifted. We further ask if any observed changes in these two key health-related variables were related.

1.1 Sleep and anxiety in childhood

A growing literature supports an association between anxiety and sleep-related problems in childhood^{see 4-6}. Across studies of children with clinical anxiety, sleep-related problems are reported in ~90% of cases ^7-13. In the community too, correlations are evident, with anxiety being related to bedtime resistance, fear of sleeping alone, fear of the dark and nightmares in 8-11 year olds¹⁴ and parent-reported anxiety/depression symptoms predicting daytime sleepiness¹⁵.

The relationship between sleep problems and anxiety is likely bidirectional^{see 16}. Not only is anxiety associated with pre-sleep rumination¹⁷, but sleep difficulties can also precede high anxiety. Kelly and El-Sheikh (2014)¹⁸ followed a community sample over five years (from mean age 8.68 years) and found that worse sleep quality and reduced sleep duration predicted greater anxiety over the course of the study, highlighting a role for sleep problems in escalating anxiety symptomology during the transition to adolescence. Sleep problems predict anxiety over time within childhood¹⁹, as well as being a risk factor for anxiety in adulthood²⁰.

1.2 COVID-19 in the UK

The coronavirus SAR-CoV-2, which causes the acute respiratory disease COVID-19, was first confirmed in the UK on 31st January, 2020. The disease was declared a pandemic by the World Health Organisation on 11th March, and national lockdown came into force in the UK on 26th March, with all schools, leisure establishments and non-essential shops closing, and strict regulations on social interaction and non-essential travel. The first wave of the virus peaked (with respect to reported daily deaths) in mid-April. Data collection for the current study occurred towards the start of the first national lockdown, when virus-related deaths in the first wave were at their highest (967 per day), then in August, by which time restrictions had been reduced and daily death rate had fallen to around 7 per day (according to the UK Government https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public). Data were not collected over subsequent waves of the virus.

1.3 Aims of the current study

We considered whether any changes in children’s anxiety levels over the course of the first wave of the COVID-19 pandemic in the UK were associated with any changes observed in sleep behaviour over the same period. This was a valuable opportunity to study sleep and anxiety during a time when there was relatively little daytime structure to constrain sleep patterns for children. Our research questions were: Did children’s sleep behaviour and/or anxiety change at the start of lockdown? Did anxiety and sleep change over the course of lockdown (i.e., from April-May to late August)? And finally, did anxiety predict sleep behaviour at the start and/or end of lockdown? To address these questions we invited parents and their children to complete online questionnaires at the start of lockdown (Phase 1) about current (and retrospective) sleep patterns, and anxiety, and again at the end of the summer (Phase 2).

2.1 Phase 1

Questionnaire data were collected via Qualtrics²⁶. Participants were recruited through social media, schools and academy trusts, the University of York staff newsletter, and by encouraging participants to share the questionnaire link. Phase 1 went live on 16^th April 2020, three and a half weeks after the start of the first UK COVID-19 lockdown, and was closed on 1^st June 2020. Phase 2 went live on 17th August 2020 and closed on 6th September 2020, the day before most schools re-opened after the summer (see Figure 1). The questionnaires took around 10 minutes to complete. At the end of the Phase 1 questionnaire participants were re-directed to an educational resource about sleep^b. Respondents who gave consent were entered into a prize draw to win one of five £60 Amazon vouchers, which were distributed after Phase 2 was completed. At both Phases, the first half of the questionnaire was for the parent/carer and the second was for the child (to be filled in on their own or with a caregiver). Full details of the questionnaires along with responses are provided in Additional File 1. Ethical approval was granted by the Department of Psychology University of York Ethics Committee.

2.1.1 Participants

At Phase 1, 302 parents/carers (henceforth ‘parents’) responded to at least the parent section of the questionnaire and gave an email address to be re-contacted at Phase 2; of these, 288 reported that they lived in the UK and were consequently including in the analysis. The following demographics were reported for children/young people (henceforth ‘children’)^c at Phase 1: 52.0% were male and 48.0% female; average age was 97.8 months (sd = 34.1 month; see Figure 2); 8.0% of the sample were reported to have one neurodevelopmental disorder (NDD) either diagnosed or under assessment, and 4.5% had two or more disorders (see Table A1 in Additional File 2 for details). Mean national indices of multiple deprivation (IMD) decile for families was 7.1 (sd = 2.6). IMD data were moderately negatively skewed (skewness = -0.76, kurtosis = 2.63), with the more of respondents living in high IMD areas. The mean number of people per bedroom (PPB) was 1.2 (sd = 0.4). PPB is a measure of overcrowding²⁷ and as such taken as an additional measure of economic prosperity. 15.8% of households included at least one healthcare worker. We asked respondents whether anyone in the household had experienced symptoms of COVID-19 (18.5% had) or had tested positive for/received a diagnosis of COVID-19 (1.3% had).

2.2 Phase two

188 respondents out of 288 filled in the second questionnaire, 179 of whom lived in the UK and were therefore included in the analysis: 48.6% of the children were male, 51.4% were female; average age 96.53 months (sd =29.82 month, see Figure 2); 11.17% had one or more NDD. The mean number of people per bedroom (PPB) was 0.92 (sd = 0.39; not significantly different to Phase 1, t = 1.030). 15.1% of households included at least one healthcare worker. 30.7% had someone in their household experience symptoms of COVID-19; 3.4% had tested positive for/received a diagnosis of COVID-19.

At Phase 2 (August, 2020), children and their parents were invited to fill out the second questionnaire. As detailed in Additional File 1, questions were repeated from Phase 1 where appropriate in order to assess changes between timepoints. In addition, parents were asked about changes they had noticed in their children over the course of lockdown.

3.1 Did children’s sleep behaviour and/or anxiety change at the start of lockdown?

3.1.1 Parent reported sleep

Parents were asked questions about their child’s sleep ‘during the past week (while schools were closed)’ and also ‘during a typical week (when schools were open)’ before the COVID-19 pandemic. Parents were asked What time does your child go to bed on weeknights? and What time does your child wake up on weekdays?. Options were given to the nearest hour as bedtimes are known to vary substantially²⁸ and parents are approximate in their estimates of their children’s sleep times even over the primary school years²⁹. Mean bed time became significantly later at the start of lockdown (mean = 8.37pm, sd = 66.6 mins) relative to a typical week of school (mean = 7.50pm, sd = 49.2 mins; t(529.8)= -9.675, p < 0.001) as did mean wake-up time (6.39am (sd = 35 mins) to 7.21am (sd = 50mins); t(409.83) = -8.755, p < 0.001) (Figure 3). However, total sleep time (TST), calculated to the nearest hour based on bed time and wake-up times, did not change: TST during a typical week was 10 hours 50 minutes (sd = 51.7 minutes), and during the surveyed lockdown week, 10 hours 43 minutes (sd = 61.2 minutes). Age in months predicted change in both bed time (B = -0.003, t = -2.13, p = 0.034) and wake-up time (B = -0.012, t = -6.57, p < 0.001), with younger children being less likely to show change in patterns of behaviour.

3.1.2 Parent reported anxiety

We explored parent-reported anxiety for both parents themselves and their children (see Table 1). A notable shift is evident in reported bedtime anxiety, with 61.8% of children being described as ‘not at all anxious’ at bedtime before the lockdown, dropping to 51.0% at the start of lockdown.

We considered whether the change in bedtime anxiety from before lockdown to the start of lockdown could be predicted by the child’s general anxiety level, the extent to which they had expressed worry about COVID-19 to their parents, days since lockdown began, the child’s age and whether anyone in the household had experienced symptoms at the time of parents’ responses. In an ordinal logistic regression, every step up in children’s expressed COVID-19 anxiety increased the proportional odds of them showing an increase in bedtime anxiety. Most notably, with a shift in a child’s COVID-19 related anxiety from ‘Quite a bit’ to ‘A lot’, children were 56.3 times more likely to show an increased level of bedtime anxiety (Table 2).

3.2 Did anxiety and sleep change over the course of lockdown?

3.2.1 Sleep

At Phase 2, mean bed time was 8.32pm (sd=64 minutes), and wake up time was 7.15am (sd = 66 minutes), with a mean TST of 10 hours 43 minutes (sd=60 minutes). Compared with the start of lockdown none of these values significantly changed (bed time t(355.62) = 0.957, p = 0.339; wake time t(353.9) = 0, p=1.000; TST t(355.79)=-1.016, p=0.310).

At both phases, parents were asked additional questions regarding their child’s sleep: How long do you think it takes your child to fall asleep after lights are turned out? (this question will hereafter be referred to as sleep onset latency; SOL); and Does your child seem sleepy during the day? (for responses see Figure 4). Finally, relating to sleep behaviour, parents were asked Are you currently worried about your child's sleep?: at Phase 1 39.2% reported yes, with the remaining 60.8% reporting no. At Phase 2, 38.0% reported that yes they were, with the remaining 62.0% reporting no.

No significant differences were evident from the start to the end of lockdown for daytime sleepiness (for n=179; Wilcoxon V = 1750.5, p=0.973) or whether parents were worried about their child’s sleep (Wilcoxon V = 644, p = 0.227) but a difference did emerge for SOL, for n=176, Wilcoxon V = 1418, p=0.024, with median response at both phases ‘10-30 minutes’ (option 3) but with a larger IQR at Phase 2 (IQR = 1 vs IQR = 1.5); as is evident in Figure 4, fewer parents reported that their children took ’30-60 minutes’ or ‘more than 60 minutes’ to fall asleep at Phase 2 compared to Phase 1.

Parents were asked if they felt their child’s sleep had changed during lockdown, 43.0% of respondents said ‘yes’, 25.7% ‘maybe’ and 31.3% ‘no’. Those parents who reported that ‘yes’ or ‘maybe’ their child’s sleep had changed (68.7% of the whole sample), were asked to select from one or more of seven possible reasons for that change: ‘Not tired in the evenings’ (35.0%); ‘Taking longer to fall asleep’ (66.7%); ‘Needing someone else in the room’ (30.1%); ‘Waking in the night’ (34.1%); ‘Nightmares/night terrors’ (22.0%); ‘Early morning waking’ (17.9%); ‘Daytime sleepiness’(18.7%); ‘Other’ (15.4%). Parents who said their child’s sleep changed over lockdown were then asked if their child’s sleep had returned to normal. Only 7.3% said ‘yes’, with 39.8% reporting ‘somewhat’ and 52.8% ‘no’.

Children themselves were asked if they would be happy to complete a few questions regarding their sleep and feelings about the pandemic. 13.2% did not consent to answer the questions and were consequently not asked to complete any. Where a percentage of ‘no response’ is given, this does not include those who opted to not respond to any questions in this section; rather, responses are detailed here for the 243 children who answered at least some questions. Children were asked questions about their sleep at both phases (Figure 5): At the moment, do you feel you get enough sleep? and At the moment, how sleepy do you feel during the day?, with responses to these questions strongly correlated, r_s=0.53, p<0.001; After your lights are turned off, do you spend a long time thinking or worrying about things? Children’s responses to whether they get enough sleep did not significantly change from Phase 1 to Phase 2, based on 137 respondents (Wilcoxon V = 1509.5, p = 0.968). For child-reported SOL, 134 respondents answered at both phases, over which time median response at Phase 2 = 3 (IQR = 1.5), at Phase 1 = 3 ‘I spend some time thinking’ (IQR=1, Wilcoxon’s V=1226.5, p=0.004). The correlation between child-reported enough sleep and daytime sleepiness was again significant, r_s=0.71, p<0.001.

Children were asked How many times do you think you wake up in the night? Mean response at Phase 2 (134 responses) was 1.37 (sd = 1.27), significantly less than at Phase 1, where mean = 1.63 (sd = 1.48), t(133) = -2.49, p = 0.014. Finally regarding wake after sleep onset, children were asked If you wake in the night does it take you a long time to get back to sleep?: again, this measure changed significantly from Phase 1 to Phase 2 for the 134 respondents who answered this question twice. At Phase 1 median response = “some time” (IQR = 3) to Phase 2 median response = ‘very little time’ (IQR = 2), Wilcoxon’s V = 1133.5, p=0.003.

3.2.2 Anxiety

At Phase 2, parents were asked about current bedtime anxiety and COVID-related anxiety in their child, as well as their own current COVID-19-related anxiety (Table 3). All three of these anxiety measures improved significantly from Phase 1 to Phase 2. Child bedtime anxiety improved from a median response ‘a little anxious’ (IQR = 2) to a median response ‘not at all anxious’ (IQR = 1; n = 179); Wilcoxon V = 821, p<0.001. Children’s anxiety about COVID-19 changed from a median response ‘a little anxiety’ (IQR = 1) to ‘no anxiety’ (IQR = 1), for 179 respondents, Wilcoxon’s V = 604, p < 0.001. Finally, parental anxiety about COVID-19 also decreased, from a median response ‘somewhat anxious’ (IQR = 2) to a median response ‘a little anxious’ (IQR = 2), for 179 respondents, Wilcoxon’s V=834, p<0.001.

Children were asked about anxiety: During the past week, did you feel scared or worried for no particular reason? and During the past week, did you worry about the virus?: see Table 5 for responses from those participants who responded on both occasions. General worry did not significantly change from Phase 1 to Phase 2 (Wilcoxon’s V = 1419, p=0.067), while COVID-19-specific worry did with median response at Phase 1 being I ‘sometimes’ worry, to I ‘rarely’ worry at Phase 2 (Phase 1 IQR=2, Phase 2 IQR=2): Wilcoxon’s V = 966, p<0.001 (see Table A2 in Additional File 2 for full breakdown of responses).

3.3 Did anxiety predict sleep behaviour at the start and/or end of lockdown?

3.3.1 Phase 1

We asked whether children’s TST or SOL, as reported by their parents, could be predicted by children’s anxiety levels at bedtime, along with household symptoms, age, PPB and whether the child had been diagnosed with or been referred for an NDD. Table 3 gives the results of ordinal logistic regressions, suggesting that bedtime anxiety is the best predictor of SOL during lockdown, with every step up in children’s bedtime anxiety increasing the proportional odds of it taking longer for them to fall asleep after lights out (Figure 6). Conversely, age was the most reliable predictor of TST.

As the relationships between parent-reported child anxiety and sleep were strong, we assessed the relationships between worry and sleep parameters as reported by children themselves at Phase 1 (Table 4). The correlation between worry about the virus and child-reported sleep onset latency was particularly strong, similar to the parent-reported data.

3.3.2 Phase 2

To establish whether anxiety at Phase 2 continued to predict children’s sleep parameters, we ran a second regression model predicting parent-reported SOL and TST at Phase 2, with child bedtime anxiety, and child anxiety about COVID-19 at Phase 2, along with whether the household reported symptoms at Phase 2, whether the child had a NDD, PPB and child age at Phase 2 as predictors (see Table 5). Bedtime anxiety remained the only predictor of SOL at Phase 2, as it was at Phase 1, although odds ratios were lower. For TST, age remained a significant predictor, along with a shift in bedtime anxiety from ‘somewhat anxious’ to ‘anxious’, which was associated with shorter TST.

Given the established links between anxiety and sleep behaviour in children, the aim of the current paper was to present a broad picture of sleep and anxiety in UK children over the COVID-19 lockdown. We asked whether children’s sleep behaviour and/or anxiety changed at the start of lockdown, and then changed over the course of lockdown; and whether anxiety predicted sleep behaviour in lockdown.

4.1 Summary of findings

In the present sample of UK children, parents reported that sleep and anxiety changed at the start of lockdown compared to a typical school week. Mean reported bed time became significantly later during the surveyed week at the start of lockdown relative to a typical week of school (by a mean of 47 minutes) as did mean wake up time (by a mean of 42 minutes), though total sleep time did not change. We also saw a notable shift in bedtime anxiety, with 10.8% fewer children being rated as ‘not at all’ anxious at bedtime at the start of lockdown compared to a typical week. This change in bedtime anxiety was predicted by anxiety expressed about COVID-19, but not by parental-rated general anxiety.

According to parent-report, children’s bedtime anxiety improved over the course of lockdown. COVID-19-related anxiety also improved in children according to both parent and self-report. However, no significant shifts were seen from the start of lockdown to the end in bed time, wake-up time, total sleep time, daytime sleepiness or whether parents are worried about their child’s sleep. The only sleep parameters that changed over this period were parent-reported and self-reported sleep onset latency, with fewer parents reporting that their children took ’30-60 minutes’ or ‘more than 60 minutes’ to fall asleep at Phase 2 compared to Phase 1, and fewer children reporting that they ‘spend ages thinking’. Children also reported fewer night time awakenings and taking less time to get back to sleep after waking in the night. 68.7% of parents responding at Phase 2 reported that their child’s sleep had or maybe had changed during lockdown, with the most popular responses as to why being ‘taking longer to fall asleep’ ‘not tired in the evening’, ‘waking in the night’ and ‘needing someone in the room to fall asleep’. When asked if their child’s sleep had returned to normal, only 7.3% said ‘yes’.

Bedtime anxiety predicted sleep onset latency at both Phase 1 and Phase 2. Interestingly however, bedtime anxiety did not predict total sleep time, suggesting that with no school to attend, children were able to make up for later nights by sleeping in longer in the morning.

4.2 Anxiety and sleep behaviour in children

Our data suggest that anxiety relating to COVID-19 was associated with UK children’s sleep-related behaviour. Sleep onset latency, which was predicted by bedtime anxiety, improved over lockdown, though parents still perceived sleep-related problems, possibly reflecting parameters more associated with change in routine (e.g., the time at which children went to bed) or possibly to other signs of lingering anxiety (e.g., needing someone to stay in the room while falling asleep).

It is notable that total sleep time was not influenced by bedtime anxiety in these data and was not observed to change over lockdown owing to children waking up later in the morning. A lack of change in total sleep time through COVID-19 lockdown has been demonstrated elsewhere with an adolescent sample. Gruber et al (2020)³⁰ conducted semi-structured phone interviews with adolescents in Canada and showed a two-hour shift in sleep patterns but with no disruption to sleep duration, indeed they demonstrated longer sleep duration and better sleep quality. This resilience of total sleep time is encouraging in the light of evidence to suggest that sleep plays a protective role against the impact of negative emotional experiences^{31, see3}.

If heightened anxiety is experienced during the normal school term, time asleep could be diminished by increased sleep onset latency. So while extant evidence suggests that the causal links between sleep and anxiety are bi-directional, our data suggest that this may only be true in circumstances where there is no potential for the adjustment of daytime schedules. Furthermore, under circumstances where children and young people were able to adjust their daytime schedules, those who experience anxiety should see the biggest gains with respect to sleep duration.

4.3 Limitations

This study set out to capture a broad picture of correlations between sleep and anxiety in children in the UK over the COVID-19 lockdown, and as such we acknowledge that the measures of sleep, anxiety and daytime behaviours were approximate and subjective. Accurate subjective, parent-reported measures of sleep, especially sleep after lights out, are difficult to obtain with a broad age range of children and young people. We therefore opted to leave the wording of the questionnaire vague (e.g., what time does your child go to bed?) and consider responses as approximations. While it is possible that that objective measures would have resulted in even stronger correlational relationships, subjective measurements can sometimes be more revealing than objective measures. For example, self-reported sleepiness has been shown to be a stronger predictor of school performance than sleep duration in children and adolescents³². Other difficulties include the relatively high SES of the sample, and its self-selecting nature, especially at Phase 2.

While we were not able to consider the internal reliability of our questionnaire (in the interests of brevity), we do see indications of reliability with strong correlations between responses at Phase 1 and Phase 2 (see Table A3 in Additional File 2), and strong correlations between self-reported daytime sleepiness and whether children felt they were getting enough sleep at both Phase 1 and Phase 2.

Finally, numerous other variables may well have influenced both sleep and anxiety over the manipulation period, including seasonal effects and economic factors, especially the latter given that a recession was declared in the UK on 12th August, shortly before phase two of the study went live (ONS, 2020); family stress may have been easing with respect to infection rate at the same time as increasing as a result of financial pressure and looming economic crisis.

4.4 Summary & conclusions

The COVID-19 pandemic provided an opportunity to study the correlative relationship between children’s anxiety and sleep behaviour. Here we have seen that bedtime anxiety initially increased at the start of lockdown, then decreased along with COVID-19-related anxiety, and that bedtime anxiety predicted how long it took children to fall asleep at night. Total sleep time was notably resilient in the face of heightened anxiety in children. Change in certain aspects of sleep behaviour as estimated by both parents and self-report may be a useful marker of the stress status of children in response to health crisis. Our data suggest that sleep onset latency might be a useful marker, while total sleep time would not. A key message from the Sleep Council and the Sleep Charity’s Sleep Manifesto (www.sleepcouncil.org.uk) is that sleep quality should be taken as a key indicator of health and wellbeing; checking in with children as to how they are sleeping could provide a window into their mental health.

Ethics approval and consent to participate:

Approval for this work was granted by the Department of Psychology Research Ethics Committee at the University of York (ID:851). All parents completed an informed, online consent form for both themselves and their child; children were also asked for online assent before any questions were asked of them. This research was conducted in accordance with the Declaration of Helsinki and is compliant with the General Data Protection Regulation and Data Protection Act (2018), as set out by the University of York, here: https://www.york.ac.uk/records-management/dp/guidance/gdprcompliantresearch/

Consent for publication:

N/A (no individual participants are identified in this manuscript).

Availability of data and materials:

The dataset supporting the conclusions of this article is included within the article and its Additional Files.

Competing interests:

None.

Funding:

This work was funded by ESRC grant ref ES/N009924/1 awarded to Dr Lisa Henderson & Professor Gareth Gaskell, and an internal grant from the University of York.

Authors' contributions:

VK designed the study, analysed the data, prepared the figures and wrote the manuscript; EvR designed the study, edited the manuscript and approved the final version; GG designed the study, edited the manuscript and approved the final version; LH designed the study, edited the manuscript and approved the final version.

Acknowledgements:

The authors would like to thank all families who so generously gave their time to fill out the questionnaires.

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Table 1

Responses to questions regarding anxiety. Note that exact responses were worded in a way that was appropriate to the question – see the dataset in Additional File 1 for exact wording. Responses at Phase 2 are shown (in italics).

	Question	% ‘Not at all anxious’	% ‘A little anxious’	% ‘Somewhat anxious’	% ‘Anxious’	% ‘Very anxious’
CHILD	Would you typically describe your child as anxious (before Covid-19)?	35.8	38.5	16.3	7.3	2.1
	Did your child get anxious about going to bed before Covid-19?	61.8	27.1	8.0	2.1	1.0
	Does your child get anxious before going to bed at the moment?	51.0 (59.2)	22.6 (21.2)	9.0 (11.7)	11.1 (5.6)	6.3 (2.2)
	Has your child expressed anxiety about Covid-19?	24.7 (57.0)	36.1 (29.1)	27.7 (7.3)	8.3 (5.6)	4.2 (1.1)
PARENT	Are you typically an anxious person (before Covid-19)?	28.1	35.1	17.7	14.2	4.9
PARENT	Do you feel anxious about Covid-19?	6.3 (27.4)	32.6 (44.7)	35.1 (17.3)	16.7 (6.7)	9.4 (3.9)

Table 2

Proportional odds ratios with 97.5% CIs for changes in bedtime anxiety predicted by change in general (parent reported) child anxiety, expressed anxiety about covid, time since lockdown in days, child age in months and whether someone in the household has symptoms of the virus (yes or no). * = significant at p < 0.05, *** = significant at p< 0.001.

	Term	OR	Lower 97.5% CI	Upper 97.5% CI	p
Would you typically describe your child as anxious (before Covid-19)?	Not at all anxious -> A little anxious	0.94	0.52	1.71	0.846
	A little anxious -> Somewhat anxious	0.80	0.36	1.76	0.575
	Somewhat anxious -> Anxious	1.15	0.41	3.14	0.794
	Anxious -> Very anxious	0.05	0.00	0.54	0.017*
Has your child expressed anxiety about COVID-19?	No anxiety -> A little anxiety	1.53	0.74	3.23	0.258
	A little anxiety -> Some anxiety	5.93	2.76	13.24	<0.001***
	Some anxiety -> Quite a bit of anxiety	10.60	3.69	30.87	<0.001***
	Quite a bit of anxiety -> A lot of anxiety	56.30	14.59	233.99	<0.001***
	Days since lockdown	1.02	1.00	1.03	0.078
	Age in months	1.00	0.99	1.01	0.588
	Household symptoms	0.70	0.35	1.36	0.300

Table 3

Ordinal logistic regression model predicting parent-reported Total Sleep Time (TST) and Sleep Onset Latency (SOL) at Phase 1 for 288 children

		TST Phase 1				SOL Phase 1
		OR	2.5	97.5	p	OR	2.5	97.5	p
Does your child get anxious before going to bed at the moment?	Not at all -> A little	0.63	0.36	1.11	0.107	2.39	1.39	4.14	0.002**
	A little -> Somewhat	0.97	0.41	2.28	0.944	6.24	2.79	14.25	<0.001***
	Somewhat -> Anxious	0.58	0.27	1.27	0.174	3.49	1.53	8.01	0.003**
	Anxious -> Very	1.25	0.46	3.43	0.656	4.93	1.73	14.21	0.003**
Has your child expressed anxiety about Covid-19?	No -> A little	0.89	0.50	1.57	0.689	1.39	0.79	2.46	0.254
	A little -> Some	1.08	0.57	2.04	0.810	1.30	0.69	2.45	0.420
	Some -> Quite a bit	1.76	0.67	4.61	0.248	2.46	0.94	6.48	0.067
	Quite a bit -> A lot	0.26	0.07	0.93	0.037*	2.29	0.63	8.41	0.208
	Household symptoms	1.48	0.85	2.58	0.169	0.98	0.56	1.71	0.931
	Days since lockdown	1.00	0.98	1.01	0.562	1.01	0.99	1.02	0.472
	Age in months	0.99	0.98	1.00	0.010*	1.01	1.00	1.01	0.073
	PPB	0.70	0.34	1.44	0.329	0.78	0.43	1.42	0.413
	NDD	0.55	0.28	1.08	0.083	1.05	0.53	2.09	0.884

Table 4

Spearman’s Rho correlations between questions regarding sleep behaviour and worry answered by children at Phase 1. n=243.

Sleep onset latency

Daytime sleepiness

Nightwakings

SOL after nightwaking

During the past week, did you feel scared or worried for no particular reason?

r_s = .37

p < 0.001

r_s = .30

p < 0.001

r_s = .35

p < 0.001

r_s = .32

p < 0.001

During the past week, did you worry about the virus?

r_s = .33

p < 0.001

r_s = .18

p = 0.007

r_s = .26

p < 0.001

r_s = .24

p < 0.001

Table 5

Ordinal logistic regression model predicting parent-reported Total Sleep Time (TST) and Sleep Onset Latency (SOL) at Phase 2 for 179 children.

		TST Phase 2				SOL_Phase 2
		OR	Lower 97.5%CI	Upper 97.5%CI	p	OR	Lower 97.5%CI	Upper 97.5%CI	p
Does your child get anxious before going to bed at the moment?	Not at all -> A little	0.84	0.40	1.75	0.649	2.27	1.12	4.62	0.023*
	A little -> Somewhat	0.69	0.23	2.01	0.499	4.26	1.61	11.62	0.004**
	Somewhat -> Anxious	0.08	0.01	0.37	0.002**	4.57	1.10	19.27	0.035*
	Anxious -> Very	0.35	0.04	2.42	0.297	2.30	0.35	15.70	0.381
Has your child expressed anxiety about Covid-19?	No -> A little	0.64	0.33	1.24	0.188	1.33	0.71	2.50	0.381
	A little -> Some	2.08	0.54	7.83	0.282	1.28	0.40	4.04	0.669
	Some -> Quite a bit	1.12	0.25	4.92	0.878	1.86	0.44	7.70	0.389
	Quite a bit -> A lot	8.58	0.52	244.37	0.138	0.49	0.02	11.40	0.632
	Household symptoms	0.97	0.52	1.79	0.918	0.92	0.50	1.67	0.776
	Age in months	0.99	0.98	1.00	0.003**	1.00	0.99	1.01	0.796
	PPB	0.77	0.29	2.04	0.598	1.14	0.44	2.97	0.780
	NDD	2.69	0.99	7.22	0.050*	2.26	0.84	6.07	0.102

No competing interests reported.

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UK Children’s Sleep and Anxiety During the COVID-19 Pandemic

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Abstract

Figures

1.0 Introduction

1.1 Sleep and anxiety in childhood

1.2 COVID-19 in the UK

1.3 Aims of the current study

2.0 Method

2.1 Phase 1

2.1.1 Participants

2.2 Phase two

3.0 Results

3.1 Did children’s sleep behaviour and/or anxiety change at the start of lockdown?

3.1.1 Parent reported sleep

3.1.2 Parent reported anxiety

3.2 Did anxiety and sleep change over the course of lockdown?

3.2.1 Sleep

3.2.2 Anxiety

3.3 Did anxiety predict sleep behaviour at the start and/or end of lockdown?

3.3.1 Phase 1

3.3.2 Phase 2

4.0 Discussion

4.1 Summary of findings

4.2 Anxiety and sleep behaviour in children

4.3 Limitations

4.4 Summary & conclusions

Declarations

Ethics approval and consent to participate:

Consent for publication:

Availability of data and materials:

Competing interests:

Funding:

Authors' contributions:

Acknowledgements:

References

Tables

Competing Interests

Supplementary Files

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