Understanding the Relationship Between Sleep Problems in Early Childhood and Borderline Personality Disorder: A Narrative Review

Figures & data

Figure 1 Flowchart outlining the search and selection strategy. This figure describes the search and selection for strategy for the studies included in this narrative review. Initially, 4359 studies were identified through database searching; then, 3543 studies out of them were screened for titles and abstracts; and out of these 3543 studies, 160 full-text articles were assessed for eligibility. Finally, 96 studies were included in this narrative review.

Table 1 Description of the Studies Included in the Narrative Review

	Study Design	N	Age/Age Grouping	Sleep Measure		Main Findings
				Objective	Subjective
Sleep and HPA
El-Sheikh et al (2008)^Citation13	Cross-sectional	64	Mean=8.75 years Age grouping: childhood.	Actigraphy: total sleep minutes, sleep efficiency, minutes awake after sleep onset, and sleep activity	The Sleep Habits Survey: sleepiness and sleep/wake problems.	Cortisol measure: children came to the laboratory to provide saliva samples, which were used to assess cortisol. There was a significant relationship between higher levels of cortisol and increased subjective sleep problems, poorer sleep quality and shorter sleep duration.
Fernandez-Mendoza et al (2014)^Citation15	Cross-sectional	327	Range=5–12 years Age grouping: childhood.	Polysomnography: sleep duration	Pediatric Behavior Scale: insomnia symptoms of difficulty initiating and/or maintaining sleep.	Cortisol measure: children provided evening and morning saliva samples to assay for cortisol. There was a significant association between parent-reported insomnia symptoms with objective sleep duration and higher cortisol levels in the evening and morning.
Hatzinger et al (2008)^Citation17	Cross-sectional	67	Mean=4.91 years Age grouping: childhood.	Polysomnography: REM sleep time, number of awakenings after sleep onset, and sleep efficiency	N/A	Cortisol measure: for baseline HPA-activity assessment, saliva samples were collected immediately after awakening, whereas saliva samples before, while and after a psychological challenge were used to assess the HPA-activity under stress conditions. “Poor” sleepers showed significantly increased morning cortisol levels. An elevated number of awakenings after sleep onset were significantly associated with increased cortisol levels under stress conditions.
Hatzinger et al (2010)^Citation18	Cross-sectional	82	Mean=4.91 years Age grouping: childhood.	Actigraphy: sleep onset latency, awakening time, number and times of awakenings after sleep onset, sleep period time and sleep efficiency	Daily log of their child’s sleep: bedtime, wake-up time, sleep duration, awakenings.	Cortisol measure: on the first and on the last morning of sleep registration, the activity of the HPA axis was assessed via the amount of cortisol in the saliva. Children who have poor sleep patterns with high HPA activity showed extended sleep onset latency and sleep efficiency.
Kiel et al (2015)^Citation20	Longitudinal	51	Mean=18.96 months Age grouping: toddlers.	N/A	Infant-Toddler Social and Emotional Assessment: Sleep scale (5 items).	Cortisol measure: Mothers were trained by laboratory staff to gather saliva from their toddlers using a cotton dental roll. High morning levels of cortisol predicted increasing sleep problems from age 2 to age 3.
LaVoy et al (2020)^Citation10	Cross-sectional	55	Range=8–16 years Age grouping: adolescence.	Actigraphy: minutes awake, sleep efficiency, sleep duration, sleep onset latency and night awakenings	Sleep diaries, The School Habits Survey; sleep duration, night awakenings, wake-up and bedtime, sleepiness and sleep/wake behaviour problems.	Cortisol measure: participants donated first waking saliva samples, which were later assayed for α-amylase (sAA), cortisol, interleukin (IL)-6, and IL-1β. Morning cortisol levels were associated with objective sleep variables such as sleep efficiency, minutes spent awake the night before and night awakening the night after.
Lemola et al (2015)^Citation12	Cross-sectional	113	Mean=8.3 years Age grouping: childhood.	Sleep-electroencephalography: sleep duration, sleep continuity, and sleep architecture.	N/A	Cortisol measure: The parents of the children were instructed to collect four saliva samples on the following morning, with the first one after awakening and 10, 20, and 30 minutes later. Cortisol secretion was negatively associated with sleep duration in school age children and slow wave sleep and positively associated with the stage 2 sleep during the preceding night.
Pesonen et al (2012)^Citation14	Cross-sectional	248	Mean=8.1 years Age grouping: childhood.	Actigraphy: sleep duration.	Sleep Disturbance Scale for Children: sleep-wake transition, arousal, excessive daytime somnolence, sleep hyperhidrosis.	Cortisol measure: salivary cortisol was sampled throughout one day at home and during the Trier Social Stress Test for Children (TSST-C) in clinic. Boys with parent-reported sleep problems had lower levels of diurnal salivary cortisol levels. Girls with sleep problems had unaltered diurnal salivary cortisol.
Pesonen et al (2014)^Citation9	Longitudinal	305	Mean=123 years Age grouping= Adolescence	Actigraphy: sleep duration, awakening times, temporary pauses in actigraph registration, sleep quality or quantity.	N/A	Cortisol measure: Saliva was obtained during a 2-day period at awakening and 15, 30, 45, 60 minutes after awakening, at 12:00, at 17:00 and at bedtime. Long sleep duration in boys associated with higher cortisol awakening response (CAR). Lower sleep quality in boys was associated with lower CAR. In girls, no significant associations were found.
Räikkönen et al (2010)^Citation11	Cross-sectional	282	Age=8 years Age grouping: childhood.	Actigraphy: sleep duration and efficiency	Sleep log: bed and awakening times.	Cortisol measure: diurnal salivary cortisol and salivary cortisol and α-amylase (a sympatho-adrenal-medullary system marker) responses to the Trier Social Stress Test for Children (TSST-C) were measured. Children with short average sleep duration displayed higher salivary cortisol awakening response. Children with low sleep efficiency displayed higher diurnal cortisol levels.
Saridjan et al (2017)^Citation19	Longitudinal	322	Range=12–20 months Age grouping: infancy/toddlers.	N/A	Parental report, Child Behavior Checklist: Sleep duration and sleep behaviour.	Cortisol measure: the diurnal cortisol rhythm was determined by calculating the area under the curve (AUC), the cortisol awakening response (CAR), and the diurnal slope. Infants with a flatter cortisol slope and those with a more marked morning cortisol rise had shorter nighttime sleep duration.
Zeiders et al (2011)^Citation8	Cross-sectional	119	Mean=19.01 years Age grouping: young adults.	Actigraphy: hours of sleep and wake times	Sleep diary: hours of sleep and wake times.	Cortisol measure: participants provided six cortisol samples (wake-up, +30 minutes, +2 hours, +8 hours, +12 hours, and bedtime) on each of three consecutive days while wearing an actigraph. The hours of sleep of the previous night predicted steeper diurnal slopes the next day. Greater waking cortisol levels and steeper slopes predicted more hours of sleep and a later wake time the next day.
Sleep and Prefrontal Cortex
Cheng et al (2020)^Citation27	Cross-sectional	11,067	Range=9–11 years Age grouping: childhood.	N/A	Parent Sleep Disturbance Scale for Children: sleep duration.	Higher volume in orbitofrontal cortex, prefrontal and temporal cortex, precuneus and supramarginal gyrus was correlated with longer sleep duration.
Kocevska et al (2017)^Citation31	Longitudinal	720	From 2 months old until 7 years. Age grouping: From toddlerhood until childhood	N/A	Parental reports of postal questionnaires, parental reports of the Child Behavior Checklist: sleep disturbance.	Sleep disturbances from age 2 onwards were associated with smaller grey matter volumes and thinner dorsolateral prefrontal cortex.
Lunsford-Avery et al (2020)^Citation26	Cross-sectional	25	Mean=18.08 years Age grouping: young adults.	Actigraphy: Sleep regularity	N/A	Irregular sleep patterns were significantly associated with increased path length within the default mode network, specifically in the right and left lateral parietal lobule.
Reidy et al (2016)^Citation30	Cross-sectional	15	Range=7–11 years Age grouping: childhood.	N/A	Parental report of child’s sleep duration.	Sleep duration linked positively to amygdala-prefrontal functional connectivity.
Telzer et al (2013)^Citation29	Cross-sectional	46	Mean=15.23 Age grouping: Adolescence.	N/A	Pittsburgh Sleep Quality Index: poor sleep quality.	Adolescents showed less dorsolateral prefrontal cortex (DLPFC) activation during cognitive control, greater insula activation during reward processing, and reduced functional coupling between the DLPFC and affective regions.
Urrila et al (2017)^Citation28	Cross-sectional	177	Mean=14.4 years Age grouping: adolescence.	fMRI	Adolescents report on habitual bedtimes and wake-up times.	The medial prefrontal cortex was significantly associated both with bedtime and wake-up times during weekends, also with poor school performance.
Sleep and Family Psychopathology
Bat-Pitault et al (2017)^Citation48	Cross-sectional	64	Age=<37 weeks Age grouping: infancy.	Polysomnography: Sleep macro-structural parameters	N/A	Maternal psychopathology measurement: being born to mothers diagnosed with depression. Altered sleep structure was observed during the first months of life in infants born from depressed mothers.
Dennis & Ross (2005)^Citation39	Longitudinal	505	Age= Newborns Age grouping: infancy.	N/A	Maternal report of infant’s sleep patterns: number of night awakenings, sleep duration, sleep quality, and enough sleep.	Maternal psychopathology measurement: Edinburgh Postnatal Depression Scale. Infant sleep patterns and maternal fatigue were strongly associated with a new set of depressive symptoms in the postpartum period.
Dias & Figueiredo (2020)^Citation38	Longitudinal	164	Age= Newborns Age grouping: infancy.	N/A	Children’s Sleep Habits Questionnaire: sleep anxiety, daytime sleepiness and bedtime resistance.	Maternal psychopathology measurement: Edinburgh Postnatal Depression Scale. Both mother’s prenatal and postpartum depression symptoms predicted infant’s sleep difficulties.
Field et al (2007)^Citation35	Longitudinal	253	Age= Newborns Age grouping: infancy.	N/A	Sleep scale: quiet sleep (no REM), active sleep (without REM), REM sleep, drowsy, inactive alert, active awake, crying, indeterminate sleep.	Maternal psychopathology measurement: SCID diagnosis of depression, and self-report measures on depression, anxiety and anger. The infants of the depressed mothers had more sleep difficulties such as less time in deep sleep and more time in disorganised sleep.
Gregory et al (2005)^Citation46	Cross-sectional	6612	Range=3–4 years Age grouping: childhood.	N/A	Parental report: hard to go to sleep, frequent awakenings, nightmares, and early waking.	Family psychopathology measurement: parent-report of family disorganization and depression. Maternal depression and family disorganization were associated with sleep problems and anxiety in twins.
Halal et al (2021)^Citation36	Longitudinal	2222	Age=Newborns Age grouping: infancy.	Actigraphy: sleep duration, night awakenings and sleep efficiency.	Brief Infant Sleep Questionnaire: sleep duration and night awakenings.	Maternal psychopathology measurement: Edinburgh Postnatal Depression Scale. Prenatal maternal depression predicted more sleep problems in newborns.
Hiscock & Wake (2001)^Citation41	Cross-sectional	738	Range=6–12 months Age grouping: infancy.	N/A	Maternal report: infant sleeping in the parent’s bed, being nursed to sleep, time to fall asleep, night awakenings, and naps duration.	Maternal psychopathology measurement: Edinburgh Postnatal Depression Scale. Infant sleep problems were associated with maternal postnatal depression scores.
Martin et al (2007)^Citation49	Cross-sectional	5107 infants 4983 pre-school	Range= Newborns and 4–5 years Age grouping: infancy and children.	N/A	Maternal report: whether their child’s sleep was a problem (no, mild, moderate or severe problem).	Parents psychopathology measurement: the Kessler-6. Preschool sleep problems were associated with poor maternal general health.
Morales-Munoz et al (2018)^Citation52	Longitudinal	1221	Age= Newborns Age grouping: infancy.	N/A	The Brief Infant Sleep Questionnaire: number of nocturnal sleep hours; number of daytime sleep hours; total number of sleep hours per day; and method for falling asleep.	Maternal psychopathology measurement: The Alcohol Use Disorders Identification Test, The Global Seasonality Score, The List of Threatening Experiences, The State-Trait Anxiety Inventory, The Center for Epidemiological Studies Depression Scale and The Adult ADHD Self-Report Scale. Several maternal risk factors, including anxiety, depression, insomnia or ADHD during pregnancy were related to sleep difficulties.
O’Connor et al (2007)^Citation37	Longitudinal	11,490	Age= Newborns Age grouping: infancy.	N/A	Parental report: amount of sleep, frequency of awakening, child regularly refuses to go to bed, wakes very early, difficulty going to sleep, nightmares, get up after being put to bed, woke in the night, or got up after few hours sleep.	Maternal psychopathology measurement: Crown-Crisp experiential index and the Edinburgh Postnatal Depression Scale. Higher levels of prenatal maternal depression and anxiety predicted more sleep difficulties at 18 and 30 months.
Petzoldt et al (2016)^Citation44	Longitudinal	286	Age= Newborns Age grouping: infancy.	N/A	Baby-DIPS: sleeping problems.	Maternal psychopathology measurement: Composite International Diagnostic Interview for Women (CIDI-V) to assess DSM-IV anxiety and depressive disorders. Infant sleeping difficulties were associated with maternal depressive and comorbid anxiety disorders irrespective of maternal parity.
Reid et al (2009)^Citation45	Cross-sectional	8868	Range=2–3 years Age grouping: toddlers.	N/A	Parental report: trouble falling asleep, particular and long bedtime routine, and waking up several times at night.	Maternal psychopathology measurement: 12-item short-form of the Center for Epidemiologic Studies – depression scale. Maternal symptoms of anxiety and depression during the first year of the child’s life were both associated with child nocturnal awakening at 6 and 18 months.
Schuetze et al (2006)^Citation51	Longitudinal	118	Age= Newborns Age grouping: infancy.	N/A	The Maternal Cognitions About Infant Sleep: five subscales on Limit Setting, Anger, Doubt, Feeding, and Safety.	Maternal psychopathology measurement: The Brief Symptom Inventory. Prenatal exposure to cocaine was significantly associated with more severe sleep difficulties in newborns and maternal anxiety mediated the association.
Seifer et al (1996)^Citation53	Longitudinal	182	Age grouping: toddlers.	N/A	The Sleep Habits Questionnaire: total sleep time, bedtime struggles, sleep behavior, night waking, morning waking, and daytime sleepiness.	Maternal psychopathology measurement: maternal diagnostic classification. Poorly functioning families had children whose sleep habits were less optimal.
Shang et al (2006)^Citation47	Cross-sectional	1391	Range=4–9 years Age grouping: childhood.	N/A	The Sleep Habit Questionnaire: early insomnia, late sleep, night wakening, sleep talking, sleepwalking, nightmare, enuresis, bruxism and snoring.	Maternal psychopathology measurement: The Chinese Health Questionnaire. Parental distress, including maternal depression, was significantly associated with children’s sleep problems.
Stoléru et al (1997)^Citation42	Longitudinal	85	Range=1–12 years Age grouping: infancy, toddlers, childhood, early adolescence.	N/A	The Child Behavior Checklist: sleep problems.	Maternal psychopathology measurement: diagnosis of unipolar and bipolar affective illness. Sleep problems were more frequent and severe in children of affectively ill mothers.
Warren et al (2003)^Citation50	Cross-sectional	94	Age= Newborns Age grouping: infancy.	Videotaping	The Sleep Habits Questionnaire, Sleep logs: early insomnia, late sleep, night wakening, sleep duration.	Maternal psychopathology measurement: diagnosis of panic disorder. Infants from the 4-month cohort with panic disorder mothers had more awakenings and greater time awake during the night at 8 months.
Ystrom et al (2017)^Citation43	Longitudinal	14,926	Age= Newborns Age grouping: infancy.	N/A	Parental report: nocturnal awakenings.	Maternal psychopathology measurement: Hopkins Symptom Checklist (SCL-8). Maternal symptoms of anxiety and depression in infants were both associated with child nocturnal awakening at 6 and 18 months.
Sleep and Disrupted Attachment
Belanger et al (2018)^Citation57	Longitudinal	64	Mean=25.35 months Age grouping: toddlers.	Actigraphy: sleep duration, sleep efficiency.	Sleep diaries, Child Behavior Checklist: sleep duration, sleep efficiency, sleep difficulties.	Securely attached children subsequently slept more at night and had higher sleep efficiency.
Beijers et al (2011)^Citation60	Longitudinal	193	Age= Newborns Age grouping: infancy.	N/A	Sleep diaries: night awakenings.	Infants with an insecure-resistant attachment style at 12 months of age woke up more during the night in their first 6 months of life than the other infants.
Bilgin & Wolke (2020)^Citation63	Longitudinal	105	Age= Newborns Age grouping: infancy.	N/A	Maternal report: symptoms of sleeping problems.	Sleep problems in infants at 3 months were associated with disorganized attachment with the mother at 18 months.
McNamara et al (2003)^Citation62	Longitudinal	342	Age= Newborns Age grouping: infancy.	N/A	Maternal report: sleep problems.	Infants with insecure-resistant attachments had greater numbers of night wakings and longer mean durations of night waking episodes than infants with insecure-avoidant attachment style.
Pennestri et al (2015)^Citation58	Longitudinal	134	Age= Newborns Age grouping: infancy.	N/A	Maternal report: duration of sleep, bedtime, awakenings, and periods of time in bed.	Infants with disorganised attachment had more sleep difficulties than infants with secure or ambivalent attachment style.
Simard et al (2013)^Citation59	Longitudinal	55	Age=18 months Age grouping: toddlers.	Actigraphy	Sleep diaries: sleep efficiency, wake duration at night, sleep duration.	Higher resistance attachment behavior predicted longer wake duration at night in children.
Zentall et al (2012)^Citation61	Longitudinal	46	Age= Newborns Age grouping: infancy.	N/A	Parent reported night waking.	Infants with a secure pattern of attachment with mothers had lower number of night wakings over time.
Sleep and Childhood Maltreatment
April-Sanders et al (2021)^Citation74	Longitudinal	2491	Range=5–9 and 10–16 years Age grouping: childhood and adolescence.	N/A	Parent and youth report; prevalence of sleep disturbances.	Childhood adversity was associated with sleep disturbances in youth of 10–16 years of age, but not in 5–9 years of olds.
Glod et al (1997)^Citation71	Cross-sectional	44	Range=6–12 years Age grouping: childhood and early adolescence.	Actigraphy: nocturnal activity and algorithmic estimation of sleep initiation and continuity.	N/A	Abused children were twice as active at night as normal and depressed children.
Hamilton et al (2018)^Citation66	Cross-sectional	102	Range=18–22 years Age grouping: young adulthood.	N/A	Sleep diary: sleep duration and insomnia symptoms.	Only childhood emotional neglect significantly predicted higher levels of insomnia symptoms.
Kaubrys et al (2021)^Citation67	Cross-sectional	181	Age grouping: college students.	N/A	Self-reports on sleep: sleep efficiency, sleep duration, sleep latency, sleep quality, and restful sleep.	Experiencing more daily stressors than usual was significantly associated with delayed sleep latency and lower sleep efficiency. Students who reported more childhood maltreatment also reported significantly lower quality of sleep and feeling less rested upon awakening.
McPhie et al (2014)^Citation68	Longitudinal	73	Mean=15.8 Age grouping: adolescence.	N/A	Self-reports on current sleep disturbances.	More severe childhood maltreatment was related to increased sleep problems during adolescence. Psychological distress was a significant mediator of the childhood maltreatment-adolescent sleep disturbance association.
Noll et al (2006)^Citation73	Longitudinal	147	Range=6–16 years Age grouping: childhood and adolescence.	N/A	Subjective reports of sleep: typical sleeping patterns and sleep disturbances.	Sexually abused female adolescents reported significantly greater rates of sleep disturbances than controls.
Turner et al (2020)^Citation69	Cross-sectional	2910	Range=14–17 years Age grouping: adolescence.	N/A	Subjective Reports of sleep experiences: time to fall asleep, waking during the night, and hours of sleep.	All types of childhood maltreatment were significantly related to increased odds of taking more than 10 minutes to fall asleep, fewer hours slept on weekdays and waking more often during the night.
Wang et al (2016)^Citation72	Cross-sectional	9582	Range=13–18 years Age grouping: adolescence and young adulthood.	N/A	The International Classification of Sleep Disorders II: risk of insomnia.	Adolescents exposed to at least one childhood adversity of any type were more likely to experience insomnia than nonexposed children.
Xiao et al (2019)^Citation70	Cross-sectional	153,547	Mean=15.0 years Age grouping: adolescence.	N/A	The Chinese Version of the Pittsburgh Sleep Quality Index: sleep disturbance.	Sleep disturbance was significantly associated with physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect in adolescents.
Sleep and Impulsivity
Fallone et al (2001)^Citation79	Cross-sectional	82	Mean=11.9 years Age grouping: early adolescence.	Actigraphy, Polysomnography: daytime sleep latency.	Multiple sleep latency test, Subjective sleepiness ratings: sleep latency and subjective sleepiness.	Sleepiness following acute sleep restriction was not sufficient to produce deficits on impulsivity and sustained attention.
Gershon et al (2019)^Citation77	Cross-sectional	59	Range=13–19 years Age grouping: adolescence and young adulthood.	N/A	Self-report questionnaire: bedtime, rise time, and sleep duration.	Greater change in sleep duration between school days and weekends was related to higher levels of impulsivity among adolescents with bipolar disorder compared to controls.
Grant & Chamberlain (2018)^Citation76	Cross-sectional	373	Range=18–29 years Age grouping: young adulthood.	N/A	The Epworth Sleepiness Scale: sleepiness.	Higher levels of sleepiness were significantly associated with a range of impulsive measures.
Gruber et al (2012)^Citation81	Cross-sectional	34	Range:7–11 Age grouping: Childhood	Actigraphy: sleep duration, sleep quality	The Modified Epworth Sleepiness Scale	A cumulative extension of sleep duration of 27.36 minutes was associated with improvement in emotional lability and restless-impulsive behaviour and a significant reduction in reported daytime sleepiness. A cumulative restriction of sleep of 54.04 minutes was associated with detectable deterioration on emotion regulation and impulsivity.
Medeiros et al (2005)^Citation80	Cross-sectional	1180	Range=7–10 years Age grouping: childhood.	N/A	Parental report: sleep disorders and sleep-related respiratory disorders.	Children with non-respiratory sleep disorders had greater predisposition to impulsivity than children without sleep disorders.
Rossa et al (2014)^Citation78	Cross-sectional	19	Mean=20.16 years Age grouping: young adulthood.	N/A	Karolinska Sleepiness Scale: sleepiness.	An acute sleep restriction paradigm significantly impacted on affective experiences and increased impulsive and high-risk behaviour in young adults.
Sleep and Emotion dysregulation
Alfano et al (2020)^Citation86	Cross-sectional	53	Mean=9.0 Age grouping: Childhood	Polysomnography and actigraphy: sleep duration and sleep quality.	N/A	Deleterious alterations were observed in children’s affect, emotional arousal, facial expressions, and emotion regulation after sleep restriction.
Baum et al (2014)^Citation85	Cross-sectional	50	Range=14–17 years Age grouping: adolescence.	Actigraphy: sleep duration.	Sleep diary: sleep duration.	Several nights of sleep restriction adversely affected adolescents’ mood and ability to regulate their emotions.
Berger et al (2012)^Citation87	Cross-sectional	10	Range=30–36 months Age grouping: toddlers.	Actigraphy: sleep duration.	Children’s Sleep Habits Questionnaire, Sleep diary: sleep duration.	Sleep restriction resulted in a reduction in positive responses, and an increase in negative emotion responses.
Grove et al (2017)^Citation89	Cross-sectional	481	Mean=23 years Age grouping: young adulthood.	N/A	The Pittsburgh Sleep Quality Index: sleep quality.	BPD features related to emotion dysregulation were most strongly associated with poor sleep quality.
Palmer et al (2018)^Citation88	Cross-sectional	10,148	Range=13–18 years Age grouping: adolescence and young adulthood.	N/A	Self-report: sleep problems.	Adolescents with greater sleep difficulties reported poorer emotion regulation.
Simor et al (2010)^Citation91	Cross-sectional	46	N/A	N/A	The Dream Quality Questionnaire: dream disturbances.	Dream disturbances were more frequent in patients with BPD than in controls.
Wall et al (2020)^Citation90	Longitudinal	217	Range= 12–17 Age grouping: Adolescence	N/A	The School Sleep Habits Survey: sleep disturbance.	Borderline personality features and emotion dysregulation were significantly related to sleep disturbances.
Zhang et al (2019)^Citation84	Cross-sectional	51	Range=18 months-3 years Age grouping: toddlers.	N/A	The Chinese Version of the Pittsburgh Sleep Quality Index: sleep quality.	Emotion regulation strategies (ie, distraction and reappraisal) were impaired by sleep deprivation.
Sleep and Internalising/Externalising disorders
Alfano et al (2009)^Citation117	Cross-sectional	175	Mean=11.4 years Age grouping: childhood.	N/A	A sleep scale was created from sleep related items from various measures: sleep problems.	There were significant associations between sleep problems and both anxiety and depressive symptoms.
Bai et al (2020)^Citation95	Longitudinal	319	Range=11–26 years Age grouping: childhood, adolescence and young adulthood.	N/A	The Physical Symptom Checklist: dysregulated sleep.	Dysregulated sleep was bidirectionally associated with clinician-rated anxiety and depression symptom severity.
Chang et al (2018)^Citation97	Longitudinal	2510	Range=11–12 years Age grouping: Adolescence	N/A	Subjective reports of sleep times.	Significant inter-relationships for sleep duration and cigarette smoking trajectories were found during adolescence; all atypical sleep duration trajectories conferred increased risks of cigarette smoking. The effects of sleep duration and cigarette smoking on later internalizing problems were found to vary by sex and trajectory patterns.
Cho et al (2017)^Citation114	Longitudinal	123	Mean=24.43 years Age grouping: young adulthood.	N/A	Parental report: sleep duration.	Short sleep predicted greater daytime externalizing behaviors a year later.
Conway et al (2017)^Citation118	Longitudinal	1001	Range=24–36 months Age grouping: toddlers.	N/A	Parental report: trouble getting to sleep, bedtime resistance, sleep problems.	There were reciprocal associations between trouble getting to sleep and internalizing problems, and unidirectional links between externalizing problems and bedtime resistance.
Gregory et al (2006)^Citation93	Cross-sectional	300	Mean=8.6 years Age grouping: childhood.	N/A	The Child Sleep Habits Questionnaire: sleep problems.	A range of sleep difficulties were associated with depression in children.
Gruber et al (2020)^Citation110	Cross-sectional	122	Range=7–11 Age grouping: Childhood	Actigraphy: Night-time sleep, sleep schedule, and sleep efficiency	Child Sleep Habits Questionnaire, parental report on daily sleep logs: sleep disturbances.	Children who were above the cutoff score of the Children Sleep Habits Questionnaire were less likely to obtain the recommended amount of sleep for their age, had higher levels of internalizing and externalizing symptoms and a higher prevalence of clinical levels of externalizing and internalizing problems, had lower grades in English and French and were more likely to fail these subjects.
Hoyniak et al (2020)^Citation100	Longitudinal	119	30 months of age Age grouping: Childhood	Actigraphy: sleep duration, sleep timing, sleep vulnerability, and sleep activity	Parental report on daily sleep diaries	More variable sleep at 30 months had higher teacher-reported internalizing problems in preschool. Children with later sleep timing at 30 months had poorer cognitive and academic skills at 54 months. Changes in sleep from 30 to 54 months were not associated with any of the domains of adjustment.
Lavigne et al (1999)^Citation103	Cross-sectional	510	Range=2–5 Age grouping: Childhood	N/A	Parental report on the amount of sleep child obtained	The relationship between less sleep at night and the presence of a DSM-III-R psychiatric diagnosis was significant. Less night sleep and less sleep in a 24 hour period were associated with increased total behavior problems on the Child Behavior Checklist and with more externalizing problems.
Lee et al (2021)^Citation104	Cross-sectional	196	Mean=59.6 months Age grouping: Childhood	N/A	Children’s Sleep Habits Questionnaire: poor and good sleepers.	Externalising problems such as aggressive behaviors and attention problems, rather than cognitive development, are associated with sleep difficulties in preschool children with developmental disability.
Madrid-Valero et al (2020)^Citation94	Cross-sectional	5111 twin pairs	Mean=16.32 years Age grouping: adolescence.	N/A	The Pittsburgh Sleep Quality Index, The Insomnia Severity Index: sleep quality and insomnia.	Associations between sleep and internalizing problems were moderate and there was a large genetic overlap between these problems.
Mindell et al (2017)^Citation115	Longitudinal	117	Range=3–18 months Age grouping: toddlers.	N/A	The Brief Infant Sleep Questionnaire: bedtime, sleep duration, sleep latency and night awakenings.	Later bedtimes and less total sleep predicted higher internalising problem scores.
Morales- Muñoz et al (2020)^Citation113	Longitudinal	936	Age= Newborns Age grouping: infancy.	N/A	The Brief Infant Sleep Questionnaire, The Infant Sleep Questionnaire: sleep duration, sleep latency and night awakenings.	Shorter sleep and poorer sleep quality in infancy were prospectively related to emotional and behavioural symptoms in toddlers.
Mulraney et al (2016)^Citation107	Longitudinal	270	Range=5–13 years Age grouping: childhood.	N/A	Children’s Sleep Habits Questionnaire: sleep problems.	There was a weak bidirectional relationship between sleep problems and emotional problems.
Muratori et al (2019)^Citation101	Longitudinal	227	Range=6–10 years Age grouping: childhood.	N/A	The Sleep Disturbance Scale for Children: sleep problems.	A significant association was found between increased sleep problems and worsening of inattentive and hyperactive behavioral problems 1 year later.
Nunes et al (2020)^Citation96	Longitudinal	1729	Range=10–11 years Age grouping: childhood.	N/A	Parental and self-reports: sleep duration, difficulties getting to sleep and changes in difficulties getting to sleep.	Sleep duration was not longitudinally associated with internalizing problems, but it was in the cross-sectional analyses.
Paavonen et al (2009)^Citation108	Cross-sectional	297	Range=5–6 years Age grouping: childhood.	N/A	The Sleep Disturbance Scale for Children: Sleep quality and sleep duration.	Both short sleep duration and sleeping difficulties were significantly associated with children’s behavioral symptoms.
Pieters et al (2015)^Citation105	Longitudinal	555	Mean=13.96 years Age grouping: early adolescence.	N/A	The Adolescent Sleep Wake Scale, The Adolescent Hygiene Sleep Scale: sleep quality and sleep hygiene.	Sleep problems predicted changes in substance use, internalizing and externalizing problems over time, but problematic behaviours did not predict changes in sleep problems.
Reynolds & Alfano (2016)^Citation98	Longitudinal	1364	Participants were assessed from birth to age 15	N/A	A set of questions was derived from the Children’s Sleep Habits Questionnaire: bedtime and nighttime waking problems.	Bedtime but not nighttime waking problems significantly predicted adolescent internalising problems.
Rubens et al (2017)^Citation111	Cross-sectional	285	Range=8–11 years Age grouping: Childhood	N/A	Self-reports of sleep quality and time in bed.	Sleep quality was negatively associated with anxiety, depressive symptoms, irritability, reactive aggression, and delinquency engagement.
Quach et al (2018)^Citation106	Longitudinal	4983	Range=4–5 years Age grouping: childhood.	N/A	Parental report: difficulty getting to sleep at night, not happy sleeping alone, waking during night, and restless sleep.	Significant bidirectional associations were found between sleep and externalizing problems, with greater sleep problems associated with later externalizing behaviours.
Scharf et al (2013)^Citation102	Cross-sectional	8950	Age=4 years Age grouping: childhood.	N/A	Parental report: night-time sleep duration.	Shorter nighttime sleep duration was associated with higher likelihood of parent-reported externalizing behavioral symptoms.
Sivertsen et al (2015)^Citation116	Longitudinal	32,662	The data were collected at gestational week 17, 18 months and 5 years after birth. Age grouping: Childhood	N/A	Mother reported child sleep duration and nocturnal awakenings.	Short sleep duration and frequent nocturnal awakenings at 18 months significantly predicted both concurrent and later incidence of emotional and behavioural problems at 5 years.
Sivertsen et al (2021)^Citation99	Longitudinal	35,075	Range=1.5–8 years Age grouping: Childhood	N/A	Child Behavior Checklist: sleep duration and nocturnal awakenings.	Short sleep duration and frequent nightly awakenings at 1.5 years predicted the development of depressive symptoms at 8 years of age. Internalising problems at 1.5 years predicted onset of later short sleep duration.
Williamson et al (2020)^Citation112	Longitudinal	4517	Range=10–11 years Age grouping: childhood.	N/A	Parental report: sleep problems.	Children with increased sleep problems experienced greater internalizing and externalizing symptoms.
Wong et al (2009)^Citation109	Longitudinal	386	Range=3–11 Age grouping: Childhood	N/A	Maternal reports on Child Behavior Checklist: sleep problems.	Sleep problems at ages 3–8 predicted onset of alcohol, cigarette, and marijuana use among boys and onset of alcohol use among girls. Childhood sleep problems were related to maternal ratings of internalising and externalising problems during adolescence for both boys and girls.

Abbreviations: ADHD, attention deficit hyperactivity disorder; fMRI, functional magnetic resonance imaging; BPD, borderline personality disorder.

Figure 2 Adaptation of the biosocial developmental model of BPD. In this figure we present the pathways that could explain why sleep problems and subsequent BPD symptoms associate, using the biosocial developmental model by Crowell et al. In bold we have highlighted the processes that could have potential interaction with sleep problems and thus could explain the potential associations between sleep and BPD. These are HPA, prefrontal cortex, impulsivity, family psychopathology, disrupted attachment, childhood maltreatment, emotional dysregulation and internalizing/externalizing symptoms.

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