Point Prevalence and Risk Factors for Insomnia in Children and Adolescents

Findings of a population-based survey

Background: Insomnia in children and adolescents can be associated with poorer cognitive, emotional, social, and academic development. At present, no estimates of the prevalence of insomnia and its risk factors among adolescents in Germany are available from which the potential need for treatment could be assessed.

Methods: We conducted an online survey of a representative German sample of 1128 children and adolescents (age 10–17) and one parent for each. Levels of severity of insomnia as defined by the ICD-11 criteria were assessed by means of standardized self-reporting with use of the internationally established Insomnia Severity Index. The point prevalences of the levels of severity were calculated via relative frequencies. Potential risk factors for insomnia (sociodemographic factors, obesity, media consumption time, depression, anxiety, parental insomnia) were assessed with validated screening questionnaires and investigated in a multinomial regression model for the prediction of insomnia in childhood.

Results: The following point prevalences were determined: mild insomnia, 26.6%; moderate insomnia, 21.4%; severe insomnia, 1.6%. The most important risk factors for moderate and severe insomnia were existing anxiety (odds ratio and 95% confidence interval 4.54 [2.09; 9.88] and 7.96 [1.72; 36.94], respectively) and parental insomnia (2.49 [1.66; 3.72] and 3.30 [1.06; 10.30], respectively). The most important risk factor for mild and moderate insomnia was depression (1.83 [1.49; 2.24]), while older age (adolescents versus 10– to 13-year-olds) was protective ([0.51; 1.00]).

Conclusion: Many children and adolescents meet the ICD-11 criteria for insomnia according to their self-assessment. Critical life events and stressful experiences were not found to have any significant association with insomnia. A primarily non-pharmacological treatment approach involving the child and parents is indicated to alleviate the, often considerable, psychological strain on the family and prevent chronification of insomnia with adverse effects on the development of the child.

Cite this as: Wieder M, Thomasius R, Paschke K: Point prevalence and risk factors for insomnia in children and adolescents: Findings of a population-based survey. Dtsch Arztebl Int 2025; 122: 461–6. DOI: 10.3238/arztebl.m2025.0096

The impact of disturbed nighttime sleep on cognitive, psychological and physiological processes has been the subject of much debate: According to studies, reduced sleep duration and quality are associated with reduced attention (1), aggression inhibition (2) and emotional reactivity (3), as well as increased peripheral insulin resistance, elevated fasting fatty acid and cortisol levels (e1), and dysregulated inflammatory processes (4).

The specific spectrum of sleep problems seen in children and adolescents is due to the developmental psychological, (neuro-)biological, and social peculiarities of this age group. In the young age group, these are associated with externalizing and internalizing behavioral problems (5), learning difficulties (6), school refusal behavior (7), and obesity. A meta-analysis of cohort studies identified disturbed sleep as a risk factor for depression in young people (8). At the same time, a high level of media consumption is associated with poor sleep quality (9). In addition, sleep disorders in children have a negative impact on parental sleep quality (e2). Differences in sleep behavior between the sexes are observed from the onset of puberty onwards as the result of the accompanying hormonal changes (10).

The often synonymous use of the terms “sleep problems”, “sleep disorders” and “insomnia” in the literature without standardized and differentiated data collection impairs the comparability and generalizability of findings (e3). Unlike other sleep–wake disorders and subclinical sleep problems, insomnia is characterized by ongoing impairments in everyday life as the result of subjective problems falling and staying asleep (e4). Table 1 provides an overview of the diagnostic criteria for chronic (7A00) and acute insomnia (7A01) in the most recent edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). They are listed in the chapter of sleep–wake disorders and follow the structure and terminology of the third edition of the International Classification of Sleep disorders (ICSD-3) (e4, e5). The previous distinction between psychogenic (nonorganic) insomnia and (organic) insomnia due to a neurological condition of the present ICD-10 is thus no longer applied due to its lack of discriminatory power (e5). According to the German S3-level clinical practice guideline “Non-Restorative Sleep/Sleep Disorders“ (11), the diagnosis is usually established based on clinical findings and a stepped diagnostic procedure. It should include a comprehensive medical history, investigation of physical or mental illnesses and a physical examination as well as an evaluation of self-observations and self-reported information obtained from sleep questionnaires and sleep diaries. The use of the Insomnia Severity Index (ISI) is recommended for screening purposes and for the documentation of treatment effects. This questionnaire is designed to assess the level of insomnia severity (11, 12).

Table 1

Classification of insomnia according to ICD-11

There is a lack of current data on the prevalence of insomnia in children and adolescents and the related health care situation in Germany. The 2002 Cologne Children‘s Sleep Study estimated the prevalence of insomnia symptoms in children at 15% (13). A more pronounced sleep disorder was found in 5–10% of school beginners (14). In a large German cohort study covering the period from 2011 to 2015, approximately 20% of the surveyed children and adolescents had sleep-related difficulties (15), including parasomnias, which are non-specific for insomnia, in addition to problems falling asleep and staying asleep.

Cognitive behavioral interventions have proven effective in the treatment of insomnia (11). However, despite evidence to the contrary, the use of medication as the initial treatment is common in everyday clinical practice (16). In the adult population, a gap in care for patients with chronic insomnia is noted (17).

The aim of our study was to investigate health care-related needs and practical implications, using the following research questions:

• What is the point prevalence of insomnia, taking into account the ICD-11 symptoms as well as the differentiation into mild, moderate and severe insomnia in a population-based sample of children and adolescents in Germany?
• Which protective and risk factors can be identified for the respective levels of insomnia severity?

Methods

A detailed description of the methods used is provided in the eMethods section.

Data collection

Our study is part of a large population-based, representative online survey of parent-child households on psychological family health which was conducted in cooperation with Forsa Institute (forsa), a German market research and opinion polling company. A total of 1128 children and adolescents aged 10–17 and one parent of each consented to participate in the research. The study was approved by the local Psychological Ethics Committee of the Center for Psychosocial Medicine at the University Medical Center Hamburg-Eppendorf (UKE) and conducted in accordance with national and institutional ethical guidelines and in compliance with the Declaration of Helsinki.

eFigure

Recruitment of sample

Survey methods

In addition to sociodemographic information, height and weight, the following variables were captured, using standardized screening questionnaires established for epidemiological surveys. Symptoms of parental and children’s insomnia were surveyed with the Insomnia Severity Index (ISI) which is recommended as a screening instrument in the S3-level German clinical practice guidelines mentioned above and also validated for children and adolescents (11). The severity and clinical significance of insomnia could be determined from the total scores of the scale: 0–7 points = no clinically significant insomnia; 8–14 = subthreshold (mild) insomnia; 15–21 = moderate clinical insomnia; and 22–28 = severe clinical insomnia.

The Patient Health Questionnaire (PHQ)-9 is an instrument which reliably and also validly for young target groups assesses the self-reported frequencies of the nine criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV for depressive disorders, using the following severity classification: 0–4 points = no depression; 5–9 points = mild depression; 10–14 points = moderate depression; 15–19 points = moderately severe depression; >20 points = severe depression. The two-item Generalized Anxiety Disorder (GAD-2) scale was used to measure anxiety levels. This short screening tool indicates the presence of a generalized (non-specific) anxiety disorder if the total score is 3 or higher. Media use during leisure time (days of use per week and duration of use per day in minutes) was systematically surveyed for digital games, social media, and online video platforms and aggregated into a weighted weekly average.

Total scores of perceived stress, measured using the Perceived Stress Scale (PSS-4), and critical life events, captured using the Life Events Questionnaire (LEQ), served as covariates to cover possible environmental influences on sleep behavior at the time of survey (18).

Data analysis

The statistical software R 4.3.2 was used for the statistical analysis. Response patterns, which were incomplete by at least one third, were not included in the analysis. Remaining missing values of a questionnaire were estimated by imputation (19). With this approach, data of 1100 persons were included in the final analyses. The point prevalences of the levels of severity of insomnia were calculated as relative frequencies. Next, 95% confidence intervals were determined for the total survey sample and stratified by sex and age group (children [10–13 years] versus adolescents [14–17 years]).

The effects of the categorical variables age group (children versus adolescents), sex, obesity (body mass index [BMI] ≥ 97^th percentile versus BMI < 97^th percentile), severity of depression (no depression to severe depression), symptoms of anxiety (yes versus no), and parental insomnia (no versus at least moderate) were estimated in a joint multinomial logistic regression model together with the metric variables of the weekly media use duration and the above-mentioned covariates to predict mild, moderate or severe symptoms of insomnia.

Results

Sociodemographic characteristics and point prevalences

Table 2 lists the sociodemographic characteristics and point prevalences of insomnia of the parent-child sample. More detailed information is provided in the eTable.

Table 2

Characteristics of the parent-child dyads and insomnia prevalences

eTable

Supplementary characteristics of the parent-child dyads and insomnia prevalences

Altogether, 293 of the 1100 children and adolescents, corresponding to about one quarter of the total sample, met the criteria for mild insomnia, 235 children and adolescents for moderate insomnia (about one-fifth) and 18 respondents for severe insomnia (1.6%). The confidence intervals for the prevalence rates, stratified by sex and age group, overlap and thus do not indicate the presence of group differences (eTable).

Risk and protective factors

Table 3 presents the findings of the multinomial model, explaining 21.5% of the total variance. Compared to children and adolescents without insomnia, adolescents had a 29% lower chance of suffering from mild insomnia than children, while for moderate insomnia, the chance was 34% lower. With each additional level of severity of depression, children and adolescents had a 1.8-fold increased risk of mild insomnia and a 1.3-fold increased risk of moderate insomnia.

Table 3

Multinomial regression model for the prediction of levels of insomnia severity

The association between risk factor and greater severity of insomnia is stronger in the presence of existing anxiety (4.5-fold increased chance of moderate insomnia, 8-fold increased chance of severe insomnia) and parental (clinically significant) insomnia (2.5-fold increased chance of moderate insomnia, 3.3-fold increased chance of severe insomnia). Sex has no influence. Contrary effects were observed for obesity; with p-values of 0.08, however, they did not reach the significance threshold: While respondents with obesity had a 52% lower chance of having moderate insomnia, their chance of having severe insomnia was increased by factor 3.2. Longer media use times were associated with an 18% increased chance only with regard to mild insomnia. However, with a p-value of 0.052, this result also narrowly fell short of the threshold for statistical significance.

Discussion

Our study is the first to systematically and in a standardized way record the ICD-11 criteria of insomnia in a large German sample of parent-child dyads to estimate the point prevalence. Aside from identifying age group-related and psychological risk and protective factors, relevant associations between parental and children’s insomnia were revealed.

Half of the 10– to 17-year-olds reported experiencing symptoms of mild to moderate insomnia in the previous month. This is consistent with the proportion of children and adolescents suffering from sleep disorders according to the findings of a meta-analysis (20). Approximately one-fifth meet the criteria for moderate insomnia. This proportion corresponds to the results of a meta-analysis on adolescent insomnia (21); however, it is higher than the proportions found in meta-analyses using the same instrument (ISI) that primarily looked at adult study populations (22). It approximately corresponds to the proportion of children and adolescents in Germany who experience emotional and behavioral problems (23). The proportion of severe insomnia (1.6%) does not differ from the findings in adult populations (22). It is comparable to the prevalence of (severe) depression in children and adolescents (24).

In a meta-analysis on sleep disturbances, Jahrami et al. (20) identified children and adolescents as one of the most vulnerable groups. In the current study, belonging to the adolescent age group was identified as a protective factor for mild and moderate insomnia. This may be attributable to the fact that behavior-related insomnia is more prevalent in the younger age group; this type of insomnia is commonly associated with resistance to going to bed (25) and is also more strongly influenced by parental interaction and genetic factors (26). This finding stands in contrast to representative results on chronic lack of sleep, a condition that is significantly more common among adolescents than children (27). Compared to boys, girls suffered more frequently from chronic lack of sleep (27) and other overt sleep problems (28). However, in our survey sample, female sex was not identified as a risk factor for insomnia. The findings of studies on adults are inconclusive: While a systematic review reported appreciable sex differences for sleep–wake disorders (29), a meta-analysis of international studies on ISI found no differences (22). This may be attributable to the use of different measuring instruments and varying concepts of insomnia and sleep problems.

In our study, depression was found to be a risk factor mainly for less severe forms of insomnia. We identified anxiety as the most significant risk factor (up to 8 times higher odds ratios) for more severe forms of insomnia. In children and adolescents, the relationships between sleep disorders on the one hand and depression and anxiety on the other are bidirectional (30, 31). According to a prospective meta-analysis, sleep disorders can predict depressive symptoms in children and adolescents (8). Genetic causes have been identified in this regard (32). At the same time, depression and anxiety disorders as well as developmental disorders (attention deficit hyperactivity disorder, autism, epilepsy) frequently occurred as comorbidities or in association with insomnia in children and adolescents (25, e7). In adolescents, the relationship between mental illness and insomnia is complex as it is influenced by biological, psychological and social factors, including cytokine and cortisol levels, altered sleep architecture, dysfunctional beliefs, cognitive distortions, and reduced social interactions (33).

Parental insomnia of at least moderate severity was found to be a further important risk factor for moderate to severe insomnia among their children. This finding is consistent with the findings of a recent Chinese study on a random sample of 68 751 parent-child dyads (34). Insomnia is a polygenic, stress-associated illness that is most likely caused by an interaction between genetic and environmental factors (e8). Possible environmental factors include family functionality (35), features of the surroundings, such as green spaces and air pollution (e9), as well as parental monitoring (e10) and handling of children’s sleep problems (e11).

Obesity as a risk factor for severe insomnia failed to reach the threshold for statistical significance. According to a meta-analysis of prospective studies, a shorter sleep duration, which can be due to insomnia, can increase the risk of obesity in children (36). There is, however, a global lack of studies focusing on sleep quality rather than sleep quantity (e6).

High media consumption is widely discussed as a factor contributing to disturbed nighttime sleep (37). In our study, media use narrowly missed the significance threshold as a risk factor for mild insomnia. Previous studies, lacking a uniform conceptualization of sleep problems, have shown considerable heterogeneity also with regard to media consumption (38). This is compounded by the fact that long media use times during the COVID-19-Pandemie have become the norm and correlate less with use quality, for example problematic use patterns (39). These, in turn, seem to have a greater impact on sleep quantity and quality than media use time alone (40).

The treatment of children and adolescents with insomnia consists primarily of psychoeducation for those affected and their caregivers. It includes sleep hygiene and age-adapted cognitive behavioral therapy techniques with exercises for cognitive restructuring as well as teaching relaxation techniques (e12). If patients with chronic insomnia fail to respond to this treatment, the temporary use of melatonin may be considered (e28). At a higher level, holistic treatment with improvement of stress tolerance appears to be a promising approach (26). Clinical management recommendations for Germany are expected to become available once the development of the S2e-level clinical practice guideline “Non-Restorative Sleep/Sleep Disorders —Insomnia in Children and Adolescents” is completed (AWMF register no. 028–012).

Strengths and limitations

The strengths of our study include the large parent-child survey sample and the standardized collection of data on insomnia at the various levels of severity. The following limitations apply: Data collection was carried out during the COVID-19 pandemic. It cannot be ruled out that the prevalence estimate was influenced by the pandemic situation in combination with increased psychological stress (e9). To take potential environmental influences at the time the survey was conducted into account, critical life events and perceived stress were included in the analysis as covariates (18). The meta-analysis by AlRasheed et al. (22) showed that only subthreshold (mild) insomnia cases increased during the COVID-19 pandemic, while the prevalence of more severe forms of insomnia did not change. Furthermore, our findings are comparable with the results of international pre-pandemic meta-analyses (21). The data collected is entirely based on self-reports with limited numbers of items. It is not possible to establish a clinical diagnosis solely on the basis of the screening questionnaires used. Data on mental and physical comorbidities as well as objective parameters could not be collected. This is a general limitation of epidemiological studies. As a consequence, an over- or underestimation of the reported findings may have occurred due to self-misjudgments or selection bias, with particularly affected groups being underrepresented. To address these limitations, standardized validated and reliable survey instruments were used in combination with a complex sampling method.

Follow-up studies should aim for oversampling of particular groups, such as children with obesity, in order to increase the power to also detect smaller effects. In addition, future research should collect data on chronic and short-term insomnia using differentiated time criteria and prospective study designs should be implemented to allow for a causal interpretation of risk and protective factors. In our study, only one parent could be included in the survey for reasons of practicability. Further research should include genetic testing of entire families. The described strong association between parental and children’s insomnia can be taken into account in everyday clinical practice: If parents report sleep problems, the possibility that the child may have a sleep disorder that requires treatment should be given consideration, and vice versa.

Conclusion

The presented epidemiological findings have implications for everyday clinical practice. Almost one in four children aged between 10 and 17 reported symptoms of at least moderate insomnia. Thus, a low-threshold systematic insomnia assessment is warranted. A holistic, primarily non-pharmacological treatment approach involving the child and parents is indicated to alleviate the often considerable psychological strain on the family and prevent adverse effects on the development of the child and chronification of insomnia. There is a need for prospective research focusing on biological and environmental influences on insomnia in children and adolescents.

Funding

This study was conducted with financial support from the DAK-Gesundheit health insurance.

Acknowledgement

We would like to thank forsa for their high-quality data collection as well as all families who participated in the survey.

Conflict of interest statement

The authors declare that no conflicts of interest exist.

Manuscript received on 22 January 2025, revised version accepted on 20 May 2025

Translated from the original German by Ralf Thoene, M.D.

Correspondence
PD Dr. med. Dipl.-Psych. Kerstin Paschke

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