A study of 518 children and adolescents receiving active cancer treatment in China found that those who reported better family functioning also reported fewer areas of sleep difficulty. The findings point to a relationship between family life, mood symptoms and sleep—but they do not show that changing one factor would cause another to improve.
The participants were part of the Chinese Childhood Cancer Survivorship Wellbeing Cohort, a multicenter study that began in 2021. The group included 448 children ages 7 to 14 and 70 adolescents ages 15 to 17. There were 301 boys and 217 girls, and 315 participants—60.8%—were surveyed within 180 days of diagnosis.
What the study found
Family functioning was assessed with the five-question Family APGAR scale, scored from 0 to 10. After accounting for age, sex, household income, cancer type and time since diagnosis, each one-point increase on the scale was associated with 0.109 fewer sleep-problem areas out of five.
The 95% confidence interval for that estimate ranged from 0.053 to 0.165 fewer problem areas. The sleep measure, known as BEARS, covered bedtime problems, excessive daytime sleepiness, night awakenings, sleep regularity and duration, and snoring.
The cancers represented in the sample included leukemia in 258 participants, lymphoma in 100 and solid tumors in 160. Participants with a psychiatric disorder, brain metastases, communication disorders or other major chronic illnesses were excluded.
The role of depression and anxiety
Researchers used a mediation model to examine whether depression and anxiety statistically helped explain the relationship between family functioning and sleep problems. Depression accounted for about 22% of the association, while anxiety accounted for about 23%.
The researchers described the remaining association as direct within the model. Its estimate was B = −0.061, representing 55.9% of the total association, with a 95% confidence interval from −0.118 to −0.004.
These pathways are statistical descriptions of the data, not proof of a sequence in which family functioning changes mood and mood then changes sleep. The study collected all measures in one questionnaire session, so it could not establish which factor came first. The researchers noted that poor sleep could also affect mood or perceptions of family life.
Family resilience showed a different pattern
Family resilience was measured with the 20-item Family Hardiness Index. Higher resilience was also associated with fewer sleep problems: the adjusted estimate was B = −0.026 per point on the index, with a 95% confidence interval from −0.044 to −0.010.
About 37% of that association ran statistically through depression and anxiety. After those symptoms were added to the model, the direct association between resilience and sleep problems was no longer statistically significant, with B = −0.017 and a confidence interval from −0.034 to 0.0004.
A sensitivity analysis using a Poisson model found that the indirect links through depression and anxiety remained for both family factors.
Differences across groups
In the sample, the 40 children with divorced parents had higher average depression and anxiety scores than the 478 children with married parents. Average depression scores were 54.1 versus 50.7, and anxiety scores were 50.7 versus 47.6. The children with divorced parents also reported lower family functioning and resilience.
Children from lower-income families reported more sleep-problem areas on average than children from higher-income families—1.52 versus 1.30. Participants surveyed within 180 days of diagnosis also had more sleep problems in the adjusted model. Because these comparisons came from the same one-time survey, they identify groups that may warrant closer attention rather than causes of sleep difficulty.
What the findings do—and do not—show
Earlier studies cited in the paper have estimated that sleep problems occur in 40% to 80% of children and adolescents with cancer. In this study, however, sleep was assessed with a screening tool rather than sleep diaries, wrist-worn activity trackers or sleep studies.
All measures were self-reported, so a participant’s general outlook may have influenced responses, although the source reported that a statistical check suggested this was not a major problem. Treatment details such as chemotherapy regimen, treatment intensity, disease stage and relapse were not fully available, leaving room for other explanations.
The model containing depression and anxiety explained 15% of the variation in sleep scores. The study also did not measure possible pathways such as bedtime routines, a sense of safety, parent–child time before sleep or practical caregiving.
Overall, the findings describe an association between family experiences and sleep problems among children receiving cancer treatment. Whether family-focused support improves sleep was not tested. The researchers called for longitudinal studies and intervention trials to examine that question.
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