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Cited by 87Substance Abuse Treatment and OutcomesSleep and related disordersChild and Adolescent Psychosocial and Emotional Development

Restless Sleep and Variable Sleep Timing During Late Childhood Accelerate the Onset of Alcohol and Other Drug Involvement

Open access
Hasler, Brant P., Kirisci, Levent, Clark, Duncan B.·2016·Journal of Studies on Alcohol and Drugs
DOI 10.15288/jsad.2016.77.649PMC PMC4987074
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Abstract

OBJECTIVE: Limited prospective data indicate that premorbid sleep disturbances elevate the risk for subsequent alcohol and other drug problems, yet the implications for subsequent substance involvement trajectories remain unclear. In the present analyses, we examined risk associations between sleep characteristics during late childhood and the onset of substance use and substance use disorders into adulthood. METHOD: A sample of 707 children was recruited at ages 9-13 years and followed over seven additional visits through age 30 years. In 304 participants, fathers had a history of substance use disorder involving illicit drugs. Self-reported baseline sleep characteristics (restless sleep and variable sleep timing) were assessed at approximately ages 9-13 years. Assessment of alcohol, cannabis, and cocaine involvement occurred at follow-up visits. Cox proportional hazard models tested sleep characteristics as predictors of two substance-related outcomes (age at first use or diagnosis of disorder), as well as the onset of major depressive disorder. RESULTS: Restless sleep at baseline significantly predicted an earlier onset age for trying alcohol and cannabis and showed a trend toward predicting early onset of cannabis use disorder. Restless sleep also predicted an earlier onset of depression. Irregular sleep timing at baseline significantly predicted an earlier onset age for alcohol use disorder and showed trends toward predicting early onsets of disorders of cannabis and cocaine use. CONCLUSIONS: Disturbed sleep during late childhood appears to accelerate the onset of not only initial substance use but also the development of clinically defined substance use disorder. Sleep-focused preventative efforts during late childhood may reduce the incidence of mood and substance use disorders.

AI snapshot

Written from the paper’s full text.

TL;DR

In a high-risk longitudinal sample followed from late childhood into adulthood, self-reported restless sleep and variable sleep timing predicted earlier onset of alcohol and other drug involvement, including clinically defined substance use disorders. The authors conclude that disturbed sleep in late childhood may accelerate substance-related trajectories and that sleep-focused prevention may reduce mood and substance use disorders.

Key findings

  • Restless sleep at baseline predicted earlier onset of alcohol use (HR = 1.11, 95% CI [1.02, 1.21], p = .016) and cannabis use (HR = 1.13, 95% CI [1.02, 1.24], p = .021), with a trend for cannabis use disorder (HR = 1.15, 95% CI [0.98, 1.34], p = .079). It did not predict cocaine use or cocaine use disorder.
  • Restless sleep also predicted earlier onset of depressive disorder (HR = 1.23, 95% CI [1.06, 1.42], p = .006).
  • More variable sleep timing predicted earlier onset of alcohol use disorder (HR = 0.82, 95% CI [0.71, 0.95], p = .01; reported as an 18% faster onset per 1-SD increase) and showed trends for cannabis use disorder (HR = 0.88, 95% CI [0.75, 1.02], p = .097) and cocaine use disorder (HR = 0.72, 95% CI [0.51, 1.01], p = .054).
  • Variable sleep timing did not predict onset of alcohol, cannabis, or cocaine use, nor depressive disorder.

Methods

  • Participants were 707 children recruited at ages 9–13 years and followed over seven additional visits through age 30 years; 304 had fathers with a substance use disorder involving illicit drugs.
  • Baseline sleep was assessed with two DOTS-R subscales: Activity-Sleep (restless sleep) and Rhythmicity-Sleep (variability in sleep timing). Outcomes included age at first use and first diagnosis of alcohol, cannabis, and cocaine use disorders, plus major depressive disorder.
  • Cox proportional hazard models tested sleep predictors with covariates for sex, age at Visit 1, race, and parental substance use disorder; no data were missing for sleep variables, covariates, or baseline-dependent variables, and Cox models used all available follow-up data.

Limitations

  • The authors state that sleep variables were self-reported and not validated against sleep diaries or actigraphy, and the Rhythmicity-Sleep scale had relatively low internal consistency (current-sample Cronbach’s alpha = .61).
  • The authors note the high-risk sample limits population-wide generalizability and that the study focused on a limited range of risk factors, precluding examination of interactions with other risk factors such as genetics or parental monitoring.
  • The text also makes evident that the sample was predominantly male (503 males, 204 females) and European American (562 vs. 145 African American), which may further constrain generalizability.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.15288/jsad.2016.77.649

Cites

47 of 47 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 27 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Variability of sleep timing at baseline did not predict onset of depressive disorder.

    “Variability of sleep timing did not predict onset of depressive disorder.”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Variability in sleep timing is an indicator of sleep/circadian misalignment.
    • Rests on an assumption: The DOTS-R Activity-Sleep and Rhythmicity-Sleep subscales validly measure restless sleep and variability in sleep timing in this sample.
  • Findingown data

    More variable sleep timing at baseline showed a trend toward predicting earlier onset of cocaine use disorder.

    “showed trends toward predicting early onsets of disorders of cannabis and cocaine use.”
    • Also stated in: § Sleep-related risk of alcohol and drug involvement · hedged
      “More variable sleep timing predicted an earlier onset of AUD (Figure 1C; also see Table 1) and showed trends toward predicting earlier onset of cannabis use disorder and cocaine use disorder.”
    • Also stated in: § Sleep-related risk of alcohol and drug involvement · plain
      “Specifically, a 1-SD increase in the Rhythmicity-Sleep scale (3.65 points) was associated with an 18% faster onset to AUD, a 12% faster onset to cannabis use disorder, and a 28% faster onset to cocaine use disorder (Table 1).”
    Quote in the paperNot a substantial claim
    • The authors state this as an assumption: Variability in sleep timing is an indicator of sleep/circadian misalignment.
    • Rests on an assumption: The DOTS-R Activity-Sleep and Rhythmicity-Sleep subscales validly measure restless sleep and variability in sleep timing in this sample.
  • Findingown data

    Restless sleep at baseline showed a trend toward predicting early onset of cannabis use disorder.

    “showed a trend toward predicting early onset of cannabis use disorder.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Restless sleep is an indicator of insomnia or difficulty sleeping.
    • Rests on an assumption: The DOTS-R Activity-Sleep and Rhythmicity-Sleep subscales validly measure restless sleep and variability in sleep timing in this sample.
  • Findingown data

    Restless sleep at baseline significantly predicted an earlier onset age for trying alcohol.

    “Restless sleep at baseline significantly predicted an earlier onset age for trying alcohol and cannabis and showed a trend toward predicting early onset of cannabis use disorder.”
    • Also stated in: § Sleep-related risk of alcohol and drug involvement · plain
      “more restless sleep predicted an earlier onset of alcohol use and cannabis use (Figures 1A and 1B) but not cocaine use.”
    • Also stated in: § Sleep-related risk of alcohol and drug involvement · plain
      “A 1-SD increase in the Activity-Sleep scale (3.45 points) was associated with an 11% faster onset to alcohol use and a 13% faster onset to cannabis use (Table 1).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Restless sleep is an indicator of insomnia or difficulty sleeping.
    • Rests on an assumption: The DOTS-R Activity-Sleep and Rhythmicity-Sleep subscales validly measure restless sleep and variability in sleep timing in this sample.
  • Findingown data

    More variable sleep timing at baseline predicted an earlier onset of alcohol use disorder.

    “More variable sleep timing predicted an earlier onset of AUD (Figure 1C; also see Table 1) and showed trends toward predicting earlier onset of cannabis use disorder and cocaine use disorder.”
    • Also stated in: § Sleep-related risk of alcohol and drug involvement · plain
      “Specifically, a 1-SD increase in the Rhythmicity-Sleep scale (3.65 points) was associated with an 18% faster onset to AUD, a 12% faster onset to cannabis use disorder, and a 28% faster onset to cocaine use disorder (Table 1).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Variability in sleep timing is an indicator of sleep/circadian misalignment.
    • Rests on an assumption: The DOTS-R Activity-Sleep and Rhythmicity-Sleep subscales validly measure restless sleep and variability in sleep timing in this sample.
  • May combine two claims. 8
  • Classified as probably not a substantial claim. 19
  • The quote only partly states this claim. 1

  • May combine two claims.

    Interpretationown data

    More disturbed sleep during late childhood appears to accelerate the onset of initial substance use and the development of clinically defined substance use disorders.

    “Our findings indicate that sleep characteristics during late childhood are predictive of subsequent alcohol and drug involvement during adolescence and young adulthood; that is, more disturbed sleep appears to accelerate the onset of not only initial substance use, but also the development of clinically defined SUDs.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Restless sleep is an indicator of insomnia or difficulty sleeping.
    • The authors state this as an assumption: Variability in sleep timing is an indicator of sleep/circadian misalignment.
    • Rests on an assumption: The DOTS-R Activity-Sleep and Rhythmicity-Sleep subscales validly measure restless sleep and variability in sleep timing in this sample.

  • Classified as probably not a substantial claim.

    Premisecitation

    A few prospective studies indicate that premorbid sleep disturbances elevate the risk for subsequent alcohol and drug problems.

    “A few prospective studies indicate that premorbid sleep disturbances elevate the risk for subsequent alcohol and drug problems”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Breslau et al., 1996

      Not checked in the free run.

    • cites Hasler et al., 2014

      Not checked in the free run.

    • cites Wong et al., 2004, 2010, 2015

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The Activity-Sleep and Rhythmicity-Sleep subscales had Cronbach's alphas of .78 and .61 in the current sample.

    “In the current sample, Cronbach's alphas were .78and .61,respectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Sleep problems are a risk factor for depression.

    “Given abundant evidence that sleep problems are a risk factor for depression (e.g., Baglioni et al., 2011), a diagnosis of major depression was also considered in the analyses.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Baglioni et al., 2011

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In the original validation study, the Activity-Sleep and Rhythmicity-Sleep subscales had Cronbach's alphas of .81 and .69 in a sample of sixth graders.

    “In the original validation study, these subscales had Cronbach's alphas of .81 and .69,respectively, in a sample of sixth graders.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Windle & Lerner, 1986

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Sleep problems are a modifiable risk factor.

    “Fortunately, sleep problems are a modifiable risk factor; the means to address this vulnerability are available at both the individual and systemic levels.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Gradisar et al., 2011

      Not checked in the free run.

    • cites van Geijlswijk et al., 2010

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    In the present sample of 707 participants, no data were missing for the sleep variables, covariates, or baseline-dependent variables.

    “In the present sample of 707 participants, no data were missing for the sleep variables, covariates, or baseline-dependent variables.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    All models included sex, age at Visit 1, race, and the presence of parental SUD as covariates.

    “All models included sex, age at Visit 1, race, and the presence of parental SUD as covariates.”
    • Also stated in: § Discussion · plain
      “All models included sex, age at Visit 1, race, and the presence of parental substance use disorder as covariates.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Cox proportional hazard models use all available data, so all individuals are included in the analysis despite missing dependent variable data after baseline.

    “With regard to missing data in the dependent variables after baseline, Cox proportional hazard models use all available data; thus, all individuals are included in the analysis.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Prior research has shown that onset dates for SUD symptoms and diagnoses can be reliably assessed in adolescent samples.

    “Prior research has shown that onset dates for SUD symptoms and diagnoses can be reliably assessed in adolescent samples (Martin et al., 2000).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Martin et al., 2000

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The Rhythmicity-Sleep scale had relatively low internal consistency.

    “In addition, the Rhythmicity-Sleep scale had relatively low internal consistency.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The sleep variables were based on self-report items that have not been validated against more widely used subjective and objective sleep measures.

    “First, the sleep variables were based on self-report items that have not been validated against more widely used subjective (e.g., sleep diaries) and objective (e.g., actigraphy) sleep measures.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    The implications of sleep disturbances for subsequent substance involvement remain unclear.

    “Nevertheless, the implications of sleep disturbances for subsequent substance involvement remain unclear.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    Variability in sleep timing and/or duration has received less attention in prospective studies.

    “A third category of sleep problem-variability in sleep timing and/ or duration-has received less attention in prospective studies.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Abundant cross-sectional data and clinical lore recognize that sleep disturbances are highly prevalent among individuals with alcohol and other drug problems.

    “A BUNDANT CROSS-SECTIONAL DATA and clini- cal lore recognize that sleep disturbances are highly prevalent among individuals with alcohol and other drug problems (Blank et al., 2015;Conroy & Arnedt, 2014;Johnson & Breslau, 2001).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Blank et al., 2015

      Not checked in the free run.

    • cites Conroy & Arnedt, 2014

      Not checked in the free run.

    • cites Johnson & Breslau, 2001

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Early childhood sleep problems may predict the onset of substance use during adolescence as well as continued sleep problems that, in turn, predict substance problems in young adulthood.

    “Early childhood sleep problems may predict the onset of substance use during adolescence as well as continued sleep problems that, in turn, predict substance problems in young adulthood (Wong et al., 2004(Wong et al., , 2010)).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Wong et al., 2004

      Not checked in the free run.

    • cites Wong et al., 2010

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    In adolescents, sleep variability may be operationalized as the difference between weekday and weekend sleep and is thought to reflect the degree of circadian misalignment (or social jet lag) suffered because of imposed academic schedules.

    “In adolescents, sleep variability may be operationalized as the difference between weekday and weekend sleep and is thought to reflect the degree of circadian misalignment (or”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Hasler & Clark, 2013

      Not checked in the free run.

    • cites Wittmann et al., 2006

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The degree of risk for various substance-related outcomes may vary according to the nature of the sleep problem.

    “These prior studies suggest that the degree of risk for various substance-related outcomes may vary according to the nature of the sleep problem.”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Premisecitation

    Wong and colleagues reported that baseline sleep predicted a range of alcohol-related problems, illicit drug use, and drug-related problems at a 1-year follow-up and, to a lesser degree, at the 6- to 7-year follow-up.

    “In contrast, Wong and colleagues used continuous measures of insomnia (”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wong et al., 2015

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Sleep complaints among young adults increase the risk for new-onset alcohol use disorders or other substance use disorders.

    “Sleep complaints among young adults increase the risk for new-onset alcohol use disorders (AUDs) or other substance use disorders (SUDs) (Breslau et al., 1996).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Breslau et al., 1996

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Among adolescents without baseline AUDs in the PAARC study, baseline insomnia (but not hypersomnia) predicted an increase in alcohol symptoms at the 1-year follow-up.

    “Furthermore, among the adolescents without baseline AUDs, baseline insomnia (but not hypersomnia) predicted an increase in alcohol symptoms at the 1-year follow-up.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Hasler et al., 2014

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Roane and Taylor (2008) reported cross-sectional associations between the presence or absence of insomnia and substance use among 4,494 participants at baseline but no significant prospective associations between baseline insomnia and substance use 6-7 years later.

    “Roane and Taylor (2008) reported cross-sectional associations between the presence or absence of insomnia and substance use among 4,494 participants at baseline (M age = 15.83years) but no significant prospective associations between baseline insomnia and substance use 6-7 years later.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Roane & Taylor, 2008

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Once an AUD is established, sleep disturbance can predict relapse.

    “Furthermore, once an AUD is established, sleep disturbance can predict relapse (Brower et al., 2001;Drummond et al., 1998).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Brower et al., 2001

      Not checked in the free run.

    • cites Drummond et al., 1998

      Not checked in the free run.

23 of 23

  • The authors state this as an assumption.

    Restless sleep is an indicator of insomnia or difficulty sleeping.

    “Interpreting restless sleep as an indicator of insomnia or difficulty sleeping, this finding is consistent with other research showing that sleep difficulty predicts the earlier onset of alcohol and other drug use”

  • The authors state this as an assumption.

    Variability in sleep timing is an indicator of sleep/circadian misalignment.

    “The present study assessed two distinct sleep parameters relevant to adolescence: restless sleep, as an indicator of insomnia, and variability in sleep timing, as an indicator of sleep/circadian misalignment.”

  • The paper relies on this without support.

    The DOTS-R Activity-Sleep and Rhythmicity-Sleep subscales validly measure restless sleep and variability in sleep timing in this sample.

    “Sleep variables were based on two subscales, originally derived via factor analysis from the Dimensions of Temperament Survey-Revised (DOTS-R; Windle & Lerner, 1986): Activity-Sleep and Rhythmicity-Sleep.”
    “First, the sleep variables were based on self-report items that have not been validated against more widely used subjective (e.g., sleep diaries) and objective (e.g., actigraphy) sleep measures.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Longitudinal follow-up studies have found that weekend delay and sleep-timing variability during adolescence and young adulthood positively correlate with alcohol use 2 years later and the incidence of alcohol use disorder symptoms 3 and 5 years later, and are associated with an earlier onset of alcohol use disorder.

    “Longitudinal follow-up studies have found that weekend delay and sleep-timing variability during adolescence and young adulthood positively correlate with alcohol use 2 years later162 and the incidence of alcohol use disorder symptoms 3 and 5 years later163 and are associated with an earlier onset of alcohol use disorder164.”

    From Rhythms of life: circadian disruption and brain disorders across the lifespan (2019) · cites this paper as [164]

  • Several longitudinal studies have linked markers of social jet-lag, including larger weekend delays and more variable sleep timing, with greater likelihood of alcohol use 2 years later, greater alcohol use disorder symptoms 3 and 5 years later, and earlier onset of alcohol use disorder.

    “Several longitudinal studies have linked markers of social jet-lag, including larger weekend delays and more variable sleep timing, with greater likelihood of alcohol use 2-years later (59); greater alcohol use disorder symptoms 3- and 5-years later (68); and an earlier onset of alcohol use disorder (69).”

    From Impact of Sleep and Circadian Rhythms on Addiction Vulnerability in Adolescents (2018) · cites this paper as [69]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Rhythmicity-Sleep increases are described as accelerating disorder onset despite hazard ratios below 1

    Minor

    The text says a 1-SD increase in Rhythmicity-Sleep produces an 18% faster onset of alcohol use disorder, but Table 1 gives a hazard ratio of 0.82 for that increase, indicating an 18% lower onset hazard. The same direction mismatch appears in the stated cannabis and cocaine use disorder effects.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Conroy, D. A., Hairston, I. S., Zucker, R. A., & Heitzeg, M. M. (2015). Sleep patterns in children of alcoholics and the relationship with pa- rental reports. Austin Journal of Sleep Disorders, 2, 1009. Retrieved from http://austinpublishinggroup.com/sleep-disorders/fulltext/ajsd v2-id1009.php
  2. First, M. B., Spitzer, R. C., Gibbon, M., & Williams, J. B. W. (2002). Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Re- search Edition. New York, NY: Biometrics Research, New York State Psychiatric Institute.

Cited by

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Related

Authors
Hasler, B. P., Kirisci, L., & Clark, D. B.
Affiliations
University of Pittsburgh (US)
Corresponding author
Hasler, Brant P.
ORCID
Venue
Journal of Studies on Alcohol and Drugs
Publisher
Alcohol Research Documentation, Inc.
Published
2016-07
Volume
77
Issue
4
Pages
649-655
ISSN
  • 1937-1888 (ISSN-L)
  • 1938-4114
DOI
10.15288/jsad.2016.77.649
PMC
PMC4987074
OpenAlex
W2466710881
Semantic Scholar
beecc9d3afaa71d1a7df0a69b5064f2785c3bf43
Cited by
87
References
47
Citations by year
2026: 3 · 2025: 10 · 2024: 13 · 2023: 4 · 2022: 9 · 2021: 10 · 2020: 11 · 2019: 8 · 2018: 8 · 2017: 10 · 2016: 1
Type
journal article
Language
en
Open access
Locations
  • Journal of Studies on Alcohol and Drugs (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • National Institutes of Health
  • National Institute on Alcohol Abuse and Alcoholism (U01AA021690)
  • National Institute on Drug Abuse (K01DA032557, P50DA005605)
Topics
  • Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords
restless sleep, sleep disorders, late childhood, alcohol use onset, substance use disorders, major depressive disorder, age at first use, premorbid risk factors
MeSH terms
Adolescent, Adult, Child, Female, Humans, Male, Pennsylvania, Prospective Studies, Risk Factors, Sleep Wake Disorders, Proportional Hazards Models, Substance-Related Disorders, Young Adult

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