Sleep-Related Problems Among Children and Adolescents With Anxiety Disorders

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Sleep-Related Problems Among Children andAdolescents With Anxiety Disorders

CANDICE A. ALFANO, PH.D., GOLDA S. GINSBURG, PH.D.,

AND JULIE NEWMAN KINGERY, PH.D.

ABSTRACT

Objective: The present study examined sleep-related problems (SRPs) among a large sample (n = 128) of youth with

anxiety disorders (i.e., generalized, separation, and social). The frequency of eight specific SRPs was examined in relation

to age, gender, type of anxiety disorder, anxiety severity, and functional impairment. The impact of pharmacological

treatment (fluvoxamine versus pill placebo) in reducing SRPs also was examined.Method:As part of a large, double-blind,

randomized, controlled trial (Research Units on Pediatric Psychopharmacology Anxiety Study Group), clinician and parent

reports of SRPs were examined among children and adolescents, ages 6 to 17 years, before and after treatment.

Results: Eighty-eight percent of youth experienced at least one SRP, and a majority (55%) experienced three or more.

Total SRPs were positively associated with anxiety severity and interference in family functioning. Significantly greater

reductions in SRPs were found among children treated with fluvoxamine compared with placebo. Conclusions: These

findings indicate that SRPs are commonly associated with childhood anxiety disorders and suggest a need for the

assessment of and attention to these problems in research and clinical settings. J. Am. Acad. Child Adolesc. Psychiatry,

2007;46(2):224Y232. Key Words: sleep problems, childhood anxiety, anxiety severity, impairment, treatment.

Adequate sleep is essential for health and normalgrowth and development in children. Because insuffi-cient sleep has been associated with impairments such

as decreased attention, impulsivity, behavioral prob-lems, and decrements in school performance (Mindellet al., 1999), there is a need to better understand theassociation between sleep disturbances and psychiatricsymptoms in children. The term sleep disturbance is, infact, quite broad and often is used to refer to a range ofsleep problems that may be influenced by intrinsic (e.g.,difficulty initiating/maintaining sleep) and/or extrinsic(e.g., poor sleep hygiene, bedtime resistance) factors.Moreover, compared with adults, sleep disturbancesamong children generally encompass a wider range ofproblem behaviors. For example, in addition toproblems initiating sleep, anxious children commonlyexperience nonspecific nighttime fears, nightmares, anddifficulty sleeping alone/away from home, all of whichmay disrupt sleep continuity and quality and result inexcessive daytime somnolence. Thus, we refer to thisrange of potential nighttime difficulties among anxiouschildren more broadly as sleep-related problems (SRPs).Among children with anxiety disorders, research

examining SRPs and their potential impact on daytimefunctioning is extremely limited. However, data basedon community samples of children reveal an important

Accepted July 18, 2006.Dr. Alfano is with the Department of Psychiatry, Children’s National

Medical Center, Washington, DC; Drs. Ginsburg and Kingery are with theDepartment of Psychiatry and Behavioral Sciences, Division of Child andAdolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore.Preparation of this paper was supported by NIMH grant K23-MH63427-02

awarded to Dr. Ginsburg.The authors wish to acknowledge the Research Units on Pediatric

Psychopharmacology Anxiety Group (RUPP) sites that supported the datacollection for this study: Mark A. Riddle, M.D., John T. Walkup, M.D., andMichael J. Labellarte, M.D., Johns Hopkins University; Daniel S. Pine, M.D.,Laurence Greenhill, M.D., Rachel Klein, Ph.D., and Michael Sweeney, Ph.D.,Columbia University and New York State Psychiatric Institute; HowardAbikoff, Ph.D., Sabine Hack, M.D., and Brian Klee, M.D., New YorkUniversity; James McCracken, M.D., Lindsey Bergman, Ph.D., and JohnPiacentini, Ph.D., University of California, Los Angeles; John March, M.D.,M.P.H., and Scott Compton, Ph.D., Duke University; and Ben Vitiello, M.D., National Institute of Mental Health.Correspondence to Dr. Candice Alfano, Department of Psychiatry, Children_s

National Medical Center, 111 Michigan Avenue, NW, Washington, DC20010; e-mail: [email protected]/07/4602-0224�2007 by the American Academy of Child

and Adolescent Psychiatry.DOI: 10.1097/01.chi.0000242233.06011.8e

224 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:2, FEBRUARY 2007


association between sleep problems and anxiety. Forexample, Mindell and Barrett (2002) reported incre-mental increases in trait anxiety relative to an increasedfrequency of nightmares among 60 children (ages 5Y11years) recruited from elementary school classrooms. Forchildren reporting three or more nightmares per week,parent-reported anxiety scores approached the clinicallysignificant range. Using longitudinal data, Gregory andO_Connor (2002) examined the relation between par-ent report of early sleep problems and the developmentof emotional/behavioral problems during midadoles-cence in a large community sample of children (n = 490).The presence of sleep problems at age 4 significantlypredictedproblemsofanxiety/depressionatages13to15.A second longitudinal investigation used a large com-munity sample (n = 943) to examine early sleep problemsas predictors of later psychiatric diagnoses (Gregoryet al., 2005). Among the 12% of children whose parentsreported persistent sleep problems from ages 5 to 9,almost half (46%) developed an adult anxiety disorder.In contrast, persistent sleep problems during childhooddid not significantly predict the development of adultdepressive disorders.

Only a few studies have examined SRPs amongclinically anxious youth. Using a large sample of children(n = 157) with generalized anxiety disorder (GAD), Masiand colleagues (2004) found that 56% of children and49% of adolescents experienced a Bsleep disturbance[based on combined parent and child reports. Similarly,Pina and colleagues (2002) reported that 42%of childrenand 57% of adolescents with GAD/overanxious disorder(n = 111; ages 7Y16) experienced Btrouble sleeping,[ andKendall and Pimentel (2003) reported the presence ofBsleep disturbance[ among 66% of children with GAD(n = 47; ages 9Y13) based on child and parent report.Further information regarding the specific nature of sleepproblems experienced by anxious youth was notprovided. Thus, this small body of research is limitedto children with GAD and is restricted to broad,nonspecific indexes of sleep disturbance.

Limited data based on the use of polysomnographyalso provide preliminary support for the presence ofdisrupted sleep among anxious youth. Rapoport et al.(1981) reported reduced sleep efficiency and increasedsleep latency among nine adolescents (ages 13Y17) withobsessive-compulsive disorder compared with matchedhealthy controls. Adolescents with obsessive-compulsivedisorder required twice as long as control adolescents to

initiate sleep onset. Although research using objectivemeasures of sleep among youth with other anxietydisorders has not been conducted, studies of anxiety-disordered adults indicate different forms of sleepdisruption to be highly prevalent (see Uhde, 2000).Research examining the frequency of specific SRPsamong anxious youth, including potential associationswith age, gender, type of anxiety disorder, anxietyseverity, and impaired daytime functioning, may there-fore provide important information for both researchersand clinicians.Similar to a need for information concerning sleep

disruption among anxious youth, data examining theimpact of effective treatments for childhood anxiety onco-occurring SRPs also are needed. One study reportedgeneral decreases in somatic symptoms (including oneBsleep disturbance[ item) among children with GADafter cognitive-behavioral treatment, although reduc-tions in specific SRPs were not examined (Kendall andPimentel, 2003). With regard to pharmacologicaltreatment studies, outcomes related to sleep areparticularly relevant. Because the neurotransmittersystems involved in the modulation of anxiety also areimplicated in the regulation of sleep and becausepharmacological agents, including selective serotoninreuptake inhibitors (SSRIs), that reduce anxiety alsohave been shown to alter sleep (see Sandor and Shapiro,1994), improvement in symptoms across both domainsmay be observed. Several published studies havereported significant decreases in children_s anxietysymptoms after treatment with an SSRI (March et al.,1998; Research Unit on Pediatric PsychopharmacologyAnxiety Study Group, 2001; Wagner et al., 2004), yetsleep-related outcomes have not been examined.The present study begins to address these gaps in the

literature through preliminary examination of severaltypes of SRPs among a large sample of youth withanxiety disorders. In particular, the frequency of eightspecific SRPs was examined in relation to age, gender,and type of anxiety disorder (i.e., GAD, separationanxiety [SAD], and social anxiety [SOC]) on the basisof both parent and clinician assessment. Second,associations between SRPs, anxiety severity, andimpairment in daytime functioning both within andoutside the home were examined. On the basis offindings from community-based samples of children(e.g., Mindell and Barrett, 2002; Mindell et al., 1999),we hypothesized that the presence of SRPs would be

SLEEP PROBLEMS AND ANXIOUS CHILDREN

225J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:2, FEBRUARY 2007


related to higher levels of anxiety severity and im-pairments across both domains. Finally, we examinedthe impact of pharmacological treatment in reducingSRPs among anxious youth. In particular, we examinedclinician report of three specific SRPs after 8 weeks oftreatment with either fluvoxamine (FLV) or pill pla-cebo (PBO). We hypothesized that treatment with anSSRI would produce a significant decrease in SRPsrelative to placebo.

METHOD

Participants

Participants were 128 children, 6 to 17 years of age (mean, 10.8years), who met DSM-IV criteria for GAD, SAD, and/or SOC onthe basis of child and parent Schedule for Affective Disorders andSchizophrenia for School-Aged Children (Kaufman et al., 1997)interviews with a trained clinician (see Research Units on PediatricPsychopharmacology Anxiety Study Group, 2001). All childrenwere enrolled in a double-blind, placebo-controlled, clinical trial ofFLV for youth with anxiety disorders (i.e., SOC, SAD, and/orGAD). Children were recruited from five sites designated ResearchUnits in Pediatric Psychopharmacology (RUPP): Duke University,Johns Hopkins School of Medicine, New York State PsychiatricInstitute/Columbia University, New York University, and Univer-sity of California, Los Angeles. Sample characteristics are presentedin Table 1.Exclusion criteria included current use of any illicit or prescribed

psychoactive substance; current diagnoses of major depressivedisorder, Tourette_s disorder, obsessive-compulsive disorder, post-traumatic stress disorder, conduct disorder, or panic disorder; anypast or current history of mania, psychosis, or pervasive develop-mental disorder; suicidal ideation; mental retardation; previoustreatment with a selective serotonin reuptake inhibitors; and adiagnosis of attention-deficit/hyperactivity disorder that requiredpharmacological treatment.

Measures

Pediatric Anxiety Rating Scale. The Pediatric Anxiety Rating Scale(PARS; Research Units on Pediatric Psychopharmacology AnxietyStudy Group, 2002) is a clinician-rated instrument for assessing theseverity of anxiety symptoms associated with childhood anxietydisorders. The instrument has two sections. The first sectionincludes a 50-item symptom checklist in which items are rated aspresent or absent during the past week. The second section is madeup of five severity items and two impairment items (rated on a 5-point Likert scale), with higher scores reflecting greater severity/impairment. Internal consistency, test-retest reliability, and validityfor the PARS have been found to be acceptable (Research Units onPediatric Psychopharmacology Anxiety Study Group, 2002).Hamilton Anxiety Rating Scale. TheHamiltonAnxiety Rating Scale

(HAM-A; Hamilton, 1959) is a 14-item, clinician-rated instrument forassessing the severity of anxiety symptoms. Items are scored from none(0) to very severe (4). The psychometric properties of the HAM-A havebeen shown to be acceptable (Maier et al., 1988).Child Behavior Checklist-Parent Version. The Child Behavior

Checklist-Parent Version (CBCL; Achenbach and Edelbrock,

1991) is a factor analytically derived checklist including a broadrange of child behaviors. Parents are asked to rate 113 items as nottrue (0), sometimes true (1), or often/always true (2) on the basis oftheir child_s behavior during the past 6 months. The CBCL yields atotal problems score, internalizing and externalizing problemsscores, and eight subscales. Ample evidence supports the psycho-metric properties of the CBCL.Children_s Global Assessment Scale. The Children_s Global

Assessment Scale (CGAS; Shaffer et al., 1983), a modification ofthe adult GAS, is a widely used measure of global impairment infunctioning. Scores range from 1 to 100, with higher scores reflectinghigher levels of functioning.Clinician_s Global Impression-Severity of Illness. The Clinician_s

Global Impression-Severity of Illness (CGI-S; Guy, 1976), a widelyused measure to assess global severity of illness, was used to assessseverity of anxiety (based on a 7-point scale). Higher scores reflectmore severe anxiety.Sleep-Related Problems. Because a standardized measure of sleep

problems was unavailable as part of the original RUPP anxiety dataset, information on eight specific SRPs was gathered from threeseparate measures. Specifically, the PARS includes two sleep itemsassessing refusal/reluctance to sleep alone and refusal/reluctance tosleep away from home; the HAM-A includes one item assessing thepresence of insomnia (defined as difficulty initiating or maintainingsleep); and the CBCL includes five sleep items assessing nightmares,being overtired without good reason, sleeping less than most kids,sleeping more than most kids, and talking/walking during sleep. To

TABLE 1Demographic and Clinical Characteristics of Entire Sample

Characteristic n %

Age, y6Y11 86 6712Y17 42 33

Female gender 63 49.2EthnicityWhite 81 63.3Hispanic 24 18.8Black (non-Hispanic) 9 7.0Other 14 10.9

Total family income, $<25,000 19 14.825,000Y39,999 20 15.640,000Y59,999 18 14.1960,000 55 43.0Refused/unknown 16 12.5

K-SADS diagnosisSOC only 26 20.3SAD only 18 14.1GAD only 5 3.9SOC and SAD only 11 8.6SOC and GAD only 21 16.4SAD and GAD only 21 16.4SOC, SAD, and GAD 26 20.3

Note: K-SADS = Schedule for Affective Disorders andSchizophrenia for School-Aged Children; SOC = social anxietydisorder; SAD = separation anxiety disorder; GAD = generalizedanxiety disorder. N = 128.

ALFANO ET AL.



examine overall levels of sleep disturbance, these eight sleep itemswere combined to create a total SRP score, computed by addingresponses for all items across measures (scored as either 0 = notpresent or 1 = present) for a total possible score ranging from 0 to 8.To standardize total SRP scores, some items had to be recoded. Forthe CBCL items, responses based on a 3-point scale weredichotomized so that a response of either sometimes true (1) oroften/always true (2) was coded as a yes. For the HAM-A items,responses based on a 5-point scale were dichotomized so that aresponse of moderate (2), severe (3), or very severe (4) was coded asa yes. Internal consistency was computed for the total SRP scale andwas acceptable (! = .64).Anxiety Severity. In addition to the CGI-S, which assesses global

severity of illness, three severity items from the PARS werecombined to create a total anxiety severity score. These itemsincluded overall anxiety severity, severity of somatic/physicalsymptoms of anxiety, and frequency of anxiety symptoms. Twoseverity items from the PARS were not used in the present studybecause the calculation of one item (total number of anxietysymptoms) is directly influenced by the endorsement of sleep items,and the conceptual basis for examining the other item (overallavoidance of anxiety-provoking situations) in association with SRPis unclear. The HAM-A total anxiety score (minus the insomniaitem) also was used to assess overall severity of anxiety.Impairment. Two items from the PARS were used to assess

impairment: interference at home/family functioning (includingrelationships with parents/siblings, impact on family activities,completion of chores, etc.) and interference outside the home/peerrelationships (including, e.g., school performance, extracurricularactivities, relationships with peers). The CGAS provided a measureof global impairment of functioning.

Procedure

After a full description of the study, all of the parents and childrensigned informed consent/assent (see RUPP, 2001 for details). Acomprehensive pretreatment evaluation, including a diagnosticinterview and additional measures to assess inclusion/exclusioncriteria and primary outcomes, was conducted. During the 8-weektreatment phase, child psychiatrists who were naıve about children_streatment assignment saw each child and parent on a weekly basisfor the first 6 weeks and again at week 8. At each visit, child

psychiatrists administered supportive psychoeducational therapy tochildren and families, conducted a clinical assessment of anxietysymptoms, assessed adverse events, and determined medicationdosage following a flexible, forced dose titration (i.e., psychiatristsfollowed a fixed schedule unless clinical factors indicated the needfor a slower titration).

Data Analyses

Data were analyzed with SPSS 13.0 statistical software. Paired-sample t tests and x2 tests were used to examine differences in totaland individual SRPs based on age, gender, and type of anxietydisorder. Pearson correlation coefficients were used to examineassociations between SRPs, anxiety severity, and functionalimpairment, and a hierarchical linear regression model was usedto examine SRPs as a predictor of impaired functioning. A repeated-measures analysis of variance was used to examine changes in totalSRPs from before to after treatment, and follow-up x2 tests wereused to examine changes across individual SRP.

RESULTS

Gender, Age, and Anxiety Disorder

Frequencies of the eight sleep items are presented inTables 2 and 3 for the total sample and by gender, agegroup, and diagnosis (GAD, SAD, and SOC). Eighty-eight percent of the total sample reported at least oneSRP; 55% reported three or more SRPs. The mostcommon SRPs were insomnia, nightmares, and refusal/reluctance to sleep alone.Gender. The difference for mean number of SRPs

among girls compared with boys was not statisticallysignificant. In terms of individual SRPs, nightmares[x2(117) = 4.12, p < .05] were significantly morecommon among girls than boys.Age. The difference for mean number of SRPs

among younger children (ages 6Y11) compared with

TABLE 2Sleep-Related Problems by Gender and Age

SRPTotal

(N = 128), %Male

(n = 65), %Female

(n = 63), %Ages 6Y11(n = 86), %

Ages 12Y17(n = 42), %

Insomnia 66.6 60.7 72.1 70.7 59.5Reluctance/refusal to sleep alone 47.9 46.5 50.8 61.0** 26.2Reluctance/refusal to sleep away from home 40.9 44.8 40.0 44.7 38.1Nightmares 54.5 44.0 62.7* 63.8** 31.6Overtired without good reason 43.2 40.7 45.8 42.5 44.7Sleeps less than most kids 36.9 33.3 40.7 36.3 38.5Sleeps more than most kids 15.1 15.0 15.3 11.3 23.1Talks/walks in sleep 22.7 21.7 23.7 25.0 17.9Mean no. SRPs (SD) 2.9 (1.9) 2.7 (1.9) 3.1 (2.0) 3.1 (1.8) 2.5 (2.1)

Note: SRPs = sleep-related problems. Some SRP items were missing for some subjects.* p < 0.05; **p < 0.01.




older children (ages 12Y17) was not statisticallysignificant. However, younger anxious children weremore likely to exhibit refusal/reluctance to sleep alone[x2(119) = 13.21, p < .001] and to experience nightmares[x2(118) = 10.72, p < .01] than older children.Anxiety Diagnosis. The limited number of children

with a single anxiety disorder precluded statisticallymeaningful comparisons of SRPs for children with onlyone anxiety disorder. Thus, Table 3 displays the meansfor total number of SRPs and the frequencies for eachindividual SRP among youth with and without GAD,SAD, and SOC.Ninety-eight percent of children with a GAD

diagnosis had at least one SRP. Children with adiagnosis of GAD had a significantly greater number ofSRPs compared with youth without a GAD diagnosis[t (1, 125) = 2.55, p < .01]. In addition, children with GADwere more likely to experience insomnia [x2(117) = 4.51,p < .05] than children without GAD.Ninety-seven percent of children with a SAD

diagnosis had at least one SRP. Children with adiagnosis of SAD had a significantly greater number ofSRPs compared with youth without an SAD diagnosis[t (1, 125) = 4.55, p < .001]. Analyses of individual SRPrevealed that children with a diagnosis of SAD weremore likely to experience insomnia [x2(117) = 6.11,p < .025], reluctance/refusal to sleep alone [x2(119) =21.47, p < .001], reluctance/refusal to sleep away fromhome [x2(117) = 24.03, p < .001], and nightmares[x2(118) = 8.21, p < .01] than children without SAD.Ninety percent of children with an SOC diagnosis

had at least one SRP. Overall, children with a diagnosisof SOC had significantly fewer SRPs compared with

youth without an SOC diagnosis [t (1, 124) = j3.05,p < .01]. Children with a diagnosis of SOC were lesslikely to exhibit reluctance/refusal to sleep alone[x2(118) = 9.82, p < .01] and reluctance/refusal tosleep away from home [x2(116) = 8.56, p < .01] thanchildren without a diagnosis of SOC.

Anxiety Severity and Impairment

Pearson correlation coefficients between total SRPscores and measures of anxiety severity and impairmentin functioning at baseline are presented in Table 4. TotalSRPs were positively and significantly associated withCGI-S scores, PARS anxiety severity, HAM-A total scores,and PARS interference at home/family functioning.

Do SRPs Independently Predict Impairment in Family

Functioning?

Because correlations between total SRPs, anxietyseverity, and interference at home/family functioningwere found to be significant, we were interested inexamining whether SRPs independently predictedinterference at home/family functioning or alternativelywhether this association may be better explained byoverall higher levels of anxiety severity among childrenwith SRPs. A hierarchical linear regression examiningthe prediction of interference at home/family function-ing was therefore conducted. PARS anxiety severity,HAM-A total score, and CGI-S score were entered andcontrolled for in step 1 of the model. Total SRP scorewas then entered into the model in the step 2. Resultsindicated that total SRP score was a significant predic-tor of impairment in home functioning after control-ling for severity of anxiety (" = .26, p < .01, R2 = 0.21).

TABLE 3Sleep-Related Problems by Anxiety Diagnosis

SRPSOCj(n = 52)

SOC+(n = 76)

GADj(n = 67)

GAD+(n = 61)

SADj(n = 52)

SAD+(n = 76)

Insomnia 77.3 60.3 37.3 56.9* 52.1 76.8**Reluctance/refusal to sleep alone 66.7* 37.0 48.4 49.1 22.9 66.2**Reluctance/refusal to sleep away from home 60.0* 32.4 40.3 45.5 16.3 61.8**Nightmares 62.5 46.4 45.9 61.4 37.5 64.3**Overtired without good reason 43.8 43.5 35.5 51.8 37.5 47.1Sleeps less than most kids 42.9 31.9 30.6 43.9 33.3 39.4Sleeps more than most kids 16.3 14.5 16.1 14.0 14.6 15.5Talks/walks in sleep 26.5 18.8 16.1 29.8 16.7 26.8Mean no. SRPs (SD) 3.5 (1.7) 2.5 (2.0)* 2.5 (1.8) 3.3 (1.9)* 2.0 (1.8) 3.5 (1.8)**

Note: SOC = social anxiety disorder; SAD = separation anxiety disorder; GAD = generalized anxiety disorder; j = not present; + = present.* p < 0.05; **p < 0.01.

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Impact of Treatment

Mean total scores and percentages for individual SRPitems at baseline and after treatment for children in theFLV and PBO groups are presented in Table 5. BecauseCBCL data were available only at baseline, changes inSRP from pre- to posttreatment were examined forthree clinician-rated SRP items only (from the PARSand HAM-A), with total SRP scores ranging from 0 to3. At baseline, children in the FLV and PBO groups didnot differ in terms of total SRP scores or on any of theindividual SRP items.

A 2 � 2 repeated-measures analysis of variance(treatment group by time) examining changes in total

SRP scores revealed a significant main effect for time[F(1, 104) = 34.41, p < .001]. The treatment group-by-time interaction also was significant [F(1, 104) = 9.43,p < .01], revealing a significantly greater reduction inSRP among children treated with FLV. Treatmentresults were not moderated by gender or age. Follow-upx2 analyses examining change in status (i.e., present atbaseline versus present/absent after treatment) for eachof the three SRP items from baseline to posttreatmentrevealed a significant difference between the groupsfor two of the three items. Both insomnia [x2(102) =10.55, p < .05] and reluctance/refusal to sleep alone[x2(104) = 10.18, p < .05] were significantly reducedwith FLV compared with PBO. Significant reductionsin reluctance/refusal to sleep away from home werefound for both FLV and PBO children after treatment.

DISCUSSION

Prevalence of SRPs Among Anxious Youth

Eighty-eight percent of anxious youth experienced atleast one SRP, and more than half experienced three ormore. The most common SRPs were insomnia, night-mares, and reluctance/refusal to sleep alone. Rates ofinsomnia found in the present study are consistent withdata indicating insomnia to be present among 60% to70% of adults with anxiety disorders (Ohayon, 1997;Uhde, 2000). Although there were no gender or agedifferences in total number of SRPs, nightmares were

TABLE 5Mean Scores and Percentages for Sleep-Related Problems AmongFluvoxamine and Placebo Children at Baseline and After Treatment

SRP

FLV (n = 54) PBO (n = 51)

BaselineAfter

Treatment BaselineAfter

Treatment

Insomnia, % 50.8 11.1* 43.1 33.9Reluctance/refusal tosleep alone, %

53.3 27.3* 44.1 39.3

Reluctance/refusal tosleep away fromhome, %

44.1 22.2* 41.4 27.8*

Total mean SRPs(SD), no.

1.4(1.2)

0.61(9.4)*

1.2(1.1)

0.90(1.0)

Note: FLV = fluvoxamine; PBO = placebo.* Between-group change from baseline to after treatment, p < .05.

TABLE 4Bivariate Correlations for Sleep-Related Problems, Anxiety Severity, and Impairment

TotalSRP CGI-S

PARS AnxietySeverity

HAM-A TotalAnxiety CGAS

At-HomeImpairment

Out-of-HomeImpairment

Total SRP VCGI-S 0.18* VPARS anxietyseverity

0.34** 0.41** V

HAM-A totalanxiety

0.54** 0.22* 0.59** V

CGAS j0.18 j0.58** j0.32** j0.15 VAt-homeimpairment

0.39** 0.30** 0.24** 0.34** j0.22* V

Out-of-homeimpairment

j0.05 0.42** 0.30** 0.09 j0.35** 0.12 V

Note: CGI-S = Clinical Global Impression Scale-Severity of Illness; PARS = Pediatric Anxiety Rating Scale; HAM-A = Hamilton AnxietyRating Scale; CGAS = Children_s Global Assessment Scale.

* p < 0.05, **p < 0.01.




significantly more common among girls compared withboys, and younger children were more likely to refuse tosleep alone and experience nightmares than adolescents.Although some specific SRPs represent appropriatedevelopmental fears for many young children, theseproblems were experienced by almost two thirds of girls/young anxious children, a rate that is considerably higherthan that found in the general population (Mindell,1993). It should be noted, however, that because many ofthe younger children in the present study had a diagnosisof SAD, age-based differences in SRPs may have beeninfluenced by anxiety diagnosis. Future research will needto further examine these differences.

SRPs Across Anxiety Diagnoses

SRP were most prevalent among youth with GADand SAD. For children with a GAD diagnosis, insom-nia was the most common SRP. Because complaints ofdifficulty initiating/maintaining sleep are highly pre-valent in adults with GAD, insomnia is considered acore feature of the illness (Monti and Monti, 2000).Such findings have led to the hypothesis that symptomsof hypervigilance and hyperarousal associated with GADmay directly lead to problems initiating/maintainingsleep (Saletu-Zyhlarz et al., 1997). Indeed, a similarprocess may be present for youth with the disorder.Because the self-regulatory skills of children are likely tobe underdeveloped compared with adults, sleep onsetand maintenance, which require the ability to self-regulate and self-soothe, may pose a particular challengefor children and adolescents.Among children with an SAD diagnosis, insomnia,

nightmares, and refusal to sleep alone were commonlyreported. However, specific overlap in some SRPsexamined in the present study and DSM-IV diagnosticcriteria for SAD are noteworthy. Nighttime may beparticularly difficult for children with SAD because ofassociations with darkness and separation from care-givers. Nonetheless, because feelings of fear and arousalare inherently incompatible with sleep onset andmaintenance, the potential exists for these SRPs todisrupt sleep continuity and quality on an ongoingbasis. The extent to which nighttime fears and otherSRPs among anxious children may result in chronicsleep disruption is unknown.Although examination of the shared mechanisms

underlying sleep disruption and anxiety in children hasyet to be conducted, SRPs also may be influenced by

environmental/familial factors. Parents of anxiouschildren may reinforce children_s nighttime fears andavoidant behaviors through the use of ineffectiveparenting strategies, including excessive reassurance,extension of bedtimes, and/or permitting cosleepingwith parents or siblings (e.g., Dadds et al., 1996). Onerecent study found that not putting children to bedwhile awake and cosleeping were associated withchildhood sleep disorders among children at risk forthe development of anxiety (Warren et al., 2003).Among clinically anxious children, such parentingbehaviors may interfere with the development of self-regulatory skills and contribute to increased levels ofarousal at bedtime, ultimately resulting in an increase inboth anxiety and sleep disruption.

SRPs, Anxiety Severity, and Impairment

Consistent with community-based research (Mindelland Barrett, 2002), these findings suggest that thepresence of SRPs is associatedwith higher levels of anxietyseverity. Although the causal nature of this relationshipcannot be determined from these data, several possibi-lities remain to be addressed. Longitudinal studiesindicate sleep problems to be early markers for the laterdevelopment of psychopathology (Ford and Kamerow,1989), including anxiety disorders (Gregory et al., 2005),and the presence of increased levels of anxiety maysimilarly lead to the development of SRP in children. Asdiscussed by Dahl (1996), a reciprocal relationshipbetween sleep disruption and psychopathology, ingeneral, is most likely. Because sleep, arousal, and affectrepresent overlapping regulatory systems, the presence ofsleep disruption during critical periods of maturationaldevelopment may provide a pathway toward lateraffective dysregulation and vice versa (see Dahl, 1996for a review). At present, specific mechanisms andprocesses mediating the regulation of sleep and affect arepoorly understood, and data examining this overlap insymptoms among clinic-referred children are needed.The presence of SRPs also was associated with

impairment within the home. In fact, SRPs indepen-dently predicted interference at home/in familyfunctioning after controlling for severity of anxiety.Contrary to expectations, SRPs and impairment out-side the home/in peer relationships were not associated.This finding is somewhat surprising in light of researchlinking childhood sleep disruption with impairments inacademic and behavioral functioning (Bruni et al.,

ALFANO ET AL.



2006; Wolfson and Carskadon, 1998). One possibilityfor these divergent findings includes the limitedmeasures of interference used in the present study.Future research examining SRPs among anxious youthshould include more specific measures of academic,behavioral, and interpersonal functioning to begin toelucidate the potential daytime sequelae of SRP in thispopulation of children.

It also is possible that among anxious children,functioning within the home and in family relation-ships may be affected more adversely by the occurrenceof SRPs. Previous studies examining family andparenting variables in connection with childhoodanxiety have highlighted the presence of dysfunctionalprocesses, including overcontrol, enmeshment, reinfor-cement of anxious behaviors, and conflict (see Ginsburget al., 2004). Children_s SRPs may be particularlydisruptive within these environments because of theirimpact on other family members. Over time, thesenighttime difficulties may become a major componentof parenting stress and family discord within the home.

Changes in SRPs After Pharmacological Treatment

As predicted, children treated with FLV evidencedgreater decreases in SRPs after treatment relative tochildren receiving PBO. The greatest reduction wasfound for insomnia. Although several treatment studieshave reported insomnia as an adverse effect of SSRItreatment in children, the present results suggest thatinsomnia and other SRPs are diminished after 8 weeksof treatment with FLV. However, it is important tonote that only three SRPs were examined aftertreatment, that significant improvement in one SRPwas found among PBO children, and that approxi-mately one fourth of children treated with FLV con-tinued to experience difficulty sleeping alone and/oraway from home after treatment. As such, the potentialrole of neurobiological, biobehavioral, and environ-mental factors in the presentation of SRPs amonganxious children requires further investigation. As a firststep toward gathering these data, both pharmacologicaland behavioral treatment studies should includestructured assessment of children_s sleep problems atbaseline, after treatment, and at follow-up intervals.

Limitations

We examined eight specific SRPs in the presentstudy, but many other potential SRPs were not

examined (e.g., bedtime resistance, poor sleep hygiene)and should be included in future research. The presentstudy did not include a standardized instrument toassess sleep behaviors/problems but instead relied ondata from several parent- and clinician-reported mea-sures as part of an existing database. Thus, findingsshould be interpreted with caution because, in general,sleep problems are common in children and do notnecessarily indicate the presence of a sleep disorder.Along these lines, the extent to which parents of anxiousyouth may have simply endorsed SRPs as symptomsconfirming their child_s anxiety diagnosis also is unclear.Ultimately, because parent, child, or clinician reportdoes not provide an objective assessment of children_ssleep, data based on the use of polysomnography andactigraphymethods are needed to better determine sleepcharacteristics of anxious youth. We also note thatbecause some sleep items and measures of anxietyseverity/impairment were drawn from the same instru-ments, the possibility of measurement effects exists.Finally, because anxious children in the present studyvolunteered to participate in a psychopharmacologicaltreatment trial and met specific inclusion/exclusioncriteria, the generalizability of phenomenological find-ings to all anxious youth awaits further study.

Clinical Implications

Findings from the present study indicate SRPs to bea common feature of childhood anxiety disorders andunderscore the need for research in this area thatincludes objective assessment of sleep. Results suggestthat clinicians should obtain detailed informationrelated to both sleep and anxiety in children presentingwith difficulties in either domain. Research in this areamay provide crucial information on the temporality ofthe relationship between childhood SRPs and anxietybecause emerging data suggest sleep problems to beearly markers for nascent psychopathology, includinganxiety disorders (Gregory et al., 2005). The significantassociation found between SRPs and impaired familyfunctioning also is worthy of further investigation. Abetter understanding of the nature of this relationshipmay provide guidance in designing effective interven-tions for both childhood anxiety and sleep problems.Finally, data suggest that FLV may be an effectivetreatment for children with comorbid anxiety and sleepproblems, although prospective data based on standar-dized instruments for assessing sleep are needed.




Disclosure: The authors have no financial relationships to disclose.

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Sleep-Related Problems Among Children and Adolescents With Anxiety Disorders

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