Sleep-Related Problems Among Children and Adolescents With Anxiety Disorders

doi:10.1097/01.chi.0000242233.06011.8e

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 46, Issue 2, February 2007, Pages 224-232

https://doi.org/10.1097/01.chi.0000242233.06011.8e Get rights and content

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.

Section snippets

Participants

Participants were 128 children, 6 to 17 years of age (mean, 10.8 years), who met DSM-IV criteria for GAD, SAD, and/or SOC on the basis of child and parent Schedule for Affective Disorders and Schizophrenia for School-Aged Children (Kaufman et al., 1997) interviews with a trained clinician (see Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2001). All children were enrolled in a double-blind, placebo-controlled, clinical trial of FLV for youth with anxiety disorders (i.e.,

Gender, Age, and Anxiety Disorder

Frequencies of the eight sleep items are presented in Tables 2 and 3 for the total sample and by gender, age group, and diagnosis (GAD, SAD, and SOC). Eighty-eight percent of the total sample reported at least one SRP; 55% reported three or more SRPs. The most common SRPs were insomnia, nightmares, and refusal/reluctance to sleep alone.

Prevalence of SRPs Among Anxious Youth

Eighty-eight percent of anxious youth experienced at least one SRP, and more than half experienced three or more. The most common SRPs were insomnia, nightmares, and reluctance/refusal to sleep alone. Rates of insomnia found in the present study are consistent with data indicating insomnia to be present among 60% to 70% of adults with anxiety disorders (Ohayon, 1997, Uhde, 2000). Although there were no gender or age differences in total number of SRPs, nightmares were significantly more common

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Given the high prevalence of anxiety disorders and their associated impairment, elucidating neural mechanisms related to these disorders has been increasingly prioritized. The error-related negativity (ERN) has been identified as a neural marker that indexes risk for anxiety across development. The ERN seems to confer risk for developing anxiety, especially in the context of stressful life events. The present study sought to examine sleep-related difficulties as another stressful factor that might impact the ERN. In a sample of 221 girls, aged 8 to 15 years old, we first examined the relationship between longer-term (i.e., over the past month) and shorter-term (i.e., over the past week) sleep difficulties and the ERN. We then investigated whether specific sleep difficulties uniquely predict the ERN. In exploratory analyses, we assessed whether sleep difficulties moderate the relationship between the ERN and anxiety. Results indicated that youth who report longer-term lower sleep duration, longer-term worse sleep, and shorter-term lower sleep duration on school days over the past week have a larger (i.e., more negative) ERN. Additionally, only shorter-term sleep duration on school days over the past week uniquely predicted the ERN. Finally, an elevated ERN predicted greater clinical anxiety in the context of longer-term sleep difficulties. Future studies should clarify the direction of these associations via longitudinal designs.
Social interaction anxiety and sleep quality in youth: Individual difference in childhood adversity and cardiac vagal control
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Social interaction anxiety and sleep problems are prevalent during adolescence. Social interaction anxiety undermines sleep quality, however, little is known whether the association between social interaction anxiety and sleep quality is moderated by environmental factors such as childhood adversity and individual factors such as cardiac vagal control. This study sought to investigate the moderating effects of childhood adversity and cardiac vagal control on the link between social interaction anxiety and sleep quality.
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Social interaction anxiety was negatively associated with sleep quality, and this association was moderated by childhood adversity and cardiac vagal control. In specific, social interaction anxiety was negatively associated with sleep quality among adolescents with low childhood adversity regardless of cardiac vagal control. Sleep quality was generally disrupted when adolescents exposed to high childhood adversity, but the negative association between social interaction anxiety and sleep quality among adolescents with high childhood adversity could be amortized by high cardiac vagal control.
Cross-sectional design precluded establishing causality among variables.
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The prevalence of insomnia in children aged 5 to 12 years old is 20% to 31%. Currently, there is no well-validated questionnaire assessing all the components of insomnia in school-aged children. The present study aims to introduce an adaptation of the Insomnia Severity Index for this purpose.
Fifty-nine children aged 8- to 12-years-old with at least one anxiety disorder were recruited from youth mental health care settings. Their parents completed the pediatric adaptation of the Insomnia Severity Index which includes two scales used to report insomnia symptoms in children and their impact on the child (ISI-Child) and parents (ISI-Parent), My Child's Sleep Habits questionnaire, and the Child Behavior Checklist.
Both the ISI-Child and the ISI-Parent scales presented adequate factorial structure (RMSEA ≤ 0.05) and internal consistency (ISI-Child: α = 0.87; ISI-Parent: α = 0.88). Furthermore, the results of the two scales were strongly correlated (r = 0.91, P < 0.001). The convergent validity was assessed using the Waking During the Night scale of the My Child's Sleep Habits questionnaire and was adequate for the ISI-Child (r = 0.52, P < 0.001) and the ISI-Parent (r = 0.53, P < 0.001). Finally, the Rule-Breaking Behavior (r ≤ 0.26, P ≥ 0.05) and Aggressive Behavior (r ≤ 0.19, P ≥ 0.19) scales of the Child Behavior Checklist showed small correlations with both subscales, indicating good divergent validity.
The pediatric adaptation of the Insomnia Severity Index is a potentially reliable and valid measure for screening and assessing insomnia in children.
La prévalence de l’insomnie chez les enfants âgés de 5 à 12 ans est de 20 à 31 %. À ce jour, il n’existe aucun questionnaire validé permettant d’évaluer toutes les composantes de l’insomnie chez les enfants d’âge scolaire. La présente étude vise donc à valider de façon préliminaire une adaptation pédiatrique de l’Index de sévérité de l’insomnie (Morin, C., 1993).
Cinquante-neuf enfants âgés de 8 à 12 ans présentant au moins un trouble anxieux ont été recrutés dans des milieux pédiatriques en santé mentale. Leurs parents remplissaient l’Index de sévérité de l’insomnie pédiatrique qui inclut deux échelles utilisées pour rapporter les symptômes d’insomnie et leur impact sur l’enfant (ISI-Enfant) et sur le parent (ISI-Parent), le questionnaire My Child Sleep Habits, et le Child Behavior Checklist.
Les deux échelles, soit l’ISI-Enfant et l’ISI-Parent, présentent une structure factorielle (RMSEA ≤ 0,05) et une cohérence interne (ISI-Child: α = 0,87; ISI-Parent: α = 0,88) adéquates. De plus, les résultats aux deux échelles sont fortement corrélés (r = 0,91, p < 0,001). La validité convergente avec l’échelle Waking During the Night du questionnaire My Child's Sleep Habits s’est avérée adéquate pour l’ISI-Enfant (r = 0,52, p < 0,001) et pour l’ISI-Parent (r = 0,53, p < 0,001). Enfin, les échelles Comportements de bris de règles (r ≤ 0,26, p ≥ 0,05) et Comportements agressifs (r ≤ 0,19, p ≥ 0,19) du Child Behavior Checklist ont montré de faibles corrélations, ce qui indique une bonne validité divergente.
L’adaptation pédiatrique de l’Index de sévérité de l’insomnie apparaît comme un instrument potentiellement fiable et valide pour dépister et évaluer l’insomnie chez les enfants.

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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 data collection for this study: Mark A. Riddle, M.D., John T. Walkup, M.D., and Michael 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; Howard Abikoff, Ph.D., Sabine Hack, M.D., and Brian Klee, M.D., New York University; James McCracken, M.D., Lindsey Bergman, Ph.D., and John Piacentini, 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.

Disclosure: The authors have no financial relationships to disclose.

¹: Dr. Alfano is with the Department of Psychiatry, Children's National Medical Center, Washington, DC; Drs. Ginsburg and Kingery are with the Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore.

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ARTICLESSleep-Related Problems Among Children and Adolescents With Anxiety Disorders

ABSTRACT

Objective

Method

Results

Conclusions

Section snippets

Participants

Gender, Age, and Anxiety Disorder

Prevalence of SRPs Among Anxious Youth

Sleep Med

Cog Behav Pract

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Anxiety Disord

J Affect Disord

J Am Acad Child Adolesc Psychiatry

Child Adol Psychiatr Clin N Am

Sleep Med Rev

J Psychiatr Res

J Psychosom Res

J Am Acad Child Adolesc Psychiatry

Manual for the Child Behavior Checklist

Family process and child anxiety and aggression: an observational analysis

J Abnorm Child Psychol

The regulation of sleep and arousal: development and psychopathology

Dev Psychopathol

ARTICLES
Sleep-Related Problems Among Children and Adolescents With Anxiety Disorders