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Sleep-Related Problems Among Children and Adolescents 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 normal growth and development in children. Because insufficient sleep has been associated with impairments such 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 the Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent 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 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. Correspondence to Dr. Candice Alfano, Department of Psychiatry, Children_s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010; e-mail: [email protected] 0890-8567/07/4602-0224Ó2007 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000242233.06011.8e

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as decreased attention, impulsivity, behavioral problems, and decrements in school performance (Mindell et al., 1999), there is a need to better understand the association between sleep disturbances and psychiatric symptoms in children. The term sleep disturbance is, in fact, quite broad and often is used to refer to a range of sleep 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 disturbances among children generally encompass a wider range of problem behaviors. For example, in addition to problems initiating sleep, anxious children commonly experience nonspecific nighttime fears, nightmares, and difficulty sleeping alone/away from home, all of which may disrupt sleep continuity and quality and result in excessive daytime somnolence. Thus, we refer to this range of potential nighttime difficulties among anxious children more broadly as sleep-related problems (SRPs). Among children with anxiety disorders, research examining SRPs and their potential impact on daytime functioning is extremely limited. However, data based on community samples of children reveal an important

J. AM . ACAD. CHILD ADOLESC. PSYCH IATRY, 46:2, FEBRUARY 2007

Copyright @ 2007 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

SLEEP PROBLEMS AND ANXIOUS CHILDREN

association between sleep problems and anxiety. For example, Mindell and Barrett (2002) reported incremental increases in trait anxiety relative to an increased frequency of nightmares among 60 children (ages 5Y11 years) recruited from elementary school classrooms. For children reporting three or more nightmares per week, parent-reported anxiety scores approached the clinically significant range. Using longitudinal data, Gregory and O_Connor (2002) examined the relation between parent report of early sleep problems and the development of emotional/behavioral problems during midadolescence in a large community sample of children (n = 490). The presence of sleep problems at age 4 significantly predicted problems of anxiety/depression at ages 13 to 15. A second longitudinal investigation used a large community sample (n = 943) to examine early sleep problems as predictors of later psychiatric diagnoses (Gregory et al., 2005). Among the 12% of children whose parents reported persistent sleep problems from ages 5 to 9, almost half (46%) developed an adult anxiety disorder. In contrast, persistent sleep problems during childhood did not significantly predict the development of adult depressive disorders. Only a few studies have examined SRPs among clinically anxious youth. Using a large sample of children (n = 157) with generalized anxiety disorder (GAD), Masi and colleagues (2004) found that 56% of children and 49% of adolescents experienced a Bsleep disturbance[ based on combined parent and child reports. Similarly, Pina and colleagues (2002) reported that 42% of children and 57% of adolescents with GAD/overanxious disorder (n = 111; ages 7Y16) experienced Btrouble sleeping,[ and Kendall and Pimentel (2003) reported the presence of Bsleep disturbance[ among 66% of children with GAD (n = 47; ages 9Y13) based on child and parent report. Further information regarding the specific nature of sleep problems experienced by anxious youth was not provided. Thus, this small body of research is limited to children with GAD and is restricted to broad, nonspecific indexes of sleep disturbance. Limited data based on the use of polysomnography also provide preliminary support for the presence of disrupted sleep among anxious youth. Rapoport et al. (1981) reported reduced sleep efficiency and increased sleep latency among nine adolescents (ages 13Y17) with obsessive-compulsive disorder compared with matched healthy controls. Adolescents with obsessive-compulsive disorder required twice as long as control adolescents to

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

initiate sleep onset. Although research using objective measures of sleep among youth with other anxiety disorders has not been conducted, studies of anxietydisordered adults indicate different forms of sleep disruption to be highly prevalent (see Uhde, 2000). Research examining the frequency of specific SRPs among anxious youth, including potential associations with age, gender, type of anxiety disorder, anxiety severity, and impaired daytime functioning, may therefore provide important information for both researchers and clinicians. Similar to a need for information concerning sleep disruption among anxious youth, data examining the impact of effective treatments for childhood anxiety on co-occurring SRPs also are needed. One study reported general decreases in somatic symptoms (including one Bsleep disturbance[ item) among children with GAD after cognitive-behavioral treatment, although reductions in specific SRPs were not examined (Kendall and Pimentel, 2003). With regard to pharmacological treatment studies, outcomes related to sleep are particularly relevant. Because the neurotransmitter systems involved in the modulation of anxiety also are implicated in the regulation of sleep and because pharmacological agents, including selective serotonin reuptake inhibitors (SSRIs), that reduce anxiety also have been shown to alter sleep (see Sandor and Shapiro, 1994), improvement in symptoms across both domains may be observed. Several published studies have reported significant decreases in children_s anxiety symptoms after treatment with an SSRI (March et al., 1998; Research Unit on Pediatric Psychopharmacology Anxiety Study Group, 2001; Wagner et al., 2004), yet sleep-related outcomes have not been examined. The present study begins to address these gaps in the literature through preliminary examination of several types of SRPs among a large sample of youth with anxiety disorders. In particular, the frequency of eight specific SRPs was examined in relation to age, gender, and type of anxiety disorder (i.e., GAD, separation anxiety [SAD], and social anxiety [SOC]) on the basis of both parent and clinician assessment. Second, associations between SRPs, anxiety severity, and impairment in daytime functioning both within and outside the home were examined. On the basis of findings 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

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Copyright @ 2007 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.

ALFANO ET AL.

related to higher levels of anxiety severity and impairments across both domains. Finally, we examined the impact of pharmacological treatment in reducing SRPs among anxious youth. In particular, we examined clinician report of three specific SRPs after 8 weeks of treatment with either fluvoxamine (FLV) or pill placebo (PBO). We hypothesized that treatment with an SSRI would produce a significant decrease in SRPs relative to placebo. METHOD 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., SOC, SAD, and/or GAD). Children were recruited from five sites designated Research Units in Pediatric Psychopharmacology (RUPP): Duke University, Johns Hopkins School of Medicine, New York State Psychiatric Institute/Columbia University, New York University, and University of California, Los Angeles. Sample characteristics are presented in Table 1. Exclusion criteria included current use of any illicit or prescribed psychoactive substance; current diagnoses of major depressive disorder, Tourette_s disorder, obsessive-compulsive disorder, posttraumatic stress disorder, conduct disorder, or panic disorder; any past or current history of mania, psychosis, or pervasive developmental disorder; suicidal ideation; mental retardation; previous treatment with a selective serotonin reuptake inhibitors; and a diagnosis of attention-deficit/hyperactivity disorder that required pharmacological treatment. Measures Pediatric Anxiety Rating Scale. The Pediatric Anxiety Rating Scale (PARS; Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002) is a clinician-rated instrument for assessing the severity of anxiety symptoms associated with childhood anxiety disorders. The instrument has two sections. The first section includes a 50-item symptom checklist in which items are rated as present or absent during the past week. The second section is made up of five severity items and two impairment items (rated on a 5point Likert scale), with higher scores reflecting greater severity/ impairment. Internal consistency, test-retest reliability, and validity for the PARS have been found to be acceptable (Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002). Hamilton Anxiety Rating Scale. The Hamilton Anxiety Rating Scale (HAM-A; Hamilton, 1959) is a 14-item, clinician-rated instrument for assessing the severity of anxiety symptoms. Items are scored from none (0) to very severe (4). The psychometric properties of the HAM-A have been shown to be acceptable (Maier et al., 1988). Child Behavior Checklist-Parent Version. The Child Behavior Checklist-Parent Version (CBCL; Achenbach and Edelbrock,

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TABLE 1 Demographic and Clinical Characteristics of Entire Sample Characteristic n % Age, y 6Y11 12Y17 Female gender Ethnicity White Hispanic Black (non-Hispanic) Other Total family income, $

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