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When a young child has difficulty falling asleep, staying asleep, or staying in their own bed, this can be the earliest form of a later, more substantial problem, such as school avoidance and generalized anxiety disorder. So, it’s worth knowing more about the relationship between sleep and anxiety in children and about targeting treatment. If you treat the anxiety problem, will sleep improve? How about the other way around? Will targeting sleep improve anxiety?
Hi! Jim Phelps here for the Psychopharmacology Institute. In this Quick Take, I’ll pull for you some of the main findings from a review of sleep and anxiety by Wan Jie Tan and colleagues. We’ll also have a look at randomized trials that offered older students a 7-week program resembling cognitive–behavioral therapy for insomnia.
To begin with, sleep-related problems are prevalent. In various studies, as many as 92% of children with anxiety were also found to have sleep difficulties, such as reluctance to sleep far away from an attachment figure. Anxiety in childhood predicts insomnia in adulthood more strongly if the onset of anxiety symptoms began between the ages of 11 and 15. It goes the other way as well; the incidence of anxiety problems is 10 times higher in kids with sleep-related problems.
For example, sleep onset latency and refusal to sleep alone in preschoolers predicts symptoms of GAD and social anxiety disorder across childhood, even amongst healthy preschoolers. In some studies of anxiety treatments, sleep characteristics were found to be the strongest predictors and moderators of treatment outcomes. This is interesting because sleep-related problems have often been viewed as a consequence of anxiety. It has been assumed that treating anxiety will address any sleep-related problem, but the data on that are mixed. Improvements in sleep-related problems following treatment for anxiety have been observed in children but not adolescents. You can imagine why that might be. Targeting specific sleep issues associated with bedtime behavioral problems, like bedtime resistance and separation concerns, might be easier in young children than shifting an adolescent’s sleep habits.
Let’s check out a couple of large studies that targeted sleep in young people with anxiety. In an open trial, meaning no control group, 130 participants aged 9 to 14 years who had already received an anxiety-focused treatment but still had sleep-related problems were offered a sleep enhancement intervention called Sleeping TIGERS. This program consisted of 6 to 8 sessions addressing bedtime thoughts, feelings and behaviors, sleep regularity, and sleeping habits. After the intervention, the percentage of participants experiencing sleep-related problems went from 90% to 67%. Remember that this is after anxiety-focused treatment, suggesting that targeting sleep directly can offer further gains beyond what an anxiety-focused program provides.
Here’s the other large study. In an adolescent program from Melbourne, Australia, investigators recruited 140 high school students who had anxiety and sleep difficulties but no past or current depression problems. Like the Sleeping TIGERS program, the treatment offered was basically a version of cognitive–behavioral therapy for insomnia (CBT-I), adapted in this study for adolescents. This was presented in seven 90-minute group sessions, and supportive materials included a 170-page workbook. By contrast, controls received a group study skills educational program. Remarkably, participants attended approximately 76% of sessions, and at the end of the intervention, participants reported practicing mindfulness for 5 minutes at a time once or twice a week.
Compared with the control condition, sleep-focused treatment was associated with subjective and objective sleep improvement with a medium effect size. Remember that one of the questions was whether targeting sleep has an impact on anxiety, and in this study, that was true—although with a small effect size. According to the participants, one among the most helpful components was going to bed and getting up at the same time each day. That’s a pretty simple intervention to offer, though of course, it’s much harder to bring about in adolescents especially.
To summarize, there are few studies that directly examine how sleep treatment affects anxiety; there are more studies looking at how anxiety treatments affect sleep. The findings there generally show residual sleep problems even when anxiety has improved. Overall, the data suggest that going after both anxiety and sleep at the same time in young people would be preferable to targeting either alone. At minimum, the authors recommend that practitioners assess sleep in young people presenting with anxiety. Finally, they also point out that sleep-related problems are not subjected to the same stigma that psychiatric disorders are. Hence, sleep assessment might be a useful screening tool to identify children who are at risk of developing anxiety disorders.
Abstract
Pediatric anxiety disorders and sleep-related problems (SRPs) are highly prevalent and are associated with serious health or psychopathological consequences. This narrative review aims to provide an overview of the current evidence of the associations between anxiety disorders and SRPs, to examine how this relationship may affect treatment, and to evaluate future directions for the field. Despite their strong bi-directional relationship, SRPs are often neglected in pediatric anxiety literature. There is little consensus on the conceptualization and related measurements of SRPs, which has led to methodological limitations and difficulties. Furthermore, available research suggests that anxiety treatment alone may be inadequate as clinically impairing SRPs were still present post-treatment, which may, in turn, diminish effects of therapy. Understanding the implications of the relationship between anxiety and SRPs on treatment outcomes may be helpful in recognizing opportunities for high impact and enduring interventions.
Keywords: Adolescents; Anxiety; Intervention outcome; School-age children; Sleep.
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Reference
Tan, W. J., Ng, M. S., Poon, S. H., & Lee, T. S. (2021). Treatment implications of sleep-related problems in pediatric anxiety disorders: A narrative review of the literature. Child Psychiatry & Human Development, 1-6.
