Sleep-related problems in pediatric obsessive-compulsive disorder

Measures of Sleep-Related Fears in Children: A Systematic Review of Psychometric Properties Using COSMIN

Sleep-related fears (i.e. fears related to sleep, nighttime and/or occurring before sleep) are linked to the development of anxiety and sleep problems in children. Parent- and child-report measurement tools are key to increasing understanding and facilitating better identification for treatment to prevent disorder development. We conducted a systematic review with the aim of identifying the breadth of parent- and child-report measures that include an assessment of sleep-related fears in children from 7 to 12 years old (stage 1) and reviewing the psychometric properties of measures that more comprehensively assess sleep-related fears (i.e. 3 or more items) using the COSMIN checklist (stage 2) to provide recommendations for measures (stage 3). A systematic search was performed using MEDLINE, EMBASE, ERIC and PsycINFO in accordance with PRISMA guidelines. At stage 1, we retrieved 14,495 records. Of these, 66 papers met eligibility and included 43 distinct measures. At stage 2, 11 out of the 43 measures met criteria for more comprehensive measurement of sleep-related fears. Findings demonstrated mixed and incomplete data and very little high-quality evidence. No measures met criteria for recommendation and the majority of measures require further validation studies.

PANS and PANDAS - symptoms beyond OCD and tics - a systematic review

This article aims to describe the symptomatology of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), and to highlight some of their potential distinctive features, by juxtaposing available data with existing literature on pediatric obsessive - compulsive disorder (OCD). Given the scarcity of high-quality studies, we decided to review a wide range of publications on the clinical presentation of PANS and PANDAS, including case series and case reports, regardless of their methodological heterogeneity. Although PANS and PANDAS share many characteristics with non-PANS/PANDAS OCD, the acute onset of obsessive-compulsive symptoms in conjunction with concomitant features, especially separation anxiety, irritability, emotional lability, or dysgraphia should prompt consideration of a possible post-infectious etiology. Further research aimed at creating more precise diagnostic tools is needed to facilitate differential diagnosis.

Sleep disorders in patients with obsessive-compulsive disorder: A systematic review of the literature

Patients with obsessive-compulsive disorder are presumed to be at higher risk of sleep disorders due to the potential interference that persistent thoughts and compulsions may exert on sleep. Although there are studies on sleep findings in patients with obsessive-compulsive disorder, there are few systematic reviews on the presence of sleep disorders in patients with obsessive-compulsive disorder for adults and children. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed to perform a comprehensive search of PubMed and Web of Science using the MeSH terms "obsessive-compulsive disorder" and "sleep wake disorders". The exclusion criteria included publications not in English, studies performed on non-humans, abstracts, reviews, and meta-analyses. After applying the exclusion criteria, 17 studies qualified for inclusion in this systematic review. Nine studies were written about children and eight on adults. In the adult studies, sleep questionnaires, actigraphy and dim light melatonin onset showed delayed circadian rhythm in those with obsessive-compulsive disorder. Several studies showed an increased prevalence of insomnia in adult patients with obsessive-compulsive disorder. Overall, these studies showed sleep-onset and maintenance insomnia, and poor sleep quality. In the paediatric studies, sleep questionnaires revealed that paediatric patients with obsessive-compulsive disorder have increased sleep-related problems, including poor sleep quality, difficulty initiating and maintaining sleep, nightmares and sleepwalking. Two studies using actigraphy demonstrated a decreased total sleep time, increased wake after sleep onset and increased duration of awakening. Studies also showed an improvement in sleep symptoms with cognitive behavioural therapy. The systematic review has shown increased sleep-related problems and poor sleep quality both in adult and paediatric patients with obsessive-compulsive disorder. All patients with obsessive-compulsive disorder should therefore be screened for sleep-related problems to help in the overall outcome of treatment plans.

A public health view and comparison between online and on-campus learning to evaluate sleep and mental health among undergraduate students

Background

The COVID-19 pandemic changed people's lives. The majority had to adapt to working online including students. The shift to online learning caused serious sleep and mental health issues among students. This study aimed to examine the variations between the prevalence of sleep and mental health problems among undergraduate students during the periods of online learning and on-campus learning.

Method

An online survey was distributed to medical students in Saudi Arabia.

Results

A total of 110 participated in the study (age = 21 ± 1.4 years). The on-campus anxiety (8.2 ± 6.3) was significantly higher than online anxiety (5.5 ± 5.1). On-campus daytime sleepiness (8.5 ± 4) was significantly higher when compared to online daytime sleepiness (6.7 ± 4.6). Although not significant, the on-campus stress (7.7 ± 5.7) and insomnia (12 ± 7.3) were higher than online stress (6.9 ± 5.5) and insomnia (11.5 ± 6). The online depression (6.6 ± 5.7) was higher than the mean on-campus depression (5.8 ± 5.4). A significant strong positive correlation was found between on-campus anxiety and on-campus stress. A significant moderate positive correlation was detected between on-campus anxiety and on-campus daytime sleepiness. A weak but significant correlation was found between on-campus anxiety and on-campus insomnia. On-campus anxiety was significantly predicted by the following model, which included on-campus stress, insomnia, and daytime sleepiness (P < .001).

Conclusion

Medical students reported lower anxiety, daytime sleepiness, stress, and insomnia during their online learning compared to on-campus learning. Only depression was higher during online learning compared to on-campus learning.

The Impact of Cognitive Behavioral Therapy on Sleep Problems in Autistic Children with Co-occurring Anxiety

PURPOSE

This study seeks to examine the relationship between anxiety-symptom severity and sleep behaviors in autistic children receiving cognitive behavioral therapy (CBT).

METHODS

We conducted a secondary-data analysis from a sample of 93 autistic youth, 4 to 14 years, participating in 24 weeks of CBT. Clinicians completed the Pediatric Anxiety Rating Scale (PARS) and parents completed the Children's Sleep Habits Questionnaire, Abbreviated/Short Form (CSHQ-SF) at baseline, mid-treatment, post-treatment and 3 months post-treatment. Mediation analysis evaluated the role of anxiety symptoms in mediating the effect of time in treatment on sleep.

RESULTS

There was a negative association between time in treatment and scores on the CSHQ-SF (b = - 3.23, SE = 0.493, t = - 6.553, p < 0.001). Increased time in treatment was associated with decreased anxiety (b = - 4.66, SE = 0.405, t = - 11.507, p < 0.001), and anxiety symptoms decreased with CSHQ-SF scores (b = 0.322, SE = 0.112, t = 2.869, p = 0.005). The indirect effect of time in treatment on CSHQ-SF scores through PARS reduction was negative, but not statistically significant.

CONCLUSION

Increased time in CBT was associated with decreased anxiety severity and improved sleep behaviors. Reductions in anxiety symptoms may mediate improvements in sleep problems, but larger sample sizes are necessary to explore this further.

Sleep-Related Problems and Pediatric Anxiety Disorders

Sleep-related problems are highly prevalent among childhood and adolescent anxiety disorders. The objective of this review was to summarize the relevant clinical research literature as it pertains to the nature of the association between sleep-related problems and youth anxiety, developmental factors relevant to this association, and intervention efforts to target comorbid sleep challenges and anxiety. Limitations of the literature and future directions are discussed.

Mediating role of psychological flexibility in the effect of obsessive-compulsive symptoms on sleep quality among nurses during the COVID-19 pandemic

Front-line nurses suffered unprecedented mental distress and severe insomnia during the COVID-19 pandemic. Present study aimed to explore the relationship between obsessive-compulsive symptoms and sleep quality and examine the potential mediating role of psychological flexibility between obsessive-compulsive symptoms and sleep quality. A total of 496 nurses from a Chinese large-scale Class 3 A Comprehensive Hospital were included in an online cross-sectional survey and completed the revised obsessive-compulsive inventory (OCI-R), Multidimensional Psychological Flexibility Inventory (MPFI) and Pittsburgh Sleep Quality Index (PSQI). As predicted, obsessive-compulsive symptoms were negatively associated with psychological flexibility and sleep quality, and psychological flexibility was positively associated with sleep quality. In addition, the relationship between obsessive-compulsive symptoms and sleep quality was partially mediated by psychological flexibility, which can provide some reference for the treatment of the obsessive-compulsive disorder (OCD) and insomnia, and lead to improvements in clinical and psychotherapy planning.

Sleep Disorders, Sleep Medication Use, and Predictors of Sleep Disturbance in Children with Persistent Tic Disorders

The present study examined rates of sleep disorders and sleep medication use, and predictors of sleep disturbance in children with persistent tic disorders (PTD). Sixty-three parents of children aged 10 to 17 years with PTDs completed an internet survey evaluating sleep patterns and clinical symptoms. Insomnia (19.4%), nightmares (16.1%), and bruxism (13.1%) were the most commonly reported lifetime sleep disorders. Fifty-two percent endorsed current sleep medication use. Higher ADHD severity, overall life impairment, and female sex predicted greater sleep disturbance. Findings suggest the utility of clinical management of co-occurring ADHD and impairment to mitigate sleep disturbance in children with PTDs.

Delayed circadian rhythms and insomnia symptoms in obsessive-compulsive disorder

BACKGROUND

Accumulating evidence implicates sleep and circadian rhythm disturbance in obsessive-compulsive disorder (OCD). However, a multimethod characterization of sleep and circadian rhythms in OCD, their association with symptom severity, and the functional relationship between these variables is lacking.

METHODS

The present study measured multiple indicators of sleep and circadian rhythms in a sample of adults with OCD, adults without OCD, and healthy controls (n = 74). Participants completed measures of morningness-eveningness, delayed sleep-wake phase disorder (DSWPD), insomnia symptoms, and OCD symptoms, as well as one week of sleep monitoring via a sleep diary and actigraphy.

RESULTS

Delayed circadian rhythms (higher eveningness, later mid-sleep timing, and higher rates of DSWPD) and higher insomnia symptoms were observed in those with OCD compared to healthy controls, as well as associations between delayed circadian rhythms and insomnia symptoms and OCD symptom severity across the full sample. Further, insomnia symptoms mediated the relationship between delayed circadian rhythms and OCD symptoms. In contrast, there were no links between total sleep time or sleep quality and OCD.

LIMITATIONS

Data collection during COVID-19 pandemic, correlational data, no physiological measure of circadian rhythms.

CONCLUSIONS

These findings highlight a robust association between delayed circadian rhythms and OCD and suggest insomnia symptoms may be one mechanism in this relationship. Sleep and circadian rhythm disturbance may be novel targets for OCD treatment.

A systematic review of sleep problems in children and adolescents with obsessive compulsive disorder

There is growing interest in the relationship between obsessive-compulsive disorder (OCD) and sleep problems in youth, including the development of a theoretical model proposing how these disorders maintain each other. The model suggests that OCD symptoms are proposed to interfere with sleep duration (e.g., via increased arousal and delayed bedtime), which compounds OCD symptom severity during the daytime and into the evening, feeding back into the model. Whether the recent influx of research on sleep problems in youth with OCD supports this model is unknown. The primary aim of this systematic review was to characterize sleep problems in youth with OCD and evaluate whether current research supports previous theoretical inferences. Findings across 20 studies revealed a high prevalence of sleep problems among youth with OCD and support a bidirectional relationship. Studies largely did not assess hypothesized relationships proposed by the model; support for the model is therefore preliminary. A secondary aim was to assess the impacts of comorbidity and developmental stage. Findings suggest that in childhood, comorbid anxiety disorders may initially predate sleep problems, but they become mutually maintained over time; the role of comorbid depression appears to increase with age. Limitations, future directions, and clinical implications are discussed.

Sleep Duration and Internalizing Symptoms in Children

OBJECTIVE

Emotional problems such as anxiety and low mood have been associated with sleep problems in children. The study's objectives were to 1) assess the association between sleep duration and internalizing symptoms (anxiety and low mood) in children aged 5-12 years (y), and 2) evaluate whether insufficient sleep according to the National Sleep Foundation (NSF) guidelines is associated with internalizing symptoms.

METHODS

A cross-sectional study of N =796 children aged 5-12y, recruited from primary care physicians' offices in Toronto, Canada was conducted through the TARGet Kids! research network. Using linear regression, we investigated 1) the cross-sectional association between parent reported 24-hour sleep duration (hours) and parent reported symptoms using the Strengths and Difficulties Questionnaire (SDQ), controlling for child age, sex, family income, maternal education, family composition, and standardized body-mass index (zBMI). The analysis was repeated using insufficient sleep per NSF guideline as the independent variable.

RESULTS

Sleep duration was inversely associated with internalizing symptoms, B estimate = -0.33 (95%CI -0.57, -0.07), p=0.012. Twenty-eight (14%) children aged 5 y, and 36 (6%) of those aged 6-12y, experienced insufficient sleep. There was a trend toward association between insufficient sleep and internalizing symptoms, B estimate = 0.64 (-0.09, 1.38), p=0.086.

CONCLUSION

The relationship between insufficient sleep and internalizing symptoms among children requires further elucidation. Children who show internalizing symptoms may benefit from interventions supporting sleep.

Effect of early intervention for anxiety on sleep outcomes in adolescents: a randomized trial

The potential effect of early intervention for anxiety on sleep outcomes was examined in a sample of adolescents with anxiety (N = 313, mean 14.0 years, SD = 0.84, 84% girls, 95.7% Norwegians). Participants were randomized to one of three conditions: a brief or a standard-length cognitive-behavioral group-intervention (GCBT), or a waitlist control-group (WL). Interventions were delivered at schools, during school hours. Adolescents with elevated anxiety were recruited by school health services. Questionnaires on self-reported anxiety symptoms, depressive symptoms, and sleep characteristics were administered at pre- and post-intervention, post-waitlist, and at 1-year follow-up. Adolescents reported reduced insomnia (odds ratio (OR) = 0.42, p < 0.001) and shorter sleep onset latency (d = 0.27, p <  0.001) from pre- to post-intervention. For insomnia, this effect was maintained at 1-year follow-up (OR = 0.54, p = 0.020). However, no effect of GCBT on sleep outcomes was found when comparing GCBT and WL. Also, no difference was found in sleep outcomes between brief and standard-length interventions. Adolescents defined as responders (i.e., having improved much or very much on anxiety after GCBT), did not differ from non-responders regarding sleep outcomes. Thus, anxiety-focused CBT, delivered in groups, showed no effect on sleep outcomes. Strategies specifically targeting sleep problems in adolescents should be included in GCBT when delivered as early intervention for adolescents with elevated anxiety.Trial registry Clinical trial registration: School Based Low-intensity Cognitive Behavioral Intervention for Anxious Youth (LIST); http://clinicalrials.gov/ ; NCT02279251, Date: 11.31. 2014.

[Sleep disturbances and their associations with disorders in emotional sphere and behavior in children]

The paper addresses associations between sleep disorders and emotional and behavioral disturbances in children. These associations are considered in a view of commonly found co-occurrences of sleep problems, signs of anxiety and depression, oppositional-defiant behavior, and increased aggressiveness. The authors put forward a conception of reciprocal influences of these disturbances and provide information on potential physiological mechanisms responsible for associations between sleep problems and emotional and behavioral disturbances in children. Attention is drawn to hypothalamus-hypophysis-adrenal axis activation, serotonergic and aminergic systems imbalance, impaired melatonin and orexins production. Possibility of an existing pattern encompassing sleep problems, emotional and behavioral disturbances is discussed. Practical recommendations aimed at timely identification and treatment of the mentioned disorders are suggested.

Evaluation of Sleep Habits, Generalized Anxiety, Perceived Stress, and Research Outputs Among Postgraduate Research Students in Hong Kong During the Coronavirus (COVID-19) Pandemic

Purpose

The current study aimed to evaluate the impact of coronavirus (COVID-19) pandemic on sleep hygiene, anxiety levels, perceived stress, and research output among postgraduate research students in Hong Kong.

Methods

An online survey was developed and distributed to Hong Kong postgraduate research students. The sleep hygiene, anxiety levels, and perceived stress during the outbreak of COVID-19 were assessed. Questions about COVID-19’s impact on research outputs were asked.

Results

A total of 108 (response rate, 72%) full-time postgraduate students (PhD, 64%; M Phil, 8%; and Masters, 28%) participated. Approximately 83% of students reported poor sleep hygiene. Similarly, nearly 76% of students reported mild to severe levels of self-perceived anxiety levels. Most of the respondents (89%) expressed a moderate level of perceived stress. Sleep hygiene scores were moderately associated with anxiety levels (r = 0.384, p < 0.01) and perceived stress scores (r = 0.423, p < 0.01). Perceived stress was strongly correlated with anxiety levels (r = 0.601, p < 0.01). A hierarchical regression analysis revealed a significant association between respondents’ ethnicity (B = −0.923, p = 0.003), past medical history (such as hypertension, diabetes, and musculoskeletal disorders) (B = 1.112, p = 0.005), or poor sleep hygiene (B = 0.259, p = 0.000) and high levels of perceived stress. Additionally, prior medical history (such as hypertension, diabetes, and musculoskeletal disorders) (B = 1.957, p = 0.001) and poor sleep hygiene (B = 0.312, p = 0.000) were found to be strongly related to anxiety levels among postgraduate research students.

Conclusion

This is the first study that highlights poor sleep hygiene, moderate-to-severe levels of anxiety, and perceived stress during the COVID-19 pandemic in postgraduate research students in Hong Kong. These findings will help educators to prepare strategies to alleviate the stress and psychological problems in postgraduate students.

Targeting Co-Sleeping in Children With Anxiety Disorders Using a Modified Bedtime Pass Intervention: A Case Series Using a Changing Criterion Design

Children with anxiety disorders experience high rates of sleep-related problems, with co-sleeping and resistance to sleeping independently being among the more frequent problems reported. Although extinction-based behavioral sleep interventions have repeatedly been shown to be highly effective for treating bedtime resistance, the primary obstacle to their implementation is parent discomfort with these procedures. The bedtime pass intervention was developed to minimize extinction bursts when implementing extinction procedures for childhood sleep problems. Several studies have found this intervention to be effective for treating bedtime resistance behaviors, but not co-sleeping specifically, in nonclinical samples of children. The current paper describes the use of a modified bedtime pass procedure to target problematic co-sleeping and related bedtime resistance behaviors in two children with anxiety disorders who presented for treatment at an outpatient pediatric anxiety specialty clinic. A changing criterion, single subject methodology was used to evaluate the effectiveness of this procedure. Data indicate that both children were able to transition from co-sleeping with parents every night, to sleeping independently, with relatively limited need for contact with parents at night during the intervention. These findings extend the data for the bedtime pass procedure to both co-sleeping and children with anxiety disorders. Clinical implications of these findings are discussed given the limited guidance for treating comorbid sleep problems in anxious children. Strengths and limitations of the data being drawn from a clinical treatment setting are also discussed.

Sleep quality in children and adolescents with obsessive-compulsive disorders

BACKGROUND

Although the effect of obsessive-compulsive disorder (OCD) on sleep is not well-known, recent studies suggest an association between OCD and sleep quality.

AIMS

We aimed to assess sleep quality in children and adolescents with OCD and to seek its association with OCD symptoms and OCD severity.

METHODS

All of the subjects were assessed using DSM 5 and affective disorders and schizophrenia for school-age children - present and lifetime version, which is based on DSM-IV. The Yale-Brown obsessive-compulsive scale and children's Yale-Brown obsessive-compulsive scale were applied to the subjects with OCD. Pittsburgh sleep quality index (PSQI) was used to assess sleep quality, and the Wechsler intelligence scale for children-revised (WISC-R) was used to measure their intelligence levels.

RESULTS

PSQI total score was significantly higher in patients with OCD (p < 0.001), suggesting that patients with OCD have a significantly worse sleep quality. The presence of somatic disorders was also associated with worse sleep quality (p = 0.040). Sleep quality was not significantly associated with OCD severity (p = 0.152). Among patients with extreme OCD, the 'sleep duration' component of the PSQI was higher than those with moderate or severe OCD (p = 0.019). The patients with 'contamination/cleaning' symptom group had a lower total PSQI score compared with 'symmetry/hoarding' symptom group (p = 0.014).

CONCLUSIONS

The findings of the present study indicate that the sleep quality of children and adolescents with OCD is influenced, and there may be an association between sleep quality and OCD symptoms and severity in these patients.

Innovations in the Delivery of Exposure and Response Prevention for Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder is an important cause of global health-related disability. In the last several decades, exposure and response prevention (EX/RP) has emerged as one of the most evidence-based treatments for adult and pediatric OCD. Recommended as a first-line treatment in practice guidelines for OCD, EX/RP, when expertly delivered, can be superior to serotonin reuptake inhibitor (SRI) medications alone and superior to adding antipsychotic medication to augment SRI treatment response. Despite a robust evidence base, EX/RP is not widely available. Moreover, although effective, only about half of patients who receive a standard course of EX/RP will achieve remission.This chapter will review innovations in delivering EX/RP, focusing on technology-based methods designed to increase access to EX/RP and translational neuroscience approaches to personalizing and optimizing EX/RP. Technology-based innovations to deliver EX/RP include video conferencing, internet-based treatment, and smartphone apps. Of these, internet-based, clinician-supported treatment has the most evidence base to date. Relevant to all technology-based innovations are the need for advances in the ethical, regulatory and financial aspects of understanding how access to EX/RP may be delivered to individuals of diverse socioeconomic backgrounds in accordance with professional standards and regulations and covered by healthcare.Advances in our understanding of the neural processes underlying learning and memory have led to new ways to combine EX/RP with medications, behavioral interventions, or neuromodulatory methods, with the goal of enhancing the functioning of brain circuits that subserve fear processing and cognitive control. Among the pharmacological approaches to enhancing EX/RP outcome, both ketamine and cannabinoids show promise in small open trials but are in need of further study. Studies to train cognitive control are at an early stage of development yet provide preliminary evidence that training neural processes may be a new path to personalize treatment. How best to combine EX/RP with different types of neuromodulation is being actively studied.Together these innovations in the delivery of EX/RP for OCD hold great promise for improving outcomes of care for individuals with OCD by increasing the availability and the individual treatment effects of this already effective treatment.

Sleep-Related Problems and Pediatric Anxiety Disorders

Sleep-related problems are highly prevalent among childhood and adolescent anxiety disorders. The objective of this review was to summarize the relevant clinical research literature as it pertains to the nature of the association between sleep-related problems and youth anxiety, developmental factors relevant to this association, and intervention efforts to target comorbid sleep challenges and anxiety. Limitations of the literature and future directions are discussed.

Antidepressant Tolerability in Pediatric Anxiety and Obsessive-Compulsive Disorders: A Bayesian Hierarchical Modeling Meta-analysis

OBJECTIVE

To compare adverse events (AEs), suicidality, and AE-related discontinuation in double-blind, placebo-controlled trials of pediatric patients with obsessive-compulsive disorder (OCD) and anxiety disorders treated with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs).

METHOD

MEDLINE, PubMed, Web of Science, PsycINFO, and Embase were searched for peer-reviewed, English-language articles from inception through March 1, 2019. We identified prospective, randomized SSRI and SNRI studies in patients <18 years of age with OCD or generalized, separation, or social anxiety disorders. AE rates were extracted and medication-placebo differences were examined using Bayesian hierarchical models, then posterior estimates of relative risk (RR) were determined for each AE by medication class and disorder.

RESULTS

Data were included from 18 trials (2,631 patients) and 7 medications (16 SSRI and 4 SNRI trials). Compared with placebo, SSRIs were associated with a greater likelihood of AE-related discontinuation (RR 3.59, credible interval [CrI] 0.019-0.067, p = .0003), activation (RR 2.39, CrI 0.048-0.125, p = .003), sedation (RR 1.94, CrI 0.035-0.157, p = .002), insomnia (RR 1.93, CrI 0.040-0.149, p = .001), abdominal pain (RR 1.53, CrI 0.032-0.164, p = .005), and headache (RR 1.24, CrI 0.003-0.139, p = .04). Activation was more common with SSRIs (versus SNRIs, RR 1.32, CrI 0.018-0.114, p = .007). Neither SSRIs nor SNRIs were associated with treatment-emergent suicidality.

CONCLUSION

In pediatric OCD and anxiety disorders, SSRIs (compared with placebo) are associated with distinct AEs and greater AE-related discontinuation, although their tolerability does not differ between anxiety disorders and OCD. Compared with SNRIs, SSRIs are more likely to produce activation. Class-related AEs are important for clinicians to consider, particularly in light of data suggesting differences in class-related efficacy. Whereas SSRIs are superior to SNRIs and the treatment of choice for anxiety, for youths who become activated on SSRIs, SNRIs might represent a good second choice given their reported efficacy and lower risk of activation.

Novel insights from actigraphy: Anxiety is associated with sleep quantity but not quality during childhood

Anxiety and sleep function change dynamically across development, and sleep dysfunction has emerged as a correlate and predictor of anxiety in pediatric clinical samples. Despite this, previous research has not investigated how associations between qualitative and quantitative measures of sleep function change with anxiety across development, specifically from childhood to adolescence. The present study used actigraphy collection to examine whether associations between quantitative and qualitative sleep function and anxiety differed as a function of developmental stage in a community pediatric sample (8-17 years old; N = 92). Age moderated the association between anxiety and sleep quantity, but not sleep quality. Contrary to hypotheses, higher anxiety was related to increased sleep for children, but not adolescents. Results suggest age-related changes in the association between sleep function and anxiety across development, with implications for targeting sleep-related interventions for youth with anxiety.

A cross-lagged panel analysis of children's sleep, attention, and mood in a prenatally stressed cohort: The QF2011 Queensland flood study

BACKGROUND

It is well recognized that childhood sleep, attention and mood problems increase risk for multiple adverse outcomes across the life-span; therefore, understanding factors, such as prenatal maternal stress, that underlie these types of childhood problems is critical for developing interventions that may optimize longer-term functioning. Our goal was to determine the association between disaster-related stress in pregnancy and young children's sleep, attention, and anxious/depressed symptoms.

METHODS

Soon after a major flood in Australia in 2011, we assessed various aspects of disaster-related prenatal maternal stress (PNMS) in women who had been pregnant at the time. Mothers rated several domains of their children's development with the Child Behavior Checklist (CBCL) at ages 2½ (n = 134) and 4 years (n = 118).

RESULTS

The primary finding was that more severe objective flood-related hardship in pregnancy predicted higher sleep problem scores at 2½ years, and that a negative maternal cognitive appraisal of the flood predicted lower attention problem scores at 2½ years. A cross-lagged panel analysis examined the association between children's sleep, attention, and anxious/depressed symptoms within and across ages. Results showed that these problems were likely to co-occur at each age, and that they were stable from 2½ to 4 years. Additionally, anxious/depressed scores at age 2½ predicted sleep problem scores at 4 years, all else being equal.

LIMITATIONS

Limitations of the study include a relatively small sample size and the children's outcome data relied on maternal report using the CBCL, rather than independent observation of the children's functioning, which may have introduced reporter bias.

CONCLUSIONS

These findings highlight the importance of early intervention for these childhood problems to optimize long-term mental health, particularly under conditions of prenatal stress.

(Re)Conceptualizing Sleep Among Children with Anxiety Disorders: Where to Next?

Children with anxiety disorders (AD) characteristically complain of sleep problems and the extent to which cognitive behavioral treatments (CBT) for childhood anxiety produce sleep-based improvements is a topic of increasing interest. The current paper reviews available evidence for subjective sleep complaints and objective sleep alterations in children and adolescents with AD, including investigations of potential changes in sleep following anxiety-focused CBT. Despite pervasive complaints of poor sleep, the empirical literature provides minimal evidence for actual sleep-wake alterations in this population of youth and evidence for sleep-based changes following treatment for anxiety is minimal. In line with calls for more comprehensive models of the role of sleep in developmental psychopathology, several fundamental gaps in understanding are described and highlighted as essential avenues for clarifying the nature and consequences of poor quality sleep among youth with clinical levels of anxiety. In a second section of the paper, an emerging body of novel, translational research investigating more intricate sleep-anxiety relationships is introduced with potential implications for both etiological models and treatment design and delivery.

Sleep-Related Problems in Pediatric Obsessive-Compulsive Disorder and Intensive Exposure Therapy

Limited research has examined sleep-related problems (SRPs) among children and adolescents with obsessive-compulsive disorder (OCD). The present study addresses this gap by investigating preliminary associations between SRPs, demographic factors (gender and age), family variables (family accommodation and parental stress), and clinical factors (medication status, internalizing and externalizing symptoms, OCD severity, OCD-related impairment), and treatment outcomes in a sample of 103 youth (aged 7 to 17 years; 53% female) with a primary diagnosis of OCD. Clinician, parent, and child measures were used to assess demographic, family, and clinical predictors. SRPs were assessed using an 8-item measure comprising items of the Child Behaviour Checklist, Child Depression Inventory, and Multidimensional Anxiety Scale for Children as used in previous studies. Results showed that SRPs were highly prevalent among this sample and that more SRPs were associated with younger age, internalizing problems, and functional impairment. However, SRPs were not an independent predictor of OCD severity, impairment, or treatment response. Preliminary findings suggest that SRPs among youth with OCD may be more strongly associated with broader internalizing symptoms than with OCD itself. Future longitudinal research is warranted to further explore the complexity of SRPs when co-occurring with pediatric OCD.

Family accommodation mediates nightmares and sleep-related problems in anxious children

Nightmares are commonly reported in clinically anxious children and are associated with the presence of other sleep-related problems. Family accommodation has been theorized as playing a central role in the sleep-related problems of anxious children, but empirical data is lacking. We examined associations between nightmares, maternal reports of family accommodation, and sleep-related problems in clinically anxious children. We also examined a hypothesized mediational pathway linking nightmares to other sleep-related problems, through increased family accommodation using structural equation modeling. Participants were 277 clinically anxious children (ages 6-17), and their mothers. Nightmares were reported in over three quarters of the children and were linked to higher mother-rated accommodation and to sleep-related problems. Fit indices for the structural equation model were excellent, and data supported the hypothesis that family accommodation mediates the association between nightmares and sleep-related problems in the anxious children. Results provide the first empirical evidence for the role of family accommodation in nightmares and other sleep-related problems in anxious children. Implications for assessment and treatment of childhood anxiety are discussed.

Electrophysiology of obsessive compulsive disorder: A systematic review of the electroencephalographic literature

Obsessive-compulsive disorder (OCD) is a chronic disease that causes significant decline in the quality of life of those affected. Due to our limited understanding of the underlying pathophysiology of OCD, successful treatment remains elusive. Although many have studied the pathophysiology of OCD through electroencephalography (EEG), limited attempts have been made to synthesize and interpret their findings. To bridge this gap, we conducted a comprehensive literature review using Medline/PubMed and considered the 65 most relevant studies published before June 2018. The findings are categorised into quantitative EEG, sleep related EEG and event related potentials (ERPs). Increased frontal asymmetry, frontal slowing and an enhancement in the ERP known as error related negativity (ERN) were consistent findings in OCD. However, sleep EEG and other ERP (P3 and N2) findings were inconsistent. Additionally, we analysed the usefulness of ERN as a potential candidate endophenotype. We hypothesize that dysfunctional frontal circuitry and overactive performance monitoring are the major underlying impairments in OCD. Additionally, we conceptualized that defective fronto-striato-thalamic circuitry causing poor cerebral functional connectivity gives rise to the OCD behavioural manifestations. Finally, we have discussed transcranial magnetic stimulation and EEG (TMS-EEG) applications in future research to further our knowledge of the underlying pathophysiology of OCD.

Obsessive-Compulsive Symptom Dimensions and Insomnia: Associations Among a Treatment-Seeking Veteran Sample

Sleep disturbances are a prevalent and pernicious correlate of most emotional disorders. A growing body of literature has recently found evidence for an association between sleep disturbances and obsessive-compulsive disorder (OCD). Though informative, this link has yet to be explored in a veteran population. Further, the degree to which this relationship is accounted for by relevant third variables is limited. The current study investigated the relationship between self-reported insomnia and OCD symptoms after controlling for probable depression and posttraumatic stress disorder (PTSD) using an unselected sample of veterans (N = 57). Most of the sample reported clinically significant OCD (61%) and insomnia symptoms (58%). Results revealed associations between insomnia and OCD unacceptable thoughts/neutralizing compulsions, but not contamination obsessions/washing compulsions, responsibility for harm obsessions/checking compulsions, or symmetry obsessions/ordering compulsions. Findings highlight the need for more research on OCD and sleep problems and clinical work focused on sleep for patients reporting increased OCD symptoms, particularly veterans.

Insomnia in pediatric obsessive-compulsive disorder: prevalence and association with multimodal treatment outcomes in a naturalistic clinical setting

OBJECTIVE

Little is known about the prevalence and impact of insomnia on clinical outcomes in youth with obsessive-compulsive disorder (OCD). This study aimed to investigate this subject.

PATIENTS/METHODS

A total of 193 patients from a specialist pediatric OCD clinic completed a range of diagnostic and clinical measures, including the Insomnia Severity Index (ISI). Patients scoring above a previously validated cut-off on the ISI (score ≥9) were compared to the rest of the sample on sociodemographic and clinical characteristics. In a subsample of 143 (from the initial 193) patients who were treated at the clinic, a mixed-model analysis of variance (ANOVA) was used to compare the outcomes of multimodal OCD treatment in the insomnia (N = 60) vs no insomnia (N = 83) groups. The primary outcome measure was the clinician-administered Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at post-treatment and at three-month follow-up.

RESULTS

The psychometric properties of the ISI in our sample were excellent. At baseline, 42% (81/193) of the sample scored above the ISI cut-off for clinical insomnia. These participants had significantly higher OCD severity, higher rates of psychiatric comorbidities, more severe depressive symptoms, poorer general functioning, and were more likely to take sleep medications, compared to those who scored below the ISI cut-off. In the treated subsample, while the insomnia group remained more severely affected through the three time-points, both groups improved similarly on the CY-BOCS at post-treatment and at three-month follow-up.

CONCLUSION

Insomnia is relatively common in pediatric OCD and is associated with more severe psychopathology. However, with adequate multimodal, evidence-based treatment, these patients can improve as much as those without insomnia.

Behavioral intervention for sleep problems in childhood: a Brazilian randomized controlled trial

Background

Sleep problems are common in children and can have an effect on behavioral and emotional functioning. Despite the importance of sleep for children’s health, there is a lack of studies on this topic in Brazil. The aim of this study was to evaluate the efficacy of behavioral intervention for sleep problems in young children and to investigate the effects on their daytime behavior.

Methods

Sixty-two children (ages 1–5; M = 2.3, SD = 1.3) with bedtime problems and night waking were randomized to a parent-based intervention or a wait list control group. After the waiting period, the wait list participants were offered treatment. The intervention was composed of five sessions over 2 months, during which the parents were educated on their child’s sleep and received guidance on the establishment of sleeping schedules and routines and on the use of extinction and positive reinforcement techniques. Sleep patterns and behavior problems were assessed with parent-report measures. Sleep patterns were also assessed with actigraphy. Assessments were completed at pre-intervention, post-intervention, 1-month follow-up, and 6-month follow-up.

Results

Children who received intervention showed greater baseline to post-treatment improvements in sleep latency, night waking, behavior such as resisting going to bed, the desire to sleep with their parents, and daytime behavior than the control group. These improvements were maintained at follow-up.

Conclusions

We concluded that behavioral parent-based intervention is effective in improving the quality of sleep and the diurnal behavior of children. This study provides initial support for use of this protocol in psychology clinics/schools. Brazilian clinical trials registration, RBR-4kxxd5. Retrospectively registered on December 13, 2016.

Exposure and response prevention for obsessive-compulsive disorder: A review and new directions

Obsessive-compulsive disorder (OCD) is characterized by distressing thoughts and repetitive behaviors that are interfering, time-consuming, and difficult to control. Although OCD was once thought to be untreatable, the last few decades have seen great success in reducing symptoms with exposure and response prevention (ERP), which is now considered to be the first-line psychotherapy for the disorder. Despite these significant therapeutic advances, there remain a number of challenges in treating OCD. In this review, we will describe the theoretical underpinnings and elements of ERP, examine the evidence for its effectiveness, and discuss new directions for enhancing it as a therapy for OCD.

Psychometric Analysis Of The Sleep Hygiene Index And Correlation With Stress And Anxiety Among Saudi University Students

AIMS

This study aimed to assess the psychometric properties of the Sleep Hygiene Index (SHI) instrument in screening poor sleep hygiene practices among Saudi university students. As a secondary goal, the association of sleep hygiene practices with stress and anxiety scores were assessed.

METHODS

Two-hundred and four healthy college and university students aged 18 to 25 years participated in this cross-sectional questionnaire-based survey. Participants were asked to complete the English version of the SHI instrument, the Perceived Stress Scale (PSS-10), the Generalized Anxiety Disorder (GAD-7) scale, and to provide demographic details.

RESULTS

The average scores for the SHI, the GAD-7, and the PSS-10 were 6.6, 5.3, and 16.2, respectively. The internal consistency of the SHI was adequate (McDonald's Omega 0.76). The corrected item-total correlations for all the items were fair (range, 0.31-0.50). A statistically significant positive correlation/association of the SHI scores with the PSS score, GAD-7, and self-reported poor sleep were obtained in this sample of Saudi university students. Factor analysis favored a 4-factor model of the SHI in the study sample.

CONCLUSION

The SHI scale demonstrated an adequate level of internal consistency as a self-reported instrument in the assessment of sleep hygiene among Saudi university students. In addition, poor sleep hygiene was correlated with stress and anxiety scores.

Living with obsessive-compulsive disorder (OCD): a South African narrative

Background

Obsessive–compulsive disorder (OCD) is a highly prevalent and debilitating psychiatric disorder known to interfere with several life domains. Yet little is known about the subjective experiences of living with OCD amongst South Africans and more so, the ways in which it impacts daily functioning and quality of life (QOL).

Methods

The aim of this study was to explore daily functioning and QOL among South African adults living with OCD. Qualitative semi-structured interviews were conducted with 20 adults with a primary diagnosis of OCD. We used ATLAS.ti v7 to analyse the data, thematically. The study was conducted at the SU/UCT MRC Unit on Risk and Resilience in Mental Disorders in South Africa.

Results

Three key themes were identified namely, (1) realisation of OCD, (2) disruptions to daily life and (3) managing the disruptions to daily life. Participants recounted their earliest recollections of OCD, the instances when they recognised something was wrong and ways in which they came to terms with their OCD. Disruptions to daily life included poor sleep quality, inability to enjoy leisure activities which impacted on socialisation and impairment in school/work performance. Perceived social support from family members, friends and colleagues were invaluable to helping participants manage these disruptions. Further, strategies such as self-talk, diary-keeping and humour helped them cope.

Conclusion

While some individuals with OCD have found ways to cope with and accept having OCD, all participants perceived their QOL to be significantly reduced and their functioning impaired due to the condition, on multiple levels. The importance of acceptance in OCD ties in with research on the potential value of Acceptance and Commitment Therapy, which could form an adjunct to more conventional techniques such as Cognitive-Behavioural Therapy. The themes emanating from this study can be used to help clinicians better understand what treatment works best for patients with OCD—and whether this treatment be focused on the individual or together with close members of their microsystem, such as spouses/partners. Further these findings may potentially help to improve access, affordability and the quality of life of South Africans living with OCD from various income backgrounds.

The Link Between Anxiety Severity and Irritability Among Anxious Youth: Evaluating the Mediating Role of Sleep Problems

Although recent studies have linked pediatric anxiety to irritability, research has yet to examine the mechanisms through which youth anxiety may be associated with irritability. Importantly, sleep related problems (SRPs) have been associated with both child anxiety and irritability, but research has not considered whether the link between youth anxiety and irritability may be accounted for by SRPs. The present study investigated whether SRPs mediated the relationship between anxiety severity and irritability in a large sample of treatment-seeking anxious youth (N = 435; ages 7-19 years, M = 12.7; 55.1% female). Anxiety severity, SRPs and irritability showed significant pairwise associations, and the indirect effect of youth anxiety severity on irritability, via SRPs, was positive and significant. The present analysis is the first to examine youth anxiety, irritability, and SPRs in a single model in a sample of anxious youth, and provides preliminary evidence that SRPs partially mediate links between child anxiety and irritability.

The Relationship between Sleep Problems, Neurobiological Alterations, Core Symptoms of Autism Spectrum Disorder, and Psychiatric Comorbidities

Children with Autism Spectrum Disorder (ASD) are at an increased risk for sleep disturbances, and studies indicate that between 50 and 80% of children with ASD experience sleep problems. These problems increase parental stress and adversely affect family quality of life. Studies have also suggested that sleep disturbances may increase behavioral problems in this clinical population. Although understanding the causes of sleep disorders in ASD is a clinical priority, the causal relationship between these two conditions remains unclear. Given the complex nature of ASD, the etiology of sleep problems in this clinical population is probably multi-factorial. In this overview, we discuss in detail three possible etiological explanations of sleep problems in ASD that can all contribute to the high rate of these symptoms in ASD. Specifically, we examine how neurobiological alterations, genetic mutations, and disrupted sleep architecture can cause sleep problems in individuals with ASD. We also discuss how sleep problems may be a direct result of core symptoms of ASD. Finally, a detailed examination of the relationship between sleep problems and associated clinical features and psychiatric comorbidities in individuals with ASD is described.

A case-control study of sleep disturbances in pediatric obsessive-compulsive disorder

BACKGROUND

Sleep disturbances, including delayed sleep phase disorder (DSPD) and disorders of sleep initiation and maintenance (DIMS), have repeatedly been identified in adult obsessive-compulsive disorder (OCD). These disturbances have not been well-characterized objectively in pediatric OCD.

METHODS

Thirty OCD-affected youth (8-18 yrs, 40% male) and 30 age and gender-matched healthy controls (HCs) completed the Sleep Disturbances Scale for Children (SDSC), and one week of continuous actigraphy with concurrent sleep diary documentation. A subsample completed the Children's Sleep Hygiene Scale (CSHS) and Sleep Attitudes and Beliefs Scale (SABS).

RESULTS

Seventy-two percent of OCD participants reported sleep disturbances versus 15% of HC participants (p < 0.001). Convergent actigraphy results suggested DIMS but not DSPD were common.

DISCUSSION

The parents of OCD-affected children seem to be successfully controlling bedtimes, preventing circadian rhythm system disruptions. OCD status does adversely impact, however, the perisleep arousal system. These results have important clinical implications, suggesting sleep problems may be best managed through direct treatment of OCD symptoms. It is recommended that all pediatric OCD patients be screened for sleep disturbances to inform treatment plan development.

Comorbidity of ADHD and Anxiety Disorders in School-Age Children: Impact on Sleep and Response to a Cognitive-Behavioral Treatment

OBJECTIVE

This exploratory study measured the impact of comorbid anxiety disorders on sleep in children with ADHD and tested the effect of cognitive-behavioral therapy (CBT) on these measures.

METHOD

Fifty-seven children (8-12 years old) were assessed with the Child Sleep Habits Questionnaire. Four groups were formed: ADHD ( n = 20), ADHD + Anxiety ( n = 20), Anxiety ( n = 8), and Healthy Controls ( n = 9). A subgroup of 10 children with ADHD + Anxiety underwent CBT for anxiety.

RESULTS

The results showed that sleep difficulties were better associated with anxiety than with ADHD. CBT reduced sleep onset latency and marginally decreased the total amount of sleep problems.

CONCLUSION

The present study demonstrates that comorbid anxiety in ADHD children is linked with specific sleep disturbances and is sensitive to CBT aimed at reducing anxiety.

Sleep-Related Problems and the Effects of Anxiety Treatment in Children and Adolescents

This study examined (a) demographic and clinical characteristics associated with sleep-related problems (SRPs) among youth with anxiety disorders, and (b) the impact of anxiety treatment: cognitive-behavioral therapy (CBT; Coping Cat), medication (sertraline), their combination, and pill placebo on SRPs. Youth (N = 488, ages 7-17, 50% female, 79% White) with a principal diagnosis of generalized anxiety disorder, separation anxiety disorder, or social phobia participated. SRPs were reported by parents and youth. Findings differed by informant and by type of SRP, with evidence that SRPs are associated with age, anxiety severity, externalizing problems, functional impairment, and family burden at pretreatment. Anxiety treatment reduced SRPs; effect sizes were small to medium. Reductions in parent-reported separation-related sleep difficulties were significantly greater in active treatment than in the placebo condition, with the greatest reductions reported by parents of youth whose active treatment was multimodal or included sertraline. Youth whose anxiety treatment involved CBT reported significantly greater decreases in dysregulated sleep (e.g., sleeplessness). Both CBT for anxiety and sertraline appear to be somewhat effective in reducing SRPs, and multimodal treatment may be preferable depending on the symptom presentation. To inform practice, future research should examine a broad range of SRPs, incorporate objective measures of sleep, and evaluate the impact of behavioral strategies that directly target SRPs in youth with anxiety disorders.

Sleep, anxiety and psychiatric symptoms in children with Tourette syndrome and tic disorders

OBJECTIVE

The current study evaluated the relationship between tic, sleep disorders and specific psychiatric symptoms (anxiety, depression, obsessive compulsive symptoms).

METHODS

Assessment of 36 consecutive children and adolescents with tic disorders included: the Yale Global Tic Severity Scale (YGTSS) to assess the severity of tic symptoms; the Self-administered scale for children and adolescents (SAFA) to evaluate the psychopathological profile; a specific sleep questionnaire consisting of 45 items to assess the presence of sleep disorders. An age and sex-matched control group was used for comparisons.

RESULTS

Sleep was significantly more disturbed in patients with tic disorders than in controls. Difficulties in initiating sleep and increased motor activity during sleep were the most frequent sleep disturbances found in our sample. Patients showed also symptoms of anxiety (SAFA A), depressed mood (SAFA D) and doubt-indecision (SAFA O). Additionally, difficulties in initiating sleep resulted associated with other SAFA subscales relative to obsessive-compulsive symptoms and depression symptoms. Furthermore, anxiety symptoms (SAFA A) resulted associated with increased motor activity during sleep.

CONCLUSIONS

Findings confirm literature studies reporting high frequency of sleep problems, anxiety and other psychopathological symptoms in patients with tic disorders, and support the hypothesis that intrusive thoughts and other emotional disturbances might disrupt the sleep onset of these patients. These results suggest the importance of a thorough assessment of sleep and psychiatric disturbances in patients with tic disorders.

Does an Online CBT Program for Anxiety Impact Upon Sleep Problems in Anxious Youth?

This study aimed to assess whether the transdiagnostic therapy elements of an online cognitive behaviour therapy anxiety program also impact on sleep-related problems (SRPs) in anxious youth. Participants were drawn from two previously published studies evaluating online cognitive behaviour therapy for child anxiety (BRAVE-ONLINE). The study included 63 children 7-12 years of age (M = 9.49, SD = 1.37) and 71 adolescents 12-18 years of age (M = 13.90, SD = 1.68). SRPs, severity of anxiety diagnosis, anxiety symptoms, number of diagnoses, depressive symptoms, and global functioning were assessed at pre-, post-, and 6-month follow-up assessment points. SRPs were positively related to anxiety symptoms and severity for children and were positively related to depression for adolescents. SRPs did not differ between male and female participants, between children and adolescents, or between those who had generalised anxiety disorder in their profile and those who did not. Finally, children but not adolescents participating in the online program demonstrated a significantly greater reduction in SRPs from pre- to posttreatment compared to the waitlist group, and these gains were maintained at 6-month follow-up. Treatment focusing on child anxiety alone may reduce SRPs in children but not adolescents. Although further research is clearly needed, clinicians should ensure that they assess for SRPs in their teenage clients and directly target SRPs in treatment where required.

Sleep disturbance and obsessive-compulsive symptoms: Results from the national comorbidity survey replication

A small body of developing research has found evidence for sleep disturbance in obsessive-compulsive disorder (OCD) and links between sleep disturbance and obsessive-compulsive symptoms (OCS) in unselected samples. However, the link between sleep disturbance and OCS is yet to be examined in a nationally representative sample. Furthermore, the extent to which the link between sleep disturbance and OCS is accounted for by symptoms of depression remains unclear. To address this gap in the literature, the present study examined the relationship between sleep disturbance and OCS in a nationally representative sample. Participants were assessed in the National Comorbidity Survey Replication (NCS-R; n = 2073). Consistent with predictions, results revealed that individuals with sleep disturbance reported increased OCS severity compared to individuals without sleep disturbance. Further, sleep disturbance severity was associated with OCS severity, even when controlling for depression (and other anxiety-related disorders). This study is the first to link sleep disturbance and OCS in a nationally representative sample, and these findings highlight the unique role of sleep disturbance in the experience of OCS. Future research is necessary to delineate specific mechanisms that may account for this relationship.

Annual Research Review: Sleep problems in childhood psychiatric disorders--a review of the latest science

BACKGROUND

Hippocrates flagged the value of sleep for good health. Nonetheless, historically, researchers with an interest in developmental psychopathology have largely ignored a possible role for atypical sleep. Recently, however, there has been a surge of interest in this area, perhaps reflecting increased evidence that disturbed or insufficient sleep can result in poor functioning in numerous domains. This review outlines what is known about sleep in the psychiatric diagnoses most relevant to children and for which associations with sleep are beginning to be understood. While based on a comprehensive survey of the literature, the focus of the current review is on the latest science (largely from 2010). There is a description of both concurrent and longitudinal links as well as possible mechanisms underlying associations. Preliminary treatment research is also considered which suggests that treating sleep difficulties may result in improvements in behavioural areas beyond sleep quality.

FINDINGS

To maximise progress in this field, there now needs to be: (a) greater attention to the assessment of sleep in children; (b) sleep research on a wider range of psychiatric disorders; (c) a greater focus on and examination of mechanisms underlying associations; (d) a clearer consideration of developmental questions and (e) large-scale well-designed treatment studies.

CONCLUSIONS

While sleep problems may sometimes be missed by parents and healthcare providers; hence constituting a hidden risk for other psychopathologies - knowing about these difficulties creates unique opportunities. The current excitement in this field from experts in diverse areas including developmental psychology, clinical psychology, genetics and neuropsychology should make these opportunities a reality.

Insomnia and Relationship with Anxiety in University Students: A Cross-Sectional Designed Study

Purpose

Sleep disorders (SDs) are now recognized as a public health concern with considerable psychiatric and societal consequences specifically on the academic life of students. The aims of this study were to assess SDs in a group of university students in Lebanon and to examine the relationship between SDs and anxiety.

Methods

An observational cross-sectional study was conducted at Saint-Joseph University, Lebanon, during the academic year 2013–2014. Four questionnaires were face-to-face administered to 462 students after obtaining their written consent: Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Generalized Anxiety Disorder 7-item scale (GAD-7).

Results

The prevalence of clinically significant insomnia was 10.6% (95% CI: 7.8–13.4%), more frequent in first year students. ISI mean score was 10.06 (SD = 3.76). 37.1% of the participants were poor sleepers. Excessive daytime sleepiness (EDS) and poor sleep were significantly more frequent among participants with clinical insomnia (p = 0.031 and 0.001 respectively). Clinically significant anxiety was more frequent in students suffering from clinical insomnia (p = 0.006) and in poor sleepers (p = 0.003). 50.8% of the participants with clinically significant anxiety presented EDS versus 30.9% of those with no clinically significant anxiety (p<0.0001).

Conclusions

The magnitude of SDs in this sample of Lebanese university students demonstrate the importance of examining sleep health in this population. Moreover, the link between SD and anxiety reminds us of the importance of treating anxiety as soon as detected and not simply targeting the reduction of sleep problems.