Sleep problems and cognitive behavior therapy in pediatric obsessive-compulsive disorder have bidirectional effects
Introduction
Sleep problems are common in both children and adolescents and have been reported among young people in the range 10–75% (assessment methods have varied). Moreover, the difficulties seem to persist in many, although decreasing with age in many as well (Gregory, Rijsdijk, Dahl, McGuffin, & Eley, 2006; Zuckerman, Stevenson, & Bailey, 1987). However, childhood sleep problems may persist into adolescence (Gregory & O'Connor, 2002).
Continued sleep problems are associated with psychiatric disorders (Chorney, Detweiler, Morris, & Kuhn, 2008; Gregory and Sadeh, 2012, Ivanenko and Johnson, 2008). In anxiety disorders and depression, sleep problems are especially common (Alfano, Beidel, Turner, & Lewin, 2006; Alfano, Ginsburg, & Kingery, 2007; Charuvastra and Cloitre, 2009, Chase and Pincus, 2011; Hudson, Gradisar, Gamble, Schniering, & Rebelo, 2009; Ivanenko, Crabtree, & Gozal, 2004), less than 1 in 10 reported, for example, no problems (Chase & Pincus, 2011). Such problems are essential parts of the disorder in generalized anxiety and depression (American Psychiatric Association, 2013). However, other psychiatric disorder with high levels of anxiety, e.g. OCD, is also strongly associated with sleep problems (Dubitsky, 2005, Ivarsson and Larsson, 2009), as are ADHD (Cortese et al., 2013) and autism (Goldman, Richdale, Clemons, & Malow, 2012).
In paediatric anxiety disorders and OCD, studies using sleep assessment methods have clarified that sleep problems are both prevalent and specific (Alfano & Kim 2011; Alfano, Pina, Zerr, & Villalta, 2010; Alfano, Reynolds, Scott, Dahl, & Mellman, 2013; Alfano, Zakem, Costa, Taylor, & Weems, 2009; Forbes et al., 2008). That is, that the sleep problems are not a halo effect from the disorder, or due to a lack of specificity in assessment methods.
Clinical experience shows that obsessive ruminations with elevated levels of anxiety and arousal before bedtime as well as rituals that delay sleep onset are common in paediatric OCD, even though research did not show increased latency to sleep (Alfano & Kim, 2011). However, residual arousal leading to more shallow sleep, and difficulties in falling asleep again following awakening may cause the fragmented sleep pattern noted by Alfano and Kim (2011). Although, it is difficult to explain the link between too little sleep and more severe compulsive behaviours it is possible that different rituals (e.g. mental rituals bed) may be responsible. This relationship needs to be replicated. Few studies have examined sleep problems in paediatric OCD, two studies using large samples (Ivarsson and Larsson, 2009, Storch et al., 2008), showed that such problems were prevalent, in that, about a third had significant problems, and that less than 10% had none. However, the assessment methods used were unspecific (CBCL – depression and anxiety scales sleep items). The findings are substantiated by a study using sleep specific assessment methods in a smaller sample, showing that sleep problems are both common and severe (Alfano & Kim, 2011). She found that the patients' sleep patterns were fragmented, that the total sleep time was reduced and that patients spent longer wake periods after sleep onset as compared to controls. Moreover, the severity of compulsions but not obsessions was significantly related to total sleep time (TST), indicating less TST among children with elevated compulsions.
However, there is still little data as to whether sleep problems associated with OCD reduce from treatment, and whether it is common with residual significant sleep problems in responders or non-responders to treatment. Storch et al. (2008) found a significant reduction of sleep problems following cognitive behaviour therapy (CBT) for OCD. However, we are not aware of any studies showing whether serotonin re-uptake-inhibiting (SRI) agents for OCD reduce sleep problems as well. Moreover, we as well lack data on whether sleep problems may compromise treatment with CBT.
Section snippets
Aims
To investigate the presence of sleep problems in the Nordic Long-Term OCD Treatment Study (NordLOTS) (Torp et al., 2015) and to what extent sleep was affected by CBT for the OCD-symptoms. Furthermore, to investigate whether sleep problems at baseline were associated with poorer response of CBT.
Methods
The data are part of the NordLOTS, a stepwise treatment study aiming at evaluating whether CBT or drug treatment with sertraline is best for children and adolescents with OCD who do not respond to CBT. The rationale, design and methods of the NordLOTS are described elsewhere (Ivarsson et al., 2010, Thomsen et al., 2013). In short, it started in September 2008 and finished inclusion in June 2012, when a large cohort of patients with OCD (n = 269) their first treatment step with 14 weeks of CBT in
Demographics
There were no gender differences with regard to sleep problems (Girls m = 2.09, SD = 1.98 and Boys m = 1.96, SD = 2.40, p = .63), nor any age differences (7–11 years m = 2.23, SD = 2.34 and 12–18 years m = 1.94, SD = 2.12, p = .33). When examined with regard to the frequency of individual sleep problems both differences with regard to gender and age group (children vs. adolescents) were not significant, so we did not use age or gender as covariates.
Baseline prevalence of sleep problems
68.3% (n = 168) of children had at least one mild sleep problem.
Discussion
This is, to our knowledge, the second study to report on how sleep problems in paediatric patients with OCD change following treatment with CBT. Like Storch et al. (2008) showed, sleep problems tend to decrease together with the OCD symptoms, so that, although two-thirds still had sleep problems, treatment responders have less sleep problems. Moreover, a new report from the CAMS researcher group shows similar results from the treatment with CBT on sleep problems in children and adolescents with
Limitations
The main limitation of our study is due to the measure used, i.e. the CBCL. Although used in many studies, the sleep items are not specific for the kind of sleep problems encountered in paediatric OCD, so there is a risk of a lack of ascertainment as well as overlap between some items. Future studies need to use sleep-specific scales (e.g. the use of Actigraphy, a parental report like the “Children's Sleep Habits Questionnaire”, and a self-report as exemplified by the “Sleep self-report” (
Conclusion
It is reasonable to interpret our findings that in patients with OCD in general, sleep problems associated with OCD gets better as the OCD symptoms respond to treatment. However, it is as well clear that a significant minority have continued sleep problems, and though this study does not prove it, it seems probable that the failure of CBT to bring relief to the OCD symptoms are associated with the failure with regard to the sleep problems. However, we cannot say based on our data anything about
Acknowledgements
The Norwegian Research Council NFR grant no. 196291/V50 financed the NordLOTS project. We are also grateful for the supportive RBUP leadership particularly Administrator Roy Larsson during the study's inception and the building of the data facilities.
References (51)
- et al.
Preliminary evidence for sleep complaints among children referred for anxiety
Sleep Medicine
(2006) - et al.
Sleep-related problems among children and adolescents with anxiety disorders
Journal of the American Academy of Child and Adolescent Psychiatry
(2007) - et al.
Objective sleep patterns and severity of symptoms in pediatric obsessive compulsive disorder: a pilot investigation
Journal of Anxiety Disorders
(2011) - et al.
Polysomnographic sleep patterns of non-depressed, non-medicated children with generalized anxiety disorder
Journal of Affective Disorders
(2013) - et al.
Safe enough to sleep: sleep disruptions associated with trauma, posttraumatic stress, and anxiety in children and adolescents
Child and Adolescent Psychiatric Clinics of North America
(2009) - et al.
Assessment and management of sleep problems in youths with attention-deficit/hyperactivity disorder
Journal of the American Academy of Child and Adolescent Psychiatry
(2013) - et al.
Sleep in children with autistic spectrum disorder
Sleep Medicine
(2010) - et al.
Objective sleep in pediatric anxiety disorders and major depressive disorder
Journal of the American Academy of Child and Adolescent Psychiatry
(2008) - et al.
Convergent and discriminant validity of the Children's Yale-Brown Obsessive Compulsive Scale-Symptom Checklist
Journal of Anxiety Disorders
(2008) - et al.
Sleep problems in childhood: a longitudinal study of developmental change and association with behavioral problems
Journal of the American Academy of Child and Adolescent Psychiatry
(2002)
Sleep, emotional and behavioral difficulties in children and adolescents
Sleep Medicine Reviews
The sleep patterns and problems of clinically anxious children
Behaviour Research and Therapy
Sleep in children with psychiatric disorders
Pediatric Clinics of North America
Sleep disturbances in children with psychiatric disorders
Seminars in Pediatric Neurology
Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version (K-SADS-PL): Initial reliability and validity data
Journal of the American Academy of Child and Adolescent Psychiatry
A randomised controlled trial of cognitive-behaviour therapy for behavioural insomnia of childhood in school-aged children
Behaviour Research and Therapy
Multiple imputation of missing repeated outcome measurements did not add to linear mixed-effects models
Journal of Clinical Epidemiology
Controlled comparison of family cognitive behavioral therapy and psychoeducation/relaxation training for child obsessive-compulsive disorder
Journal of the American Academy of Child and Adolescent Psychiatry
The role of actigraphy in sleep medicine
Sleep Medicine Reviews
Children's Yale-Brown Obsessive Compulsive Scale: reliability and validity
Journal of the American Academy of Child and Adolescent Psychiatry
Melatonin improves health status and sleep in children with idiopathic chronic sleep-onset insomnia: a randomized placebo-controlled trial
Journal of the American Academy of Child and Adolescent Psychiatry
Psychometric evaluation of the Children's Yale-Brown Obsessive-Compulsive Scale
Psychiatry Research
Sleep-related problems in pediatric obsessive-compulsive disorder
Journal of Anxiety Disorders
The effectiveness of CBT for pediatric OCD: cognitive behavior treatment for obsessive-compulsive disorder in childhood and adolescence. Step 1 of the Nordic Long-term OCD Treatment Study (NordLOTS)
Behavior Research and Therapy
Manual for the ASEBA school-age forms & profiles
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