Clinical Psychologist 16 (2012) 44–56

Dismantling the bidirectional relationship

between paediatric sleep and anxiety cp_39 44..56

Erin LEAHY and Michael GRADISAR

School of Psychology, Flinders University, Adelaide, South Australia, Australia

Key words Abstract

sleep-related problems, anxiety, paediatric,
child, adolescent. Background: Sleep-related problems are a common occurrence during child-
hood and adolescence. Over the past decade, there has been mounting evi-
Correspondence dence for a relationship between sleep disturbance and anxiety during this
Michael Gradisar, School of Psychology, c/o developmental period. The literature suggests that these associations are likely
Flinders University, GPO Box 2100, Adelaide,
complex and bidirectional. That is, sleep disturbance may serve as a precursor
SA 5001, Australia.
to poor psychological outcomes (e.g., anxiety), or conversely, anxiety may
Email: grad0011@flinders.edu.au
predict the development of sleep-related problems (SRPs). However, the direc-
Received 10 October 2011; accepted 21 tion of effect between sleep and anxiety remains unclear.
December 2011. Aim: The purpose of this review is to explore the evidence for a bidirectional
relationship between sleep and anxiety in children and adolescents.
doi:10.1111/j.1742-9552.2012.00039.x Methods: A literature search was conducted to identify articles relating to the
relationship between paediatric sleep and anxiety.
Results: A plethora of cross-sectional research has demonstrated that SRPs
and anxiety frequently overlap in the child and adolescent population. Pre-
liminary support for the role of sleep disturbance as a precursor to the devel-
opment of anxiety has been evidenced by a small number of longitudinal,
experimental, and treatment studies. However, there is a paucity of such
research examining the opposite direction of effect.
Conclusions: The research has provided preliminary support for the role of
sleep problems serving as a “red flag” for the later development of anxiety in
childhood and adolescent populations. However, empirical evidence supporting
a relationship in the opposite direction has not been as conclusive. Additional
studies of longitudinal, experimental, and treatment design are warranted to
further delineate the direction of effect between childhood sleep and anxiety.

Introduction
Key Points
Sleep disturbance is commonly reported in the paediatric
1 SRPs and anxiety are reported to frequently population, with up to 40% of children estimated to
co-occur in the paediatric population. have experienced a sleep-related problem (SRP) during
2 Preliminary support has been found for the role of their development (Alfano, Zakem, Costa, Taylor, &
sleep disturbance as a precursor to the development Weems, 2009; Gregory & Sadeh, 2011). For many chil-
of paediatric anxiety. dren, these disruptions represent a temporary problem,
3 Research examining the role of anxiety in the which will elapse without intervention. While for others,
development of SRPs is limited in design and scope. these problems persist, impacting on their overall quality
of life (Alfano et al., 2009). The literature has drawn
attention to a number of poor outcomes associated with
Funding: None. paediatric sleep disturbance including impairments in
Conflict of interest: None. academic performance, behaviour, cognitive functioning

© 2012 Flinders University

44 Clinical Psychologist © 2012 The Australian Psychological Society
 Paediatric sleep and anxiety

(e.g., attention and concentration), socialisation, family addition, sleep disorders take many forms, and their clas-
well-being, and mental health (e.g., Billows, Gradisar, sification varies depending on which classification system
Dohnt, Johnston, & McCappin, 2009; Fallone, Acebo, is followed (i.e., Diagnostic and Statistical Manual,
Seifer, & Carskadon, 2005; Gradisar, Terrill, Johnston, Fourth Edition (DSM-IV-TR); American Psychiatric Asso-
& Douglas, 2008; Meijer, Habekothe, & van den Witten- ciation (APA), 2000; International Classification of Sleep
boer, 2001; Sadeh, Gruber, & Raviv, 2002; Smaldone, Disorders, Second Edition (ICSD-2); American Academy
Honig, & Byrne, 2007). Due to the volume of negative of Sleep Medicine (AASM), 2005).
outcomes associated with sleep disturbance, a better According to the ICSD-2, childhood sleep disorders can
understanding of the association between sleep problems be divided into two distinct categories: dyssomnias and
and psychiatric symptoms (e.g., anxiety) in children is parasomnias (AASM, 2005). The term dyssomnia encom-
warranted. passes a number of sleep disorders relating to difficulties
Over the past decade, the literature has drawn atten- initiating or maintaining sleep (e.g., insomnia; delayed
tion to the co-occurrence of sleep disturbance and sleep phase disorder (DSPD)), and non-restorative sleep
anxiety in the paediatric population. For example, (e.g., restless legs syndrome (RLS); Petit, Touchette,
researchers have observed a link between disturbed sleep Tremblay, Boivin, and Montplaisir, 2007). In contrast, the
and poor emotional functioning in children and adoles- term parasomnia describes a group of disorders associated
cents (e.g., Gregory, Caspi, Eley, Moffitt, & O’Connor, with the occurrence of arousal or partial arousal during
2005; Gregory & O’Connor, 2002). Similarly, children sleep stage or sleep–wake transitions. Examples of para-
with anxiety often present with sleep-related problems somnias include sleep walking, sleep talking, nightmares,
(Forbes et al., 2008; Gregory & O’Connor, 2002). While sleep terrors, sleep bruxism (teeth grinding), rhythmic
this relationship appears bidirectional, the direction of movements, and nocturnal enuresis (bed-wetting)
effect between these two variables is unclear. The aim of (Ivanenko, Barnes, Crabtree, & Gozal, 2004). In contrast
this review is to examine the evidence for a bidirectional to the insomnia symptoms commonly experienced in
relationship between paediatric sleep and anxiety. That adolescence, the ICSD-2 diagnostic category of Behav-
is, the extent to which anxiety is predicted from early ioural Insomnia of Childhood (BIC) describes a group of
sleep disturbance, and conversely, the degree to which insomnia symptoms unique to the childhood period due
the onset of SRPs is preceded by anxiety. to the presence of extrinsic factors, such as parenting
The review commences with an introduction to the practices (AASM, 2005; Ivanenko et al., 2004). These
numerous types of SRPs associated with childhood insomnia symptoms, including problematic sleep associa-
anxiety in the literature. Issues regarding the definition tions (e.g., parental presence) and related behavioural
of sleep disturbance and anxiety are then discussed. Inter- difficulties (e.g., bedtime resistance) are observed to share
related mechanisms are addressed to provide the reader a considerable overlap with the symptoms of anxiety dis-
rationale for the overlap between sleep and anxi- orders of childhood, namely Separation Anxiety Disorder
ety. Cross-sectional research examining the association (SAD; AASM, 2005).
between childhood sleep disturbance and anxiety is then
reviewed, followed by a presentation of research exam-
ining the direction of effect in this relationship. The
Paediatric Anxiety
review concludes with a summary of proposed directions
for future research. Anxiety is one of the most commonly reported childhood
Within the literature, several SRPs of childhood have psychiatric conditions, with an estimated 3.7% to 9.9% of
been associated with emotional regulation difficulties, children and adolescents meeting the criteria for an
such as anxiety. However, there is a lack of consistency in anxiety disorder at any stage during their development
the research regarding what constitutes a sleep problem. (Alfano, Beidel, Turner, & Lewin, 2006; Ford, Goodman, &
For example, some studies have addressed a broad range Meltzer, 2003). However, there is a lack of consensus in
of SRPs (e.g., Gregory & O’Connor, 2002; Johnson, the research regarding the conceptualisation of anxiety
Chilcoat, & Breslau, 2000; Sadeh et al., 2002), while within this population. For example, several studies
others have assessed specific sleep disorders (e.g., Gian- define anxiety according to a broad “internalising” phe-
notti, Cortesi, Sebastiani, & Ottaviano, 2002; Ivanenko, notype, encompassing both anxious and depressive symp-
McLaughlin Crabtree, O’Brien, & Gozal, 2006; Picchietti toms, while others define anxiety in terms of specific
et al., 2007). This may be partly due to the fact that in the disorders. The DSM-IV-TR distinguishes several anxiety
past, sleep disturbance was often conceptualised as a sec- disorders observable in both child and adult populations,
ondary symptom of other problems, rather than a distinct including generalised anxiety disorder (GAD), social
condition in its own right (Gregory & Sadeh, 2011). In anxiety disorder (SOC), post-traumatic stress disorder

© 2012 Flinders University

Clinical Psychologist © 2012 The Australian Psychological Society 45
Leahy and Gradisar

(PTSD), panic disorder, Specific Phobia, and obsessive– the locus coeruleus, which has been strongly linked to
compulsive disorder (OCD; APA, 2000). GAD is the most sleep regulation (Osaka & Matsumara, 1994), control of
commonly reported anxiety condition in children and arousal and stress responses (Aston-Jones, Rajkowski,
adolescents and is characterised by excessive worry, Kubiak, & Alexinsky, 1994; Valentino, Page, Van Bocks-
hyper-vigilance, and agitation (Muris, Schmidt, & Merck- taele, & Aston-Jones, 1992), and dysregulation of affect
elbach, 2000). Of relevance to this population, SAD is the in clinical disorders, such as anxiety (Curtis & Valentino,
only anxiety condition defined as unique to the period of 1994; Kitayama, Kayahara, & Nakano, 1994). In addition
childhood (APA, 2000). According to the DSM-IV-TR, to the influence of shared brain structures, a strong
SAD is distinguished by the presence of heightened overlap is present between the genes that influence sleep
anxiety following separation from a significant attach- disturbance and anxiety symptoms, with twin studies
ment figure or the home environment (APA, 2000). reporting an overlap of genes responsible for up to 74%
Childhood anxiety disorders are associated with numer- of the accounted variance (Gregory et al., 2011). While
ous impairments, including sleep disturbance. GAD and these studies do not provide information regarding the
SAD both feature sleep-related symptoms within the specific genes involved, the serotonin transporter gene
DSM-IV-TR diagnostic criteria, including difficulty falling (5HTTLPR) has been previously associated with both
asleep in GAD, and nightmares observed in SAD (APA, sleep disturbance (e.g., Barclay et al., 2011; Brummett
2000). Not surprisingly, these two anxiety disorders are et al., 2007) and anxiety phenotypes (Jorm et al., 2000;
the most commonly cited in the literature addressing the Lesch et al., 1996).
relationship between paediatric sleep and anxiety. In addition to the suggested interaction between
shared brain structures, sleep and anxiety are also theo-
rised to be governed by related psychobiological pro-
The Interrelated Mechanisms of Sleep
cesses. Under the influence of both the circadian and
and Anxiety
homeostatic sleep/wake systems, the brain pendulates
While the literature has drawn attention to the associa- between higher and lower states of arousal across a 24-hr
tion between sleep and internalising problems, the inter- period. Dahl (1996) theorises that high states of arousal,
related mechanisms underlying this relationship are characterised by vigilance, are incompatible with lower
complex and poorly understood. The intricate neurobio- states of arousal, such as sleep. Thus, at the most basic
logical systems critical for the regulation of sleep (e.g., level, sleep and arousal represent closely linked, oppo-
wakefulness; slow-wave sleep; rapid eye movement nent processes (Dahl, 1996). The author theorises that
sleep; sleep stage transition) and psychiatric disorders the delicate balancing act between sleep and vigilance is
(e.g., anxiety) are not yet fully known and beyond the greatly affected by a perceived sense of safety versus
scope of this review. However, an overlap is apparent threat (Dahl, 1996). Perceptions of threat are theorised to
between a number of cortical and subcortical regions of trigger an increase in arousal, drawing the system back in
the brain implicated in both sleep and anxiety. These the opposing direction of sleep. This premise explains
include the prefrontal cortex (PFC), thalamus, limbic why an emotionally distressing experience, such as
midbrain, pontine, and medullary regions (Dahl, 1996). trauma or separation, is often followed by at least a
To date, a breadth of research has implicated various transient disturbance in sleep for the general population
sectors of the PFC in disorders of emotion dysregulation, (Cartwright & Wood, 1991; Hall, Dahl, Dew, & Reynolds,
such as anxiety (e.g., Bishop, Duncan, Brett, & Lawrence, 1995). However, this process is more prominent in
2004; Davidson, 2002). More specifically, neuroimaging clinical populations, where persistent sleep disturbance
differences have been observed in the symmetry of acti- is considered a major diagnostic symptom of several
vation of the PFC in individuals with anxiety, compared anxiety disorders (e.g., GAD, SAD; APA, 2000). It is theo-
with non-anxious individuals (Davidson, Ekman, Saron, rised that the vigilant processes and biased information
Senulis, & Friesen, 1990). Similarly, defective functioning processing thought to characterise early onset anxiety
(i.e., deactivation) of the PFC has been observed in may explain the occurrence of sleep problems in this
experimental studies following sleep deprivation (e.g., population (Dahl & Harvey, 2007). For example, children
Harrison & Horne, 2000; Horne, 1993; Thomas et al., and adolescents with anxiety disorders exhibit an atten-
2000) and noted in functional neuroimaging of adults tional bias towards potential threats (Dahl & Harvey,
with insomnia (e.g., Altena et al., 2008; Nofzinger et al., 2007; Taghavi, Neshat-Doost, & Moradi, 1999). While
2004). These studies highlight the sensitivity of the PFC these observations provide support for the notion of
in problems of both sleep and anxiety (Muzur, Pace- interrelated mechanisms driving the processes of sleep,
Schott, & Hobson, 2002). Another noteworthy area of arousal, and affective functioning; the specific cause
research has focused on a section of the pons, known as and effect relationships between sleep changes and

© 2012 Flinders University

46 Clinical Psychologist © 2012 The Australian Psychological Society
 Paediatric sleep and anxiety

psychopathology are unknown. The following sections of including difficulty initiating and maintaining sleep
this review will first attempt to outline the evidence for a (Ivanenko et al., 2006; Stein, Mendelsohn, Obermeyer,
bidirectional relationship between paediatric sleep and Amromin, & Benca, 2001). Other studies have provided
anxiety, and then compare the evidence for the strength support for this link in regards to the behavioural symp-
of individual predictive associations between sleep and toms often seen in childhood insomnia, including limit
anxiety (and vice versa). setting (e.g., bedtime resistance) and problematic sleep-
onset associations (e.g., Alfano et al., 2006; Gregory &
Eley, 2005; Gregory, Rijsdijk, Dahl, McGuffin, & Eley,
Literature Search and Inclusion Criteria
2006; Ivanenko et al., 2006). In addition to insomnia,
A literature search was conducted to identify articles emotional problems have been associated with numerous
relating to the relationship between paediatric sleep and other types of dyssomnias. For example, a study assessing
anxiety. A variety of search terms (e.g., “childhood the circadian rhythm profiles of adolescents established
anxiety AND sleep”; “paediatric sleep AND anxiety”) that self-reported “evening types” (fitting a DSPD profile)
were used to retrieve suitable articles from numerous exhibited higher levels of emotional problems on a com-
electronic databases (e.g., OvidSP; PsycInfo; MEDLINE) bined anxiety/depression scale than typical sleepers or
and online journal home pages (e.g., Pediatrics; Journal self-reported “morning types” (Giannotti et al., 2002).
of the American Child and Adolescent Psychiatry; Furthermore, Picchietti et al.’s (2007) study of the preva-
Depression and Anxiety; Sleep Medicine). Additional lence of RLS in children demonstrated significant levels
articles of interest were identified by manually examin- of co-morbidity with anxiety. Numerous studies have
ing the reference list of retrieved articles. Included articles also revealed correlations between childhood anxiety and
described original research studies that measured both an a variety of parasomnias, including: night terrors, night-
aspect of paediatric sleep and anxiety. Articles were only mares, sleep talking, sleep walking, sleep bruxism, enure-
included if they contained participants aged approxi- sis, and body rocking (e.g., Coulombe, Reid, Boyle, &
mately 1–17 years and were published in English. Pub- Racine, 2010; Gregory & Eley, 2005; Ivanenko et al.,
lished abstracts, unpublished theses and dissertations, 2006; Laberge, Tremblay, Vitaro, & Montplaisir, 2000;
and articles that primarily focused on age groups outside Nielsen et al., 2000; Stein et al., 2001).
the range specified earlier were excluded from this While a number of SRPs have been identified in the
review. Following these criteria, 32 research articles of literature, there has been a lack of consensus regarding
relevance were identified. Of these, 21 related to the the conceptualisation and related measurement of
correlation between paediatric sleep and anxiety, eight anxiety symptoms in children. Several studies have taken
related to the role of paediatric sleep disturbance in the a broad approach, combining anxiety and depression into
development of anxiety, and five related to the role of a single “internalising” phenotype (e.g., Aronen et al.,
paediatric anxiety in the development of sleep distur- 2000; Bos et al., 2009; Coulombe et al., 2010; Sadeh
bance (Tables 1–3). et al., 2002; Stein et al., 2001), while others have been
narrower in their focus, distinguishing between the spe-
cific subtypes of anxiety (e.g., Alfano et al., 2006, 2009;
The Association between Paediatric
Nielsen et al., 2000). Studies examining the associations
SRPs and Anxiety
between sleep and the anxiety/depression phenotype
Support for the relationship between sleep problems and have assessed children across various stages of their
emotional regulation has largely been provided by cross- development. For example, Johnson et al. (2000) found
sectional studies in the literature (Table 1). Such studies that the association between sleep and anxiety/
have demonstrated positive correlations between emo- depression symptoms increased in magnitude from age 6
tional difficulties and SRPs (conceptualised in numerous to 11 years. Gregory and O’Connor (2002) built upon
ways) using both parental- and self-report (e.g., Sadeh this finding by demonstrating an increase in the associa-
et al., 2002). However, evidence for this relationship tion between reported sleep and anxiety/depression
using teacher report has not been demonstrated (Aronen, symptoms from childhood (4 years) to adolescence (13–
Paavonen, Fjallberg, Soninen, & Torronen, 2000). In con- 15 years). These studies provide preliminary support for
trast, only a small number of studies have used objective the notion that the increasing magnitude of associations
sleep measures (e.g., actigraphy) to examine this rela- between sleep and anxiety may be moderated by devel-
tionship (e.g., Aronen et al., 2000; Sadeh et al., 2002). In opment. Other studies have demonstrated an association
terms of specific sleep problems, researchers have pro- between SRPs and cognitive factors, including attribu-
vided support for a relationship between parent-reported tional style and dysfunctional beliefs (e.g., Gregory, Cox,
internalising scores and childhood insomnia symptoms, Crawford, Holland, & Harvey, 2009; Gregory & Eley,

© 2012 Flinders University

Clinical Psychologist © 2012 The Australian Psychological Society 47
48
Table 1 The association between paediatric sleep-related problems and anxiety

Author Design n Age Dx Anxiety measures Sleep measures Findings

Alfano et al. C 35 6–17 Anxiety (GAD, ADIS-C/P SRP scale: seven The presence of at least one intermittent sleep complaint was reported by 83% of
Leahy and Gradisar

(2006) SOC, OCD, SP, items from the parents of children with anxiety, with almost half reporting at least one frequent SRP.
SAD, PTSD, & CBCL CBCL Children with GAD had a significantly greater number of SRPs than children with
PD) other anxiety subtypes.
Alfano et al. C 175 6–17 Non-clinical RCADS SRP scale: items Sleep problems were significantly associated with anxiety across all ages.
(2009) RCMAS from theRCADS,
CBCL RCMAS, &
CNCEQ CBCL.
ACQ-C
Alfano et al. C 52 7–14 Anxiety (GAD, ADIS-C/P CSHQ SRPs were significantly associated with anxiety in 85% of children and 54% of
(2010) SAD, SOC, & PSAS-C adolescents. Pre-sleep cognitions were significantly associated with decreased TST
OCD) Child sleep and greater SRPs. Children with GAD experienced the greatest levels of sleep
Report disturbance, when compared with other anxiety subtypes.
Aronen et al. C 49 7–12 Non-clinical CBCL Actigraphy The association between internalising symptoms and TST was not statistically
(2000) TRF significant.
Bos et al. C 1,381 6–11 Non-clinical Rutter B2 Sleep–wake Emotional problems in preadolescent girls were associated with earlier TIB during
(2009) Scale questionnaire school nights and longer TST during school nights and weekends.
Coulombe C 980 12–16 Non-clinical CBCL SRP scale: items After accounting for psychological co-morbidity, nightmares and trouble sleeping were
et al. (2010) from the CBCL & significantly associated with adolescent-rated anxiety.
YSR
YSR
Forbes et al. C 32 9–15 Anxiety (GAD, PD, K-SADS-PL PSG Children with anxiety had significantly higher peri-sleep onset cortisol levels than
(2006) SAD, & SOC) children in the control group.
Giannotti et al. C 6,631 14–18 Non-clinical Rutter B2 Scale SSHS Emotional problems were significantly associated with female gender, daytime
(2002) sleepiness, restricted sleep, and evening preference.
Gregory et al. C 79 8–11 Non-clinical SCARED SSR Total anxiety score was significantly associated with bedtime resistance, sleep anxiety,
(2005) and nightmares. After controlling for other symptoms of anxiety, attributional style
CASQ-R
predicted the presence of SRPs.
Gregory et al. C 300 8 Non-clinical SCARED CSHQ Self-reported anxiety was significantly higher in individuals with parent-rated bedtime
(2006) Parent- resistance than in those without it. Anxiety scores were not significantly different for
reportedanxiety those with and without reports of other SRPs.
scale
Gregory et al. C 123 8–10 Non-Clinical DBAS CSHQ Dysfunctional beliefs and attitudes about sleep were significantly associated with SRPs
(2009) SSR in children.
Hudson et al. C 37 7–12 Anxiety ADIS-IV-C/P Sleep diary Anxious children reported significantly later TIB and TST on school nights, compared
(2009) SCAS PDSS with non-anxious children. On weekends, anxious children exhibited significant
decreases in SOL and WASO, when compared when weeknights. Anxious children
SDQ FFS did not differ with the control group on SOL, WASO, daytime sleepiness, or fatigue.
Ivanenko et al. C 174 7–11 Anxiety BASC CSQ Children with anxiety experienced significantly more frequent night-time awakenings
(2006) than non-anxious children.

© 2012 Flinders University

Clinical Psychologist © 2012 The Australian Psychological Society
© 2012 Flinders University
Table 1 Continued

Author Design n Age Dx Anxiety measures Sleep measures Findings

Johnson et al. C/R 823 6–11 Non-clinical CBCL One item from the Trouble sleeping was significantly associated with anxiety at age 6 and 11 years.
(2000) TRF CBCL
Laberge et al. C 1,353 11–13 Non-clinical CSBQ Parent-administered High anxiety scores in preadolescent children were significantly associated with night
(2000) questionnaire terrors, somniloquy, leg restlessness, sleep bruxism, and body rocking.
Nielsen et al. C 610 13–16 Non-clinical DISC Self-administered The frequent occurrence of disturbing dreams was associated with anxiety at age 13
(2000) CSBQ Questionnaire and 16 years.
Noll et al. C 147 6–16 PTSD PSS SRP scale: items The presence of SRPs significantly correlated with PTSD.

Clinical Psychologist © 2012 The Australian Psychological Society

(2006) from the YSR &
BSI
Petit et al. C 1,997 2.5–6 Non-clinical SAQM SAQM SAD was significantly associated with persistent night waking, somnambulism,
(2007) ICCQ ICCQ bruxism, sleep terrors, and somniloquy.
Picchietti et al. C 10,523 8–17 RLS Survey ICSD-2 RLS was associated with anxiety disorders in 3.7% of children and 14.4% of adolescents
(2007) with the condition.
Sadeh et al. C 135 7–12 Non-clinical CBCL Actigraphy The CBCL ratings of poor sleepers were significantly higher on the Thought–Problem
(2002) scale.
Stein et al. C 472 4–12 Non-clinical CBCL SBQ SRP factor scores were highly correlated with CBCL internalising scores. Enuresis was
(2001) significantly associated with the CBCL Thought–Problem scale.

C, cross-sectional; R, retrospective; Dx, diagnosis; GAD, generalized anxiety disorder; SOC, social anxiety disorder; OCD, obsessive–compulsive disorder; SP, Specific Phobia; SAD, Separation Anxiety
Disorder; PTSD, post-traumatic stress disorder; PD, panic disorder; RLS, restless legs syndrome; ADIS-C/P, the Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent versions; CBCL, Child
Behavior Checklist; RCADS, The Revised Child Anxiety and Depression Scale; RCMAS, The Revised Children’s Manifest Anxiety Scale; CNCEQ, the Children’s Negative Cognitive Error Questionnaire; ACQ-C,
the Anxiety Control Questionnaire for Children; TRF, Teacher’s Report Form; YSR, Youth Self-Report; Actigraphy (recording of sleep/wake period via gross motor movement using a wristwatch device);
K-SADS-PL, Schedule for Affective Disorders and Schizophrenia—Present and Lifetime Version; PSG, polysomnography (electrophysiological measurement using electroencephalography, electro-
oculography, and electromyography); SCARED, Screen for Child Anxiety and Related Emotional Disorders; CASQ-R, Children’s Attributional Style Questionnaire—Revised version; DBAS, Dysfunctional
Beliefs and Attitudes about Sleep; SCAS, Spence Children’s Anxiety Scale; SDQ, strengths and difficulties scale; BASC, Behavior Assessment System for Children; CSBQ, Children’s Social Behavior
Questionnaire; DISC, Diagnostic Interview Schedule for Children; PSS, post-traumatic stress disorder Symptom Scale; SAQM, Self-Administered Questionnaire for Mother; ICCQ, Interviewer-Completed
Computerized Questionnaire; CSHQ, Children’s Sleep Habits Questionnaire; PSAS-C, Pre-sleep Arousal Survey for Children; SSHS, School Sleep Habits Survey; SSR, sleep self-report; PDSS, Paediatric
Daytime Sleepiness Scale; FFS, The Flinders Fatigue Scale; CSQ, Childhood Sleep Questionnaire; BSI, Brief Symptom Inventory; ICSD-2, International Classification of Sleep Disorders, Second Edition; SBQ,
Sleep Behavior Questionnaire; SRP, sleep-related problem; TST, total sleep time; TIB, time in bed; SOL, sleep-onset latency; WASO, wake after sleep onset.

49
Paediatric sleep and anxiety
Leahy and Gradisar

2005; Sadeh et al., 2002). These studies provide prelimi- O’Connor, 2002; Table 2). Despite the presence of a
nary evidence that cognitive style may mediate the asso- steady and significant increase in overlap between sleep
ciation between sleep problems and anxiety in these problems and parent-reported internalising symptoms
populations. from early childhood to mid-adolescence, Gregory and
In addition to studies examining community samples, O’Connor (2002) found no evidence that early anxiety
a number of studies have examined the association symptoms predicted SRPs in mid-adolescence. In con-
between anxiety and sleep in clinically anxious children trast, Johnson, Roth, and Breslau (2006) found that
(e.g., Alfano et al., 2006; Alfano, Pina, Zerr, & Villalta, retrospectively, out of a sample of 1,014 children and
2010; Hudson, Gradisar, Gamble, Schniering, & Rebelo, adolescents who experienced both insomnia and
2009; Ivanenko et al., 2006). For example, Hudson et al. co-morbid anxiety, 73% reported a pattern of anxiety
(2009) found that clinically anxious children reported symptoms preceding the onset of insomnia. However,
later bedtimes on weeknights and had significantly less given that the onset of disorders was assessed retrospec-
sleep during the school week than their non-anxious tively, questions are raised regarding the reliability of
peers. Furthermore, Forbes et al. (2006) demonstrated conclusions drawn.
that children with anxiety disorders exhibited signifi- In an attempt to further address this potential link, a
cantly higher cortisol levels during the 2 hr prior to small number of experimental studies have been con-
polysomnography-determined sleep onset, with levels ducted to allow for a more controlled examination of
approaching those of the control group by sleep onset. whether anxiety precedes SRPs. For example, Forbes
The authors hypothesised that the higher cortisol levels et al. (2008) examined the sleep of anxious and non-
found in these children may be correlated with symp- anxious children and adolescents using both subjective
toms on anxiety, arousal, and stress as they prepared for and objective sleep measures in a controlled laboratory
bed. Building these findings, Alfano et al. (2010) estab- setting. On objective measures, children with anxiety
lished that decreased total sleep duration was signifi- exhibited greater sleep latency, more awakenings, and
cantly correlated with greater levels of pre-sleep less slow-wave sleep than children in the control group.
cognitive arousal symptoms, rather than somatic arousal However, on subjective measures, anxious children only
symptoms, in a sample of 52 clinically anxious children reported increased sleep latency. The authors suggested
and adolescents. In addition to these studies, several that children with anxiety appear to be less aware of, or
other researchers have used clinical assessment measures perhaps under-report, their sleep problems (Forbes et al.,
(e.g., Anxiety Disorders Interview Schedule for DSM-IV, 2008). Two additional studies have assessed for changes
Child and Parent versions; Diagnostic Interview Schedule in reported SRPs following treatment for anxiety disor-
for Children; Spence Children’s Anxiety Scale (SCAS)) to ders. Alfano et al. (2007) examined the impact of phar-
assess for associations between sleep disturbance and spe- macological treatment (fluvoxamine) on SRPs among
cific subtypes of anxiety. The majority of these studies cite children and adolescents with anxiety disorders (e.g.,
GAD and SAD as more strongly associated with a number GAD, SAD, SOD), compared with children given placebo.
of SRPs when compared with other anxiety subtypes Children in the treatment group exhibited significantly
(e.g., Alfano et al., 2006, 2010; Nielsen et al., 2000; Petit greater reductions in anxiety and SRPs than children in
et al., 2007). However, moderate correlations have also the control group. More specifically, insomnia accounted
been found in children with panic disorder with agora- for the greatest reduction in SRPs following pharmaco-
phobia (PDA), SOC, OCD, and PTSD (Alfano,sinsburg, & logical treatment. Similarly, Storch et al. (2008) found
Newman-Kingery, 2007; Gregory & Eley, 2005; Noll, significant reductions in parent-rated SRPs following
Trickett, Susman, & Putnam, 2006). cognitive-behaviour therapy (CBT) treatment for 41
adolescents with OCD. However, this reduction in
SRPs was below the criteria (>50%) often used to deter-
Paediatric Anxiety as a Predictor
mine clinical significance, and these youth were still
of SRPs
experiencing a mean of two or more SRPs following
Overall, evidence from correlational studies demon- treatment.
strates that sleep disturbance and anxiety commonly
overlap in the paediatric population. However, these
Paediatric SRPs as a Predictor
studies provide little insight regarding the direction of
of Anxiety
effect within this relationship. Presently, only one longi-
tudinal study has sought to examine the direction of While there is a paucity of research examining the role of
effect of early anxiety symptoms on the development osf anxiety as a precursor to SRPs, the predictive role of sleep
sleep problems during later development (Gregory & disturbance in the development of anxiety has received

© 2012 Flinders University

50 Clinical Psychologist © 2012 The Australian Psychological Society
 Paediatric sleep and anxiety

Table 2 Paediatric anxiety as a predictor of sleep-related problems

Author Design n Age Dx Anxiety measures Sleep measures Findings

Alfano et al. T 128 6–17 Anxiety (SOC, K-SADS SRP scale: items Clinically anxious children treated with
(2007) OCD, & PARS from the PARS, fluvoxamine demonstrated significantly greater
GAD) HAM-A HAM-A & CBCL reductions in SRPs following treatment, when
CBCL compared with placebo.
Forbes et al. E 253 7–17 Anxiety K-SADS-PL Sleep diary On objective measures, the anxiety group
(2008) exhibited less slow-wave sleep and greater
SCARED PSG SOL on the second night, when compared with
VAS scale of the control group. On subjective measures,
subjective sleep children with anxiety reported greater SOL on
impressions the second night and no decrease in sleep
latency.
Gregory and L 490 4–15 Non-clinical CBCL SRP scale: 6 items There was no evidence that early anxiety
O’Connor from the CBCL symptoms predicted sleep problems in
(2002) mid-adolescence.
Johnson et al. L 1,014 13–16 Anxiety CDISC-IV DSM-IV 73% of children and adolescents who
(2006) experienced co-morbid anxiety and insomnia
Insomnia ICSD-R reported a pattern of anxiety symptoms
preceding the onset of insomnia.
Storch et al. T 66 8–17 Anxiety (OCD) C-YBOCS CBCL SRP scale: 6 items Children demonstrated significant reductions in
(2008) COIS-P from the CBCL total SRPs following CBT treatment for OCD.
MASC

T, treatment; E, experimental; L, longitudinal; Dx, diagnosis; SOC, social anxiety disorder; OCD, obsessive–compulsive disorder; GAD, generalized anxiety
disorder; K-SADS, Schedule for Affective Disorders and Schizophrenia in School-Age Children; PARS, Pediatric Anxiety Rating Scale; HAM-A, Hamilton
Anxiety Rating Scale; CBCL, Child Behaviour Checklist; K-SADS-PL, Schedule for Affective Disorders and Schizophrenia—Present and Lifetime Version;
SCARED, Screen for Child Anxiety and Related Emotional Disorders; CDISC-IV, Computerized Diagnostic Schedule for Children—Version 4; C-YBOCS,
Children’s Yale-Brown Obsessive–Compulsive Scale; COIS-P, Child Obsessive–Compulsive Impact Scale—Parent Version; MASC, Multidimensional Anxiety
Scale for Children; PSG, polysomnography (electrophysiological measurement using electroencephalography, electro-oculography, and electromyogra-
phy); SRP, sleep-related problem; VAS, Visual Analogue Scale; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; ICSD-R,
International Classification of Sleep Disorders, Revised; SOL, sleep-onset latency; CBT, cognitive-behaviour therapy.

substantially more attention (Table 3). Research examin- between parental reported SRPs at age 6 years and the
ing the predictive associations between sleep problems development of internalising problems at age 11 years.
and the development of psychopathology in adults has Gregory et al. (2005) sought to extend upon this research
been well established, particularly regarding the identifi- by examining the extent to which childhood sleep prob-
cation of insomnia as a “red flag” for the development of lems predict clinically significant levels of anxiety in
depression (e.g., Breslau, Roth, Rosenthal, & Andreski, adulthood by administering standardised clinical inter-
1996; Chang, Ford, Mead, Cooper-Patrick, & Klag, 1997; views. After controlling for childhood internalising prob-
Ford & Kamerow, 1989). Following this research, several lems, persistent sleep problems in childhood were found
longitudinal studies have provided support for the role to significantly predict anxiety disorders in adulthood.
of SRPs in early childhood as a precursor to the develop- The authors hypothesised that persistent sleep problems
ment of internalising problems (e.g., anxiety) in both in childhood may represent a prodrome of symptoms, or
preadolescent and adolescent years (e.g., Gregory, Eley, an early risk factor, for the development of clinical anxiety
O’Connor, & Plomin, 2004; Gregory & O’Connor, 2002; in adulthood.
Gregory, van der Ende, Willis, & Verhulst, 2008). For Other studies have utilised an experimental design to
example, Gregory and O’Connor (2002) examined the allow for a more controlled assessment of the cause-and-
longitudinal effect of sleep problems and the development effect relationship between childhood sleep problems and
of internalising symptoms in 490 children. After control- anxiety. For example, Talbot, McGlinchey, Kaplan, Dahl,
ling for early internalising symptoms, high scores on a and Harvey (2010) examined the effect of experimental
SRP measure at age 4 years significantly predicted an sleep restriction on anxiety in adolescents using a com-
increase in parent-reported anxiety in mid-adolescence. It prehensive affective-functioning battery. Included in the
should be noted, however, that the Johnson et al. (2000) battery were a number of tasks that assessed cognitive
study did not establish a significant longitudinal link factors considered central to the development of anxiety,

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Clinical Psychologist © 2012 The Australian Psychological Society 51
Leahy and Gradisar

Table 3 Paediatric sleep-related problems as a predictor of anxiety

Author Design N Age Dx Anxiety measures Sleep measures Findings

Fallone et al. E 74 6–12 Non-clinical Teacher-rating Actigraphy Sleep restriction was not significantly associated
(2005) questionnaire Sleep diary with teacher-rated internalising symptoms.
Daily phone
logs
Gregory and L 490 4–15 Non-clinical CBCL SRP scale: six SRPs at 4 years predicted a significant increase in
O’Connor items from anxiety during mid-adolescence.
(2002) the CBCL
Gregory et al. L 6,000 3–7 Non-Clinical SDQ SRP scale SRPs at age 3 to 4 years significantly predicted
(2004) anxiety at age 7 years.
Gregory et al. L 943 5–9 Non-clinical Rutter B2 scale SRP scale Persistent SRPs in childhood significantly predicted
(2005) DIS anxiety disorders in adulthood.
DSM-IV
Gregory et al. L 2,076 4–16 Non-clinical CBCL SRP scale:six Parental reports of sleeping less than others in early
(2008) items from childhood were a significant risk factor for anxiety
the CBCL in adolescence. Parental reports of sleeping more
YASR
than others and nightmares in early childhood did
not significantly predict anxiety.
Johnson et al. C/L 823 6–11 Non-clinical CBCL One SRP item The association of trouble sleeping at age 6 with
(2000) from the incidence of anxiety at age 11 was not statistically
TRF
CBCL significant.
Paine and T 42 7–13 BIC SCAS CSHI Compared with wait-list controls, children receiving
Gradisar SMFQ Sleep diary CBT showed significant improvements in sleep
(2011) PDSS quality (i.e., SOL, WASO, SE) and anxiety (i.e.,
Actigraphy overall and SAD).
Talbot et al. E 44 10–16 Non-clinical SCID Sleep diary Participants reported a greater increase in anxiety
(2010) K-SADS-PL Actigraphy during a catastrophising task and rated the
PANAS-C SSS likelihood of potential catastrophes as higher
Self-rating DSISD when sleep deprived, relative to when rested.
Scale for Early adolescents appraised their main worry as
pubertal significantly more threatening when sleep
development deprived, relative to when rested.

E, experimental; L, longitudinal; C, cross-sectional; T, treatment; Dx, diagnosis; BIC, Behavioural Insomnia of Childhood; SCID, Structured Clinical Interview
for DSM-IV; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; K-SADS-PL, Schedule for Affective Disorders and
Schizophrenia—Present and Lifetime Version; PANAS-C, Child Version of the Positive and Negative Affect Schedule; Actigraphy (recording of sleep/wake
period via gross motor movement using a wristwatch device); DIS, Diagnostic Interview Schedule; CBCL, Child Behavior Checklist; SDQ, Strengths and
Difficulties Questionnaire; YASR, Young Adult Self Report; TRF, Teacher’s Report Form; SCAS, Spence Children’s Anxiety Scale; SMFQ, Short Mood and
Feelings Questionnaire; SOL, sleep-onset latency; WASO, wake after sleep onset; SE, sleep efficiency; SAD,Separation Anxiety Disorder; SSS, Stanford
Sleepiness Scale; DSISD, Duke Structured Interview for Sleep Disorders; SRP, sleep-related problem; CHSI, Clinical Sleep History Interview; PDSS, Pediatric
Daytime Sleepiness Scale; CBT, cognitive-behaviour therapy.

including: worry, catastrophising, and appraisal of threat. has examined the therapeutic potential for sleep inter-
Adolescents reported a significantly greater increase in ventions to reduce anxiety in children with SRPs. In
anxiety during the task and reported the likelihood of an attempt to address this gap, Paine and Gradisar
potential catastrophes as higher when sleep deprived, (2011) examined the effect of a multi-component
compared with when rested. Furthermore, young ado- CBT treatment programme for 42 preadolescent chil-
lescents (e.g., 11–13 years) judged their main worry as dren (7–13 years) with BIC. Compared with wait-list
significantly more threatening when sleep deprived, rela- controls, children receiving CBT showed significant
tive to when rested. However, it should be noted that the improvements in sleep (e.g., sleep-onset latency, wake
effect of experimental sleep restriction on internalising after sleep onset, and sleep efficiency) in addition to an
symptoms, as assessed by teacher-rating scales, has not overall reduction in general and separation anxiety. The
demonstrated such a predictive relationship (Fallone authors speculated that the subsequent increase in
et al., 2005). night-time sleepiness following sleep restriction tech-
While numerous studies have addressed the direction niques (i.e., bedtime fading) may have assisted in
of effect between SRPs and anxiety, very little research dampening evening hyper-arousal levels and decreased

© 2012 Flinders University

52 Clinical Psychologist © 2012 The Australian Psychological Society
 Paediatric sleep and anxiety

the time spent awake in bed, thereby reducing the tions likely represent a complex, bidirectional relation-
opportunity for maladaptive conditioning processes to ship. The research has provided preliminary support for
occur. However, given the multi-component treatment the role of sleep problems serving as a “red flag” for the
design used in this study, the unique contribution of later development of anxiety in childhood and adolescent
bedtime fading on this dampening process cannot be populations. However, empirical evidence supporting a
determined. relationship in the opposite direction has not been as
conclusive. Additional studies of longitudinal, experi-
mental, and treatment design are warranted to further
Future Directions delineate the direction of effect between childhood sleep
and anxiety.
Over the past decade, a plethora of cross-sectional
research has provided evidence that SRPs and anxiety
co-occur in paediatric populations. While these associa-
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