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 and 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 and 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 and 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 and 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.
