Although methodologically rigorous data exist on SRPs in youth with other anxiety disorders, currently, there is little known about SRPs in youth with OCD. With this in mind, the purpose of this paper was to report on the prevalence, symptom correlates, and treatment sensitivity of SRPs in a large sample of pediatric OCD patients. Overall, SRPs were widely endorsed, with 92% of youth experiencing at least one SRP and 27.3% experiencing five or more. Consistent with Alfano et al. (2007)
, the most common SRPs included experiencing nightmares, being overtired, sleeping next to someone in family, and parent and child reports of having trouble sleeping. Significant gender differences were found, with females being rated as more frequently overtired and sleeping more than other kids. Younger children had more nightmares and overall SRPs than older youth, but older youth were more frequently rated as sleeping more than other kids. Our rates of SRPs in younger children are consistent with frequencies found in other young, clinical samples (e.g., DeVincent, Gadow, Delosh, & Geller, 2007
) and higher than in non-clinical samples (Eitner et al., 2007
; Spruyt, O’Brien, Cluydts, Verleye, & Ferri, 2005
). Similar to data from clinically anxious youth (Alfano et al., 2007
) and non-clinical controls (Mindell & Barrett, 2002
), it was found that anxiety severity, both OCD specific and general anxiety, was positively related to the presence of SRPs. Although the correlational nature of these data prevents the directionality of the relationships from being established, others (e.g., Alfano et al., 2007
; Dahl, 1996
) have suggested a cyclical relationship in which anxiety first contributes to SRPs, which then contributes to increased anxiety symptoms, which then contributes to more SRPs. Most concerning about this relationship are data highlighting childhood SRPs as a predictor of later psychosocial distress (Gregory et al., 2005
). Somewhat surprisingly, no significant relationship was found between SRPs and depressive symptoms in youth, a finding that was unexpected given research linking pediatric sleep problems with depressive symptoms in non-clinical (Gregory et al., 2006
) and clinically depressed pediatric patients (Robert et al., 2006
). One possibility for these divergent findings is the reported low level of overall depressive symptoms in the current sample, as measured by the CDI. Sleep related problems were also not significantly related to OCD-related functional impairment, which may be because the COIS-P does not tap into the type of impairments that sleep difficulties cause in youth. Another reason for the non-significant association may be due to the large standard deviation of the COIS-P together with the leptokurtic distribution of the SRP variable.
As expected, rates of overall SRPs decreased following CBT. Significant reductions in individual SRPs were found for the following items: nightmares, overtired, sleeps more than most kids, sleeps less than most children, has trouble sleeping (by parent report), and sleeps next to someone in family. There are several possible explanations for this. First, improved anxiety and mood may be associated with reductions in certain SRPs such as having nightmares and sleeping more or less. Second, targeting family accommodation and parental anxiety, as was done in the Storch et al. (2007)
study, may explain reductions in having a parent sleep next to their child. Clinically, this is suggestive of the need to include structured assessments of sleep problems in psychotherapeutic and pharmacological studies of pediatric OCD (Alfano et al., 2007
). From a treatment perspective, it is reasonable to suggest that presence of SRPs may decrease modestly following a course of cognitive-behavioral therapy. This is consistent with findings that targeted CBT for OCD may also impact non-OCD symptoms such as depression or general anxiety (Storch et al., 2007
). In addition, family-based cognitive-behavioral interventions may be particularly helpful in reducing symptoms that are maintained, in part, through family accommodation (i.e., refusal to sleep alone).
Several limitations of the present study should be noted. First, although the methodology was similar to that used by Alfano et al. (2007)
, our measure of SRPs was not standardized and represented a composite of child and parent responses. On balance, internal consistency for the SRP score was adequate, and the present findings provide construct validity support (i.e., correlations with measures of anxiety, treatment sensitivity). Additional studies incorporating objective, physiological sleep assessments (i.e., polysomnography) are warranted in order to determine the prevalence of actual sleep disorders (rather than only SRPs), particularly since endorsed items may have been reflective of the child’s OCD and, when present, comorbid diagnoses. Second, although our assessment of SRPs was fairly comprehensive, there are other SRPs that were not assessed (e.g., bedtime resistance). Third, as SRPs were taken from three measures that were ultimately used in correlational analyses (CBCL, MASC, CDI), the chance of slightly inflated associations exists. Fourth, the majority of our youth was on stable doses of medication for their OCD. Side effects of seretonergic medications often include impacted sleep (Safer & Zito, 2006
) and thus, it is difficult to tease out the degree to which SRPs are related to medication use.ж
Finally, as subjects were presenting for evaluation and treatment at an OCD specialty clinic and were primarily Caucasian, results may be limited in generalizability.
Within these limitations, present findings have clinical implications for working with pediatric OCD patients. First, given the high rate with which SRPs were endorsed, clinicians would be well advised to assess for the presence of SRPs during the initial assessment and periodically throughout treatment to gauge changes. Although measures such as the CBCL may have particular utility as sleep problems and co-occurring emotional and behavioral concerns can be concurrently assessed, it may be most relevant to include a well-validated index of sleep behavior such as the Children’s Sleep Habits Questionnaire (Owens, Spirito, & McGuinn, 2000
). Second, the present data suggest that CBT may be associated with modest reductions in SRPs. As noted, we suspect that this finding was due to decreased parental accommodation to their child’s anxiety, as well as an overall decrease in child distress. Cognitive-behavioral interventions have shown promise for treating pediatric sleep problems (see Morganthaler et al., 2006 for a review) and the present data suggest addressing anxiety may be one manner of achieving this goal. Alternatively, for youth with clinically significant comorbid sleep problems, targeting SRPs specifically through structured treatment protocols may be warranted.