Efficacy of an Integrated Sleep and Anxiety Intervention for Anxious Children: A Pilot Randomized Controlled Trial
Less than optimal response rates and long-term outcomes following treatment for child anxiety disorders suggest that interventions may need to target more precise underlying mechanisms that maintain anxiety in order to improve treatment outcomes. Children with anxiety disorders report high rates of sleep-related problems and evidence suggests that sleep may impact exposure-based treatment outcomes given the role of sleep in facilitating extinction learning. Thus, addressing sleep as part of anxiety-focused interventions may produce superior outcomes in terms of both anxiety and sleep. Although three studies have shown purely anxiety-focused interventions improve sleep-related problems, wide developmental ranges, lack of control groups, and a proxy measure for sleep are notable limitations. Preliminary findings support the efficacy of Targeted Behavioral Therapy (TBT), an integrated intervention that targets sleep problems and anxiety in children with generalized anxiety disorder (GAD). The current pilot study used a randomized, controlled design to examine the efficacy of TBT compared to ‘gold standard’ cognitive-behavioral therapy (CBT) for anxiety among 20 children (ages 6-12) with primary GAD. Assessments were conducted at baseline, post-treatment, and 6-month follow-up, which included diagnostic interviews, multi-informant measures, and objective sleep monitoring (i.e., actigraphy). Sleep-related questions were also collected on a weekly basis, as well as more comprehensive assessment of sleep and anxiety at mid-treatment. Results indicate that sleep, anxiety, and global functioning significantly improved across both groups from baseline to post-treatment, and improvements were maintained at 6-month follow-up based on moderate to very large effect sizes. Objective sleep onset latency also decreased marginally for both groups at post-treatment. The TBT group demonstrated a significant decrease in child-reported anxiety from mid-treatment to post-treatment (i.e., after the sleep intervention) that was not observed in the CBT group. A linear decrease in weekly bedtime problems was observed for nearly twice as many TBT participants compared to CBT participants, suggesting progressive improvement in bedtime problems across 16-weeks of treatment with TBT. Findings demonstrate the potential utility of anxiety interventions for improving some sleep-related problems, but raise questions about the nature of sleep disturbances in anxious youth and specific aspects of sleep to be targeted during intervention. Future directions and limitations are discussed.