Journal of Abnormal Child Psychology

, Volume 43, Issue 7, pp 1343–1353 | Cite as

Subjective – Objective Sleep Comparisons and Discrepancies Among Clinically-Anxious and Healthy Children

  • Candice A. AlfanoEmail author
  • Michelle A. Patriquin
  • Andres De Los Reyes


We compared subjective and objective sleep patterns and problems, and examined cross-method correspondence across parent reports, child reports, and actigraphy-derived sleep variables in clinically-anxious children and healthy controls. In a multi-site, cross-sectional study, 75 pre-adolescent children (6 to 11 years; M = 8.7 years; SD = 1.4; n = 39/52 % female) were examined including 39 with a diagnosis of primary generalized anxiety disorder (GAD) and 36 controls recruited from university-based clinics in Houston, TX and Washington, DC. Structured interviews, validated sleep questionnaires, and 1 week of actigraphy data were utilized. Despite subjective reports of significantly greater sleep problems among anxious children, actigraphy data revealed no significant differences between the groups. All parents estimated earlier bedtimes and greater total sleep duration relative to actigraphy, and all children endorsed more sleep problems than parents. With few exceptions, subjective reports exhibited low and non-significant correspondence with actigraphy-based sleep patterns and problems. Our findings suggest that high rates of sleep complaints found among children with GAD (and their parents) are not corroborated by objective sleep abnormalities, with the exception of marginally prolonged sleep onset latency compared to controls. Objective-subjective sleep discrepancies were observed in both groups but more apparent overall in the GAD group. Frequent complaints of sleep problems and daytime tiredness among anxious youth might more accurately reflect difficulties prior to the actual sleep period, cognitive-affective biases associated with sleep, and/or poor sleep quality. Findings highlight the importance of considering sleep from multiple perspectives.


Sleep Anxiety Children Actigraphy Informant discrepancies 



This work was supported by NIH grant #K23MH081188 awarded to the first author.

Conflicts of Interest

The authors have no conflicts of interest to disclose.


  1. Alfano, C. A., Beidel, D. C., Turner, S. M., & Lewin, D. S. (2006). Preliminary evidence for sleep complaints among children referred for anxiety. Sleep Medicine, 7, 467–473. doi: 10.1016/j.sleep.2006.05.002.CrossRefPubMedGoogle Scholar
  2. Alfano, C. A., Ginsburg, G. S., & Kingery, J. N. (2007). Sleep-related problems among children and adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 224–232. doi: 10.1097/01.chi.0000242233.06011.8.CrossRefPubMedGoogle Scholar
  3. Alfano, C. A., Pina, A. A., Zerr, A. A., & Villalta, I. K. (2010). Pre-sleep arousal and sleep problems of anxiety-disordered youth. Child Psychiatry and Human Development, 41, 156–167. doi: 10.1007/s10578-009-0158-5.PubMedCentralCrossRefPubMedGoogle Scholar
  4. Alfano, C. A., Reynolds, K., Scott, N., Dahl, R. E., & Mellman, T. A. (2013). Polysomnographic sleep patterns of non-depressed, non-medicated children with generalized anxiety disorder. Journal of Affective Disorders, 147, 379–384. doi: 10.1016/j.jad.2012.08.015.PubMedCentralCrossRefPubMedGoogle Scholar
  5. Arora, T., Broglia, E., Pushpakumar, D., Lodhi, T., & Taheri, S. (2013). An investigation into the strength of the association and agreement levels between subjective and objective sleep duration in adolescents. PloS One, 8, e72406. doi: 10.1371/journal.pone.0072406.PubMedCentralCrossRefPubMedGoogle Scholar
  6. Bordeleau, S., Bernier, A., & Carrier, J. (2012). Longitudinal associations between the quality of parent − child interactions and children’s sleep at preschool age. Journal of Family Psychology, 26, 254. doi: 10.1037/a0027366.CrossRefPubMedGoogle Scholar
  7. Buysse, D. J., Ancoli-lsrael, S., Edinger, J. D., Lichstein, K. L., & Morin, C. M. (2006). Recommendations for a standard research assessment of insomnia. Sleep: Journal of Sleep and Sleep Disorders Research, 29, 1155–1173.Google Scholar
  8. Carskadon, M. A., & Acebo, C. (1993). A self-administered rating scale for pubertal development. Journal of Adolescent Health, 14, 190–195. doi: 10.1016/1054-139X(93)90004-9.CrossRefPubMedGoogle Scholar
  9. Chase, R. M., & Pincus, D. B. (2011). Sleep-related problems in children and adolescents with anxiety disorders. Behavioral Sleep Medicine, 9, 224–236. doi: 10.1080/15402002.2011.606768.CrossRefPubMedGoogle Scholar
  10. Clementi, M. A., & Alfano, C. A. (2014). Targeted behavioral therapy for childhood generalized anxiety disorder: a time-series analysis of changes in anxiety and sleep. Journal of Anxiety Disorders, 28, 215–222. doi: 10.1016/j.janxdis.2013.10.006.CrossRefPubMedGoogle Scholar
  11. Cohen, J. (1960). A coefficient of agreement of nominal scales. Educational and Psychological Measurement, 20, 37–46.CrossRefGoogle Scholar
  12. Corkum, P., Moldofsky, H., Hogg-Johnson, S., Humphries, T., & Tannock, R. (1999). Sleep problems in children with attention‐deficit/hyperactivity disorder: impact of subtype, comorbidity, and stimulant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1285–1293. doi: 10.1097/00004583-199910000-00018.CrossRefPubMedGoogle Scholar
  13. Cousins, J. C., Whalen, D. J., Dahl, R. E., Forbes, E. E., Olino, T. M., Ryan, N. D., & Silk, J. S. (2011). The bidirectional association between daytime affect and nighttime sleep in youth with anxiety and depression. Journal of Pediatric Psychology, 36, 969–979. doi: 10.1093/jpepsy/jsr036.PubMedCentralCrossRefPubMedGoogle Scholar
  14. Cowie, J., Alfano, C. A., Patriquin, M. A., Reynolds, K. C., Talavera, D., & Clementi, M. A. (2014). Addressing sleep in children with anxiety disorders. Sleep Medicine Clinics, 9, 137–148. doi: 10.1016/j.jsmc.2014.02.001.CrossRefGoogle Scholar
  15. Dayyat, E. A., Spruyt, K., Molfese, D. L., & Gozal, D. (2011). Sleep estimates in children: parental versus actigraphic assessments. Nature and Science of Sleep, 3, 115. doi: 10.2147/NSS.S25676.PubMedCentralPubMedGoogle Scholar
  16. De Los Reyes, A. (2013). Strategic objectives for improving understanding of informant discrepancies in developmental psychopathology research. Development and Psychopathology, 25, 669–682. doi: 10.1017/S0954579413000096.CrossRefPubMedGoogle Scholar
  17. De Los Reyes, A., & Aldao, A. (2015). Introduction to the special section. Toward implementing physiological measures in clinical child and adolescent assessments. Journal of Clinical Child and Adolescent Psychology, 44, 221–237. doi: 10.1080/15374416.2014.891227.CrossRefPubMedGoogle Scholar
  18. De Los Reyes, A., & Kazdin, A. E. (2005). Informant discrepancies in the assessment of childhood psychopathology: a critical review, theoretical framework, and recommendations for further study. Psychological Bulletin, 131, 483–509. doi: 10.1037/0033-2909.131.4.483.CrossRefPubMedGoogle Scholar
  19. De Los Reyes, A., Alfano, C. A., & Beidel, D. C. (2011a). Are clinicians’ assessments of improvements in children’s functioning “global”? Journal of Clinical Child and Adolescent Psychology, 40, 281–294. doi: 10.1080/15374416.2011.546043.PubMedCentralCrossRefPubMedGoogle Scholar
  20. De Los Reyes, A., Kundey, S., & Wang, M. (2011b). The end of the primary outcome measure: a research agenda for constructing its replacement. Clinical Psychology Review, 31, 829–838. doi: 10.1016/j.cpr.2011.03.011.CrossRefPubMedGoogle Scholar
  21. De Los Reyes, A., Aldao, A., Thomas, S. A., Daruwala, S., Swan, A. J., Van Wie, M., & Lechner, W. V. (2012). Adolescent self-reports of social anxiety: Can they disagree with objective psychophysiological measures and still be valid? Journal of Psychopathology and Behavioral Assessment, 34, 308–322. doi: 10.1007/s10862-012-9289-2.CrossRefGoogle Scholar
  22. De Los Reyes, A., Lerner, M. D., Thomas, S. A., Daruwala, S., & Goepel, K. (2013a). Discrepancies between parent and adolescent beliefs about daily life topics and performance on an emotion recognition task. Journal of Abnormal Child Psychology, 41, 971–982. doi: 10.1007/s10802-013-9733-0.PubMedCentralCrossRefPubMedGoogle Scholar
  23. De Los Reyes, A., Thomas, S. A., Goodman, K. L., & Kundey, S. M. A. (2013b). Principles underlying the use of multiple informants’ reports. Annual Review of Clinical Psychology, 9, 123–149. doi: 10.1146/annurev-clinpsy-050212-185617.PubMedCentralCrossRefPubMedGoogle Scholar
  24. De Los Reyes, A., Augenstein, T. M., Wang, M., Thomas, S. A., Drabick, D., Burgers, D., & Rabinowitz, J. (2015). The validity of the multi-informant approach to assessing child and adolescent mental health. Psychological Bulletin. doi: 10.1037/a0038498.
  25. Edinger, J. D., Fins, A. I., Glenn, D. M., Sullivan, R. J., Jr., Bastian, L. A., Marsh, G. R., & Shaw, E. (2000). Insomnia and the eye of the beholder: Are there clinical markers of objective sleep disturbances among adults with and without insomnia complaints? Journal of Consulting and Clinical Psychology, 68, 586. doi: 10.1037/0022-006X.68.4.586.CrossRefPubMedGoogle Scholar
  26. Fleiss, J. (1981). Statistical methods for rates and proportions (2nd ed.). New York: Wiley.Google Scholar
  27. Gregory, A. M., & O’Connor, T. G. (2002). 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, 41, 964–971. doi: 10.1097/00004583-200208000-00015.CrossRefPubMedGoogle Scholar
  28. Gregory, A. M., Rijsdijk, F. V., & Eley, T. C. (2006). A twin‐study of sleep difficulties in school‐aged children. Child Development, 77, 1668–1679. doi: 10.1111/j.1467-8624.2006.00966.x.CrossRefPubMedGoogle Scholar
  29. Gregory, A. M., Cousins, J. C., Forbes, E. E., Trubnick, L., Ryan, N. D., Axelson, D. A., & Dahl, R. E. (2011). Sleep items in the child behavior checklist: a comparison with sleep diaries, actigraphy, and polysomnography. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 499–507. doi: 10.1016/j.jaac.2011.02.003.PubMedCentralCrossRefPubMedGoogle Scholar
  30. Guan, N.C., Yusoff, M.S.B., Zainal, N.Z., & Yun, L.W. (2012). Analyses of two independent samples with non normailty using non parametric method, data transformation and bootsrapping method. International Medical Journal, 19 (3). 227-229.Google Scholar
  31. Hanley, J. A., Negassa, A., & Forrester, J. E. (2003). Statistical analysis of correlated data using generalized estimating equations: an orientation. American Journal of Epidemiology, 157, 364–375. doi: 10.1093/aje/kwf215.CrossRefPubMedGoogle Scholar
  32. Hudson, J. L., Gradisar, M., Gamble, A., Schniering, C. A., & Rebelo, I. (2009). The sleep patterns and problems of clinically anxious children. Behaviour Research and Therapy, 47, 339–344. doi: 10.1016/j.brat.2009.01.006.CrossRefPubMedGoogle Scholar
  33. Iglowstein, I., Jenni, O. G., Molinari, L., & Largo, R. H. (2003). Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics, 111, 302–307. doi: 10.1542/peds.111.2.302.CrossRefPubMedGoogle Scholar
  34. Ivanenko, A., Barnes, M. E., Crabtree, V. M., & Gozal, D. (2004). Psychiatric symptoms in children with insomnia referred to a pediatric sleep medicine center. Sleep Medicine, 5, 253–259. doi: 10.1016/j.sleep.2004.02.001.CrossRefPubMedGoogle Scholar
  35. Johnson, E. O., Chilcoat, H. D., & Breslau, N. (2000). Trouble sleeping and anxiety/depression in childhood. Psychiatry Research, 94, 93–102. doi: 10.1016/S0165-1781(00)00145-1.CrossRefPubMedGoogle Scholar
  36. Kushnir, J., & Sadeh, A. (2013). Correspondence between reported and actigraphic sleep measures in preschool children: the role of a clinical context. Journal of Clinical Sleep Medicine, 9, 1147–1151. doi: 10.5664/jcsm.3154.PubMedCentralPubMedGoogle Scholar
  37. Lipton, M. F., Augenstein, T. M., Weeks, J. W., & De Los Reyes, A. (2014). A multi-informant approach to assessing fear of positive evaluation in socially anxious adolescents. Journal of Child and Family Studies, 23, 1247–1257. doi: 10.1007/s10826-013-9785-3.CrossRefGoogle Scholar
  38. McDonald, L., Wardle, J., Llewellyn, C. H., van Jaarsveld, C. H. M., & Fisher, A. (2014). Predictors of shorter sleep in early childhood. Sleep Medicine, 15, 536–540. doi: 10.1016/j.sleep.2014.01.005.PubMedCentralCrossRefPubMedGoogle Scholar
  39. Meltzer, L. J., Montgomery-Downs, H. E., Insana, S. P., & Walsh, C. M. (2012a). Use of actigraphy for assessment in pediatric sleep research. Sleep Medicine Reviews, 16, 463–475. doi: 10.1016/j.smrv.2011.10.002.PubMedCentralCrossRefPubMedGoogle Scholar
  40. Meltzer, L. J., Walsh, C. M., Traylor, J., & Westin, A. M. L. (2012b). Direct comparison of two new actigraphs and polysomnography in children and adolescents. Sleep, 35, 159.PubMedCentralPubMedGoogle Scholar
  41. Mick, E., Biederman, J., Jetton, J., & Faraone, S. V. (2000). Sleep disturbances associated with attention-deficit hyperactivity disorder: the impact of psychiatric comorbidity and pharmacotherapy. Journal of Child and Adolescent Psychopharmacology, 10, 223–231. doi: 10.1089/10445460050167331.CrossRefPubMedGoogle Scholar
  42. Owens, J. A., Maxim, R., Nobile, C., McGuinn, M., & Msall, M. (2000a). Parental and self-report of sleep in children with attention-deficit/hyperactivity disorder. Archives of Pediatrics and Adolescent Medicine, 154, 549. doi: 10.1001/archpedi.154.6.549.CrossRefPubMedGoogle Scholar
  43. Owens, J. A., Spirito, A., & McGuinn, M. (2000b). The Children’s sleep habits questionnaire (CSHQ): psychometric properties of a survey instrument for school-aged children. Sleep, 23, 1043–1052.PubMedGoogle Scholar
  44. Patriquin, M. A., Mellman, T. A., Glaze, D. G., & Alfano, C. A. (2014). Polysomnographic sleep characteristics of generally-anxious and healthy children assessed in the home environment. Journal of Affective Disorders, 161, 79–83. doi: 10.1016/j.jad.2014.02.037.PubMedCentralCrossRefPubMedGoogle Scholar
  45. Reynolds, K., & Alfano, C. A. (2015). Things that go bump in the night: Frequency and predictors of nightmares in anxious and non-anxious children. Behavioral Sleep Medicine. in press.Google Scholar
  46. Robinson, A. M., & Richdale, A. L. (2004). Sleep problems in children with an intellectual disability: parental perceptions of sleep problems, and views of treatment effectiveness. Child: Care, Health and Development, 30, 139–150. doi: 10.1111/j.1365-2214.2004.00395.x.Google Scholar
  47. Rosa, R. R., & Bonnet, M. H. (2000). Reported chronic insomnia is independent of poor sleep as measured by electroencephalography. Psychosomatic Medicine, 62, 474–482.CrossRefPubMedGoogle Scholar
  48. Sadeh, A. (1996). Evaluating night wakings in sleep-disturbed infants: a methodological study of parental reports and actigraphy. Sleep, 19, 757–762.PubMedGoogle Scholar
  49. Sadeh, A., Sharkey, K. M., & Carskadon, M. A. (1994). Activity-based sleep—wake identification: an empirical test of methodological issues. Sleep, 17, 201–207.PubMedGoogle Scholar
  50. Saper, C. B., Cano, G., & Scammell, T. E. (2005). Homeostatic, circadian, and emotional regulation of sleep. Journal of Comparative Neurology, 493, 92–98. doi: 10.1002/cne.20770.CrossRefPubMedGoogle Scholar
  51. Schwarz, N. (1999). Self-reports: How the questions shape the answers. American Psychologist, 54, 93. doi: 10.1037/0003-066X.54.2.93.CrossRefGoogle Scholar
  52. Short, M. A., Gradisar, M., Lack, L. C., Wright, H., & Carskadon, M. A. (2012). The discrepancy between actigraphic and sleep diary measures of sleep in adolescents. Sleep Medicine, 13, 378–384. doi: 10.1016/j.sleep.2011.11.005.CrossRefPubMedGoogle Scholar
  53. Short, M. A., Gradisar, M., Lack, L. C., Wright, H. R., & Chatburn, A. (2013). Estimating adolescent sleep patterns: parent reports versus adolescent self-report surveys, sleep diaries, and actigraphy. Nature and Science of Sleep, 5, 23. doi: 10.2147/NSS.S38369.PubMedCentralCrossRefPubMedGoogle Scholar
  54. Silverman, W. K., & Albano, A. M. (1996). The anxiety disorders interview schedule for children (ADIS-C/P). San Antonio, TX: Psychological Corporation.Google Scholar
  55. Silverman, W. K., Saavedra, L. M., & Pina, A. A. (2001). Test-retest reliability of anxiety symptoms and diagnoses with the anxiety disorders interview schedule for DSM-IV: child and parent versions. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 937–944. doi: 10.1097/00004583-200108000-00016.CrossRefPubMedGoogle Scholar
  56. Szymczak, J. T., Jasińska, M., Pawlak, E., & Zwierzykowska, M. (1993). Annual and weekly changes in the sleep-wake rhythm of school children. Sleep, 16, 433–435.PubMedGoogle Scholar
  57. Walker, M. P. (2009). The role of sleep in cognition and emotion. Annals of the New York Academy of Sciences, 1156, 168–197. doi: 10.1111/j.1749-6632.2009.04416.x.CrossRefPubMedGoogle Scholar
  58. Weschler, D. (1983). Wechsler Abbreviated Scale of Intelligence (WASI). San Antonio: Psychological Corporation.Google Scholar
  59. Wolfson, A. R., & Carskadon, M. A. (1998). Sleep schedules and daytime functioning in adolescents. Child Development, 69, 875–887. doi: 10.1111/j.1467-8624.1998.tb06149.x.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Candice A. Alfano
    • 1
    Email author
  • Michelle A. Patriquin
    • 1
  • Andres De Los Reyes
    • 2
  1. 1.Sleep and Anxiety Center of Houston, Department of PsychologyUniversity of HoustonHoustonUSA
  2. 2.Comprehensive Assessment and Intervention Program, Department of PsychologyUniversity of Maryland at College ParkCollege ParkUSA

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