Insomnia in Children and Adolescents

Insomnia in Children and Adolescents
Insomnia in Children and Adolescents
Karen Chalanick, RN, PNP-BC
Disclosures
I have no disclosures
Learning Objectives
Recognize sleep behaviors that are maladaptive, as well as beliefs and attitudes about sleep
that contribute to insomnia.
Recognize the clinical presentation of insomnia in a pediatric patient.
Identify several of the most common problems that co-exist with insomnia.
Describe the purpose of sleep hygiene and behavioral therapy.
Identify several medications used in treatment of insomnia in children and teens.
The Purpose of Sleep
Much of what we understand has been derived from studying the impact of induced sleep
loss
Adequate sleep is a biologic necessity, rate of metabolism decreases helping to conserve
energy
Most of our major organs are less active during sleep, thereby helping to conserve function
over time
Purpose of Sleep
REM sleep plays an active role in memory consolidation
Release of growth hormone during deep, slow wave sleep links sleep to somatic growth
Proteins, cells, and tissue are synthesized in greater amounts during sleep
Insomnia
A working definition:
Occurs despite adequate opportunity for sleep
Difficulty initiating or maintaining sleep or waking up too early
Sense of non restorative sleep
There is daytime impairment related to nighttime sleep problems
Multiple “official” definitions exist for insomnia
The American Psychiatric Association
Distinguishes primary insomnia as insomnia that is considered to be a distinct diagnostic
entity from insomnia that is a symptom of another underlying medical and /or psychiatric
condition
The American Academy of Sleep Medicine
Refers to this as psychophysiologic insomnia
This term better describes how insomnia is initiated and maintained; the patient feels a
sense of hyperarousal (increased muscle tension, increased heart rate, sweating)while
1
Insomnia in Children and Adolescents
attempting to sleep. Learned sleep preventing behaviors trigger these responses and this
becomes a vicious cycle.
Initial, middle, terminal insomnia are older ways to describe when the problems occur in the
sleep cycle
Treating Insomnia in Children
It is rarely the patient themselves who is concerned about the problem of sleeplessness
Parents of older children and adolescents are less likely to be aware of sleep problems, as
compared to parents of infants and toddlers
Cultural differences in what is acceptable in regards to sleep practices have a huge effect on
how a parent views treatment
Caregivers of the sleepless child often suffer as well from sleep deprivation and stress
Increased marital tension, decreased attention to siblings, daytime sleepiness to all can
result in poor quality of life for the whole family
Behavioral Insomnia of Childhood
In young children behavioral insomnia often is characterized by
bedtime refusal and struggles, limit setting problems
and /or prolonged night wakings requiring parental intervention
Behavioral Insomnia of Childhood
Limit setting type
Characterized by noncompliant behaviors at bedtime such as bedtime refusal, verbal,
protests, repeated demands.
This leads to delayed sleep onset
Most common in preschoolers and young school age children
Usually develops from caregivers inability to provide consistent bedtime rules, and is made
worse by a child's oppositional behavior
Behavioral Insomnia of Childhood
Sleep Onset Problems
Frequent and prolonged night wakings that require care provider intervention to help the
child return to sleep
There is a significant delay in sleep onset in the absence of the required conditions (parental
presence, bottle, cup, pacifier)
Child has not learned how to self soothe, and signal the care provider until the needed
associations are provided.
Treatment
When left untreated bedtime problems can become chronic
Behavioral interventions are usually effective with no adverse effects
Care providers must be consistent
Protesting behavior often escalates at the beginning of the treatment
2
Insomnia in Children and Adolescents
Treatment
Consistent, calm bedtime routine, non-stimulating
Appropriate sleep associations; blanket, stuffed animal
Fall asleep independently, parent leaves room while drowsy but still awake
Bedtime fading; temporarily move bedtime later, then slowly move back to desired time
Positive reinforcement for good bedtime behaviors
Psychophysiologic insomnia
More common in older children and teens
Characterized by combination of learned sleep-preventing associations and heightened
physiologic response, resulting is sleeplessness
Excessive worry about sleep
Exaggerated concern regarding possible daytime consequences
The Behavioral Model of Insomnia
Spielman et al 1987
Insomnia occurs acutely in relation to predisposing and precipitating factors and the chronic
form is maintained by maladaptive coping behaviors (perpetuating factors)
A child be prone to insomnia due to personality traits (predisposing), experiences acute
insomnia because of precipitating factors, and this grows into chronic insomnia because of
perpetuating behaviors.
Predisposing Factors
Hyperarousal/Hyperreactivity (ADHD for example)
Anxiety, tendency to excessively ruminate
Work schedules of parents that disrupt a child’s natural sleep schedule
Precipitating Factors
Acute occurrences that interact with the patients predisposition for insomnia to produce
problems with sleep initiation and maintenance
Illness, injury, pain
Onset of psychiatric illness
Acute changes in social environment; divorce, new sibling, starting school, moving to new
house
Perpetuating factors
A variety of maladaptive strategies that arise from attempts to get more sleep
Spending excessive time in bed; tendency of people to go to bed earlier, get out of bed later,
and/or nap in an effort to increase the opportunity to get more sleep
Non-sleep related behaviors occurring in the bedroom; TV, computer, homework, phone,
eating
Caffeine use, stimulants
3
Insomnia in Children and Adolescents
Prevalence of Psychophysiologic Insomnia
Uncommon in prepubertal children
Roughly 12-33 % of teens who report they are poor sleepers, no prevalence studies done on
“normal” populations of school-age children or adolescents
In adults, more common in females
Assessment of Insomnia
Medical history
Developmental/school history
Family history
Behavioral assessment
Physical exam
Diagnostic Testing and Insomnia
Sleep diaries
Actigraphy
Lab evaluation
Polysomnography
Sleep diaries
The primary tool for prospective assessment of insomnia
Reveals prolonged sleep onset, nighttime awakenings, early morning awakenings
Reveals information about maladaptive bedtime behaviors
Reveals information about behaviors that maintain the insomnia
No standard for sleep diaries
Sleep diaries
Actigraphy
Measures, stores, and analyzes body activity over an extended period of time
Portable device that looks like a watch, worn on wrist or ankle
Useful in obtaining an objective measurement of sleep duration and sleep patterns in the
home
Actiwatch
Lab evaluation
Tailored to specific history given by child and family
Could include iron studies, drug screen
4
Insomnia in Children and Adolescents
Polysomnography
(Sleep study)
Not typically indicated unless underlying sleep disorder is also suspected
Insomnia does not typically alter sleep architecture (the distribution of different sleep
stages)
ADHD
Some areas of the brain that are affected in ADHD are the same structures that are involved
in the regulation of sleep; problems with attention and alertness and problems with
insomnia may be the results of abnormal cortex arousal function
The Brain and ADHD
The frontal lobes help us to pay attention to tasks, focus concentration, make good
decisions, plan ahead, learn and remember what we have learned, and behave
appropriately for the situation.
The inhibitory mechanisms of the cortex keep us from being hyperactive, from saying things
out of turn, and from getting mad at inappropriate times, for examples. They help us to
"inhibit" our behaviors.
The limbic system is the base of our emotions. A normally functioning limbic system would
control normal emotional changes, normal levels of energy, normal sleep routines, and
normal levels of coping with stress. A dysfunctional limbic system results in problems with
those areas.
The Attention Deficit Hyperactivity Disorder might affect one, two, or all three of these
areas, resulting in several different presentations.
ADHD and insomnia
ADHD has one of the highest rates of sleep problems of all child mental health disorders
Prevalence estimates of sleep problems range from 50-80%
Bedtime resistance related to co morbid anxiety
Stimulant medications impact on delayed sleep onset
Settling difficulties at bedtime due to an increase of ADHD behaviors when meds are
wearing off
ADHD and Sleep Assessment
ADHD may cause sleep problems; unable to slow down thoughts and settle for sleep
insomnia
Primary sleep disorder may cause ADHD like symptoms; OSA daytime sleepiness,
inattention
can contribute to both ADHD and insomnia
5
Insomnia in Children and Adolescents
Anxiety
The brain’s response to danger or stimuli that the child or teen actively would like to avoid
It is a response present from infancy and it is not normally pathological as it protects us
from danger
Anxiety becomes maladaptive when it interferes with functioning, becomes frequent, severe
and persistent
Children exhibit anxiety and fears as part of normal development
Anxiety disorders
There are many (over 10) specific anxiety disorders classified in the DSM- IV
Many share common clinical features such as physiologic symptoms such as increased heart
rate, sweating, sleep disturbances, increase blood pressure, extreme avoidance of certain
objects.
Some features present differently in young children and adolescents
Anxiety and sleep
Anxious children and children who have experienced significant trauma show an increased
incidence of
Difficulty falling to sleep
Refusal to sleep alone
Difficulty staying asleep
Nightmares
Nighttime fears
Anxiety and insomnia
A bidirectional relationship exists sleepanxiety and  anxietysleep
Racing thoughts, anticipatory worry  physiologic arousal at bedtime  insomnia
Insomnia in childhood is a risk factor for developing anxiety, as well as depression in
adolescence and adulthood
Restless Legs Syndrome
Sensorimotor disorder characterized by uncomfortable sensations in legs and an urge to
move the legs
The urge is worse when sitting still for a long time or when lying down
Improves with movement
Worse in the evening or night
Age-appropriate description of discomfort; legs hurt, feel tingly, creepy, legs have lots of
energy
Contributes to sleep disturbance (delayed sleep onset)
6
Insomnia in Children and Adolescents
Restless Legs Syndrome
Prevalence: 2-4 % of 8-18 year olds
No gender differences
Positive parental history in >70%
Frequently found in children with ADHD
RLS and low iron stores
The connection was made as it was recognized that populations at higher risk for iron
deficiency have higher incidence of RLS; end stage renal disease, pregnant women, frequent
blood donors
The hypothesis is that in RLS, stores of iron or the transport and metabolism of iron may be
enough to maintain RBC production but not sufficient to maintain normal brain iron stores,
which in turn may lead to reduced dopamine synthesis
Dopamine is a neurotransmitter that is, in part, involved in motor function and control
Reduced dopamine in brain decreased motor control  motor restlessness such as is
seen in RLS
CBC may be normal, but serum ferritin <50 is associated with RLS
Hypnogram in normal sleeper
Sleep Hygiene’s Role in Insomnia Therapy
Sleep Hygiene
Purposeful, intentional practices that promote good sleep quality, allow adequate sleep
duration, and prevent daytime sleepiness
Sleep environment, sleep routine, and daytime activities are all important aspects
Recommendations from the 2004 National Sleep Foundation Sleep in America Poll
2004 National Sleep Foundation “Sleep in America Poll”
Recommendations
Children of all ages should fall asleep independently
Children should be in bed before 9 pm
Children should have an established bedtime routine
Reading should be included as part of the bedtime routine
Bedrooms should not have televisions
Children should refrain from caffeine consumption
Sleep Hygiene
Concept was first introduced over 100 years ago
Healthy habits for good sleep
Helps to keep our mind and body rested and strong
Mostly common sense ideas based in science
It is not a treatment for insomnia, but it IS the foundation for all other behavioral
treatments used
7
Insomnia in Children and Adolescents
Stimulus Control
Is intended to help the insomniac learn how to fall asleep quickly in bed
Good for both problems getting to sleep and staying asleep
The first line of behavioral therapy, sometimes is all that is needed
Stimulus Control
Limits the amount of time spent in the bedroom while awake, as well as the kinds of
behaviors
Limitations are meant to strengthen the association between the bed/bedroom/bedtime
with fast, well consolidated sleep
In insomnia bed and bedtime may have become cues for behaviors that are incompatible
with falling asleep
TV, reading, eating, homework, phone are all within easy reach
This quiet time allows for rehashing of the days events, worry, excitement
Bedtime becomes a cue for arousal rather than a cue for sleep
Stimulus Control
One stimulus, the BED, should elicit one response, SLEEP!
Only go to bed when sleepy
Avoid any behavior in the bedroom other than sleep
Leave the bed if awake for more than 15 minutes
Return only when sleepy
Have a fixed wake up time 7 days/week
Sleep Restriction Therapy
Also helpful for both sleep initiation and maintenance problems
Not usually used as the first line behavioral treatment, not usually used as only treatment
Refers to the planned restriction of time in bed to a minimum number of hours, usually
based on the average amount of sleep obtained/ night
(minimum of 6 hours in children)
Sleep Restriction Therapy
Establish fixed wake up time
Decrease the opportunity for sleep by limiting the child’s time in bed to the average amount
of time they sleep
This results in a mild sleep loss at first, and creates controlled sleep deprivation  sleep
onset latency and  amount of time awake during the night
Bedtime is gradually advanced earlier at a rate that is based on good sleep efficiency
8
Insomnia in Children and Adolescents
Sleep Restriction Therapy
(SRT)
SRT works because
It prevents children from coping with their insomnia by extending their sleep opportunity
(going to bed earlier, sleeping in later)
The initial sleep loss that occurs strengthens the sleep drive, reduces the time it takes to fall
asleep, improved quality of sleep  improved sleep efficiency
Insomnia statistics from sleep study
SLEEP SUMMARY
Lights Out:
22:36:10
Lights On: 06:00:11
Analysis Duration:
444.0 min
Sleep Period:
390.0 min
Total Wake Time (During Sleep Period): 48.0 min
Total Sleep Time: 342.0 min
Sleep Efficiency (analysis period):
77.0%
Sleep Latency to first 60 seconds of sleep:
Latency to Stage N1
54.0 min
Latency to Stage N2
88.5 min
Latency to SWS 110.5 min
REM Latency from sleep onset: 136.5 min
54.0
(12.3%)
min
Number of Awakenings: 37
Awakenings Index:
6.5
Number of Arousals:
Arousal index:
67.9
387
STAGE
Duration
% of TST
N1 67.0 min
19.6%
N2 221.5 min
64.8%
N3 29.5 min
8.6%
REM
24.0 min
7.0%
Total NREM
318.0 min
93.0%
Relaxation Training
Most suitable for children and teens with anxiety, ADHD and have a hard time settling down
to sleep
Reduces physiologic arousal
Reduces cognitive processes such as racing thoughts, worrying
9
Insomnia in Children and Adolescents
Relaxation Training
Progressive Muscle Relaxation
Reduces skeletal tension
Diaphragmatic breathing
Slower, deeper breathing from the abdomen mimics the type of breathing that should occur
naturally at sleep onset
Imagery training
Developing a relaxing image or memory and engaging multiple senses to help relax; sight,
smell, sound, touch
Cognitive Restructuring
Teaching the patient to change the way they think about their sleep
Investigate negative thoughts and beliefs about sleep
Then challenge the logic of these thoughts and beliefs and replace them with balanced
thoughts
“If I don’t fall asleep soon I will definitely fail my exam tomorrow”
Replace with balanced thoughts
Well, even if I fail it’s only one test
I’m not going to fail, I studied hard and I know the material
I have a good grade in the class and I worked hard. I’ll do fine
When to use medications
Most insomnia in children and teens can be managed with a combination of behavioral
therapy and a change of habits (for both child and parents)
There are specific clinical populations for whom medications for sleep have been found to
be an important part of the treatment plan
Autism, ADHD, psychiatric illness
Guidelines for use of pharmacologic agents
Appropriate behavioral interventions have not been fully effective
Assessing appropriate care provider expectations for the child's sleep
Choice of medication should be diagnostically driven; reason for insomnia determined and
medication selected that best addresses the primary problem
Guidelines for selection of medication
Short acting agents best for problems with sleep onset
Long acting meds for problems with sleep maintenance
Half life of all medications understood with goal to minimize a “medication hangover” in the
morning
Have a clear game plan established with care provider regarding goals and long term plan
10
Insomnia in Children and Adolescents
Melatonin
Hormone secreted by the pineal gland that binds to receptors in the suprachiasmatic
nucleus (SCN) in the hypothalamus
Stimulated by dark, inhibited by light
Endogenous melatonin production begins 1-2 hours before sleep and increases throughout
the night
Melatonin suppression is associated with autism
Melatonin
Exogenous melatonin functions in 2 different ways, depending on the dose and the timing
As a chronobiotic (helps to shift the circadian sleep-wake cycle)
Smaller doses, 0.5 mg, given 5-7 hours before desired bedtime
Useful if delayed sleep onset seems circadian in nature as in delayed sleep phase syndrome
As a mild hypnotic (sedating)
Larger dose, 3-5 mg, taken 1 hour before desired sleep onset
This is the more common use
Melatonin
Peak serum levels 60-150 minutes after taken
Dose of 5 mg produces peak blood levels 25 x’s above physiologic levels
Categorized by FDA as a dietary supplement, prescription not required
Generally regarded as safe, potential adverse effect of suppression of the hypothalamic –
gonadal axis which could trigger precocious puberty in a child who has been taking it awhile
and then discontinues it abruptly
Contraindicated with autoimmune disorders or if taking immunosuppressants
Iron supplements
Used for treatment of restless legs syndrome, if the child has iron deficiency, specifically a
serum ferritin <50
Toddlers and adolescent girls are at increased risk for iron deficiency
Iron is required in dopamine synthesis, insufficient dopamine  motor restlessness such as
is seen in RLS
Iron therapy for RLS
Oral tablet, chewable or liquid 3-6 mg/kg of elemental iron/day with 250 mg vitamin C
Avoid giving with calcium containing foods
Goal is ferritin above 50 ng/ml
Side effects may include constipation, nausea and black stools, temporary staining of teeth
Reevaluate in 3 months
Often will need to continue past 3 months, some children will require some additional
supplementation throughout childhood
11
Insomnia in Children and Adolescents
Clonidine
Used for problems with sleep onset, used most often with ADHD
Rapidly absorbed , onset of action in 1 hour, peak effects 2-4 hours
Dosing in children > 6 years old 0.05 – 0.2 mg before bedtime
Potential side effects include irritability, low blood pressure, rebound hypertension with
abrupt disruption
Antihistamines
OTC diphenhydramine has shown modest efficacy in reducing sleep onset latency
Potential adverse effects include paradoxical excitation
Tolerance can develop
Typical dosing in children is 0.5 mg/kg (max of 25 mg)
Peak plasma levels in 2-3 hours
½ life in children is shorter than in adults (8 hours)
Antihistamines
Hydroxyzine
FDA approved for anxiety in children and adults, so could be considered for problems with
sleep onset when anxiety is a strong component
Potential side effects the same as diphenhydramine
Children and Adolescents: 0.6 mg/kg/dose; maximum single dose: 100 mg when used for
sedation
Benzodiazepines
Hypnotic effect is mediated by their action at GABA type A receptors
GABA is the major inhibitory neurotransmitter in the brain
Increasing the available amount of GABA typically has a relaxing, anti-anxiety, and anticonvulsive effects, decrease arousal
Benzodiazepines
Shorten sleep latency, increase total sleep time, improve sleep maintenance
Lorazepam, diazepam, clonazapam, alprazolam all are indicated for use in anxiety and
seizures but not insomnia
Risk for addiction
Should only be used for short term insomnia, or in clinical situations in which their other
properties are in useful (anxiety, seizures)
Non - benzodiazepines
Mechanism of action is the same as the benzo’s but but they bind more selectively to GABA
A receptors
Zaleplon (Sonata) and Zolpidem (Ambien) are short acting and approved for use in adults,
not in children
Eszopiclone (Lunesta) is long acting, approved for use in adults
Potential side effects include dizziness, confusion, headache
12
Insomnia in Children and Adolescents
Conclusions
Insomnia in children negatively impacts not just the child but the whole family
Most children have the capacity to be good sleepers; that’s why behavioral therapy usually
works
Coexisting medical and/or developmental conditions may require pharmacologic therapy as
well
Our job includes educating our patients and their families about the importance of sleep
References
Bootzin, Richard, Stevens, Sally (2005). Adolescents, substance abuse, and the treatment of
insomnia and daytime sleepiness. Clinical Psychology Review, 25, 629-644.
Yoon, Sun Young, Jain,Umesh (2012). Sleep in attention-deficit/hyperactivity disorder in
children and adults: Past, present, and future. Sleep Medicine Reviews, 16, 371-388.
Beesdo, Katja, Knappe, Susanne (2009). Anxiety and Anxiety Disorders in Children and
Adolescents: Developmental Issues and Implications for DSM-V. Psychiatric Clinics of North
America, 32, 483 – 524.
Corkum, Penny, Davidson, Fiona (2011). A Framework for the Assessment and Treatment of
Sleep Problems with Attention-Deficit/Hyperactivity. Pediatric Clinics of North America, 58,
667-683.
Owens, Judy, Mindell, Jodi (2011). Pediatric Insomnia. Pediatric Clinics of North America, 58,
555- 569.
Perlis, Michael, Jungquist, Carla (2008). Cognitive Behavioral Treatment of Insomnia. New
York, NY, Springer.
Spielman, Arthur, Caruso, L (1987). A behavioral perspective on insomnia treatment.
Psychiatric Clinics of North America, 4, 451-553.
13