No Simple Solution To Childhood Insomnia

Sleep problems are closely intertwined with psychiatric diagnoses in young people. Common disorders and their treatments may affect sleep, and troubled sleep patterns in turn affect daily functioning.

Unknotting this tangled web presents a challenge to clinicians, said Judith Owens, M.D., M.P.H., at a conference sponsored by the American Academy of Child and Adolescent Psychiatry. Yet many primary care physicians are unfamiliar with sleep issues.

“Things have improved over the last five years,” said Mark Goetting, M.D., another pediatric sleep specialist, “but a survey in the 1990s found that pediatricians learned more about sleep medications from their own mothers and children than they did in medical school.”

There is no one cause or constellation of symptoms for insomnia in children, said Owens. “Information comes largely from parents,” she said. “Clinicians often respond to a parental problem.”

“Insomnia is a problem because it disturbs the sleep and function of the whole family,” agreed Goetting, director of Sleep Health in Kalamazoo, Mich. A sleepless child may keep parents awake at night or provoke a power struggle at wake-up time.

The current consensus definition of pediatric insomnia includes three components: difficulty initiating or maintaining sleep; a severe, chronic, or frequent sleep problem, associated with impaired daytime functioning in the child or family; or a primary sleep disorder or one associated with medical or psychiatric disorders. In any case, according to the American Academy of Sleep Medicine, “insomnia is a symptom and not a diagnosis.”

“The key is excessive daytime sleepiness leading to behavioral deficits, mood disturbances, or changes in affect,” said Owens, co-author with Jodi A. Mindell, Ph.D., of Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems (Lippincott Williams& Wilkins, 2003).

Behavioral problems can include aggressiveness, hyperactivity, or poor impulse control. Neurocognitive deficits can appear in attention, memory, or executive functions or in cognitive flexibility, verbal creativity, or abstract reasoning. Academic, family, and social life may suffer, too.

“With a psychiatric condition combined with insomnia, the initial focus should be on improving the psychiatric condition,” Goetting said. ADHD, depression, anxiety, and bipolar disease can be aggravated by sleep disorders.

ADHD Complicates Matters

“A substantial percentage of ADHD kids may have sleep deficits,” said Owens. In fact, said Goetting, some subsyndromic hyperactivity and impulsivity in ADHD may be solely due to sleep disorders.

Diagnosis is complicated by the fact that some primary sleep disorders may present with ADHD-like symptoms. Physicians should use some simple screening tool to evaluate the child's sleeping patterns and differentiate between primary sleep disorders and those influenced by other causes, said Owens.

Comorbid psychiatric disorders with ADHD may also account for sleep problems. Bipolar disorder may reduce the need for sleep. Insomnia or early awakening may be tied to depression, while bedtime resistance or sleep-onset delays may occur with oppositional defiant disorder, obsessive-compulsive disorder, or anxiety. At the same time, treatment may also affect sleep. ADHD may alter circadian sleep patterns, shift sleeping time, and cause increased daytime sleepiness.

“Medications used to treat ADHD or comorbid conditions may affect sleep or wakefulness,” said Owens. Psychostimulants may directly delay sleep onset, decrease time asleep, or disrupt sleep continuity. Rebound effects—increased irritability and insomnia after the drug wears off—may occur too.

Insomnia Common With Depression

Depression and its treatments also engender sleep problems. About 75 percent of children and adolescents with major depressive disorder report insomnia, of which 30 percent is characterized as severe. One-third of depressed adolescents report sleep-onset delays, while 25 percent say they sleep too much. Worse sleep quality, as measured by wristband motion detectors, is associated with more depressed mood and hopelessness among hospitalized psychiatric patients, said Owens.

Antidepressants have their effects as well. Tricyclics can be sedating and can suppress random-eye movement (REM) sleep while increasing REM latency, she said. Rapid withdrawal may lead to nightmares and parasomnias. SSRIs can increase periodic limb movements, while buproprion seems to have no effect on sleep latency or total sleep time, but may increase the percentage of REM as it reduces REM latency. Some newer antidepressants, like citalopram, nefazodone, or mirtazapine, are sedating and may be useful in treating depression associated with insomnia.

Mood stabilizers and anticonvulsants like carbamazepine, valproic acid, topiramate, and gabapentin appear to be slightly sedating, she said. Most antipsychotics increase daytime somnolence, reduce sleep-onset latency, and increase sleep continuity, but they suppress REM sleep.

Use Medication Sparingly

Treating insomnia in children and adolescents raises a problem common to those age groups: “There are no sleep medications currently labeled for use in children by the FDA, and there's too little empirical, outcome-based data to recommend specific drugs in specific situations,” said Owens.

The American Academy of Sleep Medicine's Pediatric Pharmacology Task Force emphasizes that drugs be used judiciously in treating insomnia. According to their recent review of the subject (co-written by Owens), medication should rarely be the first or only treatment option. Instead, behavioral therapies should be tried first, and “pharmacological approaches should be largely considered adjuncts in the treatment of pediatric insomnia.”

However, many physicians often don't have the time or expertise to work with parents on behavioral strategies, so medication may be useful in a crisis. “Drugs can be used to bring the child or the family down from the boiling point when the safety or welfare of the child is threatened,” said Owens.

Treatment should be based on a careful diagnosis, and goals should be realistic, defined, and measurable, she said. Physicians should review side effects with the family, monitor the patient's response frequently, and avoid abrupt discontinuation. Combining behavioral with pharmacological therapy increases long-term efficacy and decreases side effects.

From a parent's point of view, the ideal sleep inducer would be in liquid form and have a quick onset; an intermediate duration; no effect on sleep architecture; and no rebound, tolerance, withdrawal, or side effects, said Owens.

By those standards, many medications used for adults are questionable when prescribed for children. The central alpha-2 agonist clonidine, for example, has a rapid onset but also has a variable half-life of from six to 24 hours, too broad a window for convenient use. Clonidine does reduce sleep-onset latency, but also increases slow wave sleep and decreases REM. Side effects include hypotension, bradycardia, irritability, dysphoria, and potential for overdose. Patients may develop tolerance or develop higher rebound blood pressure on discontinuation. Although clonidine is approved for adults, Owens prefers not to prescribe it for children for these reasons.

Benzodiazepines decrease sleep latency but produce morning hangover, cause daytime drowsiness, induce withdrawal symptoms on discontinuation, and interact with central nervous system depressants. They may mask sleep symptoms, not improve them, she said.

Zolpidem, the most widely used short-acting hypnotic in adults, acts quickly and has minimal effects on sleep architecture and few aftereffects, but so far it has not been used much in pediatrics.

Antihistamines are weak soporifics that are seen as benign, but produce daytime drowsiness, cholinergic effects, and paradoxical excitation.

“They are not the best choice in serious cases, but familiarity may make them a more acceptable choice for families,” she said.

Melatonin, often used for circadian rhythm disturbances, is sometimes used as a sedative. However, it affects the hypothalamic-gonadal axis and, in sudden withdrawal, may kick young patients into premature puberty.

Physicians and parents should collaborate on behavioral interventions. Owens disapproves of allowing children to watch late-night television or playing video games. The light levels may be enough to prevent the body's melatonin from kicking in. Some parents are “enablers” of their children's sleep problems, she said. Parents of a child who stays awake all night and sleeps all day may collaborate with the child by providing excuses to keep the child out of school.

Rather than trying to “pull” a child's sleep schedule back to normal by attempting to enforce a progressively earlier bedtime, she suggests pushing the child to delay sleep by two hours each night until reaching an acceptable normal bedtime.

In any case, clinicians should not shrug off children's sleep problems.

“A child waking up in the middle of the night is a crisis for the whole family,” said Goetting. “It destroys quality of life. The emotions accompanying the event start with sympathy and caring, but if a parent can do nothing and the child can't go back to sleep, feelings of anger and frustration emerge. So children who are sleepless are at high risk for child abuse. Sadly, most children and families who could benefit from treatment don't get it.” ▪