SLEEP DISORDERS IN CHILDREN AND ADOLESCENTS Rebecca Cho,
M.D.
Slide 2
O B J E C T I V E S Review of sleep architecture and physiology
through life stages Exploration of pediatric sleep disorders and
comorbidities Potential consequences of sleep disruption in
development Behavioral and pharmacological treatment options
Slide 3
Normal Sleep Architecture NREM Stage 1 Transition stage where
sleep usually begins, can be easily aroused Alpha waves, rhythmic =
relaxed wakefulness 1-7 min in HR and respirations, eyes move
slowly under eyelids Stage 2 Deeper sleep, more difficult to arouse
10-15 min initial cycle, longer with progressive cycles (45-55%
total sleep) Sleep spindles and K-complexes memory consolidation,
tranquil sleep Further in HR and respirations, no eye movement
Sleep Disorders and Sleep Deprivation: An Unmet Public Health
Problem. Institute of Medicine (US) Committee on Sleep Medicine and
Research; Colten HR, Altevogt BM, editors. Washington (DC):
National Academies Press (US); 2006. Klykylo, William M., Kay,
Jerald, eds Clinical Child Psychiatry. 3 rd ed. West Sussex:
Wiley-Blackwell, 2012. Print.
Slide 4
Normal Sleep Architecture Stages 3 and 4 (slow wave) o Deepest
sleep, highest arousal threshold, may be disoriented if awakened o
Stage 3 few min; stage 4 20-40 min o No significant distinguishing
pattern in shift from stage 3 to 4 o Primarily delta waves = high
voltage slow waves o Slowest rates of breathing and HR REM Rapid
eye movement Atonia, muscle paralysis safe expression of dreams
Desynchronous low-voltage mixed frequency waves + mix of wave
patterns seen in other sleep stages and wake state Sleep Disorders
and Sleep Deprivation: An Unmet Public Health Problem. Institute of
Medicine (US) Committee on Sleep Medicine and Research; Colten HR,
Altevogt BM, editors. Washington (DC): National Academies Press
(US); 2006. Klykylo, William M., Kay, Jerald, eds Clinical Child
Psychiatry. 3 rd ed. West Sussex: Wiley-Blackwell, 2012.
Print.
Slide 5
Normal Sleep Architecture Stage 1 Stage 2 Stage 3 Stage 4 REM =
one cycle Cycle repeats through the night NREM 75-80%, REM 20-25%
of total sleep First cycle 70-100 min; later cycles longer at
90-120 min Stage 2 progressively dominates NREM and REM intervals
get longer with subsequent cycles, while slow wave sleep largely
disappears Differences in sleep architecture through the ages Sleep
becomes less efficient w/ age Newborns o Sleep up to 16-18 hrs/day
in broken segments lasting 2-4 hrs o No distinct stages, circadian
rhythm not fully developed Sleep Disorders and Sleep Deprivation:
An Unmet Public Health Problem. Institute of Medicine (US)
Committee on Sleep Medicine and Research; Colten HR, Altevogt BM,
editors. Washington (DC): National Academies Press (US); 2006.
Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3
rd ed. West Sussex: Wiley-Blackwell, 2012. Print.
Slide 6
Normal Sleep Architecture By 2-3 mos o Circadian rhythm, NREM,
REM develops o Progressive consolidation of sleep, naps, less total
sleep required (14- 15 hrs) o Dreams more apparent by 12 mos,
content tends to be more vague Children o Total sleep further to
11-12 hrs by 3-5 y/o, most napping stops also o Slow wave tends to
dominate sleep cycle (w/ associated GH release) o May start having
more vivid dreams, nightmares, content related to waking
thoughts/fears/desires Adolescents o Need avg 8-10 hrs/night o in
slow wave sleep w/ onset of puberty and into adulthood o Frequent
shifts in circadian rhythm due to social/environmental factors and
potential biological/hormonal s Sleep Disorders and Sleep
Deprivation: An Unmet Public Health Problem. Institute of Medicine
(US) Committee on Sleep Medicine and Research; Colten HR, Altevogt
BM, editors. Washington (DC): National Academies Press (US); 2006.
Klykylo, William M., Kay, Jerald, eds Clinical Child Psychiatry. 3
rd ed. West Sussex: Wiley-Blackwell, 2012. Print.
Slide 7
Physiological s in Sleep Sleep Disorders and Sleep Deprivation:
An Unmet Public Health Problem. Institute of Medicine (US)
Committee on Sleep Medicine and Research; Colten HR, Altevogt BM,
editors. Washington (DC): National Academies Press (US); 2006.
Slide 8
Why Do We Sleep?? Exact role of sleep or why we alternate btwn
NREM and REM are unclear, but overwhelming evidence that lack of
sleep or disrupted sleep architecture leads to negative outcomes A
lot of interest in research; some hypotheses have arisen REM
Appears to be involved in memory consolidation; learning seems to
intensify/ REM Hippocampal neuronal activation in REM mirrors
pattern of wake state NE and 5HT post-synaptic depolarization and
long-term potentiation may aid in temporary hippocampal memory
storage, cognitive functioning, synaptic plasticity NREM Also
appears to be associated w/ learning and memory; learning seems to
intensify slow waves during NREM May play role in
differentiating/organizing important synapses from those that are
underutilized, facilitate protein synthesis Poe, Gina R., Walsh,
Christine M., Bjorness, Theresa E. Cognitive Neuroscience of Sleep.
Prog Brain Res. 2010; 185:1-19.
Slide 9
Pediatric Sleep Disorders Obstructive sleep apnea Sleep-related
movement disorders Parasomnias Narcolepsy Circadian rhythm
disorders Behavioral insomnia of childhood Psychiatric causes
Medical causes
Slide 10
Obstructive Sleep Apnea SYMPTOMS Snoring Apneic episodes
Diaphoresis Enuresis Waking up feeling unrested Daytime somnolence
Morning HAs Cognitive dysfunction ETIOLOGY Adenotonsillar
hypertrophy (most common) Obesity Craniofacial dysmorphology (e.g.,
Downs) Neuromuscular d/o (e.g., CP) RISK FACTORS Allergies Sinus
problems AA ethnicity FHx of OSA
Slide 11
Obstructive Sleep Apnea Has been associated w/ ADHD: proposed
that intermittent hypoxia + fragmented sleep prefrontal dysfunction
Dx: polysomnography + pulse ox Tx: Wt loss Adenotonsillectomy if
indicated Nasal CPAP Leukotriene receptor antagonists (montelukast)
Intranasal corticosteroids (fluticasone spray) External nasal
dilator strips Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, Carolyn. Sleep disorders
and sleep problems in childhood. Am Fam Physician. 2001 Jan 15;
63(2): 277-28
Slide 12
Sleep-related Movement Disorders Rhythmic movement disorder
Periodic limb movement disorder in sleep Restless leg syndrome
Relationship between ADHD and PLMS/RLS
Slide 13
Rhythmic Movement Disorder AKA Jactatio Capitis Nocturna
Repetitive, stereotyped movements, involvement of large muscle
groups Head banging o stress o Lying in prone/supine position o
Most common in 1 st yr o Boys > girls Head rolling o More
common, progressively declines w/ age Body rocking o Child is
usually on hands and knees rocking anterior posterior o More
associated w/ pleasurable activities (e.g., listening to music)
Hypothesized to be mechanism of self-stimulation/self-soothing
(mimicking cradling/rocking by parents) Moturi, Sricharan, Avis,
Kristin. Assessment and treatment of common pediatric sleep
disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C.
Carolyn. Sleep disorders and sleep problems in childhood. Am Fam
Physician. 2001 Jan; 63(2): 277-285
Slide 14
Rhythmic Movement Disorder Most commonly seen in infants and
children < 5 y/o Usually occurs when child is sleeping; occ
stage 1 or 2 sleep prevalence in MR (esp older individuals) Dx:
Thorough clinical eval + video polysomnography to r/o other causes
(e.g., seizures) Tx: Supportive; spontaneous resolution w/ age in
most cases If movements risk for injuries (esp head banging)
provide safe environment (e.g., padding, protective helmets)
Metronome near bed Allowing child to engage in rocking before
bedtime (e.g., rocking on chair or rocking horse) If severe, may
trial low-dose benzo such as clonazepam Moturi, Sricharan, Avis,
Kristin. Assessment and treatment of common pediatric sleep
disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C.
Carolyn. Sleep disorders and sleep problems in childhood. Am Fam
Physician. 2001 Jan; 63(2): 277-285
Slide 15
Periodic Limb Movements in Sleep (PLMS) Involuntary brief
jerking movements in 20-40 sec intervals Lower > upper
extremities In children movements may be less apparent; instead may
present as: Growing pains Leg discomfort Disrupted sleep
Difficulties initiating/maintaining sleep Moturi, Sricharan, Avis,
Kristin. Assessment and treatment of common pediatric sleep
disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C.
Carolyn. Sleep disorders and sleep problems in childhood. Am Fam
Physician. 2001 Jan; 63(2): 277-285
Slide 16
Periodic Limb Movements in Sleep (PLMS) rate of parasomnias Dx:
Video polysomnography to r/o seizures/OSA, detailed hx Tx options:
Fe supplementation (if low iron levels) Dopaminergic agents (e.g.,
ropinirole, pramipexole) Clonazepam (limited data) Bupropion (shown
to be effective for adult PLMS) Moturi, Sricharan, Avis, Kristin.
Assessment and treatment of common pediatric sleep disorders.
Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn.
Sleep disorders and sleep problems in childhood. Am Fam Physician.
2001 Jan; 63(2): 277-285
Slide 17
Restless Leg Syndrome (RLS) Frequently co-occurs w/ PLMS May
p/w nonspecific growing pains or leg discomfort Criteria include:
Urge to move legs (may also involve upper ext) Urge begins/worsens
when sitting/lying/inactive Urge partially or totally relieved upon
movement of legs Urge only occurs in evening/night or more severe
than during daytime Sleep onset or maintenance difficulties
frequent; anxieties r/t discomfort may interfere w/ ability to
achieve restful sleep Moturi, Sricharan, Avis, Kristin. Assessment
and treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 18
Restless Leg Syndrome (RLS) Tx: Behavioral interventions
including strict sleep hygiene and reg physical activity If Fe
levels low ( 50ng/dL + vit C to aid in absorption of Fe
Pharmacological options only approvde for adults; includes benzos,
clonidine, gabapentin, dopaminergic agents (need to monitor closely
for sedation) Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 19
Relationship Between ADHD & PLMS/RLS Significant
comorbidity Possible hypotheses: May be r/t impairment in DA
pathway: Fe effectiveness of tyrosine hydroxylase DA production
Insufficient sleep in children (disrupted sleep commonly seen in
those w/ PLMS & RLS) may manifest as hyperactivity,
distractibility, inattention, impulsivity, cognitive impairments
ADHD-like sx may be diurnal manifestations of PLMS/RLS during
daytime (difficulties staying seated or remaining inactive for
extended periods of time and needing to move to decrease
discomfort/urge) Fe supplementation has been shown to improve both
PLMS & RLS sx at nighttime and some research showing improved
ADHD-like sx during daytime Walters, Arthur S., Silvestri, Rosalia,
Zucconi, Marco, Chandrashekariah, Ranju, Konofal, Eric. Review of
the Possible Relationship and Hypothetical Links Between Attention
Deficit Hyperactivity Disorder (ADHD) and the Simple Sleep-Related
Movement Disorders, Parasomnias, Hypersomnias, and Circadian Rhythm
Disorders. J Clin Sleep Med. 2008 Dec 15; 4(6): 591-600.
Slide 20
Parasomnias Largely seen in children Condition appears to
spontaneous resolve w/ age, hypothesized to be 2/2 CNS immaturity
Generally benign, though may be more impairing esp in older
children if interfering w/ social functioning (e.g., sleepovers)
NREM parasomnias: AKA arousal disorders, result from sudden
awakening from deep slow wave sleep, causing confusion and
retrograde amnesia Generally do not tend to respond to external
stimuli May be autonomic/motor hyperactivity (e.g., repetitive
movements during sleep) Often +FHx Ex. sleepwalking, night terrors
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of
common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun;
7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep
problems in childhood. Am Fam Physician. 2001 Jan; 63(2):
277-285
Slide 21
Parasomnias REM parasomnias No associated confusion, recall may
be intact Ex. nightmares, REM behavior d/o (more commonly seen in
older adults), recurrent intermittent sleep paralysis Should r/o
underlying seizures esp if duration is very short,
+repetitive/stereotypic movements, inconsistent pattern in episodes
Most common in children: Sleepwalking Night terrors Nightmares
Nighttime enuresis Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 22
Sleepwalking (Somnambulism) Pathogenesis unknown Involves
complex motor movements and cognitive functioning (e.g.,
ambulation, driving) Most frequently seen in pubescent children
(peak prevalance 12 y/o) but can carry on to adulthood First third
of sleep Triggered by psychological or physiological stress (e.g.,
sleep deprivation) rates in those w/ comorbid OSA, Tourettes,
migraines Uncommonly violent/aggressive behaviors, but may become
combative and agitated if attempted to be restrained during episode
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of
common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun;
7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep
problems in childhood. Am Fam Physician. 2001 Jan; 63(2):
277-285
Slide 23
Sleepwalking (Somnambulism) Tx: Supportive, focus on ensuring
child does not injure self during episode Limit interference
Scheduled sleep awakenings Psychotherapy (esp if episodes r/t
stress) Relaxation techniques Pharmacotherapy: o Benzos o
Antidepressants (only case studies, some may worsen condition 2/2
impairment in REM sleep) Moturi, Sricharan, Avis, Kristin.
Assessment and treatment of common pediatric sleep disorders.
Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn.
Sleep disorders and sleep problems in childhood. Am Fam Physician.
2001 Jan; 63(2): 277-285
Slide 24
Night Terrors (Pavor Nocturnus) First third of deep slow wave
sleep Sx include: Loud screaming and/or crying Difficult to console
autonomic activity (e.g., tachycardia, tachypnea, sweating) Intense
feelings of panic/anxiety during episode Lasts 15-30 min Little to
no recall of event May co-occur w/ sleepwalking Peak prevalence 3-7
y/o Frequent +FHx May be triggered by fatigue, stress Moturi,
Sricharan, Avis, Kristin. Assessment and treatment of common
pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6):
24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in
childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Slide 25
Night Terrors (Pavor Nocturnus) Two categories which differ in
course of illness and tx approach Type A Common Benign,
self-limiting No tx required, parent reassurance Type B Much less
common Frequently r/t trauma Tends to be persistent throughout life
Resistant to tx Tx options include low dose benzos (diazepam
2-5mg), impramine Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 26
Nightmares Common in both children and adults, but most common
in children 3-6 y/o; persistence beyond this may warrant further
exploration for underlying trauma, anxiety, mood disorder Must
distinguish from night terrors Recall intact, not associated w/
confusion Second half of sleep in REM Tx: Reassurance for parents
CBT (e.g., progressive muscle relaxation, dream scripting)
Pharmacotx for trauma-related nightmares (e.g., prazosin,
clonidine) Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 27
Nocturnal Enuresis DSM V: Repeated involuntary bedwetting while
sleeping 2x/wk for 3 consecutive mos or cause significant
distress/impairment in child Toilet training complete by 4-5 y/o
for most children Occurs proportionally throughout diff sleep
stages Not associated w/ sleep disruption or arousal Two categories
Primary enuresis o No h/o consistent dryness through night > 1-2
wks o Strong +FHx o M > F o Neurodev delay o Probable delayed
bladder control maturation, bladder irritation, primary detrusor
muscle contraction Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 28
Nocturnal Enuresis Secondary enuresis o Wetting episodes occur
after sustained period (6-12 mos) of complete dryness o Majority of
causes medical or psychological o Potential medical causes:
a.Constipation b.DMI c.UTIs d.Seizures e.Hyperthyroidism
f.Medication side effects (antipsychotics) o Potential
psychological causes a.Death in the family b.Abuse/trauma c.Severe
bullying Sleep apnea proposed to be possible cause of both primary
and secondary nocturnal enuresis; studies show adenotonsillectomy
significantly or relieves enuretic episodes Moturi, Sricharan,
Avis, Kristin. Assessment and treatment of common pediatric sleep
disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C.
Carolyn. Sleep disorders and sleep problems in childhood. Am Fam
Physician. 2001 Jan; 63(2): 277-285
Slide 29
Nocturnal Enuresis Extensive medical eval beyond PE and UA not
necessary unless H&P c/w underlying medical d/o Tx Behavioral
modification first line tx: o Limit fluid intake in the evening o
Bedwetting alarm o Bladder stretching exercises o Positive
reinforcement through awards o Responsibility training o Visual
sequencing Pharmacological agents: o DDAVP o Oxybutynin o TCAs if
refractory Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 30
Circadian Rhythm Disorders Delayed sleep phase syndrome Sleep
schedule lags behind environmentally expected sleep schedule May be
2/2 genetics or habit Teens > children Tx: Systematc sleep
deprivation Motivational phase delay: When child has difficulties
falling asleep and waking up 2/2 distress r/t daytime event (most
commonly school); not due to physiological dyssynchrony of
circadian rhythm, must target underlying issue causing distress
Phase advance Sleep schedule is earlier than environmentally
expected sleep schedule Less common than sleep delay Tx:
Progressively delay sleep time by 30-60 min at a time, shift
activities later in the day (e.g., dinner time), until schedule
adjusts Tends to be easier to achieve due to 25-hr cycle of
circadian rhythm Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 31
Circadian Rhythm Disorders Irreg sleep/wake patterns w/o
consistent phase delay or phase advance Caused by irreg schedules
and lack of consistent structure at home Tx focuses on helping
parents develop structure in the home Some children may have
shorter sleep cycles; these children generally do not have
difficulties falling asleep or waking up in the AM Moturi,
Sricharan, Avis, Kristin. Assessment and treatment of common
pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6):
24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in
childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Slide 32
Behavioral Insomnias of Childhood Sleep-onset association
disorder Child has difficulties falling asleep independently Relies
on external interventions/circumstances; examples: o Rocking o TV o
Being w/ parent o Being held o Sleeping in parents bed o Having
bottle Esp prevalent for infants who then associate falling asleep
w/ parental support; then when waking up mid sleep has difficulties
going back to sleep on his/her own Tx o Awakenings shortly before
predicted time the child will awake and progressively interval btwn
awakenings o Remove the external cues, allow child to learn to
sleep on their own Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 33
Behavioral Insomnias of Childhood Limit-setting disorder Child
repeatedly refuses to go to sleep at bedtime and parent allows them
to stay up later Allows excessive/dev inappropriate napping
Combined type = Sleep onset association disorder + limit setting
disorder Feeding-related disorder Child must be fed when awakening
from sleep in order to fall back asleep Causes further disruptions
in sleep r/t discomfort from bladder distention, diaper soiling
Poor sleep hygiene Moturi, Sricharan, Avis, Kristin. Assessment and
treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep
disorders and sleep problems in childhood. Am Fam Physician. 2001
Jan; 63(2): 277-285
Slide 34
Psychiatric Causes Depression/mood disorders sleep issues Early
morning awakenings, incr sleep latency, interruptions/arousals,
need for sleep, changes in sleep architecture Tx underlying
condition in addition to relaxation techniques, positive
reinforcement strategies, limit setting, consistent bedtime
schedules/routines Anxiety Tx underlying condition in addition to
behavioral/environmental interventions At times strict limit
setting may worsen anxieties/fears so parents must show
understanding and compassion for childs distress and set limits
more gradually in these cases Alcohol/drug abuse Moturi, Sricharan,
Avis, Kristin. Assessment and treatment of common pediatric sleep
disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C.
Carolyn. Sleep disorders and sleep problems in childhood. Am Fam
Physician. 2001 Jan; 63(2): 277-285
Slide 35
Psychiatric Causes PTSD Associated w/ specific parasomnias
(e.g., nightmares, night terrors, enuresis) Type 1: Acute specific
trauma resulting in hyperautonomic arousal and insomnia Type 2:
Chronic trauma associated w/ hypersomnia Tx for nightmares should
be oriented more behaviorally (e.g., using dream scripting and
trauma-focused CBT) vs meds such as prazosin given limited studies
ADHD Sleep issues hypothesized to be r/t combo of hypoarousal
during day + compensatory hyperactivity to combat daytime
hypoarousal and then inability to calm down at bedtime to fall
asleep Other factors include disruptions in baseline circadian
rhythm, sensory integration difficulties, stimulant rebound
effects, comorbid psychiatric d/o (e.g., anxiety) If behavioral
interventions ineffective/suboptimal, trial melatonin/alpha-agonist
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of
common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun;
7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep
problems in childhood. Am Fam Physician. 2001 Jan; 63(2):
277-285
Slide 36
Psychiatric Causes 5 factors seen in children w/ sleep issues
> than those w/o Family member who has experienced an
accident/illness Unaccustomed absence of mother Mother w/ depressed
mood Co-sleeping Maternal ambivalence towards child Moturi,
Sricharan, Avis, Kristin. Assessment and treatment of common
pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6):
24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in
childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Slide 37
Medical Causes Colic Prolonged episodes of inconsolable crying,
fussiness, and hypertonia (e.g., fist clenching, writhing/twisting
movements, flapping, grimacing facial expressions) Usually dev by
2-3 wks old, resolves by 4 mos Hypotheses on etiology o CNS
immaturity o Adaptive purpose of exercising infant lungs o Pain r/t
gas o Cows milk allergy o Insufficient progesterone levels Studies
showing potential sleep disturbance (e.g., arousals and shorter
duration of sleep), difficult temperament, sensitivities to s in
sleep sched in children who have outgrown colic o Possbily r/t
parental overresponsiveness to childs needs during colic o Target
by educating parents on importance of strict sleep hygiene Moturi,
Sricharan, Avis, Kristin. Assessment and treatment of common
pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun; 7(6):
24-37. Thiedke, C. Carolyn. Sleep disorders and sleep problems in
childhood. Am Fam Physician. 2001 Jan; 63(2): 277-285
Slide 38
Medical Causes Medication side effects Sedative/hypnotics:
Associated w/ sleepwalking episdes, in particular non-benzos (e.g.,
zolpidemn, eszopiclone) Sedative/hypnotics and antihistamines may
cause residual daytime sedation Antibiotics Beta-blockers: Suppress
nighttime melatonin secretion Steroids: Cause imbalance in adrenal
glands SSRIs: Suppress REM sleep; some may also incr sleep latency
and/or frequency of awakenings/arousals Moturi, Sricharan, Avis,
Kristin. Assessment and treatment of common pediatric sleep
disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C.
Carolyn. Sleep disorders and sleep problems in childhood. Am Fam
Physician. 2001 Jan; 63(2): 277-285
Slide 39
Sleep Hygiene Integral part of tx for any sleep d/o Some
differences depending on age Infants: Fragmented and irreg sleep
pattern c/w nl dev for newborns (up to 3-6 mos old) so parents
should limit interference w/ sleep unless needed (e.g., getting on
a plane) As infant begins to consolidate sleep at night and
responding more to external cues for sleep, parents should
incorporate additional cues (e.g., waking them up earlier from
daytime naps, minimizing disruptions at night while changing
diapers by using low light) Begin bedtime routine to help infant
experience calm before sleep and ensure consistent routine in same
order on nightly basis o Bath, PJs o Reading/humming o Changing
diapers Moturi, Sricharan, Avis, Kristin. Assessment and treatment
of common pediatric sleep disorders. Psychiatry (Edgmont). 2010
Jun; 7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep
problems in childhood. Am Fam Physician. 2001 Jan; 63(2):
277-285
Slide 40
Sleep Hygiene Assist infant in learning to independently fall
asleep in their own bed and remove parental presence as much as
possible o Study by Anders and Keener showed 50% infants at 2 mos
old able to fall asleep after arousal on their own o Allow infant
to attempt to fall asleep on their own even if crying upon arousal
If prolonged crying, parents may come to child and make eye contact
to show support but no other interventions, and progressively
increase interval of parental presence w/ subsequent arousals By 6
mos need for nighttime feeding no longer present Start weaning
nighttime feeding over 1-2 wks to avoid feeding-related d/o Ensure
comfortable environment for sleep o Warm blankets o Supine sleep
position o Humidifier o Breathe Right strips for nasal congestion
Moturi, Sricharan, Avis, Kristin. Assessment and treatment of
common pediatric sleep disorders. Psychiatry (Edgmont). 2010 Jun;
7(6): 24-37. Thiedke, C. Carolyn. Sleep disorders and sleep
problems in childhood. Am Fam Physician. 2001 Jan; 63(2):
277-285
Slide 41
Sleep Hygiene Older children/adolescents Parents must reinforce
consistent sleep sched, even on wknds Bedroom should be reserved
for bedtime ritual and sleeping only; no TVs, games, toys,
computers, tablets, phones, etc. Child should fall asleep in their
own bed and alone Avoid excessive physical activity near bedtime,
though reg exercise earlier in the day may promote sleep No daytime
naps Avoid caffeine or other stimulating substances Avoid heaving
eating or excessive drinking prior to bedtime Avoid lying in bed
unless sleepy Provide cool, dark, quiet room Must distinguish
resistance to sleep from legitimate anxieties (e.g., school) b/c
strict limit setting may exacerbate fears/worries; if this is the
case must target underlying issue Moturi, Sricharan, Avis, Kristin.
Assessment and treatment of common pediatric sleep disorders.
Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37. Thiedke, C. Carolyn.
Sleep disorders and sleep problems in childhood. Am Fam Physician.
2001 Jan; 63(2): 277-285
Slide 42
General Pyschopharmacology First-line tx is always
behavioral/environmental/sleep hygiene!!!! Moturi, Sricharan, Avis,
Kristin. Assessment and treatment of common pediatric sleep
disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Slide 43
General Psychopharmacology Moturi, Sricharan, Avis, Kristin.
Assessment and treatment of common pediatric sleep disorders.
Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Slide 44
General Psychopharmacology Moturi, Sricharan, Avis, Kristin.
Assessment and treatment of common pediatric sleep disorders.
Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Slide 45
General Psychopharmacology Moturi, Sricharan, Avis, Kristin.
Assessment and treatment of common pediatric sleep disorders.
Psychiatry (Edgmont). 2010 Jun; 7(6): 24-37.
Slide 46
Evaluation for Sleep Disorders Etiology of pediatric sleep d/o
usually multifactorial Detailed hx most important Record sleep
diary for 2 wks (e.g.,
http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf) Questionnaires
Childrens Sleep Habits Questionnaire (CSHQ) o Vaildated for 4-12
y/o o 33 items (41 points cut off) o
http://www.education.uci.edu/childcare/pdf/questionnaire_interview/C
hildrens%20Sleep%20Habits%20Questionnaire.pdf Adolescent Sleep
Hygiene Scale o 12-18 y/o o 28 items (no specific scoring) o Dev
for evaluating healthy teens o
http://sleep.colorado.edu/sites/default/files/ASHS_website_130303.pdf
Slide 47
Evaluation for Sleep Disorders Medical work-up VS including BMI
Focused or comprehensive PE Labs (e.g., Fe levels) Polysomnography
if suspecting primary sleep d/o Evaluation of Sleep Complaints and
Pertinent Clinical Hx: Moturi, Sricharan, Avis, Kristin. Assessment
and treatment of common pediatric sleep disorders. Psychiatry
(Edgmont). 2010 Jun; 7(6): 24-37. Sleep ComplaintExploring
Pertinent History Habitual bedtimes (sleep onset/offset on wkdays
and wknds/holidays) Time taken to sleep onset; desired bedtime
Duration, frequency, and severity of complaints Difficulty falling
asleep Inappropriate nap schedules FHx Negative associations
(fears, worries) w/ distressing sensorimotor sx of restless leg
syndrome, nightmares Difficulty sleeping through the night
(nighttime awakenings, early morning awakening); activities during
the awakenings Difficulty staying asleep (and/or multiple nocturnal
awakenings) early morning awakenings Screen for mood and anxiety sx
Screen for primary sleep disorders (sleep apnea) FHx Use of
alerting substances at bedtime
Slide 48
Evaluation for Sleep Disorders Moturi, Sricharan, Avis,
Kristin. Assessment and treatment of common pediatric sleep
disorders. Psychiatry (Edgmont). 2010 Jun; 7(6): 24-3 Sleep
ComplaintExploring Pertinent History Total duration of nocturnal
sleep Quality of morning awakenings Difficulty to stay awake in the
classroom, while driving, watching TV, eating meals Persistent use
of stimulants (e.g., nicotine, caffeine) to stay awake Excessive
daytime sleepiness Exploring other potential sx associated w/
disorders of excessive sleepiness (e.g., cataplexy, sleep
paralysis, sleep attacks, hallucinations) Daytime consequences of
sleepiness (e.g., poor academic performance, learning difficulties,
impaired concentration, disruptive behaviors, mood sx) FHx
Medication use (long-acting psychotropic meds w/ hangover effects)
Substance use (alcohol and other illicit drugs, OTC meds)
Occupation (odd hrs at employment, shift-work schedules) Social
environment (co-sleeping/sharing bedroom, sleep patterns of parents
and other children, pets in bedroom) Poor sleep routine and sleep
hygiene due to environment and psychosocial variables Housing
(light, noise, temp) Activities at bedtime (computer/telephone, HW
completion, TV viewing) Substance use (alcohol and other illicit
drugs, caffeine intake, nicotine use, OTC meds) Parental
involvement (limit setting, adult supervision)
Slide 49
Ramifications of Sleep Deprivation Neurocognitive Deficits in
attention, memory, learning Hyperactivity/impulsivity (more common
in younger children) Deficits in executive functioning Daytime
sedation Psychological Depression/mood lability Irritability
Oppositionality Anxiety Fatigue/weakness OBrien, Louise M. The
neurocognitive effects of sleep disruption in children and
adolescents. Child and Adolescent Clinics of North America. 2009
Oct; 18(4): 813-823