Sleep Disorders in Children
and Adolescents
Deepti Shenoi MD
Objectives
 To gain an understanding of
normal basic sleep physiology
and pathology in children and
adolescents
 To learn developmentally
appropriate behavioral
techniques for improving sleep
 To obtain an understanding of
options in pharmacotherapy for
pediatric insomnia
 I would also like you to think of
iatrogenic causes for sleep
difficulties. Or how we can
make things worse.
Stages of Sleep
General Sleep Stages
Typical sleep need for children and
adolescents by developmental stage
Age group
Years
Total sleep need
Infants
Toddlers
Preschoolers
School-aged
Adolescents
3 to 12 months
1 to 3 years
3 to 5 years
6 to 12 years
12 to 18 years
14 to 15 hours
12 to 14 hours
11 to 13 hours
10 to 11 hours
8.5 to 9.5 hours
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents.
Psychiatr Clin North Am 2006; 29(4): 1059-76
Sleep Time During Development
Thiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84
Newborns
(0-3 months)
• Sleep 10-18 hours per day
• Many short sleep periods, with no
differentiation between day and night.
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Tips for newborns and
infants (up to 6mo)
• Nighttime awakenings for changing and feeding
should be quick and quiet
• Place baby in the crib before falling asleep (when
drowsy)
• Avoid feeding the baby to sleep
• Simple bedtime routine—soothing activities in the
same order every night
• GOAL: Babies to fall asleep by themselves and learn
to soothe themselves and go back to sleep if they
wake up in the middle of the night
Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals
Acad of Medicine. 2008; 37:722-28.
Toddlers
(12 mo-3 yrs) and
Preschoolers (3-5 yrs)
• Maintain a daily sleep schedule with regular naptimes
and bedtime
• Establish a consistent bedtime routine.
• Bedroom should be quiet, comfortable, and dark
• Have the child fall asleep independently.
• Set limits that are consistent and enforced.
• Encourage use of a security object, such as a blanket
or stuffed animal.
Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals
Acad of Medicine. 2008; 37:722-28.
School-Aged
Children(6-12 yrs)
•
•
•
•
•
Same bedtime and wake-up on weekdays and weekends
A 20- to 30-minute bedtime routine that is the same every night.
No caffeine
No TV in the bedroom
The child should spend time outside every day and get daily
exercise
Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals
Acad of Medicine. 2008; 37:722-28.
Adolescents
(12-18 years)
• Need 9-9.25 hours of sleep per night but studies
show that most get 7 hours/night
• Onset of puberty hormonal changes and shift in
melatonin  2 hour shift in circadian rhythm phase
(later sleep onset and morning wake time)
• Some experience a physiological need for a short
sleep period in early afternoon
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4):
1059-76
What to ask in a sleep
evaluation?-- Sleep History
Bedtime: Evening activities, bedtime routines
Night-time: Latency to sleep onset, behaviors
during the night, # and duration of
awakenings
Daytime: Daytime sleepiness, naps, caffeine
intake, psychological, social and family
functioning
What to ask in a sleep
evaluation?-- Sleep Hygiene
• Consistent and appropriate sleep-wake
schedule
• Similar schedule on weekdays and
weekends
• Consistent bedtime routine that involves
same 3-4 activities every night
• No technology in the bedroom
BEARS screen (for kids 218y.o.)
•
•
•
•
Bedtime problems
Excessive daytime sleepiness
Awakenings during the night
Regularity of evening sleep time and
morning awakenings
• Sleep related breathing problems or
snoring
Common Disorders
•
•
•
•
•
•
Behavioral Insomnia of Childhood
Insufficient or Inadequate sleep
Delayed Sleep Phase Syndrome
Sleep Disordered Breathing
Disorders of Arousal
Movement disorders
Behavioral Insomnia
of Childhood
• Manifests most commonly as bedtime
resistance and/or frequent night
wakings and occurs in approximately
10% to 30% of infants and toddlers
• Sleep-onset Association Type
• Limit-setting type
• Combined Type
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Insufficient or Inadequate
Sleep
• Sleep deprivation can have a cumulative
effect  being late or missing school, falling
asleep during school, fatigue, illness, and
irritability
• Poll reports that 28% of high school students
report falling asleep in school at least once a
week
• Insufficient sleep can be fatal for adolescents
who fall asleep while driving.
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Insufficient or Inadequate
Sleep
• Signs that children or adolescents are not
getting enough sleep include:
• (1) needing to be awakened for school or day
care in the morning,
• (2) sleeping 2 hours more on weekends and
vacations compared with weekdays,
• (3) falling asleep in school or at other
inappropriate times,
• (4) behavior and mood differing on days after
getting more sleep
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Delayed Sleep Phase
Syndrome
• The person’s sleep-wake cycle is
delayed by 2 or more hours
• “Night Owls”
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Delayed Sleep Phase
Syndrome
Delayed Sleep Phase
Syndrome-Treatment
• Sleep hygiene
• Shifting the internal clock
– Phase Advancement: When the difference between the
actual and desired bedtime is less than 3 hours. Every
night or two, go to sleep 15 minutes earlier.
– Phase Delay: When the difference is greater than 3 hours,
delay sleep by 2-3 hours on successive nights
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Sleep-Disordered Breathing
• Can range from primary snoring to
obstructive sleep apnea syndrome (OSAS)
and is related to significant cognitive and
behavioral sequelae, including learning,
attention, concentration, hyperactivity, and
aggressive behavior
• Incidence of habitual snoring has been reported at 3% to 12% of the general pediatric
population, with OSAS seen in 1% to 3% of
children
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Narcolepsy
• Chronic neurologic disorder that involves
excessive daytime sleepiness
– cataplexy (sudden loss of muscle control in
response to strong emotional stimuli)
– hypnagogic hallucinations (vivid dreams at sleep
onset)
– sleep paralysis
– autonomic behavior in which you continue to
funtion, talk, clean…… but then have no
recollection of performing task
• .
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Narcolepsy Work up
• Polysomnography (PSG)
– Typically fall asleep rapidly with early REM
• Multiple sleep latency test (MSLT)
– Test subjects are given opportunities to sleep
every two hours during the normal awake time and
monitored to see how quickly they fall asleep and
reach various stages of the sleep cycle.
– May provide clear evidence of narcolepsy, but in
children, results are not always conclusive, and
repeat studies may be necessary for a final
diagnosis
Narcolepsy
• Individualized based upon symptoms.
• Treatment includes education, sleep hygiene, and
pharmacologic interventions
• Daytime Sleepiness:
– Sleep scheduling is essential, with a consistent bedtime,
wake time, and good sleep hygiene
– Children and adolescents who have narcolepsy may benefit
from a scheduled daily nap in the early afternoon.
– Stimulants are commonly used to treat daytime sedation
including provigil
• Atomoxetine has also been used.
• Cataplexy: Cholinergic pathway mediated
– medications with anticholinergic properties are used to treat
cataplexy, including clomipramine and imipramine
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Disorders of Arousal
• Referred as partial arousal parasomnias and
include: confusional arousals, sleep terrors,
sleep talking, and sleepwalking
• During an event, although children are
asleep, they may appear awake (eyes open),
talk, or seem frightened or confused (eg,
screaming in the case of sleep terrors)
• Typical parasomnias resolve spontaneously
with children rapidly returning to a deep sleep
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Disorders of Arousal
• Common feature: retrograde amnesia
• Strong genetic component to partial arousal
parasomnias, with a family history typically
reported
• Partial arousals are more likely to be
triggered by insufficient sleep, a disruption to
the sleep environment or sleep schedule,
stress, illness, or certain medications (eg,
chloral hydrate or lithium)
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Sleep Terrors vs Nightmares
Comp ar ison o f Sleep Te rr ors and N igh tma re s
F ac tor
Sl ee p Te rror s
N ightm ares
Age
Gende r
Occu rr ence i n Sl eep Cyc le
A rousab le?
M em ory fo r E ven t
E xace rba ted by St re ss
3 to 8 ye ar s
M al e p redo mi nance
NR E M
No
None
Ye s
Any age
E ithe r
REM
Ye s
Ye s
Ye s
R E M = rap id eye m ove m en t, NR E M = non -ra pid eye m ove m en t
Thiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84
Disorders of Arousal
• Treatment: providing families with information about
creating a safe sleep environment (eg, preventing
windows from opening or putting alarms or bells on
doors to alert if a sleep walker is up), education about
the events, and how to interact with children
appropriately during an event
• As some children may develop a fear of going to
sleep and a prolonged sleep onset in turn increases
the likelihood of an event occurring, parents should
be encouraged to not discuss these events in the
morning with the child or other children in the home
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Restless Leg Syndrome and Periodic
Limb Movement Disorder
• RLS manifests as uncomfortable sensations in the
legs that worsen in the evening and with long periods
of inactivity (eg, long car ride or movie)
• Sensations often are described as creepy-crawly or
tingling feelings, most commonly in the legs, which
can be alleviated temporarily with movement.
• PLMS are brief repetitive movements or jerks, lasting
on average 2 seconds and occurring every 5 to 90
seconds during stages 1 and 2 of sleep
• PLMD occurs when PLMS are associated with
frequent, but brief, arousals from sleep
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Restless Leg Syndrome and Periodic
Limb Movement Disorder
• Pharmacologic treatment for RLS and PLMD in
children and adolescents may include
benzodiazepine and dopaminergic medication
• Some children who have RLS or PLMD have low
iron/ferritin and many of these children and
adolescents respond favorably to iron therapy
• At this time, there are no FDA-approved
medications available to treat RLS and PLMD in
children.
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Sleep-Related Rhythmic
Movement Disorders
• Include head banging and body rocking and
are considered to be a sleep-wake transition
disorder, occurring as children attempt to fall
asleep at bedtime, naptime, or after a normal
nighttime arousal
• common in infants (60% of 9 month olds), the
behaviors tend to resolve spontaneously with
development (only 8% of 4 year olds
demonstrate these behaviors), but they can
continue into adolescence and adulthood
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Sleep-Related Rhythmic
Movement Disorders
• Events typically last 5 to 15 minutes, but
prolonged events can go for several hours
• Important to ensure safety
• In cases that result in injury, or when the behavior
may be highly disruptive to others for a short
duration (eg, family vacation or overnight
sleepover), benzodiazepines may be indicated.
• Evaluation is recommended for severe cases or
cases persisting past age 3
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
“Optimizing” Treatment of
Sleep Problems
• Identification of the suspected causes of
disrupted sleep
• Involvement of the family by explaining the
disorder and teaching them developmentally
appropriate principles of sleep-wake
organization
• Use of behavioral treatments such as
contracts to target specific behaviors that
need to be changed
Anders, TF, Eiben LA. Pediatric Sleep Disorders: A Review of the Past 10 Years. J Am Acad Child Adolesc
Psychiatry. 1997;36:9-20.
Pharmocotherapy of Pediatric
Insomnia: General Guidelines
• Reminder: In almost all cases, medication is neither
the first treatment of choice, nor the sole treatment
for children
• Medication should be used in combination with nonpharmacological strategies as these have been
shown to have long-lasting effects
• Treatment selection - best match between clinical
circumstances and individual properties of
medications
• Medications should be closely monitored for
emerging side effects
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: General Guidelines
• Presence of both medically and behaviorallybased sleep disorders must be assessed
• Medications should be used in caution in
situations where there may be potential drugdrug interactions
• Non-prescription and over-the-counter
medication use should be assessed
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia
• Antihistamines: Prescription (hydroxyzine)
and OTC (diphenhydramine)
– Bind to H1 receptors in the CNS
– Rapidly absorbed
– Side effects: daytime drowsiness,
cholinergic effects, paradoxical excitation
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: Melatonin
• Melatonin: hormone secreted by pineal gland
in response to decreased light, mediated
through suprachiasmatic nucleus; mechanism
of commercially available melatonin is to
supplement endogenous pineal hormone
• Clinical uses for melatonin are principally in
normal children with acute or chronic
circadian rhythm disturbances and in children
with special needs (blindness, Rett
syndrome)
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: Melatonin
• Plasma levels peak within 1 hour of
administration
• Generally safe but potential side effects
include suppression of hypothalamic-gonadal
axis (i.e. could trigger precocious puberty
upon discontinuation
• Not regulated by FDA
• Reported doses: 1 mg in infants, 2.5-3 mg in
older children, 5 mg in adolescents
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: Herbal Preparations
• Valerian Root, St. John’s Wort, and Humulus
lupulus - some evidence of efficacy in adult
and/or pediatric studies
• Lemon balm, chamomile, and passion flower
- limited to no evidence
• Kava kava, Tryptophan - assoc. with
significant safety concerns (e.g.
hepatotoxicity and eosinophilic myalgia
syndrome, respectively)
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: Benzodiazepines
• Hypnotic effect mediated at GABA Type A
receptors in the brain
• They shorten sleep- onset latency, increase
total sleep time, and improve non-REM sleep
maintenance; most disrupt slow-wave sleep.
• Use of longer- acting BZDs may lead to
morning hangover, daytime sleepiness, and
compromised daytime functioning.
Anterograde amnesia and disinhibition may
also occur.
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: Benzodiazepines
• Risk for habituation or addiction with these
medications, as well as withdrawal
phenomena
• Used for short-term or transient insomnia or
in clinical situations in which their other
properties (e.g., anxiolytic) are advantageous
• BZDs are occasionally used to treat
intractable partial arousal parasomnias (e.g.,
sleep terrors) in children because of their
slow-wave sleep suppressant effects.
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: Melatonin Receptor Agonist
• Ramelteon (Rozerem): a synthetic melatonin
receptor agonist, acting selectively at the MT1
and MT2 receptors
• Approved for use in sleep initiation insomnia,
and shows moderate efficacy in reducing
sleep-onset latency (in adults)
• Two single pediatric case reports have
reported efficacy in autistic children
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: -Agonist
• Clonidine: central 2-agonist that decreases
adrenergic tone
• one of the most widely used medications for
insomnia in pediatric and child psychiatry
practice, particularly in children with sleeponset delay and ADHD
• safety and efficacy in children with ADHD and
sleep problems is limited to descriptive
studies
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: -Agonist
• Clonidine is rapidly absorbed with onset of action
within 1 hour and peak effects in 2-4 hours
• Tolerance often develops necessitating increase in
dose
• Discontinuation may lead to rebound in REM and
slow-wave sleep
• Possible side effects include: hypotension and
bradycardia, anticholinergic effects, irritability, and
dysphoria; rebound hypertension may occur on
abrupt discontinuation
• Avoid in patients with diabetes and Raynaud
syndrome
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: Atypical Antidepressants
• Trazodone: one of the most sedating
antidepressants because it both inhibits
binding of serotonin and blocks histamine
receptors
• Suppressant effects on REM and may
increase slow-wave sleep
• “Morning hangover” is a common side effect
• Associated with reports of priapism in the 50to 150-mg dose range
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia: Atypical Antidepressants
• Mirtazepine (Remeron) 2-adrenergic 5hydroxytryptamine receptor agonist with a
high degree of sedation
• Shown to decrease sleep- onset latency,
increase sleep duration, and reduce wake
after sleep onset in adults with and w/o major
depression with little effect on REM
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Pharmocotherapy of Pediatric
Insomnia
• SSRI’s: may cause sleep-onset delay and sleep
disruption (Fluoxetine) and sedation (Fluvoxamine,
Paroxetine, Citalopram)
• SSRI’s suppress REM sleep and often prolong REM
onset while increasing the number of REMs
• Most increase sleep-onset latency and decrease
sleep efficiency (time asleep/time in bed)
• Selective serotonin reuptake inhibitors frequently are
associated with motor restlessness and may
exacerbate preexisting RLS and periodic limb
movements
Pharmocotherapy of Pediatric
Insomnia
• Other classes which have reportedly been used include mood
stabilizers/anticonvulsants (e.g., carbamazepine, valproic acid,
topiramate, gabapentin), atypical antipsychotics (e.g.
risperidone, olanzapine, quetiapine), and chloral hydrate.
• These meds should be used with caution as there are no or
limited date on safety and tolerability.
• Sedating effects may interfere with daytime functioning and
learning
• Atypical antipsychotics may cause weight gain and worsen
Obstructive Sleep Apnea; also tend to sup- press REM sleep
and increase motor restlessness during sleep
• Chloral Hydrate and Barbiturates are not indication for use in
children due to significant side effects (inc. hepatotoxcity)
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
The End