Overview and General Issues
Sleep disorders in children and adolescents differ from those occurring in adults. Some sleep disorders are specific to childhood while others occur across the developmental spectrum but may have different presentations and etiologies in children and adolescents. In pediatric sleep medicine, the parents are often the ones to complain, not the child, making parental perception an important part of the picture. Often the complaint is more consistent with a problem rather than a true disorder. What is defined as a sleep problem will vary from family to family and culture to culture. Therefore, pediatric sleep disturbances need to be considered within the specific psychosocial context of the child being assessed. In fact, pediatric insomnia has recently been defined with family considerations in mind. A consensus paper on the subject in 2006 by Mindell and colleagues defined pediatric insomnia as follows: “Repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite age-appropriate time and opportunity for sleep and results in daytime functional impairment for the child and/or family.”
Sleep problems have a bidirectional relationship with many child and adolescent psychiatric disorders, particularly ADHD, anxiety disorders, and depression. Insomnia is a criterion symptom for depression and many of the anxiety disorders experienced in childhood. Conversely, chronic insomnia and sleep deprivation place children at increased risk to suffer with these conditions. Although insomnia is not a criterion symptom of ADHD, a large percentage of children with ADHD have sleep problems including initial insomnia, RLS, and OSA. Clinical and experimental research shows that sleep deprivation can result in ADHD-type symptoms and behaviors.
Sleep disorders are classified into four major categories in the Diagnostic and Statistical Manual,
Fourth Edition (DSM-IV
) : Primary Sleep Disorders; Sleep Disorder Due to a Medical Condition; Sleep Disorder Due to Another Mental Disorder; and Substance-Induced Sleep Disorder. These DSM-IV
categories appropriately describe sleep disorders in adults, but are inadequate for categorizing sleep disorders in children. Instead, it is easier to conceptualize pediatric sleep problems in three broad categories: sleeplessness; excessive daytime sleepiness; and disturbed behavior during sleep. Some of the more common pediatric sleep disorders are summarized in Table 20-2
and discussed below.
TABLE 20-2 Common Pediatric Sleep Disorders
Excessive daytime sleepiness
3-to 8-year olds and adolescents
1-2% of children
Habitual snoring, noisy breathing, pauses in breathing, nocturnal sweating, mouth breathing
Full PSG is gold standard; limited channel cardiopulmonary study; home oximetry
Excessive daytime sleepiness
5-10% of adolescents
Delayed sleep onset (usually after midnight) with difficulty awakening in a.m.; sleep very late on weekends; normal sleep quality
Detailed sleep history; sleep diaries; actigraphy
Chronotherapy; behavioral interventions; light therapy; motivational counseling; potentially melatonin
Excessive daytime sleepiness
Cataplexy, hypnogogic hallucinations, sleep paralysis, sleep attacks
PSG and MSLT
Modafinil or stimulants for EDS; SSRI’s or TCA’s for cataplexy; scheduled naps
Disturbed sleep behaviors
Toddlers and school-aged children
Occur in first third of the night; autonomic arousal with tachycardia, tachypnea, sweating; inconsolable screaming; amnesia for event
Detailed sleep history with attention to timing of episodes; family history of parasomia; video taping
Reassurance of parents; avoid sleep deprivation; benzodiazepines for severe cases
Disturbed sleep behaviors
15-40% have one episode; 3-4% have weekly/monthly episodes
Usually occur 1-2 hours after sleep onset; walks for a few minutes up to one-half hour; confusion; incoherence; difficult to awaken; amnesia for event
Detailed sleep history; video taping; family history
Reassurance of parents; safety measures (lock outside doors and windows; alarm on bedroom door); benzodiazepines for severe cases
Sleep-onset association disorder
Infants and toddlers
25-50% of 6-to 12-month-olds; 15-20% of 1-to 3-year-olds
Frequent signaling of parents after nightwakings; initiation of sleep requires parental involvement; inappropriate sleep associations (falls asleep in parent’s arms)
Detailed sleep history with attention to reinforcing behaviors of parents; charting of sleep associations; sleep diaries; video taping
Behavioral interventions (put to bed awake but sleepy); parental guidance regarding bedtime routines and sleep scheduling, education on graduated extinction.
Restless legs syndrome
School age and adolescents
Uncomfortable sensation in legs; urge to move legas at time of rest, relieved with movement
Clinical history, family history, at times PSG appropriate to evaluate for overlapping periodic limb movement disorder
Avoidance of caffeine Iron replacement if low Dopamine agonists
OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure; DSPS, delayed sleep phase syndrome; PSG, polysomnogram; MSLT, multiple sleep latency test; EDS, excessive daytime sleepiness; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.
Sleeplessness is a broad category which can be broken down into three basic types: problems settling and initiating sleep; frequent awakenings during the night; and awakening too early in the morning. These particular forms can occur in isolation or combination. It is important to determine the specific type of sleeplessness as etiologies will differ and, subsequently, so will treatment. In addition, potential causes of sleeplessness change according to the age of the child or adolescent.
Infants and toddlers often experience problems with settling and frequent awakenings. Potential medical causes (such as colic, middle ear disease or gastroesophageal reflux) need to be considered, although are rarely the problem for persistent nightly awakenings. In addition, it is quite uncommon for pain to be the cause of frequent awakenings in children. If pain were the cause of the awakenings, the child would not be able to return to sleep after being held or fed. Difficult temperaments can also manifest as sleeplessness. Behavioral issues are often the cause, specifically inappropriate sleep associations, clinically described as “sleep-onset association disorder.” Sleep-onset is a learned behavior and, therefore, is assisted or inhibited by certain environmental stimuli. If a child learns to fall asleep at bedtime in the mother’s arms, it will be difficult for the child to initiate sleep independently during a nighttime awakening. These children will signal care providers to aid in the transition back to sleep.
Family expectations can play a part in “sleeplessness” in toddlers. Often, parents expect a child to sleep more than is biologically necessary. When total sleep time is added up, including daytime naps, expected sleep is excessive leading to a decrease in homeostatic sleep drive. A sleep diary can help determine this cause.
According to the 2007 International Classification of Sleep Disorders, behavioral insomnia of childhood is divided into sleep-onset association type or limit-setting type. Inadequate limit-setting and sleep routines are often the culprits especially in overwhelmed or chaotic families. Sleep-onset association insomnia is characterized by an extended process of falling asleep that requires special conditions which are highly problematic or demanding for caregivers. In the absence of the associated conditions, sleep onset is significantly delayed or sleep is otherwise disrupted. Nighttime awakenings required caregiver intervention to return to sleep. In limit-setting insomnia, the child has difficulty initiating or maintaining sleep, refuses to go to bed at an appropriate time or refuses to return to bed after a nighttime awakening. The caregiver demonstrates insufficient and/or inappropriate limit setting to establish appropriate sleeping behavior in the child.
School-aged children (5 to 12 years) have the best sleep efficiency of any age group, so sleeplessness is concerning when it happens. Psychiatric disorders such as anxiety and depression become more common at these ages as well as circadian rhythm disturbances. Children can develop into either “larks” or “owls” based on their tendency to advance or delay their sleep schedules. The intrinsic, biologically driven sleep/wake rhythms may be in conflict with parental and societal expectations leading to a perception of sleeplessness, particularly problems falling asleep or arising either too late or early in the morning. If these children are allowed to sleep their own schedule, they sleep soundly and are rested during waking hours. Behavioral sleep disorders continue to be prevalent in this age group.
More recently, RLS has been described in children. Manifestations of RLS include uncomfortable sensations in the legs associated with urges to move the legs and motor restlessness. Patients may describe the sensation as “crazy legs, creepy-crawlies” or “growing pains.” These symptoms are experienced during times of rest and relaxation particularly in the evening and night when one is recumbent. The uncomfortable feeling is relieved when the legs are moved. RLS tends to cause sleep-onset problems as the behaviors that relieve symptoms (movement) are likely to interfere with sleep onset. In a large population-based survey, criteria for definite RLS were met by approximately 2% of 8- to 17-year-olds. RLS is thought to be an autosomal
dominant condition and, therefore, shows strong familial trends. Reduced iron stores appear to play a role in children and adults with RLS. Synthesis of iron is the rate-limiting step of dopamine synthesis and metabolism. Thus, it is compelling to consider that iron deficiency plays a role in other central nervous system dopamine-related conditions like ADHD. In this population-based study, there was approximately 35% comorbidity of self-reported ADHD and RLS. Further work has found that children with RLS and ADHD tend to have lower ferritin levels than children with ADHD alone, and tend to be more severely affected by ADHD.
Adolescents experience sleeplessness for reasons similar to those described for school-aged children. In addition, substances such as caffeine and illicit drugs can disrupt sleep. Social and academic pressures may cause worry and anxiety and, subsequently, sleep disturbance. Other psychiatric disorders to consider in teens are bipolar disorder and psychotic illnesses such as schizophrenia, both of which can cause sleeplessness. DSPS is a circadian rhythm disturbance often manifesting at puberty. Adolescents with this problem have sleep-onset insomnia and excessive daytime sleepiness during the first half of the day.
Excessive Daytime Sleepiness (EDS)
Sleepiness differs from tiredness. Tiredness is similar in nature to fatigue, lethargy, or exhaustion and typically has a medical cause such as depression or endocrine dysfunction. Sleepiness describes an actual urge to fall asleep which tiredness does not entail, although the two conditions can simultaneously exist. Daytime sleepiness in children and adolescents has long been ignored, only recently supported by systematic research. Sleepiness can range from mild to severe and can present differently depending on age. Preschoolers and school-aged children usually do not manifest the behavioral signs seen in adolescents and adults, that is, difficulty in initiating or sustaining motor activity, droopy eyelids, or head nodding. Instead, they often present paradoxically with hyperactivity, increased impulsivity and aggressiveness, as well as impaired concentration and irritability.
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