Difficulties in going to bed or falling asleep and staying asleep as well as frequent nighttime awakening are the most frequent features of childhood insomnia. The child may, for example,
only want to fall asleep with the caregiver rather than on their own. The child may resist bedtime. As Baroni and Anders (2018)
note, these have had various terminologies and classifications in the past.
TABLE 21.4 Main Categories of Sleep Disorders in DSM-5 and ICSD-3
Persistent difficulties sleeping
Adequate opportunity for sleep
Daytime impairment (e.g., chronic insomnia)
Sleep-related breathing disorders
Hypersomnolence disorder and narcolepsy
Excessive daytime sleepiness, in spite of adequate sleep (e.g., narcolepsy, hypersomnolence disorder)
Circadian rhythm disorders
Sleep-related movement disorders
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; ICSD-3, International Classification of Sleep Disorders, Third Edition.
Reprinted with permission from Baroni, A., & Anders, T. F. (2018). Sleep disorders. In A. Martin, M. H. Bloch, & F. R. Volkmar (Eds.), Lewis’s child and adolescent psychiatry: A comprehensive textbook (5th ed., p. 585). Wolters Kluwer.
Daytime difficulties can include a range of problems including irritability, behavioral difficulties, overactivity, and chronic tiredness (Reid et al., 2009
). Although this can start at any age, it is not typically diagnosed until after children are 6 months or so of age when more typical sleep patterns are established (Reid et al., 2009
). Rates of 20%-30% are reported in community samples (Honaker & Meltzer, 2014
). For adolescents, this number is somewhat reduced. Other factors in the child, for example, developmental difficulties like autism spectrum disorder (ASD), can substantially increase sleep problems (Won et al., 2019
Although mechanisms of pathogenesis are unclear, most research suggest that a combination of factors including child, parent, family, and other variables is important. Temperamental difficulties are also a risk factor. Treatments have to do with helping parents of younger children establish better sleep patterns. Behavioral methods may help significantly (Reid et al., 2009
). Most of this literature has focused on young children and there has been less work on older children and adolescents as well as those with special needs (Buckley et al., 2020
; Durand, 2014
; Meltzer & Mindell, 2014
). For younger children, behavioral treatments are very effective. These include unmodified or graduated extinction (total or phased-out parental attention after lights out); this can be difficult for parents to do.
Helping parents understand good bedtime practices like using the bed only for sleep and the use of calming bedtime routines is important. Parents should be reassured that behavioral interventions have not been associated with negative outcomes (Baroni & Anders, 2018
; Meltzer & Mindell, 2014
; Taylor & Roane, 2010
). Having phones, TVs, computers, etc., outside the bedroom is also helpful.
The addition of medications should be considered only after behavioral approaches have been attempted. There are no Food and Drug Administration (FDA)-approved medications for pediatric insomnia. Medications may be used at times of stress or illness (see Baroni & Anders, 2018
). Many of the agents used have potential for “paradoxical” reactions (i.e.,
making the child more agitated). Melatonin is frequently used given its efficacy and relatively few side effects. Typical doses range from 1 to 3 mg (see Baroni & Anders, 2018
). Other medications like clonidine or guanfacine are sometimes used particularly for children who have attention-deficit hyperactivity disorder (ADHD) (see Chapter 10
), in particular, given how frequently these children have insomnia (Owens & Moturi, 2009
). There are more risks with these agents. Although some of the antihistamines such as diphenhydramine are frequently used by pediatricians, there are limited data to support their efficacy, and these agents also have some important side effects.
Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) is a well-known but frequently unrecognized condition and should be considered in any child where snoring is reported. Overall, it has a prevalence of 1%-5% but becomes much more common in children who are obese or who have medical problems and habitual snoring (Marcus et al., 2012
). Parents may not report snoring unless they are specifically asked. Even in the absence of OSA, snoring may have some of its features and consequences (Brockmann et al., 2012
In addition to chronic snoring, the clinical features of OSA include labored breathing as well as gasping or choking during sleep. Apnea (breathing pauses) may be present and observed by parents. OSA can be associated with nocturnal enuresis (see Chapter 19
). Unlike adults, excessive sleepiness in the daytime is less frequent in children. However, children are at risk for a number of other behavioral problems (Marcus et al., 2012
; Mindell & Owens, 2015
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