Sleep disorders in children and adolescents
Gregory Stores
Introduction
It was argued in Chapter 4.14.1 that sleep disorders medicine should be viewed as an integral part of psychiatry, whatever the age group of patients, because of the various close connections between sleep disturbance and psychological disorders seen in clinical practice. This is certainly the case regarding child and adolescent psychiatry in view of the high rates of psychiatric disorder of which sleep disturbance is often a part, and also the frequent occurrence of sleep disorders in young people with potentially serious developmental effects of a psychological and sometimes physical nature. The temptation to view children’s sleep disorders as merely transitory problems, mainly in infancy, encountered by many parents and of no lasting or serious significance, should be resisted. This may be true for some families but is frequently not the case in others.
The following account summarizes sleep disorders in childhood and adolescence. Familiarity is assumed with the earlier accounts of sleep disorders in adults (4.14.1), including the introduction to that section which covers basic aspects of sleep and other fundamental issues.
Sleep and sleep disorders in children compared to adults
In spite of the fact that much has now been discovered about the special characteristics of sleep disorders occurring at an early age, very little of this information has found its way into the training of paediatricians, child and adolescent psychiatrists, psychologists, or other professionals involved in the care of children. This must mean that many treatment and preventive possibilities are missed.
The solution does not lie simply in extending the practice of adult sleep disorders medicine to children. Children are not miniature adults and they need special approaches reflecting their many differences from older patients. These differences extend from basic features of sleep to various aspects of sleep disorders.
Sleep physiology
Profound changes take place during childhood in basic sleep physiology although many are complete by about 6-12 months of age. In general, there is a progression towards differentiation and organization of conventionally defined sleep states, shorter sleep time, less napping, less slow wave sleep (SWS), and longer sleep cycles.
Specific aspects of particular clinical importance are as follows:
Typical sleep duration (including naps) at different ages as shown in Table 9.2.9.1.
The body clock controlling (amongst other processes) the circadian sleep-wake cycle has become established by about 6 months.
Rapid eye movement (REM) sleep is prominent in early infancy, perhaps reflecting its role in brain maturation and early learning, and possibly explaining why sleep is fragile at this stage.
In comparison, by early childhood SWS is especially pronounced. This predisposes children of that age to arousal disorders (e.g. sleepwalking) which arise from SWS.
Between about 5 years and puberty, overnight sleep is especially sound and alertness is maximal during the day. Various conditions causing excessive daytime sleepiness in adults (e.g. narcolepsy) may not have this effect in children because of this increased alertness. However, overnight sleep may become extended.
In contrast, adolescence is characterized by an increase in daytime sleepiness. The amount of SWS decreases, the sleep phase is physiologically delayed and, with the onset of puberty, there is no longer the decrease in physiological sleep requirements seen progressively at earlier ages. The combination of these factors and strong influences to stay up late (especially at weekends but perhaps also during the week) for social and recreational purposes frequently causes unsatisfactory sleep-wake patterns.
Parental influences
The influence of parents is seen throughout children’s sleep disorders medicine.
Especially in the case of young children, parents’ perceptions usually determine whether there is a sleep problem. The same sleep pattern or behaviour may be a problem to one family but not another. Factors influencing parental attitudes include their expectations, family and cultural practices (e.g. regarding parents and children sleeping together), and their own emotional state. Sometimes parents can be reassured that what they think is a serious problem about their child’s sleep is, in fact, within the normal range. The view taken of the situation might be the result of parental psychiatric illness needing attention in its own right; children of mothers with an affective illness have been shown to have an increased rate and severity of sleep problems although the nature of the connection is debatable.
Conversely, parents may not seek help for their child’s sleep when they ought to do. They may be unaware of the problem, indifferent, or they may mistakenly believe that the child’s sleep problem is inevitable and untreatable. This mistaken view is sometimes expressed by parents of children with a learning disability (intellectual disability) whose sleep problems can be particularly severe yet amenable to treatment.
Parental practices are commonly the reason why a child’s sleep problem develops or is maintained. Early child-rearing practices determine sleep-wake patterns which can be delayed or disrupted by over-conscientious night-time feeding in infancy, failure to set limits on bedtime activities, or inconsistency (see later). Sleep disorders of physical origin may be complicated in these ways and exacerbated. It follows that treatment of many sleep disorders relies heavily on correcting parenting practices.
Sometimes parents are not motivated to improve their child’s sleep for reasons that may be difficult to influence. For example, a child’s presence in the parental bed may be welcome by one partner as a means of distancing himself or herself from the other at night. Families of handicapped children may lose their extra state financial allowance if their child’s sleep problems are successfully treated.
The child’s basic attitude to sleeping is also influenced by its parents. Wider cultural factors are important but, within westernized societies, the child’s attitudes to going to sleep and being separated from its parents at night are strongly influenced by their ability to settle the child without being anxious about the separation. Children depend on their parents to provide positive attitudes to sleeping and to avoid negative associations such as disputes, punishment, and rejection.
Especially in the early years, most children need their parents’ help in coping with night-time separation from them, and the potentially frightening experience of the dark or their own thoughts and fantasies. Infants need the comfort of physical contact. Toddlers are helped by bedtime routines and comforting ‘transitional objects’, and encouragement to become ‘selfsoothing’ so that they can fall asleep without their parents’ presence and attention (see later). Parents’ ability to provide such help depends on their personality and sensitivity and mental state and perhaps their cognitions about their child’s sleep based partly on their own experiences in childhood. Hopefully, older children and adolescents become increasingly independent.
Effects on parenting and the family
The effects of a child’s persistent sleep disturbance on family life, including its possible influence on parenting skills, is another important dimension.
Mothers of children with a learning disability and severe sleep problems are reported to be more irritable, concerned about their own health, and less affectionate towards their children, with less control and increased use of punishment compared with mothers of such children without sleep problems. Similarly, associations have also been suggested between sleeplessness in toddlers in the general population and family problems, including marital discord and possibly physical abuse of the child.
Family tensions are likely to increase when diagnosis of the child’s sleep disorder is delayed or inaccurate, or when effective treatment is not provided.
Some reports have suggested that successful treatment of the child’s sleep problems generally leads to improvement in the
mother’s mental state, confidence in her own parenting ability, her relationship with the child, and also the child’s behaviour. Wider aspects of family function, including effects on siblings, have received little attention.
Developmental effects of sleep disturbance
These parental and wider family issues indicate ways in which a child’s psychological and social development can be affected by persistent sleep disturbance. In addition, children can be distressed by their experience of sleep disorder phenomena. Examples include night-time fears (which may be intense) alarming hypnagogic imagery, or sleepwalking and sleep (night) terrors which can be embarrassing, especially if they occur away from home. Excessive daytime sleepiness often leads to educational problems and can produce extreme reactions such as the denial, aggression or depression described in narcolepsy, or accidents and substance abuse in adolescence.
In addition to these largely indirect ways in which a child’s sleep disorder may have psychological effects, sleep disturbance can produce direct effects on mood, behaviour, and cognitive function. The developmental consequences might become severe if not arrested at an early age.
Adolescents appear to be at particular risk of sleep loss and its possible psychological consequences, i.e. depressed mood, anxiety, behaviour problems, alcohol abuse, and even attempted suicide, as well as lower academic performance. The causal relationship between sleep loss and these problems, however, have yet to be fully established. The same is true of the outcome of attempts to correct this sleep loss by various means.
Even impairment of physical growth is associated with sleep disturbance. Failure to thrive is a recognized possible consequence of early onset obstructive sleep apnoea (OSA) and possibly other severe and persistent sleep disturbance, perhaps as a result of reduced slow wave sleep (SWS) with which the production of growth hormone is closely linked.
Other possible physical consequences of sleep disruption includes impaired immunity and endocrine disorders.
Patterns of occurrence of sleep disorders
Some sleep behaviours which are developmentally usual in children are abnormal in adults and require investigation. Examples are bedwetting and repeated napping. Certain sleep disorders are seen exclusively in children (e.g. sleeplessness caused by infantile colic). Others, such as settling problems and confusion arousals, occur primarily in children (see later).
Sleeplessness caused mainly by child-rearing practices is particularly common in early childhood. That attributable to the delayed sleep phase syndrome (see later) is considered to be particularly common in adolescence.
Many of the parasomnias (such as headbanging, sleepwalking, or sleep terrors) are more common in childhood where, generally, they represent a temporary developmental phase without pathological significance. The same behaviours in adults might be more likely to be manifestations of psychological problems requiring exploration.
Some sleep disorders thought to be confined to adulthood are now recognized in children. While much attention has been paid to OSA in adults, it is now thought that at least 2 per cent of children have this condition to some degree. Restless leg syndrome (RLS) and periodic limb movements in sleep (PLMS) are now known to occur not uncommonly in children. The RLS may explain some cases of ‘growing pains’. PLMS has been implicated as a cause of poor quality sleep resulting (as in other forms of sleep disturbance) with daytime attention deficit hyperactivity disorder (ADHD) type of symptoms. Narcolepsy starts by the age of 15 years in at least one-third of cases. Even REM sleep behaviour disorder (once thought to be confined to elderly males), or something similar, has been reported in children and adolescents.
Manifestations of sleep disorders
The clinical features of basically the same sleep disorder can be very different in children compared with older people. The overall behavioural effects of excessive sleepiness in adults are a reduction of physical and mental activity. In contrast, its effects in young children can be increased activity with irritability, tantrums, or other behavioural difficulties. Some examples of ADHD are thought to be the result of sleep disorders (OSA, PLMS, or circadian sleep-wake rhythm disorder) with improvement in the difficult behaviour following treatment of the sleep disorder.
OSA illustrates the important differences between children and adults, not only in the clinical manifestations of a particular sleep disorder but also in the underlying cause and treatment needs. Similarly the many manifestations of narcolepsy in childhood may be very far removed from the classical narcolepsy syndrome in adults, at least in its fully developed form. The same sleep disorder may also show different physiological features according to age. Diagnostic criteria (e.g. for OSA and narcolepsy) derived from polysomnographic (PSG) studies in adults do not necessarily apply in children and may well need modification.
Misinterpretation of children’s sleep disorders
Chapter 4.14.1 contains an account of the fundamental issue that, especially if clinicians are unfamiliar with the manifestations and consequences of the many sleep disorders now documented in the second edition of the International Classification of Sleep Disorders (ICSD-2), there is a serious risk that these disorders will be misconstrued as something else (or even overlooked completely). The examples given include a number of particular relevance to practice in child psychiatry and paediatrics.(1)
Treatment and prognosis
Because of the aetiological differences discussed earlier, especially parental involvement, treatment often needs to be very different in children compared to adults. Appropriate behavioural approaches usually entail alterations to parenting practices designed to be acceptable and feasible in each individual family. Other forms of treatment, including chronobiological measures (such as adjustment of sleep schedules from the delayed sleep phase syndrome in adolescence) usually require considerable parental involvement. The same is true of the general sleep
hygiene principles described in Chapter 4.14.2. Explanation and (where appropriate) reassurance for the child and parents is an essential part of any treatment and may be effective in their own right without the need for more specific measures. As in adults, medication has a limited part to play overall.
An optimistic point of view can be taken of the treatment of most children’s sleep disorders because children’s sleep is usually more amenable to change than that of adults where the factors underlying the sleep problem may well have become well established and complicated, as in many cases of chronic insomnia. However, treatment needs to be chosen carefully and implemented properly, and parents’ confidence in the recommended measures, and their willingness and ability to play their part in treatment, are an important determinant of success or failure. In some instances, it is not possible to implement a treatment programme for the child until parents themselves have been helped (e.g. by treatment for a depressive illness) or problems in the family as a whole have been resolved.
Assessment
The various means by which sleep disorders might generally be detected and assessed are described in Chapter 4.14.1. These subjective and objective approaches need to be modified for use with children because of the involvement of parents, developmental factors, and the differences between children and adults regarding clinical manifestations and diagnostic criteria.
The detection of sleep problems can be improved by routinely asking basic screening questions as part of the history-taking in any child:
Does the child have difficulty getting to sleep or staying asleep?
Is there excessive sleepiness during the day?
Are there episodes of abnormal behaviour or experiences at night?
Positive answers to any of these questions call for a detailed sleep history.
Sleep history and general review
This is the cornerstone of sleep assessment. Unfortunately, history-taking schedules are usually perfunctory in the attention they pay to sleep and its possible disorders. Parents and also the child (if old enough) should be interviewed and the reasons for any disparities considered. Sometimes sibs or teachers can provide important additional information. The main aspects that should be covered are as follows:
Current sleep problems and their evolution.
Past treatments and their effects.
Review of the child’s current 24 h sleep-wake cycle (see Table 9.2.9.2) in order to determine in particular
duration of sleep
quality of sleep (continuous or disrupted)
timing of sleep
features suggestive of specific sleep disorders (e.g. breathing difficulty or jerking limbs).
Sleep environment and arrangements.
Development of the child’s sleep patterns and problems.
General review of possible sleep symptoms.
Family history of sleep disorder or other conditions.
Table 9.2.9.2 Review of child’s 24 h sleep-wake pattern (modified according to child’s age) | |||||||||||||||||||||||||||||
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