Nearly 25% of all children experience a sleep disorder at some time. Sleep complaints are related to the quality, timing, and amount of sleep. The common feature in all sleep disorders is the resultant daytime distress and impairment that results from disturbed sleep. The most common problems in children and adolescents are sleep talking, nightmares, nighttime waking, difficulty falling asleep, enuresis, bruxism, sleep rocking, restless legs syndrome, and night terrors. A self-report survey of adolescents found a 10% lifetime prevalence of difficulties with sleep initiation, sleep maintenance, and excessive daytime somnolence (Johnson et al. 2006). Children with chronic medical, neurodevelopmental, and psychiatric disorders are at greater risk of sleep disorders. An estimated 30%–80% of children with intellectual disability and 50%–70% of children with autism spectrum disorder (ASD) have associated sleep problems (Cortesi et al. 2010; Johnson 1996). Abnormalities in sleep are also symptoms of mood and anxiety disorders; thus, sleep assessment is critical for a thorough psychiatric evaluation. DSM-5 (American Psychiatric Association 2013) reclassified the sleep disorders into 10 major disorders or disorder groups.
EVALUATION OF SLEEP-RELATED COMPLAINTS
Sleep requirements vary by age. Preschool children typically require 11–12 hours of sleep, school-age children require an average of 10 hours of sleep, and adolescents require an average of 8.5–9.0 hours of sleep. Assessment of sleep disorders includes pediatric history and physical examination, particularly seeking evidence of obesity, enlarged tonsils, middle ear problems, a seizure disorder, allergies, asthma, and medication use. Although abnormal physical findings in a child with a sleep continuity disorder are relatively infrequent, the evaluation of the airway should include tonsillar size, nasal airflow, and facial abnormalities. A sleep history includes details of the patient’s environment for sleeping and inquiries about whether the patient awakens screaming and confused, walks or talks while asleep, grinds his or her teeth, snores, experiences restless legs or nocturnal leg jerks, rocks or bangs his or her head at night, or has nighttime fears, frequent nightmares, and/or enuresis. A helpful mnemonic to assist in screening for sleep-related problems is BEARS, which stands for Bedtime, Excessive daytime sleepiness, Awakenings, Regularity, and Snoring (Mindell and Owens 2003). Sleep habits are reviewed and include the physical sleep environment, sleep schedules, intake of caffeinated beverages, level of activity, and evening exposure to screens (e.g., computer, phone, television, tablet, game devices). Children may resist bedtime or develop diurnal patterns that include difficulty awakening, daytime sleepiness, fatigue, and naps. A sleep log or diary is useful.
Developmental and psychiatric histories are necessary to assess possible psychiatric etiology or comorbidity. In addition, details of recent stressors, parental reactions to sleep-related problems, prescribed and over-the-counter medications, illicit substance use (in older children or adolescents), and the effects of any prior behavioral and pharmacological interventions are needed. When there is persistent nighttime waking or sleep loss or sleep apnea or nocturnal epilepsy is suspected, a sleep laboratory evaluation with polysomnography (PSG) may be indicated. PSG may include sleep electroencephalogram (EEG) and electrocardiogram as well as video monitoring and measurement of eye movements, electromyogram, airflow, and respiratory effort. A sleep-deprived EEG is useful in the evaluation of possible seizures. The Multiple Sleep Latency Test (MSLT) may be used to evaluate excessive daytime sleepiness (if a cause is not apparent). A drug screen may be needed in adolescents. Insufficient sleep is particularly prevalent during adolescence, when late-night activities and early-morning academic schedules limit the available hours for sleep. Many adolescents tend toward delayed sleep-onset and awakening (phase shift), making it difficult to obtain adequate sleep.
Patients with insomnia have persistent difficulty (compared with norms for age) initiating or maintaining sleep that results in impaired functioning. Bedtime resistance, disruptive nocturnal awakenings, and other behavioral sleep problems are most commonly seen in younger children, with a prevalence of 25%–50% (Owens et al. 2000). By age 6–9 months, most infants sleep through the night (or at least do not fuss when they awaken). Up to one-half of all infants, however, have irregular sleep patterns and occasional or persistent night wakening throughout the first year of life. A study of children without sleep disorders found that 21% of 18- to 23-month-olds awakened during the night. Of the 24- to 29-month-olds, 31% took more than 30 minutes to fall asleep on more than three nights per week. Children ages 30–36 months are most likely to have difficulty settling for the night (16%) and express fears of the dark (24%) (Crowell et al. 1987). At age 5 years, more than 20% of children surveyed at least occasionally awakened during the night and called out to their parents. Parental reinforcement may have inadvertently contributed to this behavior. By school age, children are normally asleep for 95%–97% of the time they are in bed (Carskadon and Dement 1987).
Sleep patterns in infants and toddlers may be affected by perinatal complications, colic, separation anxiety, the absence of a favorite transitional object, and parent–child interactions. The schedule of daytime naps for preschoolers can contribute to problems sleeping at night. Young children with sleep continuity disorders have a higher rate of family stressors, including parental absence because of employment, family illness, and maternal depression.
Chronic insomnia is much more frequent in children with psychiatric disorders. It is often related to behavior or habit problems in settling for the night, especially in the child with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, or separation anxiety disorder. Or, insomnia may be a symptom of a mood disorder, ASD, or schizophrenia.
Insomnia may be secondary to the use of caffeine or prescribed (e.g., stimulants) or over-the-counter medication (e.g., decongestants) or substance use. Patients suffering from physical discomfort may have difficulty staying asleep.
After any psychiatric or medical cause is addressed, in young children the first steps are to remove any factors that interfere with sleep and to enhance structure that encourages sleep (e.g., a bedtime routine, the use of a transitional object, or a night light for the child who is afraid of the dark). Behavior modification removes the secondary gain of parental attention at night and provides positive reinforcement for the child who stays quietly in his or her own room. Older children and adolescents may benefit from hypnosis or relaxation techniques. Consistency among all family members is critical to success.
In adolescents with insomnia, behavior therapy can disrupt the conditioned association between bedtime habits and anxiety regarding inability to sleep. Sleep hygiene is improved by using the bed only for sleeping, establishing a regular sleep schedule, avoiding naps, and removing all electronic media and communication devices from the bedroom. Cognitive-behavioral therapy in older children and adolescents has proven to be an effective intervention (Kuhn and Roane 2011).
Hypnotic medications are not recommended for chronic use. To date, there are no pharmacological agents approved by the U. S. Food and Drug Administration (FDA) for use in pediatric insomnia. Moreover, many children respond to sedatives with paradoxical agitation. Melatonin has shown to be helpful in short-term use with relatively few adverse effects (see Chapter 17, “Psychopharmacology”). It may assist with circadian regulation and assist in falling asleep at bedtime.
Clinical Description and Evaluation
The classic tetrad of symptoms associated with narcolepsy includes daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Children and adolescents have variable presentations, with few experiencing all four symptoms concurrently. DSM-5 (American Psychiatric Association 2013) refined the definition of narcolepsy to include more precise parameters and specific test results. Narcolepsy is characterized by recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. This symptom must also be accompanied by either episodes of cataplexy (i.e., sudden bilateral loss of muscle tone with maintained consciousness precipitated by heightened emotional state; in children, it can present as spontaneous grimaces, jaw-opening episodes with tongue thrusting, or global hypotonia, without an emotional trigger), cerebrospinal fluid (CSF) hypocretin deficiency, or nocturnal PSG showing short rapid eye movement (REM) sleep latency (≤ 15 minutes) or MSLT showing shortened mean sleep latency with at least two sleep-onset REM periods. Narcolepsy is relatively rare, though the exact childhood prevalence is unknown. The prevalence of narcolepsy in adults is approximately 2–5 in 10,000.
In evaluation, because narcolepsy is relatively rare, other causes of daytime sleepiness should be considered. The most likely alternative diagnosis to narcolepsy is the normal increase in daytime sleep and reports of sleepiness in adolescence. Truly excessive daytime sleep may be an avoidance mechanism, even in the classroom, or secondary to insomnia or sleep apnea. Sleep-onset or waking hallucinations may be misidentified as symptoms of psychosis, and cataplexy or sleep attacks may be confused with a seizure disorder or conversion disorder. Substance use or withdrawal should also be suspected when sleep continuity is disrupted. Typically, referral to a sleep medicine program is required to make the diagnosis by clinical examination, PSG, MSLT, and/or lumbar puncture.
Course and Prognosis
Onset of narcolepsy is typically in late adolescence or early adulthood. Sleep attacks and cataplexy may interfere significantly with schoolwork and peer relationships. Behavioral and emotional changes can develop early in the clinical presentation.
Treatment of narcolepsy begins with educating the patient and family members about the nature and course of the disorder. A useful Web site is that of the Narcolepsy Network (www.narcolepsynetwork.org). A regular sleep schedule with scheduled naps is helpful. Stimulant drugs (methylphenidate, dextroamphetamine) are used to reduce sleep attacks, particularly while the child is at school. Modafinil (Provigil) is a nonstimulant wakefulness-promoting agent that is FDA approved for use in narcolepsy. Sodium oxybate (Xyrem) was shown to be effective and well tolerated in children and adolescents with excessive daytime sleepiness associated with narcolepsy (Aran et al. 2010). Other medications that can be useful in the treatment of cataplexy, sleep paralysis, and hypnagogic hallucinations include the tricyclic antidepressants (clomipramine, imipramine, protriptyline), the mixed-action antidepressants, and the selective serotonin reuptake inhibitors.
OBSTRUCTIVE SLEEP APNEA
Obstructive sleep apnea (OSA) is a common and treatable sleep disorder. It is defined by episodes of complete or partial cessation of airflow associated with oxygen desaturation. Symptoms of OSA include persistent snoring, witnessed apneas or gasping for air, restless sleep, and nocturnal diaphoresis. The prevalence of pediatric OSA is estimated to be 1%–4% (Brockmann et al. 2012). The prevalence is higher in children with neuromuscular and craniofacial abnormalities and genetic syndromes.
OSA results from the loss of patency of the upper airway, caused by structural or neurological factors. With obstruction, respiratory efforts increase and greater muscle activity and arousal lead to relief of the obstruction. Causes of OSA include obesity, adenotonsillar hypertrophy, nocturnal asthma, lax upper airway structures, maxillofacial abnormalities, neuromuscular disease, Down syndrome, and hypothyroidism.
Course and Prognosis
The degree of adenotonsillar hypertrophy does not correlate with the severity of symptoms. PSG is required to make the diagnosis. Children with OSA may have medical complications, including pulmonary hypertension, systemic hypertension, right heart failure, failure to thrive, short stature, and enuresis. Greater awareness of the disorder has decreased the incidence of medical complications. Psychiatric and academic difficulties may include developmental delay, irritability, aggressiveness, distractibility, inattention, and hyperactivity.
The treatment of OSA is most often surgical, typically an adenotonsillectomy, which is curative in the majority of cases. Continuous positive airway pressure (CPAP) is an option for children who have either failed the surgical intervention or who are not considered an appropriate surgical candidate.
CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS
Circadian rhythm sleep-wake disorders result from disruption of the internal body rhythms that regulate sleep and wakefulness. There are six subtypes in DSM-5. Delayed sleep-phase syndrome (DSPS) (i.e., delay of sleep phase in relation to the light cycle) occurs following puberty in 5%–10% of adolescents. Adolescents with DSPS have excessive daytime sleepiness, which can impact academic performance, mood, attention, and relationships. Treatment for DSPS includes sleep hygiene, psychoeducation, and gradual advancement of sleep phase. Blue light therapy has shown efficacy in shifting sleep (Revell et al. 2012), as has bright light therapy with morning exposure. Melatonin can also be used to help advance the sleep phase. Chronotherapy, a behavioral technique in which bedtime is incrementally and systematically delayed, can be used for severe DSPS.
Parasomnias are more commonly seen in children, especially those with psychiatric or neurological disorders, than in adults. They can appear as early as age 2 years and typically resolve by adolescence. These disorders disrupt sleep with abnormalities of arousal, partial arousal, or sleep-stage transitions. The patient does not complain of insomnia or sleepiness. Parasomnias include non–rapid eye movement (NREM) sleep arousal disorders, nightmare disorder, and rapid eye movement (REM) sleep behavior disorder.
NREM Sleep Arousal Disorders
NREM sleep disorders are subdivided into sleepwalking type and sleep terror type.
Sleepwalking disorder is characterized by repeated episodes of arising from bed and engaging in motor activities while still asleep. Episodes, which last a few minutes to a half hour, typically occur 1–3 hours after the child falls asleep, during Stage 3 and 4 delta (NREM) sleep. The prevalence of occasional sleepwalking is 15%. Frequent episodes occur in 1%–6% of individuals. The child or adolescent arises quietly and engages in perseverative, stereotyped movements (such as picking at blankets), which may progress to walking and other complex behaviors. He or she is difficult to awaken, and coordination is poor. Although the child may be able to see, the risk of injury is high. Speech, when present, is usually incomprehensible. The youngster may awaken and be confused, may return to bed, or may lie down somewhere else and continue sleeping. Morning amnesia is typical. Occasionally, the patient engages in inappropriate behavior, such as urinating in the closet. Young children tend to walk toward a light or sound. Older children may wake in an agitated state with garbled speech and a tendency to recoil when touched. Sleepwalking tends be familial. Of patients who sleepwalk, 10%–20% have first-degree relatives with the disorder. Sleepwalking is usually seen between ages 4 and 12 years, with most cases remitting spontaneously by age 15 years. Parents should be advised to remove hazards in the environment. Children should maintain regular sleep schedules. Scheduled awakenings prior to the expected time of sleepwalking episode may be helpful. If sleepwalking is frequent or dangerous, benzodiazepines may be considered.
Sleep Terror Type
Episodes of sleep terror disorder typically occur during the first third of the night, in Stage 3 and 4 delta (NREM) sleep, and last 1–10 minutes. The child looks terrified, screams, and appears to be staring, with dilated pupils, sweating, rapid pulse, and hyperventilation. The child is agitated and confused and cannot be comforted. Subsequently, when alert, the child typically has no memory of the episode but may have brief recall of a feeling of terror or of dream fragments. The child rapidly returns to sleep when the episode is over and in the morning has no memory of the event. The parents are far more distressed than the child. The estimated prevalence of the full disorder in children is 1%–6%, and it is more common in boys than in girls. Sleep terror disorder is considered to be developmental and is not caused by a psychiatric disorder. Sleep terrors can be increased by sleep deprivation or anything that fragments sleep, including fever, illness, a full bladder, and certain medications. Patients (or parents) may experience symptoms due to cumulative sleep loss, if night terrors are frequent. Family history of sleep terror is common. Age at onset is typically between 3 and 12 years, with spontaneous resolution by adolescence. The number and frequency of episodes are highly variable. Consecutive episodes may be separated by days or weeks, but in rare instances they may occur on consecutive nights.
Parents should be educated about the disorder and reassured that the episodes do not indicate a psychiatric or neurological problem. The child’s sleep schedule is monitored to provide a sufficient amount of time spent in bed. The patient’s safety should be ensured by parents’ erecting gates across stairs and locking doors and windows to prevent leaving the house. Waking the child before the usual time of the night terror may abort attacks. However, waking the child during the event should be avoided because it may exacerbate or prolong the episode. Medication such as a benzodiazepine is used only if the episodes are frequent, put the child in physical danger, severely disrupt the family, or interfere with daytime functioning.
Occasional normal frightening dreams occur during REM sleep, more commonly in the second half of the night. If the youngster awakens, he or she rapidly becomes oriented and alert, and can recount the dream. Although the child may rapidly fall asleep again, sometimes he or she cannot return to sleep and will ask to sleep with the parents. Frequency of nightmares typically waxes and wanes as the child develops. Among children ages 3–5 years, 10%–50% have recurrent nightmares that disturb their parents. Symptoms typically begin during preschool years and decrease in frequency with age. Occasionally, the disorder persists into adulthood. No psychiatric conditions are associated consistently with nightmare disorder in children. Nightmares tend to increase with stress, sleep deprivation, fatigue, and change in sleep environment. Medications may increase nightmares. Reassurance is generally the best approach. The child should not be pressured to describe the nightmare but should be given an opportunity to talk about his or her fears. Sleep schedules should be normalized and sleep time increased if patients suffer from sleep deprivation. Children and adolescents with more persistent problems may require anxiety reduction techniques, such as relaxation, imagery combined with systematic desensitization, and dream reorganization. If nightmares are a symptom of posttraumatic stress disorder or another syndrome, the primary etiology should be addressed.
RESTLESS LEGS SYNDROME
Restless legs syndrome (RLS) is defined as the urge to move the legs, usually accompanied by uncomfortable sensations in the legs. The urge begins or worsens during periods of rest, is worse in the evening or night, and is partially or totally relieved with movement. Developmental issues should be considered as children may not express the symptoms as “urges.” Prevalence rates range from 2% to 7%, depending on the frequency criterion. Females are more likely to have RLS, and the prevalence of RLS increases with age. The typical age at onset is young adulthood, but many adults with RLS reported having symptoms in late childhood or adolescence (American Psychiatric Association 2013).
RLS can be seen in individuals with iron deficiency. RLS also has a strong genetic component, more common in individuals of European descent as compared with African or Asian descent. Disturbances in the central dopaminergic system have also been associated with RLS.
Behavioral interventions include maintaining a regular sleep-wake schedule, avoiding sleep deprivation, reducing caffeine intake, avoiding tobacco and alcohol, and avoiding stimulating activities near bedtime. Pharmacological interventions include iron supplementation for children with iron deficiency. Dopaminergic agents have been shown to be safe and well tolerated in children (England et al. 2011). Gabapentin also has shown efficacy in pediatric RLS (Frenette 2011). Other medications that can be used in pediatric RLS include benzodiazepines, α-agonists, and carbamazepine.
PSYCHIATRIC DISORDERS AND SLEEP PROBLEMS
Children with ADHD often have sleep-related problems including difficulty settling down to sleep, delayed sleep onset, frequent nocturnal awakenings, restless sleep, and reduced total amount of sleep. OSA should be considered in children with inattention, hyperactivity, and snoring. Studies have conflicting results regarding whether adenotonsillectomy reduces symptoms of ADHD in patients with both OSA and ADHD. Many children with ADHD also have RLS and periodic limb movement disorder. Sleep complaints are included in symptom criteria for children with mood disorders. Sleep complaints can include impaired sleep initiation or sleep maintenance, hypersomnia, or insomnia. Sleep difficulties can be seen in many children with ASD, with the most frequent concerns being difficulty falling asleep, frequent nocturnal awakenings, early morning awakenings, irregular sleep-wake cycle, restless sleep, and symptoms consistent with parasomnias. Adolescents with substance use disorders often have disturbed sleep, including excessive daytime sleepiness and insomnia. Children with anxiety disorders, notably generalized anxiety disorder, separation anxiety disorder, and specific phobia, also commonly present with sleep-related concerns.
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