When a child can’t sleep, start by treating the parents

Sleep problems are very common in children but more complicated to manage than in adults. That’s because you usually must consider the parents’ opinions in making the child’s diagnosis and change the parents’ behavior for the treatment to succeed.

This article describes sleep disorders of children and adolescents, the most effective behavioral therapies, and the limited situations when hypnotic therapy may be appropriate.

A Symptom, Not a Diagnosis

Pediatric insomnia is significant difficulty in initiating and/or maintaining sleep that impairs a child’s or caregiver’s daytime function (Table 1).^1-4 Childhood sleep disorders may manifest primarily as daytime sleepiness and neurobehavioral symptoms or occur with comorbid psychiatric diagnoses such as depression, anxiety, or attention-deficit/hyperactivity disorder (ADHD).

It is important to view insomnia as a symptom—not a diagnosis. Causes of insomnia in children may be medical (drug-related, pain-induced, or obstructive sleep apnea syndrome), behavioral (poor sleep hygiene or negative sleep-onset associations), or multiple factors (Table 2).

Sleep hygiene. Before starting therapy, educate parents and children about normal sleep development and sleep hygiene, which includes:

• environmental factors (temperature, noise, ambient light)
  
• scheduling (regular sleep-wake schedule)
  
• sleep practice (bedtime routine)
  
• physiologic factors (exercise, timing of meals, caffeine intake).
  

Four mechanisms account for most pediatric sleep disturbances:

• insufficient sleep for individual physiologic needs (“lifestyle” sleep restriction, delayed sleep onset related to behavioral insomnia)
  
• adequate sleep but fragmented or disrupted by conditions such as obstructive sleep apnea or periodic limb movement disorder that cause frequent or prolonged arousals
  
• primary disorders of excessive daytime sleepiness such as narcolepsy (less common than in adults but under-recognized in children and adolescents)
  
• circadian rhythm disorders in which sleep is usually normal in structure and duration but occurs at an undesired time (delayed sleep phase syndrome).
  

For practical purposes, sleep disorders also may be defined as primarily behavioral or organic/medical. These two types often are influenced by similar psychosocial and physical/environmental factors and frequently coexist.

Table 1

Insomnia’s negative effects on children and adolescents

Problem	Manifestations
Daytime sleepiness	Yawning, rubbing eyes, resting head on desk
Neurocognitive dysfunction	Decreased cognitive flexibility and verbal creativity
	Poor abstract reasoning
	Impaired motor skills
	Decreased attention and vigilance
	Memory impairment
Externalizing behaviors	Increased impulsivity, hyperactivity, and aggressiveness
Mood dysregulation	Increased irritability
	Decreased positive mood
	Poor affect modulation
Source: References 1-4

Table 2

Diagnostic types of pediatric insomnia

Diagnosis	Characteristics
Behavioral insomnia of childhood	Learned behaviors that interfere with sleep onset or maintenance
Sleep-onset association	Prolonged nighttime arousals because child can fall asleep only with certain sleep associations, such as being soothed by parent
Limit-setting subtype	Active resistance, verbal protests, and repeated demands by child at bedtime
Psychophysiologic insomnia	Conditioned anxiety about sleep difficulty heightens physiologic and emotional arousal, further compromising ability to sleep
Delayed sleep phase disorder	Common in adolescents; persistent phase shift in sleep-wake schedule (later bedtime and wake time) that conflicts with school and lifestyle demands
Secondary insomnia	Not primary; related to other diagnoses or factors
Psychiatric disorders	Depression, anxiety, posttraumatic stress disorder, attention-deficit/hyperactivity disorder
Medical disorders	Obstructive sleep apnea syndrome, pain
Medication	Psychostimulants used to treat ADHD and antidepressants used for major depression may cause sleep-onset delay

With Psychiatric Disorders

Sleep disturbances can profoundly affect the clinical presentation, severity, and management of psychiatric disorders in children and adolescents.^5-7 Up to 75% of children with a major depressive disorder have insomnia (severe in 30%), and one-third of depressed adolescents have delayed sleep-onset. Sleep complaints—especially bedtime resistance, refusal to sleep alone, increased nighttime fears, and nightmares—are also common in anxious children and those who have experienced severe trauma (including physical and sexual abuse).

Growing evidence suggests that pediatric “primary” insomnia with no concurrent psychiatric disorder is a risk factor for developing psychiatric conditions later in life—particularly depressive and anxiety disorders. Psychotropics such as psychostimulants and antidepressants also may interfere with sleep.

ADHD. Parents often report that children with ADHD have sleep disturbances, especially difficulty initiating sleep, poor sleep quality, restless sleep, frequent nighttime arousals, and shortened sleep duration.⁸ Parental observations notwithstanding, most objective methods of examining sleep and sleep architecture (polysomnography, actigraphy) have shown few or inconsistent differences between children with ADHD and controls.

Sleep problems in children with ADHD are often multifactorial. Potential causes include:

• psychostimulant-mediated sleep-onset delay
  
• bedtime resistance related to comorbid anxiety, oppositional defiant disorder, or circadian phase delay
  
• settling difficulties related to deficits in sensory integration associated with ADHD.
  

Adjusting a psychostimulant’s dosing schedule to an earlier time may help children who have trouble falling asleep. In some children, however, sleep-onset delay is caused not by a stimulatory effect but by the medication wearing off at bedtime. A late-day psychostimulant dose might prevent this “rebound.”

When managing a child with ADHD, evaluate comorbid sleep problems and provide diagnostically driven behavioral and/or drug therapy.

Behavioral Insomnia of Childhood

 

Behavioral insomnia of childhood may manifest as sleep-onset association and limit-setting types.⁹ The two often coexist, and many children present with both bedtime delays and nighttime arousals.

Sleep-onset association type. The presenting problem is usually prolonged nighttime arousals resulting in insufficient sleep. The child has learned to fall asleep only with sleep associations, such as being soothed by a parent, that usually are available at bedtime.

During the night, when the child experiences the type of brief arousal that normally occurs at the end of each sleep cycle (every 60 to 90 minutes) or awakens for other reasons, he is unable to get back to sleep (“self-soothe”) unless those same conditions are available to him. The child then “signals” the caregiver by crying (or coming into the parents’ bedroom) until the necessary associations are provided.

Limit-setting type is characterized by active resistance, verbal protests, and repeated demands at bedtime (“curtain calls”) rather than nighttime arousals. If sufficiently prolonged, the sleep-onset delay may result in inadequate sleep duration.

Sometimes bedtime resistance is related to:

• an underlying problem (a medical condition such as asthma or medication use, a sleep disorder such as restless legs, or anxiety)
  
• a mismatch between the child’s intrinsic circadian preferences (“night owl”) and parental expectations.
  

Usually, however, this disorder—most common in preschool and older children—develops from a caregiver’s inability or unwillingness to set consistent bedtime rules and enforce a regular bedtime. The child’s oppositional behavior worsens the problem.

Behavioral therapy can alleviate bedtime resistance and nighttime arousals in young children.¹⁰ Controlled group studies strongly support three techniques: unmodified extinction, graduated extinction, and preventive parental education (Table 3).

To use graduated extinction, tell parents to ignore bedtime crying and tantrums for specified periods before checking. Tailor the duration or interval between check-ins to the child’s age and temperament; the limiting factor is how much crying the parents can tolerate, as checking is often more to reassure them than the child.

For younger children, parents might check every 2 minutes initially, then gradually lengthen to 5-, 10-, and 15-minute intervals. A common scenario is to double the time between each successive check-in (2 minutes, 4 minutes, 8 minutes, etc.). For older children, checking could start at 5- or 10-minute intervals.

During check-ins, the parents briefly comfort the child (usually 15 seconds to 1 minute). Advise parents to minimize interactions that may reinforce the child’s attention-seeking behavior.

To treat limit-setting sleep problems, recommend a combination of:

• decreased parental attention to bedtime-delaying behavior
  
• establishing a consistent bedtime routine that does not include stimulating activities such as television viewing
  
• bedtime “fading” (temporarily setting bedtime to the current sleep-onset time and then gradually advancing bedtime)
  
• positive reinforcement (sticker charts) for appropriate behavior at bedtime.
  

Self-relaxation techniques and cognitive-behavioral strategies may help older children.

Behavioral treatment strategies require parental consistency to avoid inadvertently reinforcing nighttime arousals. Warn parents that children’s protests frequently escalate temporarily as treatment begins (“postextinction burst”).

How parents define a sleep “problem” and how well they accept your treatment recommendations can depend on their cultural values and beliefs about sleep’s meaning, importance, and role in daily life. Family attitudes vary about solitary sleep versus co-sleeping and about offering children transitional objects such as a blanket or toy to help them sleep.

Parents who repeatedly fail to start or enforce behavioral management may have other issues to address, such as depression or marital conflict.

Table 3

3 treatments for behavioral insomnia of childhood

Treatment	Definition/examples
Extinction	Withdrawing parental assistance at sleep onset and during the night (‘systematic ignoring’)
Graduated extinction	Gradual rather than abrupt extinction treatment
	For toddlers, parents check child briefly at successively longer intervals during wake-sleep transition
	For older children, parents introduce transitional sleep association objects (a blanket or toy) and use positive reinforcement (stickers for remaining in bed)
Preventive parental education	Parents must consistently use behavioral treatment strategies to avoid reinforcing the child’s nighttime arousals

Psychophysiologic Insomnia

Psychophysiologic insomnia (sleep onset and/or maintenance) occurs primarily in older children and adolescents and results from:

• predisposing factors (genetic vulnerability, underlying medical or psychiatric conditions)
  
• precipitating factors (acute stress)
  
• perpetuating factors (poor sleep habits, caffeine use, maladaptive thoughts about sleep).
  

Conditioned anxiety about difficulty falling asleep or staying asleep heightens physiologic and emotional arousal, further compromising ability to sleep.¹¹ Educate the patient about sleep hygiene, including:

• using the bed only for sleep
  
• getting out of bed if unable to fall asleep (stimulus control)
  
• restricting time in bed to actual time asleep (sleep restriction)
  
• learning relaxation techniques to reduce anxiety.
  

Delayed sleep phase syndrome. Some youths presenting with sleep-initiation insomnia—particularly adolescents—may have a circadian-based sleep disorder called delayed sleep phase syndrome (DSPS). DSPS is a significant, persistent phase shift in the sleep-wake schedule (later bedtime and wake time) that conflicts with the individual’s school, work, or lifestyle demands.

 

¹² The problem is the timing rather than quality of sleep.

Sleep quantity may be compromised if the individual must arise before obtaining adequate sleep. Sleep-onset delays resolve, however, when the patient is allowed to follow his or her preferred later bedtime and wake time.

The typical DSPS sleep-wake pattern is a consistently preferred bedtime/sleep-onset time after midnight and wake time after 10 AM on weekdays and weekends. Adolescents with DSPS often complain of sleep-onset insomnia, extreme difficulty waking in the morning, and profound daytime sleepiness.

A 1- to 2-hour phase shift to a later bedtime and wake time is part of normal pubertal development and has been cited as a rationale for delaying high school start times. The phase shift in DSPS is typically much more dramatic and intractable than the norm.

Treatment options for DSPS include:

• strict sleep-wake schedule (such as 9:30 or 10 PM to 6:30 AM on school nights, with no more than a 1-hour discrepancy on non-school nights)
  
• melatonin, 3 to 5 mg, given 3 to 4 hours before the desired bedtime, if sleep schedule strategies are unsuccessful
  
• bright-light therapy in the morning to suppress melatonin secretion and “reset” the body clock, especially if morning waking is particularly difficult.¹³
  

Teens with a severely delayed sleep phase (>3 to 4 hours) may benefit from chronotherapy. Delay bedtime (“lights out”) and wake times successively—by 2 to 3 hours per day—over several days. For example, if the teen’s preferred fall asleep time is 3 AM and wake time is noon, then bedtime and wake time would be 5 AM to 2 PM the first day; 7 AM to 4 PM the next day, and so forth until the sleep-onset time coincides with the desired bedtime.

If the adolescent also has school avoidance or a mood disorder—which is often the case—noncompliance with treatment is common. More-intensive behavioral and medication approaches may be needed.

Use Hypnotics?

Most insomnia in children and adolescents can be managed from infancy on with behavior therapy alone. If not, combined behavioral and drug interventions may be appropriate, such as when:

• the family is overwhelmed by the sleep problem and cannot execute behavioral strategies
  
• the child’s safety is at risk (engaging in dangerous activities during night awakenings, for example)
  
• treating specific populations (such as children with ADHD or autistic disorders).
  

The decision to prescribe medication for a child with insomnia is based largely on clinical experience, empirical data in adults, and small case series. No medications are FDA-approved for use as hypnotics in children. Sleep aids most commonly prescribed in clinical practice or recommended by pediatric clinicians include:

• antihistamines such as diphenhydramine
  
• tricyclic antidepressants (amitriptyline, trazodone, and others)
  
• benzodiazepines (clonazepam)
  
• nonbenzodiazepine hypnotics (zolpidem, zaleplon)
  
• alpha-agonists (clonidine).^14,15
  

Sedating antipsychotics (such as risperidone) and anticonvulsants (divalproex sodium) are sometimes used, such as for children with mental retardation. Sedating antidepressants (such as mirtazapine) may help children with depression and concomitant insomnia.

Use these medications with caution in children, as safety and tolerability are unknown. Prescribe the lowest dosage for the briefest time possible, and use in combination with behavioral management strategies. Choose the shortest-acting agents to avoid morning grogginess. Chloral hydrate and barbiturates are rarely indicated in children because of side effects.

Over-the-counter products. Parents often use nonprescription products such as diphenhydramine, melatonin, and herbal preparations to treat children’s sleep problems, with or without a clinician’s recommendation. Most herbal preparations are generally safe but remain untested in pediatric patients.

Antihistamines such as diphenhydramine are generally well-tolerated, but they may have a paradoxical agitating effect. Tolerance also tends to develop, leading to increasing doses. Parents may inadvertently overdose a child by giving multiple nonprescription products with diphenhydramine as the active ingredient (such as combining Benadryl with Tylenol PM).

Related resources

• National Sleep Foundation. Information for patients and clinicians. www.sleepfoundation.org.
  
• American Academy of Sleep Medicine. Professional and patient resources and links. www.aasmnet.org.
  
• Mindell J, Owens J. A clinical guide to pediatric sleep: diagnosis and management of sleep problems in children and adolescents. Philadelphia: Lippincott Williams and Wilkins; 2003.
  
• Owens J, Mindell J. Take charge of your child’s sleep: the all-in-one resource for solving sleep problems in kids and teens. New York: Marlowe & Co.; 2005.
  

Drug brand names

• Amitriptyline • Elavil
  
• Clonazepam • Klonopin
  
• Clonidine • Catapres
  
• Diphenhydramine • Benadryl and others (nonprescription)
  
• Divalproex sodium • Depakote
  
• Mirtazapine • Remeron
  
• Risperidone • Risperdal
  
• Trazodone • Desyrel
  
• Zaleplon • Sonata
  
• Zolpidem • Ambien
  

Disclosures

Dr. Owens receives research support from Sepracor, Eli Lilly & Co., and Cephalon; is a consultant to Eli Lilly & Co., Cephalon, and Shire; and is a speaker for Eli Lilly & Co., Cephalon, and Johnson & Johnson.

Sleep problems are very common in children but more complicated to manage than in adults. That’s because you usually must consider the parents’ opinions in making the child’s diagnosis and change the parents’ behavior for the treatment to succeed.

This article describes sleep disorders of children and adolescents, the most effective behavioral therapies, and the limited situations when hypnotic therapy may be appropriate.

A Symptom, Not a Diagnosis

Pediatric insomnia is significant difficulty in initiating and/or maintaining sleep that impairs a child’s or caregiver’s daytime function (Table 1).^1-4 Childhood sleep disorders may manifest primarily as daytime sleepiness and neurobehavioral symptoms or occur with comorbid psychiatric diagnoses such as depression, anxiety, or attention-deficit/hyperactivity disorder (ADHD).

It is important to view insomnia as a symptom—not a diagnosis. Causes of insomnia in children may be medical (drug-related, pain-induced, or obstructive sleep apnea syndrome), behavioral (poor sleep hygiene or negative sleep-onset associations), or multiple factors (Table 2).

Sleep hygiene. Before starting therapy, educate parents and children about normal sleep development and sleep hygiene, which includes:

• environmental factors (temperature, noise, ambient light)
  
• scheduling (regular sleep-wake schedule)
  
• sleep practice (bedtime routine)
  
• physiologic factors (exercise, timing of meals, caffeine intake).
  

Four mechanisms account for most pediatric sleep disturbances:

• insufficient sleep for individual physiologic needs (“lifestyle” sleep restriction, delayed sleep onset related to behavioral insomnia)
  
• adequate sleep but fragmented or disrupted by conditions such as obstructive sleep apnea or periodic limb movement disorder that cause frequent or prolonged arousals
  
• primary disorders of excessive daytime sleepiness such as narcolepsy (less common than in adults but under-recognized in children and adolescents)
  
• circadian rhythm disorders in which sleep is usually normal in structure and duration but occurs at an undesired time (delayed sleep phase syndrome).
  

For practical purposes, sleep disorders also may be defined as primarily behavioral or organic/medical. These two types often are influenced by similar psychosocial and physical/environmental factors and frequently coexist.

Table 1

Insomnia’s negative effects on children and adolescents

Problem	Manifestations
Daytime sleepiness	Yawning, rubbing eyes, resting head on desk
Neurocognitive dysfunction	Decreased cognitive flexibility and verbal creativity
	Poor abstract reasoning
	Impaired motor skills
	Decreased attention and vigilance
	Memory impairment
Externalizing behaviors	Increased impulsivity, hyperactivity, and aggressiveness
Mood dysregulation	Increased irritability
	Decreased positive mood
	Poor affect modulation
Source: References 1-4

Table 2

Diagnostic types of pediatric insomnia

Diagnosis	Characteristics
Behavioral insomnia of childhood	Learned behaviors that interfere with sleep onset or maintenance
Sleep-onset association	Prolonged nighttime arousals because child can fall asleep only with certain sleep associations, such as being soothed by parent
Limit-setting subtype	Active resistance, verbal protests, and repeated demands by child at bedtime
Psychophysiologic insomnia	Conditioned anxiety about sleep difficulty heightens physiologic and emotional arousal, further compromising ability to sleep
Delayed sleep phase disorder	Common in adolescents; persistent phase shift in sleep-wake schedule (later bedtime and wake time) that conflicts with school and lifestyle demands
Secondary insomnia	Not primary; related to other diagnoses or factors
Psychiatric disorders	Depression, anxiety, posttraumatic stress disorder, attention-deficit/hyperactivity disorder
Medical disorders	Obstructive sleep apnea syndrome, pain
Medication	Psychostimulants used to treat ADHD and antidepressants used for major depression may cause sleep-onset delay

With Psychiatric Disorders

Sleep disturbances can profoundly affect the clinical presentation, severity, and management of psychiatric disorders in children and adolescents.^5-7 Up to 75% of children with a major depressive disorder have insomnia (severe in 30%), and one-third of depressed adolescents have delayed sleep-onset. Sleep complaints—especially bedtime resistance, refusal to sleep alone, increased nighttime fears, and nightmares—are also common in anxious children and those who have experienced severe trauma (including physical and sexual abuse).

Growing evidence suggests that pediatric “primary” insomnia with no concurrent psychiatric disorder is a risk factor for developing psychiatric conditions later in life—particularly depressive and anxiety disorders. Psychotropics such as psychostimulants and antidepressants also may interfere with sleep.

ADHD. Parents often report that children with ADHD have sleep disturbances, especially difficulty initiating sleep, poor sleep quality, restless sleep, frequent nighttime arousals, and shortened sleep duration.⁸ Parental observations notwithstanding, most objective methods of examining sleep and sleep architecture (polysomnography, actigraphy) have shown few or inconsistent differences between children with ADHD and controls.

Sleep problems in children with ADHD are often multifactorial. Potential causes include:

• psychostimulant-mediated sleep-onset delay
  
• bedtime resistance related to comorbid anxiety, oppositional defiant disorder, or circadian phase delay
  
• settling difficulties related to deficits in sensory integration associated with ADHD.
  

Adjusting a psychostimulant’s dosing schedule to an earlier time may help children who have trouble falling asleep. In some children, however, sleep-onset delay is caused not by a stimulatory effect but by the medication wearing off at bedtime. A late-day psychostimulant dose might prevent this “rebound.”

When managing a child with ADHD, evaluate comorbid sleep problems and provide diagnostically driven behavioral and/or drug therapy.

Behavioral Insomnia of Childhood

 

Behavioral insomnia of childhood may manifest as sleep-onset association and limit-setting types.⁹ The two often coexist, and many children present with both bedtime delays and nighttime arousals.

Sleep-onset association type. The presenting problem is usually prolonged nighttime arousals resulting in insufficient sleep. The child has learned to fall asleep only with sleep associations, such as being soothed by a parent, that usually are available at bedtime.

During the night, when the child experiences the type of brief arousal that normally occurs at the end of each sleep cycle (every 60 to 90 minutes) or awakens for other reasons, he is unable to get back to sleep (“self-soothe”) unless those same conditions are available to him. The child then “signals” the caregiver by crying (or coming into the parents’ bedroom) until the necessary associations are provided.

Limit-setting type is characterized by active resistance, verbal protests, and repeated demands at bedtime (“curtain calls”) rather than nighttime arousals. If sufficiently prolonged, the sleep-onset delay may result in inadequate sleep duration.

Sometimes bedtime resistance is related to:

• an underlying problem (a medical condition such as asthma or medication use, a sleep disorder such as restless legs, or anxiety)
  
• a mismatch between the child’s intrinsic circadian preferences (“night owl”) and parental expectations.
  

Usually, however, this disorder—most common in preschool and older children—develops from a caregiver’s inability or unwillingness to set consistent bedtime rules and enforce a regular bedtime. The child’s oppositional behavior worsens the problem.

Behavioral therapy can alleviate bedtime resistance and nighttime arousals in young children.¹⁰ Controlled group studies strongly support three techniques: unmodified extinction, graduated extinction, and preventive parental education (Table 3).

To use graduated extinction, tell parents to ignore bedtime crying and tantrums for specified periods before checking. Tailor the duration or interval between check-ins to the child’s age and temperament; the limiting factor is how much crying the parents can tolerate, as checking is often more to reassure them than the child.

For younger children, parents might check every 2 minutes initially, then gradually lengthen to 5-, 10-, and 15-minute intervals. A common scenario is to double the time between each successive check-in (2 minutes, 4 minutes, 8 minutes, etc.). For older children, checking could start at 5- or 10-minute intervals.

During check-ins, the parents briefly comfort the child (usually 15 seconds to 1 minute). Advise parents to minimize interactions that may reinforce the child’s attention-seeking behavior.

To treat limit-setting sleep problems, recommend a combination of:

• decreased parental attention to bedtime-delaying behavior
  
• establishing a consistent bedtime routine that does not include stimulating activities such as television viewing
  
• bedtime “fading” (temporarily setting bedtime to the current sleep-onset time and then gradually advancing bedtime)
  
• positive reinforcement (sticker charts) for appropriate behavior at bedtime.
  

Self-relaxation techniques and cognitive-behavioral strategies may help older children.

Behavioral treatment strategies require parental consistency to avoid inadvertently reinforcing nighttime arousals. Warn parents that children’s protests frequently escalate temporarily as treatment begins (“postextinction burst”).

How parents define a sleep “problem” and how well they accept your treatment recommendations can depend on their cultural values and beliefs about sleep’s meaning, importance, and role in daily life. Family attitudes vary about solitary sleep versus co-sleeping and about offering children transitional objects such as a blanket or toy to help them sleep.

Parents who repeatedly fail to start or enforce behavioral management may have other issues to address, such as depression or marital conflict.

Table 3

3 treatments for behavioral insomnia of childhood

Treatment	Definition/examples
Extinction	Withdrawing parental assistance at sleep onset and during the night (‘systematic ignoring’)
Graduated extinction	Gradual rather than abrupt extinction treatment
	For toddlers, parents check child briefly at successively longer intervals during wake-sleep transition
	For older children, parents introduce transitional sleep association objects (a blanket or toy) and use positive reinforcement (stickers for remaining in bed)
Preventive parental education	Parents must consistently use behavioral treatment strategies to avoid reinforcing the child’s nighttime arousals

Psychophysiologic Insomnia

Psychophysiologic insomnia (sleep onset and/or maintenance) occurs primarily in older children and adolescents and results from:

• predisposing factors (genetic vulnerability, underlying medical or psychiatric conditions)
  
• precipitating factors (acute stress)
  
• perpetuating factors (poor sleep habits, caffeine use, maladaptive thoughts about sleep).
  

Conditioned anxiety about difficulty falling asleep or staying asleep heightens physiologic and emotional arousal, further compromising ability to sleep.¹¹ Educate the patient about sleep hygiene, including:

• using the bed only for sleep
  
• getting out of bed if unable to fall asleep (stimulus control)
  
• restricting time in bed to actual time asleep (sleep restriction)
  
• learning relaxation techniques to reduce anxiety.
  

Delayed sleep phase syndrome. Some youths presenting with sleep-initiation insomnia—particularly adolescents—may have a circadian-based sleep disorder called delayed sleep phase syndrome (DSPS). DSPS is a significant, persistent phase shift in the sleep-wake schedule (later bedtime and wake time) that conflicts with the individual’s school, work, or lifestyle demands.

 

¹² The problem is the timing rather than quality of sleep.

Sleep quantity may be compromised if the individual must arise before obtaining adequate sleep. Sleep-onset delays resolve, however, when the patient is allowed to follow his or her preferred later bedtime and wake time.

The typical DSPS sleep-wake pattern is a consistently preferred bedtime/sleep-onset time after midnight and wake time after 10 AM on weekdays and weekends. Adolescents with DSPS often complain of sleep-onset insomnia, extreme difficulty waking in the morning, and profound daytime sleepiness.

A 1- to 2-hour phase shift to a later bedtime and wake time is part of normal pubertal development and has been cited as a rationale for delaying high school start times. The phase shift in DSPS is typically much more dramatic and intractable than the norm.

Treatment options for DSPS include:

• strict sleep-wake schedule (such as 9:30 or 10 PM to 6:30 AM on school nights, with no more than a 1-hour discrepancy on non-school nights)
  
• melatonin, 3 to 5 mg, given 3 to 4 hours before the desired bedtime, if sleep schedule strategies are unsuccessful
  
• bright-light therapy in the morning to suppress melatonin secretion and “reset” the body clock, especially if morning waking is particularly difficult.¹³
  

Teens with a severely delayed sleep phase (>3 to 4 hours) may benefit from chronotherapy. Delay bedtime (“lights out”) and wake times successively—by 2 to 3 hours per day—over several days. For example, if the teen’s preferred fall asleep time is 3 AM and wake time is noon, then bedtime and wake time would be 5 AM to 2 PM the first day; 7 AM to 4 PM the next day, and so forth until the sleep-onset time coincides with the desired bedtime.

If the adolescent also has school avoidance or a mood disorder—which is often the case—noncompliance with treatment is common. More-intensive behavioral and medication approaches may be needed.

Use Hypnotics?

Most insomnia in children and adolescents can be managed from infancy on with behavior therapy alone. If not, combined behavioral and drug interventions may be appropriate, such as when:

• the family is overwhelmed by the sleep problem and cannot execute behavioral strategies
  
• the child’s safety is at risk (engaging in dangerous activities during night awakenings, for example)
  
• treating specific populations (such as children with ADHD or autistic disorders).
  

The decision to prescribe medication for a child with insomnia is based largely on clinical experience, empirical data in adults, and small case series. No medications are FDA-approved for use as hypnotics in children. Sleep aids most commonly prescribed in clinical practice or recommended by pediatric clinicians include:

• antihistamines such as diphenhydramine
  
• tricyclic antidepressants (amitriptyline, trazodone, and others)
  
• benzodiazepines (clonazepam)
  
• nonbenzodiazepine hypnotics (zolpidem, zaleplon)
  
• alpha-agonists (clonidine).^14,15
  

Sedating antipsychotics (such as risperidone) and anticonvulsants (divalproex sodium) are sometimes used, such as for children with mental retardation. Sedating antidepressants (such as mirtazapine) may help children with depression and concomitant insomnia.

Use these medications with caution in children, as safety and tolerability are unknown. Prescribe the lowest dosage for the briefest time possible, and use in combination with behavioral management strategies. Choose the shortest-acting agents to avoid morning grogginess. Chloral hydrate and barbiturates are rarely indicated in children because of side effects.

Over-the-counter products. Parents often use nonprescription products such as diphenhydramine, melatonin, and herbal preparations to treat children’s sleep problems, with or without a clinician’s recommendation. Most herbal preparations are generally safe but remain untested in pediatric patients.

Antihistamines such as diphenhydramine are generally well-tolerated, but they may have a paradoxical agitating effect. Tolerance also tends to develop, leading to increasing doses. Parents may inadvertently overdose a child by giving multiple nonprescription products with diphenhydramine as the active ingredient (such as combining Benadryl with Tylenol PM).

Related resources

• National Sleep Foundation. Information for patients and clinicians. www.sleepfoundation.org.
  
• American Academy of Sleep Medicine. Professional and patient resources and links. www.aasmnet.org.
  
• Mindell J, Owens J. A clinical guide to pediatric sleep: diagnosis and management of sleep problems in children and adolescents. Philadelphia: Lippincott Williams and Wilkins; 2003.
  
• Owens J, Mindell J. Take charge of your child’s sleep: the all-in-one resource for solving sleep problems in kids and teens. New York: Marlowe & Co.; 2005.
  

Drug brand names

• Amitriptyline • Elavil
  
• Clonazepam • Klonopin
  
• Clonidine • Catapres
  
• Diphenhydramine • Benadryl and others (nonprescription)
  
• Divalproex sodium • Depakote
  
• Mirtazapine • Remeron
  
• Risperidone • Risperdal
  
• Trazodone • Desyrel
  
• Zaleplon • Sonata
  
• Zolpidem • Ambien
  

Disclosures

Dr. Owens receives research support from Sepracor, Eli Lilly & Co., and Cephalon; is a consultant to Eli Lilly & Co., Cephalon, and Shire; and is a speaker for Eli Lilly & Co., Cephalon, and Johnson & Johnson.

Sleep problems are very common in children but more complicated to manage than in adults. That’s because you usually must consider the parents’ opinions in making the child’s diagnosis and change the parents’ behavior for the treatment to succeed.

This article describes sleep disorders of children and adolescents, the most effective behavioral therapies, and the limited situations when hypnotic therapy may be appropriate.

A Symptom, Not a Diagnosis

Pediatric insomnia is significant difficulty in initiating and/or maintaining sleep that impairs a child’s or caregiver’s daytime function (Table 1).^1-4 Childhood sleep disorders may manifest primarily as daytime sleepiness and neurobehavioral symptoms or occur with comorbid psychiatric diagnoses such as depression, anxiety, or attention-deficit/hyperactivity disorder (ADHD).

It is important to view insomnia as a symptom—not a diagnosis. Causes of insomnia in children may be medical (drug-related, pain-induced, or obstructive sleep apnea syndrome), behavioral (poor sleep hygiene or negative sleep-onset associations), or multiple factors (Table 2).

Sleep hygiene. Before starting therapy, educate parents and children about normal sleep development and sleep hygiene, which includes:

• environmental factors (temperature, noise, ambient light)
  
• scheduling (regular sleep-wake schedule)
  
• sleep practice (bedtime routine)
  
• physiologic factors (exercise, timing of meals, caffeine intake).
  

Four mechanisms account for most pediatric sleep disturbances:

• insufficient sleep for individual physiologic needs (“lifestyle” sleep restriction, delayed sleep onset related to behavioral insomnia)
  
• adequate sleep but fragmented or disrupted by conditions such as obstructive sleep apnea or periodic limb movement disorder that cause frequent or prolonged arousals
  
• primary disorders of excessive daytime sleepiness such as narcolepsy (less common than in adults but under-recognized in children and adolescents)
  
• circadian rhythm disorders in which sleep is usually normal in structure and duration but occurs at an undesired time (delayed sleep phase syndrome).
  

For practical purposes, sleep disorders also may be defined as primarily behavioral or organic/medical. These two types often are influenced by similar psychosocial and physical/environmental factors and frequently coexist.

Table 1

Insomnia’s negative effects on children and adolescents

Problem	Manifestations
Daytime sleepiness	Yawning, rubbing eyes, resting head on desk
Neurocognitive dysfunction	Decreased cognitive flexibility and verbal creativity
	Poor abstract reasoning
	Impaired motor skills
	Decreased attention and vigilance
	Memory impairment
Externalizing behaviors	Increased impulsivity, hyperactivity, and aggressiveness
Mood dysregulation	Increased irritability
	Decreased positive mood
	Poor affect modulation
Source: References 1-4

Table 2

Diagnostic types of pediatric insomnia

Diagnosis	Characteristics
Behavioral insomnia of childhood	Learned behaviors that interfere with sleep onset or maintenance
Sleep-onset association	Prolonged nighttime arousals because child can fall asleep only with certain sleep associations, such as being soothed by parent
Limit-setting subtype	Active resistance, verbal protests, and repeated demands by child at bedtime
Psychophysiologic insomnia	Conditioned anxiety about sleep difficulty heightens physiologic and emotional arousal, further compromising ability to sleep
Delayed sleep phase disorder	Common in adolescents; persistent phase shift in sleep-wake schedule (later bedtime and wake time) that conflicts with school and lifestyle demands
Secondary insomnia	Not primary; related to other diagnoses or factors
Psychiatric disorders	Depression, anxiety, posttraumatic stress disorder, attention-deficit/hyperactivity disorder
Medical disorders	Obstructive sleep apnea syndrome, pain
Medication	Psychostimulants used to treat ADHD and antidepressants used for major depression may cause sleep-onset delay

With Psychiatric Disorders

Sleep disturbances can profoundly affect the clinical presentation, severity, and management of psychiatric disorders in children and adolescents.^5-7 Up to 75% of children with a major depressive disorder have insomnia (severe in 30%), and one-third of depressed adolescents have delayed sleep-onset. Sleep complaints—especially bedtime resistance, refusal to sleep alone, increased nighttime fears, and nightmares—are also common in anxious children and those who have experienced severe trauma (including physical and sexual abuse).

Growing evidence suggests that pediatric “primary” insomnia with no concurrent psychiatric disorder is a risk factor for developing psychiatric conditions later in life—particularly depressive and anxiety disorders. Psychotropics such as psychostimulants and antidepressants also may interfere with sleep.

ADHD. Parents often report that children with ADHD have sleep disturbances, especially difficulty initiating sleep, poor sleep quality, restless sleep, frequent nighttime arousals, and shortened sleep duration.⁸ Parental observations notwithstanding, most objective methods of examining sleep and sleep architecture (polysomnography, actigraphy) have shown few or inconsistent differences between children with ADHD and controls.

Sleep problems in children with ADHD are often multifactorial. Potential causes include:

• psychostimulant-mediated sleep-onset delay
  
• bedtime resistance related to comorbid anxiety, oppositional defiant disorder, or circadian phase delay
  
• settling difficulties related to deficits in sensory integration associated with ADHD.
  

Adjusting a psychostimulant’s dosing schedule to an earlier time may help children who have trouble falling asleep. In some children, however, sleep-onset delay is caused not by a stimulatory effect but by the medication wearing off at bedtime. A late-day psychostimulant dose might prevent this “rebound.”

When managing a child with ADHD, evaluate comorbid sleep problems and provide diagnostically driven behavioral and/or drug therapy.

Behavioral Insomnia of Childhood

 

Behavioral insomnia of childhood may manifest as sleep-onset association and limit-setting types.⁹ The two often coexist, and many children present with both bedtime delays and nighttime arousals.

Sleep-onset association type. The presenting problem is usually prolonged nighttime arousals resulting in insufficient sleep. The child has learned to fall asleep only with sleep associations, such as being soothed by a parent, that usually are available at bedtime.

During the night, when the child experiences the type of brief arousal that normally occurs at the end of each sleep cycle (every 60 to 90 minutes) or awakens for other reasons, he is unable to get back to sleep (“self-soothe”) unless those same conditions are available to him. The child then “signals” the caregiver by crying (or coming into the parents’ bedroom) until the necessary associations are provided.

Limit-setting type is characterized by active resistance, verbal protests, and repeated demands at bedtime (“curtain calls”) rather than nighttime arousals. If sufficiently prolonged, the sleep-onset delay may result in inadequate sleep duration.

Sometimes bedtime resistance is related to:

• an underlying problem (a medical condition such as asthma or medication use, a sleep disorder such as restless legs, or anxiety)
  
• a mismatch between the child’s intrinsic circadian preferences (“night owl”) and parental expectations.
  

Usually, however, this disorder—most common in preschool and older children—develops from a caregiver’s inability or unwillingness to set consistent bedtime rules and enforce a regular bedtime. The child’s oppositional behavior worsens the problem.

Behavioral therapy can alleviate bedtime resistance and nighttime arousals in young children.¹⁰ Controlled group studies strongly support three techniques: unmodified extinction, graduated extinction, and preventive parental education (Table 3).

To use graduated extinction, tell parents to ignore bedtime crying and tantrums for specified periods before checking. Tailor the duration or interval between check-ins to the child’s age and temperament; the limiting factor is how much crying the parents can tolerate, as checking is often more to reassure them than the child.

For younger children, parents might check every 2 minutes initially, then gradually lengthen to 5-, 10-, and 15-minute intervals. A common scenario is to double the time between each successive check-in (2 minutes, 4 minutes, 8 minutes, etc.). For older children, checking could start at 5- or 10-minute intervals.

During check-ins, the parents briefly comfort the child (usually 15 seconds to 1 minute). Advise parents to minimize interactions that may reinforce the child’s attention-seeking behavior.

To treat limit-setting sleep problems, recommend a combination of:

• decreased parental attention to bedtime-delaying behavior
  
• establishing a consistent bedtime routine that does not include stimulating activities such as television viewing
  
• bedtime “fading” (temporarily setting bedtime to the current sleep-onset time and then gradually advancing bedtime)
  
• positive reinforcement (sticker charts) for appropriate behavior at bedtime.
  

Self-relaxation techniques and cognitive-behavioral strategies may help older children.

Behavioral treatment strategies require parental consistency to avoid inadvertently reinforcing nighttime arousals. Warn parents that children’s protests frequently escalate temporarily as treatment begins (“postextinction burst”).

How parents define a sleep “problem” and how well they accept your treatment recommendations can depend on their cultural values and beliefs about sleep’s meaning, importance, and role in daily life. Family attitudes vary about solitary sleep versus co-sleeping and about offering children transitional objects such as a blanket or toy to help them sleep.

Parents who repeatedly fail to start or enforce behavioral management may have other issues to address, such as depression or marital conflict.

Table 3

3 treatments for behavioral insomnia of childhood

Treatment	Definition/examples
Extinction	Withdrawing parental assistance at sleep onset and during the night (‘systematic ignoring’)
Graduated extinction	Gradual rather than abrupt extinction treatment
	For toddlers, parents check child briefly at successively longer intervals during wake-sleep transition
	For older children, parents introduce transitional sleep association objects (a blanket or toy) and use positive reinforcement (stickers for remaining in bed)
Preventive parental education	Parents must consistently use behavioral treatment strategies to avoid reinforcing the child’s nighttime arousals

Psychophysiologic Insomnia

Psychophysiologic insomnia (sleep onset and/or maintenance) occurs primarily in older children and adolescents and results from:

• predisposing factors (genetic vulnerability, underlying medical or psychiatric conditions)
  
• precipitating factors (acute stress)
  
• perpetuating factors (poor sleep habits, caffeine use, maladaptive thoughts about sleep).
  

Conditioned anxiety about difficulty falling asleep or staying asleep heightens physiologic and emotional arousal, further compromising ability to sleep.¹¹ Educate the patient about sleep hygiene, including:

• using the bed only for sleep
  
• getting out of bed if unable to fall asleep (stimulus control)
  
• restricting time in bed to actual time asleep (sleep restriction)
  
• learning relaxation techniques to reduce anxiety.
  

Delayed sleep phase syndrome. Some youths presenting with sleep-initiation insomnia—particularly adolescents—may have a circadian-based sleep disorder called delayed sleep phase syndrome (DSPS). DSPS is a significant, persistent phase shift in the sleep-wake schedule (later bedtime and wake time) that conflicts with the individual’s school, work, or lifestyle demands.

 

¹² The problem is the timing rather than quality of sleep.

Sleep quantity may be compromised if the individual must arise before obtaining adequate sleep. Sleep-onset delays resolve, however, when the patient is allowed to follow his or her preferred later bedtime and wake time.

The typical DSPS sleep-wake pattern is a consistently preferred bedtime/sleep-onset time after midnight and wake time after 10 AM on weekdays and weekends. Adolescents with DSPS often complain of sleep-onset insomnia, extreme difficulty waking in the morning, and profound daytime sleepiness.

A 1- to 2-hour phase shift to a later bedtime and wake time is part of normal pubertal development and has been cited as a rationale for delaying high school start times. The phase shift in DSPS is typically much more dramatic and intractable than the norm.

Treatment options for DSPS include:

• strict sleep-wake schedule (such as 9:30 or 10 PM to 6:30 AM on school nights, with no more than a 1-hour discrepancy on non-school nights)
  
• melatonin, 3 to 5 mg, given 3 to 4 hours before the desired bedtime, if sleep schedule strategies are unsuccessful
  
• bright-light therapy in the morning to suppress melatonin secretion and “reset” the body clock, especially if morning waking is particularly difficult.¹³
  

Teens with a severely delayed sleep phase (>3 to 4 hours) may benefit from chronotherapy. Delay bedtime (“lights out”) and wake times successively—by 2 to 3 hours per day—over several days. For example, if the teen’s preferred fall asleep time is 3 AM and wake time is noon, then bedtime and wake time would be 5 AM to 2 PM the first day; 7 AM to 4 PM the next day, and so forth until the sleep-onset time coincides with the desired bedtime.

If the adolescent also has school avoidance or a mood disorder—which is often the case—noncompliance with treatment is common. More-intensive behavioral and medication approaches may be needed.

Use Hypnotics?

Most insomnia in children and adolescents can be managed from infancy on with behavior therapy alone. If not, combined behavioral and drug interventions may be appropriate, such as when:

• the family is overwhelmed by the sleep problem and cannot execute behavioral strategies
  
• the child’s safety is at risk (engaging in dangerous activities during night awakenings, for example)
  
• treating specific populations (such as children with ADHD or autistic disorders).
  

The decision to prescribe medication for a child with insomnia is based largely on clinical experience, empirical data in adults, and small case series. No medications are FDA-approved for use as hypnotics in children. Sleep aids most commonly prescribed in clinical practice or recommended by pediatric clinicians include:

• antihistamines such as diphenhydramine
  
• tricyclic antidepressants (amitriptyline, trazodone, and others)
  
• benzodiazepines (clonazepam)
  
• nonbenzodiazepine hypnotics (zolpidem, zaleplon)
  
• alpha-agonists (clonidine).^14,15
  

Sedating antipsychotics (such as risperidone) and anticonvulsants (divalproex sodium) are sometimes used, such as for children with mental retardation. Sedating antidepressants (such as mirtazapine) may help children with depression and concomitant insomnia.

Use these medications with caution in children, as safety and tolerability are unknown. Prescribe the lowest dosage for the briefest time possible, and use in combination with behavioral management strategies. Choose the shortest-acting agents to avoid morning grogginess. Chloral hydrate and barbiturates are rarely indicated in children because of side effects.

Over-the-counter products. Parents often use nonprescription products such as diphenhydramine, melatonin, and herbal preparations to treat children’s sleep problems, with or without a clinician’s recommendation. Most herbal preparations are generally safe but remain untested in pediatric patients.

Antihistamines such as diphenhydramine are generally well-tolerated, but they may have a paradoxical agitating effect. Tolerance also tends to develop, leading to increasing doses. Parents may inadvertently overdose a child by giving multiple nonprescription products with diphenhydramine as the active ingredient (such as combining Benadryl with Tylenol PM).

Related resources

• National Sleep Foundation. Information for patients and clinicians. www.sleepfoundation.org.
  
• American Academy of Sleep Medicine. Professional and patient resources and links. www.aasmnet.org.
  
• Mindell J, Owens J. A clinical guide to pediatric sleep: diagnosis and management of sleep problems in children and adolescents. Philadelphia: Lippincott Williams and Wilkins; 2003.
  
• Owens J, Mindell J. Take charge of your child’s sleep: the all-in-one resource for solving sleep problems in kids and teens. New York: Marlowe & Co.; 2005.
  

Drug brand names

• Amitriptyline • Elavil
  
• Clonazepam • Klonopin
  
• Clonidine • Catapres
  
• Diphenhydramine • Benadryl and others (nonprescription)
  
• Divalproex sodium • Depakote
  
• Mirtazapine • Remeron
  
• Risperidone • Risperdal
  
• Trazodone • Desyrel
  
• Zaleplon • Sonata
  
• Zolpidem • Ambien
  

Disclosures

Dr. Owens receives research support from Sepracor, Eli Lilly & Co., and Cephalon; is a consultant to Eli Lilly & Co., Cephalon, and Shire; and is a speaker for Eli Lilly & Co., Cephalon, and Johnson & Johnson.