Sleep Disorders in Children and Adolescents: Understanding Causes and Treatment Options

Sleep Disorders in Children
and Adolescents
Deepti Shenoi MD
Objectives
To gain an understanding of
normal basic sleep physiology
and pathology in children and
adolescents
To learn developmentally
appropriate behavioral
techniques for improving sleep
To obtain an understanding of
options in pharmacotherapy for
pediatric insomnia
I would also like you to think of
iatrogenic causes for sleep
difficulties. Or how we can make
things worse.
StagesofSleep
General Sleep Stages
Typical sleep need for children and

adolescents by developmental stage
Age group
Years
Total sleep need
Infants
Toddlers
Preschoolers
School-aged
Adolescents
3 to 12 months
1 to 3 years
3 to 5 years
6 to 12 years
12 to 18 years
14 to 15 hours
12 to 14 hours
11 to 13 hours
10 to 11 hours
8.5 to 9.5 hours
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents.

Psychiatr Clin North Am 2006; 29(4): 1059-76
Sleep Time During Development
Thiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84
Newborns
(0-3 months)
Sleep 10-18 hours per day
Many short sleep periods, with no
differentiation between day and night.
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am
2006; 29(4): 1059-76
Tips for newborns and

infants (up to 6mo)
Nighttime awakenings for changing and feeding
should be quick and quiet
Place baby in the crib before falling asleep (when
drowsy)
Avoid feeding the baby to sleep
Simple bedtime routinesoothing activities in the
same order every night
GOAL: Babies to fall asleep by themselves and learn
to soothe themselves and go back to sleep if they
wake up in the middle of the night
Mindell JA, Meltzer LJ. Behavioural Sleep Disorders in Children and Adolescents. Annals
Acad of Medicine. 2008; 37:722-28.
Toddlers
(12 mo-3 yrs) and
Preschoolers (3-5 yrs)
Maintain a daily sleep schedule with regular
naptimes and bedtime
Establish a consistent bedtime routine.
Bedroom should be quiet, comfortable, and
dark
Have the child fall asleep independently.
Set limits that are consistent and enforced.
Encourage use of a security object, such as a
blanket or stuffed animal.
School-Aged
Children(6-12 yrs)
Same bedtime and wake-up on weekdays and
weekends
A 20- to 30-minute bedtime routine that is the same
every night.
No caffeine
No TV in the bedroom
The child should spend time outside every day and get
daily exercise
Adolescents
(12-18 years)
Need 9-9.25 hours of sleep per night but studies
show that most get 7 hours/night
Onset of puberty hormonal changes and shift in
melatonin 2 hour shift in circadian rhythm phase
(later sleep onset and morning wake time)
Some experience a physiological need for a short
sleep period in early afternoon
Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents. Psychiatr Clin North Am 2006; 29(4):
1059-76
What to ask in a sleep

evaluation?-- Sleep History
Bedtime: Evening activities, bedtime routines
Night-time: Latency to sleep onset, behaviors
during the night, # and duration of
awakenings
Daytime: Daytime sleepiness, naps, caffeine
intake, psychological, social and family
functioning
What to ask in a sleep

evaluation?-- Sleep Hygiene
Consistentandappropriatesleepwake
schedule
Similarscheduleonweekdaysand
weekends
Consistentbedtimeroutinethatinvolves
same34activitieseverynight
Notechnologyinthebedroom
BEARS screen (for kids 218y.o.)
Bedtime problems
Excessive daytime sleepiness
Awakenings during the night
Regularity of evening sleep time and
morning awakenings
Sleep related breathing problems or
snoring
CommonDisorders
BehavioralInsomniaofChildhood
InsufficientorInadequatesleep
DelayedSleepPhaseSyndrome
SleepDisorderedBreathing
DisordersofArousal
Movementdisorders
Behavioral Insomnia
of Childhood
Manifests most commonly as
bedtime resistance and/or frequent
night wakings and occurs in
approximately 10% to 30% of
infants and toddlers
Sleep-onset Association Type
Limit-setting type
Combined Type
2006; 29(4): 1059-76
Insufficient or Inadequate
Sleep
Sleep deprivation can have a cumulative
effect being late or missing school, falling
asleep during school, fatigue, illness, and
irritability
Poll reports that 28% of high school students
report falling asleep in school at least once a
week
Insufficient sleep can be fatal for adolescents
who fall asleep while driving.
2006; 29(4): 1059-76
Insufficient or Inadequate
Sleep
Signs that children or adolescents are not
getting enough sleep include:
(1) needing to be awakened for school or
day care in the morning,
(2) sleeping 2 hours more on weekends
and vacations compared with weekdays,
(3) falling asleep in school or at other
inappropriate times,
(4) behavior and mood differing on days
after getting more sleep
2006; 29(4): 1059-76
Delayed Sleep Phase

Syndrome
The persons sleep-wake cycle is
delayed by 2 or more hours
Night Owls
2006; 29(4): 1059-76
Delayed Sleep Phase

Syndrome
Delayed Sleep Phase

Syndrome-Treatment
Sleep hygiene
Shifting the internal clock
PhaseAdvancement:Whenthedifferencebetweenthe
actualanddesiredbedtimeislessthan3hours.Every
nightortwo,gotosleep15minutesearlier.
PhaseDelay:Whenthedifferenceisgreaterthan3hours,
delaysleepby23hoursonsuccessivenights
2006; 29(4): 1059-76
Sleep-Disordered Breathing
Can range from primary snoring to
obstructive sleep apnea syndrome (OSAS)
and is related to signicant cognitive and
behavioral sequelae, including learning,
attention, concentration, hyperactivity,
and aggressive behavior
Incidence of habitual snoring has been reported at 3% to 12% of the general
pediatric population, with OSAS seen in
1% to 3% of children
2006; 29(4): 1059-76
Narcolepsy
Chronic neurologic disorder that
involves excessive daytime sleepiness
cataplexy (sudden loss of muscle control in
response to strong emotional stimuli)
hypnagogic hallucinations (vivid dreams at
sleep onset)
sleep paralysis
autonomic behavior in which you continue
to funtion, talk, clean but then have no
recollection of performing task
.
2006; 29(4): 1059-76
NarcolepsyWorkup
Polysomnography (PSG)
Typically fall asleep rapidly with early REM
Multiple sleep latency test (MSLT)
Test subjects are given opportunities to

sleep every two hours during the normal
awake time and monitored to see how
quickly they fall asleep and reach various
stages of the sleep cycle.
May provide clear evidence of narcolepsy,
but in children, results are not always
conclusive, and repeat studies may be
necessary for a nal diagnosis
Narcolepsy
Individualized based upon symptoms.
Treatment includes education, sleep hygiene, and
pharmacologic interventions
Daytime Sleepiness:
Sleep scheduling is essential, with a consistent bedtime,

wake time, and good sleep hygiene
Children and adolescents who have narcolepsy may
benet from a scheduled daily nap in the early
afternoon.
Stimulants are commonly used to treat daytime
sedation including provigil
Atomoxetine has also been used.
Cataplexy: Cholinergic pathway mediated
medications with anticholinergic properties are used to

treat cataplexy, including clomipramine and imipramine
2006; 29(4): 1059-76
Disorders of Arousal
Referred as partial arousal parasomnias and
include: confusional arousals, sleep terrors,
sleep talking, and sleepwalking
During an event, although children are
asleep, they may appear awake (eyes
open), talk, or seem frightened or confused
(eg, screaming in the case of sleep terrors)
Typical parasomnias resolve spontaneously
with children rapidly returning to a deep
sleep
2006; 29(4): 1059-76
Common feature: retrograde amnesia
Strong genetic component to partial
arousal parasomnias, with a family
history typically reported
Partial arousals are more likely to be
triggered by insufficient sleep, a
disruption to the sleep environment or
sleep schedule, stress, illness, or certain
medications (eg, chloral hydrate or
lithium)
2006; 29(4): 1059-76
Sleep Terrors vs Nightmares

ComparisonofSleepTerrorsandNightmares
Factor
SleepTerrors
Nightmares
Age
3to8years
Anyage
Gender
Malepredominance
Either
OccurrenceinSleepCycle
NREM
REM
Arousable?
No
Yes
MemoryforEvent
None
Yes
ExacerbatedbyStress
Yes
Yes
REM=rapideyemovement,NREM=nonrapideyemovement
Thiedke, CC. Sleep Disorders and Sleep Problems in Children. Am Fam Physician 2001;63:277-84
Treatment: providing families with information
about creating a safe sleep environment (eg,
preventing windows from opening or putting alarms
or bells on doors to alert if a sleep walker is up),
education about the events, and how to interact
with children appropriately during an event
As some children may develop a fear of going to
sleep and a prolonged sleep onset in turn
increases the likelihood of an event occurring,
parents should be encouraged to not discuss these
events in the morning with the child or other
children in the home
2006; 29(4): 1059-76
Restless Leg Syndrome and Periodic

Limb Movement Disorder
RLS manifests as uncomfortable sensations in the
legs that worsen in the evening and with long
periods of inactivity (eg, long car ride or movie)
Sensations often are described as creepy-crawly or
tingling feelings, most commonly in the legs, which
can be alleviated temporarily with movement.
PLMS are brief repetitive movements or jerks,
lasting on average 2 seconds and occurring every
5 to 90 seconds during stages 1 and 2 of sleep
PLMD occurs when PLMS are associated with
frequent, but brief, arousals from sleep
2006; 29(4): 1059-76
Restless Leg Syndrome and Periodic

Limb Movement Disorder
Pharmacologic treatment for RLS and PLMD in
children and adolescents may include
benzodiazepine and dopaminergic medication
Some children who have RLS or PLMD have
low iron/ferritin and many of these children
and adolescents respond favorably to iron
therapy
At this time, there are no FDA-approved
medications available to treat RLS and PLMD
in children.
2006; 29(4): 1059-76
Sleep-Related Rhythmic
Movement Disorders
Include head banging and body rocking and
are considered to be a sleep-wake transition
disorder, occurring as children attempt to
fall asleep at bedtime, naptime, or after a
normal nighttime arousal
common in infants (60% of 9 month olds),
the behaviors tend to resolve spontaneously
with development (only 8% of 4 year olds
demonstrate these behaviors), but they can
continue into adolescence and adulthood
2006; 29(4): 1059-76
Sleep-Related Rhythmic
Movement Disorders
Events typically last 5 to 15 minutes, but
prolonged events can go for several hours
Important to ensure safety
In cases that result in injury, or when the
behavior may be highly disruptive to others for
a short duration (eg, family vacation or
overnight sleepover), benzodiazepines may be
indicated.
Evaluation is recommended for severe cases or
cases persisting past age 3
2006; 29(4): 1059-76
Optimizing Treatment of
Sleep Problems
Identification of the suspected causes of
disrupted sleep
Involvement of the family by explaining the
disorder and teaching them developmentally
appropriate principles of sleep-wake
organization
Use of behavioral treatments such as
contracts to target specific behaviors that
need to be changed
Anders, TF, Eiben LA. Pediatric Sleep Disorders: A Review of the Past 10 Years. J Am Acad Child Adolesc
Psychiatry. 1997;36:9-20.
Pharmocotherapy of Pediatric
Insomnia: General Guidelines
Reminder: In almost all cases, medication is neither
the first treatment of choice, nor the sole treatment
for children
Medication should be used in combination with nonpharmacological strategies as these have been
shown to have long-lasting effects
Treatment selection - best match between clinical
circumstances and individual properties of
medications
Medications should be closely monitored for
emerging side effects
Owens, JA. Pharmocotherapy of Pediatric Insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48:99-107.
Insomnia: General Guidelines
Presence of both medically and behaviorallybased sleep disorders must be assessed
Medications should be used in caution in
situations where there may be potential drugdrug interactions
Non-prescription and over-the-counter
medication use should be assessed
Insomnia
Antihistamines: Prescription (hydroxyzine)
and OTC (diphenhydramine)
Bind to H1 receptors in the CNS
Rapidly absorbed
Side effects: daytime drowsiness,
cholinergic effects, paradoxical excitation
Insomnia: Melatonin
Melatonin: hormone secreted by pineal gland
in response to decreased light, mediated
through suprachiasmatic nucleus; mechanism
of commercially available melatonin is to
supplement endogenous pineal hormone
Clinical uses for melatonin are principally in
normal children with acute or chronic
circadian rhythm disturbances and in children
with special needs (blindness, Rett
syndrome)
Insomnia: Melatonin
Plasma levels peak within 1 hour of
administration
Generally safe but potential side effects
include suppression of hypothalamic-gonadal
axis (i.e. could trigger precocious puberty
upon discontinuation
Not regulated by FDA
Reported doses: 1 mg in infants, 2.5-3 mg in
older children, 5 mg in adolescents
Insomnia: Herbal Preparations
Valerian Root, St. Johns Wort, and Humulus
lupulus - some evidence of efficacy in adult
and/or pediatric studies
Lemon balm, chamomile, and passion flower limited to no evidence
Kava kava, Tryptophan - assoc. with
significant safety concerns (e.g. hepatotoxicity
and eosinophilic myalgia syndrome,
respectively)
Insomnia: Benzodiazepines
Hypnotic effect mediated at GABA Type A
receptors in the brain
They shorten sleep- onset latency, increase
total sleep time, and improve non-REM sleep
maintenance; most disrupt slow-wave sleep.
Use of longer- acting BZDs may lead to
morning hangover, daytime sleepiness, and
compromised daytime functioning.
Anterograde amnesia and disinhibition may
also occur.
Insomnia: Benzodiazepines
Risk for habituation or addiction with these
medications, as well as withdrawal
phenomena
Used for short-term or transient insomnia or
in clinical situations in which their other
properties (e.g., anxiolytic) are
advantageous
BZDs are occasionally used to treat
intractable partial arousal parasomnias (e.g.,
sleep terrors) in children because of their
slow-wave sleep suppressant effects.
Insomnia: Melatonin Receptor Agonist
Ramelteon (Rozerem): a synthetic melatonin
receptor agonist, acting selectively at the
MT1 and MT2 receptors
Approved for use in sleep initiation
insomnia, and shows moderate efficacy in
reducing sleep-onset latency (in adults)
Two single pediatric case reports have
reported efficacy in autistic children
Insomnia: -Agonist
Clonidine: central 2-agonist that decreases
adrenergic tone
one of the most widely used medications
for insomnia in pediatric and child
psychiatry practice, particularly in
children with sleep- onset delay and
ADHD
safety and efficacy in children with ADHD
and sleep problems is limited to
descriptive studies
Insomnia: -Agonist
Clonidine is rapidly absorbed with onset of action within
1 hour and peak effects in 2-4 hours
Tolerance often develops necessitating increase in dose
Discontinuation may lead to rebound in REM and slowwave sleep
Possible side effects include: hypotension and
bradycardia, anticholinergic effects, irritability,
and dysphoria; rebound hypertension may occur
on abrupt discontinuation
Avoid in patients with diabetes and Raynaud
syndrome
Insomnia: Atypical Antidepressants
Trazodone: one of the most sedating
antidepressants because it both inhibits
binding of serotonin and blocks histamine
receptors
Suppressant effects on REM and may
increase slow-wave sleep
Morning hangover is a common side
effect
Associated with reports of priapism in the
50- to 150-mg dose range
Insomnia: Atypical Antidepressants
Mirtazepine (Remeron) 2-adrenergic 5hydroxytryptamine receptor agonist
with a high degree of sedation
Shown to decrease sleep- onset latency,
increase sleep duration, and reduce
wake after sleep onset in adults with
and w/o major depression with little
effect on REM
Insomnia
SSRIs: may cause sleep-onset delay and sleep
disruption (Fluoxetine) and sedation (Fluvoxamine,
Paroxetine, Citalopram)
SSRIs suppress REM sleep and often prolong REM
onset while increasing the number of REMs
Most increase sleep-onset latency and decrease
sleep efficiency (time asleep/time in bed)
Selective serotonin reuptake inhibitors frequently are
associated with motor restlessness and may
exacerbate preexisting RLS and periodic limb
movements
Insomnia
Other classes which have reportedly been used include mood

stabilizers/anticonvulsants (e.g., carbamazepine, valproic acid,
topiramate, gabapentin), atypical antipsychotics (e.g.
risperidone, olanzapine, quetiapine), and chloral hydrate.
These meds should be used with caution as there are no or
limited date on safety and tolerability.
Sedating effects may interfere with daytime functioning and
learning
Atypical antipsychotics may cause weight gain and worsen
Obstructive Sleep Apnea; also tend to suppress REM sleep
and increase motor restlessness during sleep
Chloral Hydrate and Barbiturates are not indication for use in
children due to significant side effects (inc. hepatotoxcity)
The End

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Sleep Disorders in Children

General Sleep Stages

Typical sleep need for children and

Total sleep need

Meltzer LJ. Sleep and Sleep Disorders in Children and Adolescents.

Sleep Time During Development

Tips for newborns and

What to ask in a sleep

What to ask in a sleep

BEARS screen (for kids 218y.o.)

Delayed Sleep Phase

Delayed Sleep Phase

Delayed Sleep Phase

Typically fall asleep rapidly with early REM

Multiple sleep latency test (MSLT)

Test subjects are given opportunities to

Sleep scheduling is essential, with a consistent bedtime,

Cataplexy: Cholinergic pathway mediated

medications with anticholinergic properties are used to

Sleep Terrors vs Nightmares

Restless Leg Syndrome and Periodic

Restless Leg Syndrome and Periodic

Other classes which have reportedly been used include mood

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