Insomnia in Children and Adolescents
Insomnia in Children and Adolescents Insomnia in Children and Adolescents Karen Chalanick, RN, PNP-BC Disclosures I have no disclosures Learning Objectives Recognize sleep behaviors that are maladaptive, as well as beliefs and attitudes about sleep that contribute to insomnia. Recognize the clinical presentation of insomnia in a pediatric patient. Identify several of the most common problems that co-exist with insomnia. Describe the purpose of sleep hygiene and behavioral therapy. Identify several medications used in treatment of insomnia in children and teens. The Purpose of Sleep Much of what we understand has been derived from studying the impact of induced sleep loss Adequate sleep is a biologic necessity, rate of metabolism decreases helping to conserve energy Most of our major organs are less active during sleep, thereby helping to conserve function over time Purpose of Sleep REM sleep plays an active role in memory consolidation Release of growth hormone during deep, slow wave sleep links sleep to somatic growth Proteins, cells, and tissue are synthesized in greater amounts during sleep Insomnia A working definition: Occurs despite adequate opportunity for sleep Difficulty initiating or maintaining sleep or waking up too early Sense of non restorative sleep There is daytime impairment related to nighttime sleep problems Multiple “official” definitions exist for insomnia The American Psychiatric Association Distinguishes primary insomnia as insomnia that is considered to be a distinct diagnostic entity from insomnia that is a symptom of another underlying medical and /or psychiatric condition The American Academy of Sleep Medicine Refers to this as psychophysiologic insomnia This term better describes how insomnia is initiated and maintained; the patient feels a sense of hyperarousal (increased muscle tension, increased heart rate, sweating)while 1 Insomnia in Children and Adolescents attempting to sleep. Learned sleep preventing behaviors trigger these responses and this becomes a vicious cycle. Initial, middle, terminal insomnia are older ways to describe when the problems occur in the sleep cycle Treating Insomnia in Children It is rarely the patient themselves who is concerned about the problem of sleeplessness Parents of older children and adolescents are less likely to be aware of sleep problems, as compared to parents of infants and toddlers Cultural differences in what is acceptable in regards to sleep practices have a huge effect on how a parent views treatment Caregivers of the sleepless child often suffer as well from sleep deprivation and stress Increased marital tension, decreased attention to siblings, daytime sleepiness to all can result in poor quality of life for the whole family Behavioral Insomnia of Childhood In young children behavioral insomnia often is characterized by bedtime refusal and struggles, limit setting problems and /or prolonged night wakings requiring parental intervention Behavioral Insomnia of Childhood Limit setting type Characterized by noncompliant behaviors at bedtime such as bedtime refusal, verbal, protests, repeated demands. This leads to delayed sleep onset Most common in preschoolers and young school age children Usually develops from caregivers inability to provide consistent bedtime rules, and is made worse by a child's oppositional behavior Behavioral Insomnia of Childhood Sleep Onset Problems Frequent and prolonged night wakings that require care provider intervention to help the child return to sleep There is a significant delay in sleep onset in the absence of the required conditions (parental presence, bottle, cup, pacifier) Child has not learned how to self soothe, and signal the care provider until the needed associations are provided. Treatment When left untreated bedtime problems can become chronic Behavioral interventions are usually effective with no adverse effects Care providers must be consistent Protesting behavior often escalates at the beginning of the treatment 2 Insomnia in Children and Adolescents Treatment Consistent, calm bedtime routine, non-stimulating Appropriate sleep associations; blanket, stuffed animal Fall asleep independently, parent leaves room while drowsy but still awake Bedtime fading; temporarily move bedtime later, then slowly move back to desired time Positive reinforcement for good bedtime behaviors Psychophysiologic insomnia More common in older children and teens Characterized by combination of learned sleep-preventing associations and heightened physiologic response, resulting is sleeplessness Excessive worry about sleep Exaggerated concern regarding possible daytime consequences The Behavioral Model of Insomnia Spielman et al 1987 Insomnia occurs acutely in relation to predisposing and precipitating factors and the chronic form is maintained by maladaptive coping behaviors (perpetuating factors) A child be prone to insomnia due to personality traits (predisposing), experiences acute insomnia because of precipitating factors, and this grows into chronic insomnia because of perpetuating behaviors. Predisposing Factors Hyperarousal/Hyperreactivity (ADHD for example) Anxiety, tendency to excessively ruminate Work schedules of parents that disrupt a child’s natural sleep schedule Precipitating Factors Acute occurrences that interact with the patients predisposition for insomnia to produce problems with sleep initiation and maintenance Illness, injury, pain Onset of psychiatric illness Acute changes in social environment; divorce, new sibling, starting school, moving to new house Perpetuating factors A variety of maladaptive strategies that arise from attempts to get more sleep Spending excessive time in bed; tendency of people to go to bed earlier, get out of bed later, and/or nap in an effort to increase the opportunity to get more sleep Non-sleep related behaviors occurring in the bedroom; TV, computer, homework, phone, eating Caffeine use, stimulants 3 Insomnia in Children and Adolescents Prevalence of Psychophysiologic Insomnia Uncommon in prepubertal children Roughly 12-33 % of teens who report they are poor sleepers, no prevalence studies done on “normal” populations of school-age children or adolescents In adults, more common in females Assessment of Insomnia Medical history Developmental/school history Family history Behavioral assessment Physical exam Diagnostic Testing and Insomnia Sleep diaries Actigraphy Lab evaluation Polysomnography Sleep diaries The primary tool for prospective assessment of insomnia Reveals prolonged sleep onset, nighttime awakenings, early morning awakenings Reveals information about maladaptive bedtime behaviors Reveals information about behaviors that maintain the insomnia No standard for sleep diaries Sleep diaries Actigraphy Measures, stores, and analyzes body activity over an extended period of time Portable device that looks like a watch, worn on wrist or ankle Useful in obtaining an objective measurement of sleep duration and sleep patterns in the home Actiwatch Lab evaluation Tailored to specific history given by child and family Could include iron studies, drug screen 4 Insomnia in Children and Adolescents Polysomnography (Sleep study) Not typically indicated unless underlying sleep disorder is also suspected Insomnia does not typically alter sleep architecture (the distribution of different sleep stages) ADHD Some areas of the brain that are affected in ADHD are the same structures that are involved in the regulation of sleep; problems with attention and alertness and problems with insomnia may be the results of abnormal cortex arousal function The Brain and ADHD The frontal lobes help us to pay attention to tasks, focus concentration, make good decisions, plan ahead, learn and remember what we have learned, and behave appropriately for the situation. The inhibitory mechanisms of the cortex keep us from being hyperactive, from saying things out of turn, and from getting mad at inappropriate times, for examples. They help us to "inhibit" our behaviors. The limbic system is the base of our emotions. A normally functioning limbic system would control normal emotional changes, normal levels of energy, normal sleep routines, and normal levels of coping with stress. A dysfunctional limbic system results in problems with those areas. The Attention Deficit Hyperactivity Disorder might affect one, two, or all three of these areas, resulting in several different presentations. ADHD and insomnia ADHD has one of the highest rates of sleep problems of all child mental health disorders Prevalence estimates of sleep problems range from 50-80% Bedtime resistance related to co morbid anxiety Stimulant medications impact on delayed sleep onset Settling difficulties at bedtime due to an increase of ADHD behaviors when meds are wearing off ADHD and Sleep Assessment ADHD may cause sleep problems; unable to slow down thoughts and settle for sleep insomnia Primary sleep disorder may cause ADHD like symptoms; OSA daytime sleepiness, inattention can contribute to both ADHD and insomnia 5 Insomnia in Children and Adolescents Anxiety The brain’s response to danger or stimuli that the child or teen actively would like to avoid It is a response present from infancy and it is not normally pathological as it protects us from danger Anxiety becomes maladaptive when it interferes with functioning, becomes frequent, severe and persistent Children exhibit anxiety and fears as part of normal development Anxiety disorders There are many (over 10) specific anxiety disorders classified in the DSM- IV Many share common clinical features such as physiologic symptoms such as increased heart rate, sweating, sleep disturbances, increase blood pressure, extreme avoidance of certain objects. Some features present differently in young children and adolescents Anxiety and sleep Anxious children and children who have experienced significant trauma show an increased incidence of Difficulty falling to sleep Refusal to sleep alone Difficulty staying asleep Nightmares Nighttime fears Anxiety and insomnia A bidirectional relationship exists sleepanxiety and anxietysleep Racing thoughts, anticipatory worry physiologic arousal at bedtime insomnia Insomnia in childhood is a risk factor for developing anxiety, as well as depression in adolescence and adulthood Restless Legs Syndrome Sensorimotor disorder characterized by uncomfortable sensations in legs and an urge to move the legs The urge is worse when sitting still for a long time or when lying down Improves with movement Worse in the evening or night Age-appropriate description of discomfort; legs hurt, feel tingly, creepy, legs have lots of energy Contributes to sleep disturbance (delayed sleep onset) 6 Insomnia in Children and Adolescents Restless Legs Syndrome Prevalence: 2-4 % of 8-18 year olds No gender differences Positive parental history in >70% Frequently found in children with ADHD RLS and low iron stores The connection was made as it was recognized that populations at higher risk for iron deficiency have higher incidence of RLS; end stage renal disease, pregnant women, frequent blood donors The hypothesis is that in RLS, stores of iron or the transport and metabolism of iron may be enough to maintain RBC production but not sufficient to maintain normal brain iron stores, which in turn may lead to reduced dopamine synthesis Dopamine is a neurotransmitter that is, in part, involved in motor function and control Reduced dopamine in brain decreased motor control motor restlessness such as is seen in RLS CBC may be normal, but serum ferritin <50 is associated with RLS Hypnogram in normal sleeper Sleep Hygiene’s Role in Insomnia Therapy Sleep Hygiene Purposeful, intentional practices that promote good sleep quality, allow adequate sleep duration, and prevent daytime sleepiness Sleep environment, sleep routine, and daytime activities are all important aspects Recommendations from the 2004 National Sleep Foundation Sleep in America Poll 2004 National Sleep Foundation “Sleep in America Poll” Recommendations Children of all ages should fall asleep independently Children should be in bed before 9 pm Children should have an established bedtime routine Reading should be included as part of the bedtime routine Bedrooms should not have televisions Children should refrain from caffeine consumption Sleep Hygiene Concept was first introduced over 100 years ago Healthy habits for good sleep Helps to keep our mind and body rested and strong Mostly common sense ideas based in science It is not a treatment for insomnia, but it IS the foundation for all other behavioral treatments used 7 Insomnia in Children and Adolescents Stimulus Control Is intended to help the insomniac learn how to fall asleep quickly in bed Good for both problems getting to sleep and staying asleep The first line of behavioral therapy, sometimes is all that is needed Stimulus Control Limits the amount of time spent in the bedroom while awake, as well as the kinds of behaviors Limitations are meant to strengthen the association between the bed/bedroom/bedtime with fast, well consolidated sleep In insomnia bed and bedtime may have become cues for behaviors that are incompatible with falling asleep TV, reading, eating, homework, phone are all within easy reach This quiet time allows for rehashing of the days events, worry, excitement Bedtime becomes a cue for arousal rather than a cue for sleep Stimulus Control One stimulus, the BED, should elicit one response, SLEEP! Only go to bed when sleepy Avoid any behavior in the bedroom other than sleep Leave the bed if awake for more than 15 minutes Return only when sleepy Have a fixed wake up time 7 days/week Sleep Restriction Therapy Also helpful for both sleep initiation and maintenance problems Not usually used as the first line behavioral treatment, not usually used as only treatment Refers to the planned restriction of time in bed to a minimum number of hours, usually based on the average amount of sleep obtained/ night (minimum of 6 hours in children) Sleep Restriction Therapy Establish fixed wake up time Decrease the opportunity for sleep by limiting the child’s time in bed to the average amount of time they sleep This results in a mild sleep loss at first, and creates controlled sleep deprivation sleep onset latency and amount of time awake during the night Bedtime is gradually advanced earlier at a rate that is based on good sleep efficiency 8 Insomnia in Children and Adolescents Sleep Restriction Therapy (SRT) SRT works because It prevents children from coping with their insomnia by extending their sleep opportunity (going to bed earlier, sleeping in later) The initial sleep loss that occurs strengthens the sleep drive, reduces the time it takes to fall asleep, improved quality of sleep improved sleep efficiency Insomnia statistics from sleep study SLEEP SUMMARY Lights Out: 22:36:10 Lights On: 06:00:11 Analysis Duration: 444.0 min Sleep Period: 390.0 min Total Wake Time (During Sleep Period): 48.0 min Total Sleep Time: 342.0 min Sleep Efficiency (analysis period): 77.0% Sleep Latency to first 60 seconds of sleep: Latency to Stage N1 54.0 min Latency to Stage N2 88.5 min Latency to SWS 110.5 min REM Latency from sleep onset: 136.5 min 54.0 (12.3%) min Number of Awakenings: 37 Awakenings Index: 6.5 Number of Arousals: Arousal index: 67.9 387 STAGE Duration % of TST N1 67.0 min 19.6% N2 221.5 min 64.8% N3 29.5 min 8.6% REM 24.0 min 7.0% Total NREM 318.0 min 93.0% Relaxation Training Most suitable for children and teens with anxiety, ADHD and have a hard time settling down to sleep Reduces physiologic arousal Reduces cognitive processes such as racing thoughts, worrying 9 Insomnia in Children and Adolescents Relaxation Training Progressive Muscle Relaxation Reduces skeletal tension Diaphragmatic breathing Slower, deeper breathing from the abdomen mimics the type of breathing that should occur naturally at sleep onset Imagery training Developing a relaxing image or memory and engaging multiple senses to help relax; sight, smell, sound, touch Cognitive Restructuring Teaching the patient to change the way they think about their sleep Investigate negative thoughts and beliefs about sleep Then challenge the logic of these thoughts and beliefs and replace them with balanced thoughts “If I don’t fall asleep soon I will definitely fail my exam tomorrow” Replace with balanced thoughts Well, even if I fail it’s only one test I’m not going to fail, I studied hard and I know the material I have a good grade in the class and I worked hard. I’ll do fine When to use medications Most insomnia in children and teens can be managed with a combination of behavioral therapy and a change of habits (for both child and parents) There are specific clinical populations for whom medications for sleep have been found to be an important part of the treatment plan Autism, ADHD, psychiatric illness Guidelines for use of pharmacologic agents Appropriate behavioral interventions have not been fully effective Assessing appropriate care provider expectations for the child's sleep Choice of medication should be diagnostically driven; reason for insomnia determined and medication selected that best addresses the primary problem Guidelines for selection of medication Short acting agents best for problems with sleep onset Long acting meds for problems with sleep maintenance Half life of all medications understood with goal to minimize a “medication hangover” in the morning Have a clear game plan established with care provider regarding goals and long term plan 10 Insomnia in Children and Adolescents Melatonin Hormone secreted by the pineal gland that binds to receptors in the suprachiasmatic nucleus (SCN) in the hypothalamus Stimulated by dark, inhibited by light Endogenous melatonin production begins 1-2 hours before sleep and increases throughout the night Melatonin suppression is associated with autism Melatonin Exogenous melatonin functions in 2 different ways, depending on the dose and the timing As a chronobiotic (helps to shift the circadian sleep-wake cycle) Smaller doses, 0.5 mg, given 5-7 hours before desired bedtime Useful if delayed sleep onset seems circadian in nature as in delayed sleep phase syndrome As a mild hypnotic (sedating) Larger dose, 3-5 mg, taken 1 hour before desired sleep onset This is the more common use Melatonin Peak serum levels 60-150 minutes after taken Dose of 5 mg produces peak blood levels 25 x’s above physiologic levels Categorized by FDA as a dietary supplement, prescription not required Generally regarded as safe, potential adverse effect of suppression of the hypothalamic – gonadal axis which could trigger precocious puberty in a child who has been taking it awhile and then discontinues it abruptly Contraindicated with autoimmune disorders or if taking immunosuppressants Iron supplements Used for treatment of restless legs syndrome, if the child has iron deficiency, specifically a serum ferritin <50 Toddlers and adolescent girls are at increased risk for iron deficiency Iron is required in dopamine synthesis, insufficient dopamine motor restlessness such as is seen in RLS Iron therapy for RLS Oral tablet, chewable or liquid 3-6 mg/kg of elemental iron/day with 250 mg vitamin C Avoid giving with calcium containing foods Goal is ferritin above 50 ng/ml Side effects may include constipation, nausea and black stools, temporary staining of teeth Reevaluate in 3 months Often will need to continue past 3 months, some children will require some additional supplementation throughout childhood 11 Insomnia in Children and Adolescents Clonidine Used for problems with sleep onset, used most often with ADHD Rapidly absorbed , onset of action in 1 hour, peak effects 2-4 hours Dosing in children > 6 years old 0.05 – 0.2 mg before bedtime Potential side effects include irritability, low blood pressure, rebound hypertension with abrupt disruption Antihistamines OTC diphenhydramine has shown modest efficacy in reducing sleep onset latency Potential adverse effects include paradoxical excitation Tolerance can develop Typical dosing in children is 0.5 mg/kg (max of 25 mg) Peak plasma levels in 2-3 hours ½ life in children is shorter than in adults (8 hours) Antihistamines Hydroxyzine FDA approved for anxiety in children and adults, so could be considered for problems with sleep onset when anxiety is a strong component Potential side effects the same as diphenhydramine Children and Adolescents: 0.6 mg/kg/dose; maximum single dose: 100 mg when used for sedation Benzodiazepines Hypnotic effect is mediated by their action at GABA type A receptors GABA is the major inhibitory neurotransmitter in the brain Increasing the available amount of GABA typically has a relaxing, anti-anxiety, and anticonvulsive effects, decrease arousal Benzodiazepines Shorten sleep latency, increase total sleep time, improve sleep maintenance Lorazepam, diazepam, clonazapam, alprazolam all are indicated for use in anxiety and seizures but not insomnia Risk for addiction Should only be used for short term insomnia, or in clinical situations in which their other properties are in useful (anxiety, seizures) Non - benzodiazepines Mechanism of action is the same as the benzo’s but but they bind more selectively to GABA A receptors Zaleplon (Sonata) and Zolpidem (Ambien) are short acting and approved for use in adults, not in children Eszopiclone (Lunesta) is long acting, approved for use in adults Potential side effects include dizziness, confusion, headache 12 Insomnia in Children and Adolescents Conclusions Insomnia in children negatively impacts not just the child but the whole family Most children have the capacity to be good sleepers; that’s why behavioral therapy usually works Coexisting medical and/or developmental conditions may require pharmacologic therapy as well Our job includes educating our patients and their families about the importance of sleep References Bootzin, Richard, Stevens, Sally (2005). Adolescents, substance abuse, and the treatment of insomnia and daytime sleepiness. Clinical Psychology Review, 25, 629-644. Yoon, Sun Young, Jain,Umesh (2012). Sleep in attention-deficit/hyperactivity disorder in children and adults: Past, present, and future. Sleep Medicine Reviews, 16, 371-388. Beesdo, Katja, Knappe, Susanne (2009). Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V. Psychiatric Clinics of North America, 32, 483 – 524. Corkum, Penny, Davidson, Fiona (2011). A Framework for the Assessment and Treatment of Sleep Problems with Attention-Deficit/Hyperactivity. Pediatric Clinics of North America, 58, 667-683. Owens, Judy, Mindell, Jodi (2011). Pediatric Insomnia. Pediatric Clinics of North America, 58, 555- 569. Perlis, Michael, Jungquist, Carla (2008). Cognitive Behavioral Treatment of Insomnia. New York, NY, Springer. Spielman, Arthur, Caruso, L (1987). A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America, 4, 451-553. 13
© Copyright 2024