As a child’s brain develops, their sleep patterns also undergo significant changes. Sleep is regulated by the circadian rhythm, which controls cycles of sleep and wakefulness. Both the architecture of sleep and the amount of sleep needed vary throughout development. Infants typically need 14-17 hours, school-aged children need 9-12 hours, and teenagers need 8-10 hours of sleep per day. Pediatric insomnia and related sleep disturbances affect approximately 30% of school-aged children and 24% of adolescents. Insomnia is characterized by difficulty falling asleep, difficulty staying asleep, and/or early morning awakenings at least three nights per week for at least three months. Sleep disturbances can lead to poorer quality of life, impaired cognition, increased obesity, poorer school performance, and greater risk-taking behaviors. Sleep disturbances are also highly comorbid with psychiatric conditions, including depression, anxiety, substance use disorders, Attention-Deficit/Hyperactivity Disorder (ADHD), and Autism Spectrum Disorder (ASD), as well as with medical conditions, such as chronic pain.
When presented with a youth experiencing sleep problems, a provider must first take a comprehensive, developmentally appropriate sleep history. Using the “BEARS” acronym can be helpful in remembering to ask about Bedtime problems, Excessive daytime sleepiness, Awakenings during the night, Regularity of evening sleep time and morning awakenings, and Sleep-related breathing problems or Snoring. Asking youth and their families to maintain a sleep log, including sleep and wake times, caffeine intake, exercise, and any other associated behaviors, for at least two consecutive weeks can provide valuable information (see this link for an example: Sleep Diary). Questionnaires, such as the Epworth Sleepiness Scale for Children and Adolescents, School Sleep Habits Survey, and Children’s Sleep Habits Questionnaire, can provide additional insights. If there are concerns about organic causes of insomnia, such as narcolepsy or obstructive sleep apnea, consider ordering polysomnography and/or referring to a sleep specialist.
The first step in addressing pediatric insomnia is to implement behavioral interventions aimed at improving sleep hygiene. Key tips include reducing substance use (including caffeine), limiting screen time before bed, creating a healthy sleep environment, maintaining a regular sleep/wake schedule, practicing a consistent bedtime routine, avoiding naps, and exercising regularly (though not immediately before bed). It is essential to enlist the support of a parent or caregiver to help implement these behavioral changes. Such interventions alone can be highly effective in improving sleep.
If further intervention is needed, consider referring the youth to a therapist trained in Cognitive Behavioral Therapy for Insomnia (CBT-I). CBT-I is a 4-6 session, evidence-based program that can help children and adolescents with sleep onset latency, the number and duration of awakenings, and total sleep time. About 70-80% of patients experience a therapeutic response, and 40% achieve clinical remission. CBT-I involves the following components: sleep education, stimulus control, sleep restriction therapy, cognitive behavioral therapy, and relaxation techniques.
- Sleep education provides youth and their families with information on how sleep works.
- Stimulus control encourages going to bed only when sleepy, leaving the bedroom if awake for more than 20 minutes, avoiding naps, maintaining a regular wake-up time, and other strategies to strengthen the bed as a cue for sleep and weaken it as a cue for wakefulness.
- Sleep restriction therapy involves systematically limiting the time spent in bed to increase sleep efficiency, or the ratio of time asleep to time in bed.
- Cognitive behavioral therapy targets restructuring maladaptive thoughts that interfere with sleep, such as worries about sleep loss.
- Relaxation training involves learning techniques like diaphragmatic breathing, progressive muscle relaxation, imagery, and other strategies to improve sleep.
Overall, behavioral interventions are preferred over pharmacological treatments for sleep issues, especially in youth. Currently, no medications are FDA-approved for pediatric insomnia. Medications, such as melatonin, antihistamines, and alpha agonists, can be trialed off-label on a short-term basis in conjunction with behavioral interventions, but most are not evidence-based, have limited effectiveness, and may cause adverse side effects. Psychotropic medications may be warranted if comorbid psychiatric conditions are contributing to sleep difficulties.
References
Lunsford-Avery JR, Bidopia T, Jackson L, Sloan JS. Behavioral treatment of insomnia and sleep disturbances in school-aged children and adolescents. Child Adolesc Psychiatr Clin N Am. 2021 Jan;30(1):101-116. doi: 10.1016/j.chc.2020.08.006.
Moturi S, Avis K. Assessment and treatment of common pediatric sleep disorders. Psychiatry (Edgmont). 2010;7(6):24-37.
Shatkin, J, Ivanenko A, Gruber R. Cognitive behavior therapy for insomnia. Presented as part of AACAP’s 2024 Annual Meeting; October 19, 2024; Seattle, WA.
Sleep disorders: Parents’ medication guide. Available at: https://www.aacap.org/App_Themes/AACAP/Docs/families_and_youth/med_guides/SleepDisorders_Parents-Medication-Guide-web.pdf (Accessed: 13 November 2024).
AUTHOR:
Dr. Kristen Kim, MD, Psychiatrist
Vista Hill Foundation