Sleep Disorders in Children and Adolescents

John Preston, Psy.D.

    According the Shakespeare, sleep is the “bath and balm of hurt minds”. Sleep is the guardian of the brain; every night restoring the ability of the brain to function optimally. However, sleep is very fragile and almost any kind of stress can result in sleep disturbances. Sleep disturbances can occur with almost all psychiatric conditions as well as with primary sleep disorders. Poor or inadequate sleep is often not identified in many children and teens seeking psychological/psychiatric treatment, and is a common reason for less than adequate outcomes. One problem is that many parents simply do not know how well their child sleeps. Going to bed on time is one thing, but various forms of insomnia and other sleep problems may never be mentioned by youngsters and their parents simply do not know that a problem exists. It has been estimated that up to 25% of children and adolescents experience some form of sleep disturbance.

Sleep problems are commonly associated with situational stress, anxiety disorders, PTSD, depression and bipolar disorders. Initial insomnia (trouble falling asleep) is a common reaction to situational stress and is seen in most types of anxiety disorder. Middle insomnia (waking up numerous times during the night) and early morning awakening (waking up too early and being unable to go back to sleep) are frequently seen in people suffering from depression. Nightmares are very common in those with PTSD. And decreased need for sleep is a hallmark of mania. In each instance the pharmacological approach of choice is not to use sleeping pills, but rather to treat the psychiatric disorder (e.g. with psychotherapy, antidepressants, mood stabilizers, etc.).

    It is being increasingly recognized that primary sleep disorders are fairly common in children. These include night terrors, obstructive sleep apnea, bed wetting, sleep walking, and restless legs syndrome. Increasing rates of obstructive sleep apnea may be associated with significant increases in the incidence of childhood obesity. The treatment of these primary sleep disorders is beyond the scope of this article. The reader is referred to the National Sleep Foundation (www.sleepfoundation.org) for more information regarding treatment options for primary sleep disorders.

    A significant number of children do not have a sleep disorder per se, but simply do not sleep enough. Children (ages 1-5) need 12-14 hours of sleep per night; ages 6-12 need 9-11 hours and teenagers 9 hours per night. Youngsters stay up late often to play video games, watch television, be on the internet and social media or on cell phones. Of course sleep deprivation always results in some degree of daytime fatigue and decreased ability for maintaining concentration. However, beyond this is the significant negative impact of reduced sleep on all psychiatric disorders; especially evident is the adverse impact on affect regulation and a common cause of depression. Gangwisch, et al. (2010) conducted an in home survey on 15,652 adolescents, in grades 7-12 . In particular, they tried to assess the impact of sleep deprivation on rates of depression and suicidal ideations. Subjects were matched for sex, age, ethnicity and parental marital status. They compared outcomes for teens routinely going to bed before 10 pm to those going to bed after midnight. Those going to bed at midnight or later showed 24% more depression and were 20% more likely to have had suicidal ideations during the past 12 months. It should be noted that significant decreased amounts of slow wave (deep) sleep can alone result in depression in 40-45% of people (this is true for insomnias, sleep apnea and restless legs). In the Gangwisch article, the authors remarked that most adolescents actually do go to bed when told by their parents.

    Non-pharmacological treatments are the first line treatments of choice and include: no caffeine after 2 pm, sleep hygiene (e.g. reduce the amount of intensity during evening hours: including exciting video games and movies); sleeping in a dark and quiet room…with no television in the bedroom) and reduced “screen time” in the evening. Screen time refers to time spent looking at television, internet, and cell phone texting. Excessive screen time has been associated with increasing behavioral problems, psychological disorders and academic failure (for summary see: www.screentime.org). Additionally, all light emitted from screens emit large amounts of blue wave length light which has been shown to suppress the natural melatonin release that begins a couple of hours before sleep, and can thus reduce the quality of sleep. Of interest is the use of amber colored glasses that are worn in the evening which selectively screen out blue wave length light (these can be easily found on the internet).

    Medical treatments for sleep problems include the use of the following medications (note: all of these are considered to be “off label” use, with the exception of Benadryl): sleeping pills (e.g. Sonata Lunesta, Ambien), benzodiazepines (e.g. Ativan), alpha-2 agonists (e.g. clonidine), the antihistamines: Atarax and Benadryl, low doses of sedating antidepressants such as Remeron (7.5-15 mg), Silenor (3-6 mg) or Trazodone (25-100 mg)* and melatonin . The antipsychotic medication, Seroquel, is being used as a sleeping pill, but this is not recommended due to significant metabolic side effects (except as a part of treatment for bipolar disorder and psychotic disorders). Once again, research for use of these medications is scant and “off label”.

Melatonin is a naturally occurring hormone made in the pineal gland in the brain. It helps to promote deep sleep. One of melatonin’s effects is to help to cool the body down during sleep which facilitates entry into slow wave (deep) sleep. In pharmacies and grocery stores synthetic melatonin can be purchased. During the past 10 years, this product has been widely used as a sleeping pill for children and teenagers. However, recent studies suggest that this may be problematic for use in children. This is especially so for people taking doses of 1-5 mg or more. Such doses increase the melatonin in a person’s system by a factor of 1 to 20 times the normal amount. This caution is echoed by both the National Institutes of Health and the National Sleep Foundation (http//:www.sleepfoundation.org). “Melatonin should not be used in most children. It is possibly unsafe. Because of its effects on other hormones, melatonin might interfere with development during adolescence” (http//:www.nih.gov ;key word: melatonin). Doses above 0.5 mg can aggravate depression and bipolar disorder.  It is also important to note that the use of birth control pills can raise levels of melatonin. Melatonin is, however, sometimes used to treat sleep problems in children that have primary sleep disorders, severe ADHD and other neurodevelopmental disorders. A low dose strategy may be useful in promoting better quality sleep: 0.5 mg three hours prior to sleep, without adverse effects. However, it should not be used as a sleeping pill (very low doses generally do not produce sedation). If higher doses are given sedation will occur, but this is where melatonin levels may be unsafe. Higher doses can cause drowsiness and also may increase depression. The lower dose strategy is recommended. Melatonin is not habit-forming and at low doses is well tolerated. Finally, it must be noted that the use of melatonin is experimental, and if used, parents should first talk with their pediatrician.

    Caution is advised in prescribing these drugs except in cases where very short-term treatment is the goal. By in large, the non-medical approaches listed above are most strongly recommended.

    Of special concern is the use/over-use of caffeinated products. There has been an escalation in the use of various energy drinks, in addition to caffeinated sodas, tea and coffee. Recently, concentrated caffeine powder and tablets and inhalable caffeine have become available on the internet. Even modest amounts of caffeine in circulation cannot only interfere with sleep onset, but also reduce sleep efficiency by decreasing time spent in deep (slow wave) sleep. Attached is a caffeine questionnaire that can be used for rapid screening of caffeine use. All youngsters should be screened for caffeine use. Doses in excess of 500 mg, even if limited to use before noon and any amount used later in the day may cause such sleep disruptions. Any use of caffeine can increase anxiety symptoms and use can lead to sleep deprivation that is a common factor provoking manic episodes in those with bipolar disorder. Systematic assessment of caffeine use is often not a part of typical clinical psychiatric evaluations and yet reduction or elimination of caffeine can be a high yield strategy improving the quality of sleep and reducing psychiatric symptoms. 

*footnote: Some children will actually experience anxiety when treated with trazodone due to the action of metachlorophenylpiperazine [MCPP] which is a metabolic by-product of trazodone (Brent, D. 2013).

preston.john@comcast.net

References available upon request

John Preston, Psy.D., ABPP is  Professor Emeritus with Alliant International University; Sacramento campus. He has also taught on the faculty of UC Davis, School of Medicine. Dr. Preston is the author of twenty-one books, five of which are psychopharmacology texts. He is the recipient of the California Psychological Association’s Distinguished Contributions to Psychology Award. He has presented over 500 workshops during the past 25 years, lecturing in the United States, Canada, Africa, Europe, and Russia.
preston.john@comcast.net

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