Sleep and Its Disorders in Children

Timothy F. Hoban, MD

Disclosures

Semin Neurol. 2004;24(3) 

In This Article

Treatment of Insomnia in Older Children and Adolescents

Effective treatment of insomnia in older children and adolescents begins with accurate identification of all pertinent contributory influences. It is not unusual to identify multiple concurrent predisposing factors, each deserving of treatment. For example, a teenager who presents with an isolated complaint of insomnia may be found to have simultaneous bedtime resistance, poor sleep hygiene, and delayed sleep phase.

Treatment of bedtime resistance for the older child differs from the extinction techniques typically used for younger children. Treatment instead relies on enforcement of a bedtime appropriate for the child's age and individual sleep needs. Appropriate limits must be set for disruptive behaviors such as stalling or emotional agitation. As in younger children, consistent limit-setting is crucial for effective treatment of bedtime resistance. Any suboptimal aspects of general sleep hygiene should also be addressed to the extent possible. Maintenance of a regular sleep schedule and avoidance of daytime napping should be encouraged. Potentially disruptive influences such as watching television or listening to music while in bed should be avoided. Use of caffeinated beverages, vigorous exercise, and excessively stimulating activities should be avoided during the evening time hours. Although a recommendation to maintain a fixed bedtime and waking time 7 days weekly is usually received less than enthusiastically by an adolescent, it is often possible to improve compliance by working with patient and parents to implement age-appropriate incentives or by developing a "contract" that offers increasing flexibility of bedtime schedule on non-school nights after specified milestones are met. Elements of psychophysiological insomnia may be addressed in the same fashion used for adult patients. Stimulus control techniques, sleep restriction, and biofeedback have demonstrated some efficacy in adults but have not been rigorously studied in children.[37]

Treatment of DSPS in the older child and adolescent is often challenging due to the normal tendency toward circadian delay that develops in this age group and the fact that later bedtimes and waking times on non-school nights may additionally reinforce this delay. Secondary gain may be an additional reinforcing factor in some children, particularly when youngsters intentionally delay bedtime in an attempt to preclude or limit parental supervision of late-night entertainment or recreational activities. Correction of delayed sleep phase is usually achieved by gradual realignment of the patient's sleep period in a stepwise fashion toward a desired target schedule appropriate for the patient's age and school schedule. In some cases, this realignment can be achieved through consistent stepwise advances of bedtime and waking time by 10 to 15 minutes nightly. In severe or refractory cases, more rapid correction may be achieved via progressive delays in bedtime and waking time, a process also known as chronotherapy.[37,43] In this process, bedtime and waking time are delayed by 2 to 3 hours nightly until the target bedtime is reached.

After the target sleep schedule has been achieved, maintaining the desired schedule typically requires additional time and effort. During the first weeks following schedule correction, even a few days of delayed bedtime and/or waking time may be sufficient to cause the sleep schedule to revert to its prior pattern. Therefore, rigorous adherence to the target sleep schedule 7 days weekly is crucial in minimizing the chance of relapse. After several weeks of strict adherence (longer in particularly severe or refractory cases), some flexibility in bedtime and waking time on non-school nights may be reintroduced, although sleeping beyond 1 or 2 hours after the usual wake-up time should be avoided.[37]

Light therapy has been reported to be effective in the treatment of DSPS and other circadian rhythm disorders in adults.[44] Use of light therapy in children has received little formal study, so optimal timing and intensity of light exposure in this age group remains unknown. The author's practice is to use light therapy as adjunctive treatment for DSPS, beginning with 10,000 lux for 30 minutes on morning waking with further titration based on clinical response.

Drug treatment of insomnia in older children and adolescents has received little formal study despite seemingly frequent off-label use of medications for this purpose. In a survey of 671 primary care physicians in the United States, 34.1% had recommended antihistamines, 24.9% had recommended melatonin, and 22.2% had recommended herbal preparations at least once for teenage patients within the prior 6 months.[45] In several large French surveys, 10 to 12% of adolescents reported use of medication for disrupted sleep.[46,47] In the only large, double-blind, placebo-controlled study assessing drug treatment of pediatric insomnia, use of 5 mg of melatonin at 7:00 PM significantly advanced sleep onset by 57 minutes among 62 school-age children with chronic idiopathic insomnia.[48] In a smaller retrospective survey, prebedtime use of melatonin at an average dosage of 2 mg was associated with partial to complete improvement of insomnia in 32 children.[49] Most reports of melatonin use in children have consisted of case reports and uncontrolled clinical trials using doses ranging from 0.3 mg through 20 mg.[32]

Numerous other medications are used off-label for treating insomnia in children despite a significant lack of formal study in this age group. These range from nonprescription agents such as diphenhydramine and other antihistamines to prescription agents such as chloral hydrate, benzodiazepines, neuroleptics, tricyclic antidepressants, α-agonists, and the newer short-acting hypnotics. Their routine use for treating childhood insomnia cannot be recommended until further controlled studies have been performed to document safety and efficacy in this age group.

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