Evidence-Based Reviews

When a child can’t sleep, start by treating the parents

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Educated parents can change sleep-wake behaviors of toddlers to teens.



Sleep problems are very common in children but more complicated to manage than in adults. That’s because you usually must consider the parents’ opinions in making the child’s diagnosis and change the parents’ behavior for the treatment to succeed.

This article describes sleep disorders of children and adolescents, the most effective behavioral therapies, and the limited situations when hypnotic therapy may be appropriate.

A Symptom, Not a Diagnosis

Pediatric insomnia is significant difficulty in initiating and/or maintaining sleep that impairs a child’s or caregiver’s daytime function (Table 1).1-4 Childhood sleep disorders may manifest primarily as daytime sleepiness and neurobehavioral symptoms or occur with comorbid psychiatric diagnoses such as depression, anxiety, or attention-deficit/hyperactivity disorder (ADHD).

It is important to view insomnia as a symptom—not a diagnosis. Causes of insomnia in children may be medical (drug-related, pain-induced, or obstructive sleep apnea syndrome), behavioral (poor sleep hygiene or negative sleep-onset associations), or multiple factors (Table 2).

Sleep hygiene. Before starting therapy, educate parents and children about normal sleep development and sleep hygiene, which includes:

  • environmental factors (temperature, noise, ambient light)
  • scheduling (regular sleep-wake schedule)
  • sleep practice (bedtime routine)
  • physiologic factors (exercise, timing of meals, caffeine intake).
Four mechanisms account for most pediatric sleep disturbances:
  • insufficient sleep for individual physiologic needs (“lifestyle” sleep restriction, delayed sleep onset related to behavioral insomnia)
  • adequate sleep but fragmented or disrupted by conditions such as obstructive sleep apnea or periodic limb movement disorder that cause frequent or prolonged arousals
  • primary disorders of excessive daytime sleepiness such as narcolepsy (less common than in adults but under-recognized in children and adolescents)
  • circadian rhythm disorders in which sleep is usually normal in structure and duration but occurs at an undesired time (delayed sleep phase syndrome).
For practical purposes, sleep disorders also may be defined as primarily behavioral or organic/medical. These two types often are influenced by similar psychosocial and physical/environmental factors and frequently coexist.

Table 1

Insomnia’s negative effects on children and adolescents

Daytime sleepinessYawning, rubbing eyes, resting head on desk
Neurocognitive dysfunctionDecreased cognitive flexibility and verbal creativity
Poor abstract reasoning
Impaired motor skills
Decreased attention and vigilance
Memory impairment
Externalizing behaviorsIncreased impulsivity, hyperactivity, and aggressiveness
Mood dysregulationIncreased irritability
Decreased positive mood
Poor affect modulation
Source: References 1-4
Table 2

Diagnostic types of pediatric insomnia

Behavioral insomnia of childhoodLearned behaviors that interfere with sleep onset or maintenance
  Sleep-onset associationProlonged nighttime arousals because child can fall asleep only with certain sleep associations, such as being soothed by parent
  Limit-setting subtypeActive resistance, verbal protests, and repeated demands by child at bedtime
Psychophysiologic insomniaConditioned anxiety about sleep difficulty heightens physiologic and emotional arousal, further compromising ability to sleep
  Delayed sleep phase disorderCommon in adolescents; persistent phase shift in sleep-wake schedule (later bedtime and wake time) that conflicts with school and lifestyle demands
Secondary insomniaNot primary; related to other diagnoses or factors
  Psychiatric disordersDepression, anxiety, posttraumatic stress disorder, attention-deficit/hyperactivity disorder
  Medical disordersObstructive sleep apnea syndrome, pain
  MedicationPsychostimulants used to treat ADHD and antidepressants used for major depression may cause sleep-onset delay

With Psychiatric Disorders

Sleep disturbances can profoundly affect the clinical presentation, severity, and management of psychiatric disorders in children and adolescents.5-7 Up to 75% of children with a major depressive disorder have insomnia (severe in 30%), and one-third of depressed adolescents have delayed sleep-onset. Sleep complaints—especially bedtime resistance, refusal to sleep alone, increased nighttime fears, and nightmares—are also common in anxious children and those who have experienced severe trauma (including physical and sexual abuse).

Growing evidence suggests that pediatric “primary” insomnia with no concurrent psychiatric disorder is a risk factor for developing psychiatric conditions later in life—particularly depressive and anxiety disorders. Psychotropics such as psychostimulants and antidepressants also may interfere with sleep.

ADHD. Parents often report that children with ADHD have sleep disturbances, especially difficulty initiating sleep, poor sleep quality, restless sleep, frequent nighttime arousals, and shortened sleep duration.8 Parental observations notwithstanding, most objective methods of examining sleep and sleep architecture (polysomnography, actigraphy) have shown few or inconsistent differences between children with ADHD and controls.

Sleep problems in children with ADHD are often multifactorial. Potential causes include:

  • psychostimulant-mediated sleep-onset delay
  • bedtime resistance related to comorbid anxiety, oppositional defiant disorder, or circadian phase delay
  • settling difficulties related to deficits in sensory integration associated with ADHD.
Adjusting a psychostimulant’s dosing schedule to an earlier time may help children who have trouble falling asleep. In some children, however, sleep-onset delay is caused not by a stimulatory effect but by the medication wearing off at bedtime. A late-day psychostimulant dose might prevent this “rebound.”

When managing a child with ADHD, evaluate comorbid sleep problems and provide diagnostically driven behavioral and/or drug therapy.

Behavioral Insomnia of Childhood


Recommended Reading

ADHD: Switching to Atomoxetine Can Help
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Conditioned Placebo Dose Reduction Tested for ADHD
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Some Patients Respond Well to Reduced Doses of Atomoxetine
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Narcolepsy Drug Is Safe, Effective for ADHD
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Compliance Puts New Spin on Psychosis Treatment : Adolescents with prodromal psychosis had better outcomes with antidepressants than antipsychotics.
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