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

Current Psychiatry. 2006 March;05(03):21-36

March 1, 2006|Psychiatry

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

¹² The problem is the timing rather than quality of sleep.

Sleep quantity may be compromised if the individual must arise before obtaining adequate sleep. Sleep-onset delays resolve, however, when the patient is allowed to follow his or her preferred later bedtime and wake time.

The typical DSPS sleep-wake pattern is a consistently preferred bedtime/sleep-onset time after midnight and wake time after 10 AM on weekdays and weekends. Adolescents with DSPS often complain of sleep-onset insomnia, extreme difficulty waking in the morning, and profound daytime sleepiness.

A 1- to 2-hour phase shift to a later bedtime and wake time is part of normal pubertal development and has been cited as a rationale for delaying high school start times. The phase shift in DSPS is typically much more dramatic and intractable than the norm.

Treatment options for DSPS include:

strict sleep-wake schedule (such as 9:30 or 10 PM to 6:30 AM on school nights, with no more than a 1-hour discrepancy on non-school nights)
melatonin, 3 to 5 mg, given 3 to 4 hours before the desired bedtime, if sleep schedule strategies are unsuccessful
bright-light therapy in the morning to suppress melatonin secretion and “reset” the body clock, especially if morning waking is particularly difficult.¹³

Teens with a severely delayed sleep phase (>3 to 4 hours) may benefit from chronotherapy. Delay bedtime (“lights out”) and wake times successively—by 2 to 3 hours per day—over several days. For example, if the teen’s preferred fall asleep time is 3 AM and wake time is noon, then bedtime and wake time would be 5 AM to 2 PM the first day; 7 AM to 4 PM the next day, and so forth until the sleep-onset time coincides with the desired bedtime.

If the adolescent also has school avoidance or a mood disorder—which is often the case—noncompliance with treatment is common. More-intensive behavioral and medication approaches may be needed.

Use Hypnotics?

Most insomnia in children and adolescents can be managed from infancy on with behavior therapy alone. If not, combined behavioral and drug interventions may be appropriate, such as when:

the family is overwhelmed by the sleep problem and cannot execute behavioral strategies
the child’s safety is at risk (engaging in dangerous activities during night awakenings, for example)
treating specific populations (such as children with ADHD or autistic disorders).

The decision to prescribe medication for a child with insomnia is based largely on clinical experience, empirical data in adults, and small case series. No medications are FDA-approved for use as hypnotics in children. Sleep aids most commonly prescribed in clinical practice or recommended by pediatric clinicians include:

antihistamines such as diphenhydramine
tricyclic antidepressants (amitriptyline, trazodone, and others)
benzodiazepines (clonazepam)
nonbenzodiazepine hypnotics (zolpidem, zaleplon)
alpha-agonists (clonidine).^14,15

Sedating antipsychotics (such as risperidone) and anticonvulsants (divalproex sodium) are sometimes used, such as for children with mental retardation. Sedating antidepressants (such as mirtazapine) may help children with depression and concomitant insomnia.

Use these medications with caution in children, as safety and tolerability are unknown. Prescribe the lowest dosage for the briefest time possible, and use in combination with behavioral management strategies. Choose the shortest-acting agents to avoid morning grogginess. Chloral hydrate and barbiturates are rarely indicated in children because of side effects.

Over-the-counter products. Parents often use nonprescription products such as diphenhydramine, melatonin, and herbal preparations to treat children’s sleep problems, with or without a clinician’s recommendation. Most herbal preparations are generally safe but remain untested in pediatric patients.

Antihistamines such as diphenhydramine are generally well-tolerated, but they may have a paradoxical agitating effect. Tolerance also tends to develop, leading to increasing doses. Parents may inadvertently overdose a child by giving multiple nonprescription products with diphenhydramine as the active ingredient (such as combining Benadryl with Tylenol PM).

Related resources

National Sleep Foundation. Information for patients and clinicians. www.sleepfoundation.org.
American Academy of Sleep Medicine. Professional and patient resources and links. www.aasmnet.org.
Mindell J, Owens J. A clinical guide to pediatric sleep: diagnosis and management of sleep problems in children and adolescents. Philadelphia: Lippincott Williams and Wilkins; 2003.
Owens J, Mindell J. Take charge of your child’s sleep: the all-in-one resource for solving sleep problems in kids and teens. New York: Marlowe & Co.; 2005.

Drug brand names

Amitriptyline • Elavil
Clonazepam • Klonopin
Clonidine • Catapres
Diphenhydramine • Benadryl and others (nonprescription)
Divalproex sodium • Depakote
Mirtazapine • Remeron
Risperidone • Risperdal
Trazodone • Desyrel
Zaleplon • Sonata
Zolpidem • Ambien

Disclosures

Dr. Owens receives research support from Sepracor, Eli Lilly & Co., and Cephalon; is a consultant to Eli Lilly & Co., Cephalon, and Shire; and is a speaker for Eli Lilly & Co., Cephalon, and Johnson & Johnson.

References

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