diagnostic and treatment challenges in pediatric …...© associated professional sleep societies,...

© Associated Professional Sleep Societies, LLC 1

Valerie M. Crabtree, Ph.D., CBSMSt. Jude Children’s Research Hospital

Lisa J. Meltzer, Ph.D., CBSMNational Jewish Health

AASM Sleep Medicine TrendsFebruary 20-22, 2015

Talking Stick Resort – Scottsdale, AZ

Diagnostic and Treatment Challenges in Pediatric Behavioral Sleep MedicineValerie McLaughlin Crabtree, Ph.D., CBSM

Department of PsychologySt. Jude Children’s Research Hospital


1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR

X 2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support

Consultant

Speakers’ Bureaus

Financial support

Other Co-author: Meltzer and Crabtree, Pediatric Sleep Problems: A Clinican’s Guide to Behavioral Interventions (2015). APA Books.

3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

X 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:1. Lack, L.C., & Wright, H.R. (2007). Clinical management of delayed sleep phase disorder. Behavioral Sleep Medicine, 5, 57-76.2. Simard, V. & Nielsen, T. (2009). Adaptation of imagery rehearsal therapy for nightmares in children: A brief report. Psychotherapy

(Chic.), 46, 492-497.3. Mindell, J. A. & Owens, J. A. (2010). A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. (2nd ed.)

Philadelphia, PA: Lippincott, Willians, & Wilkins.


Healthy sleep in children Anxiety and bedtime worries Nightmares Nocturnal enuresis Delayed Sleep-Wake Phase Disorder (DSWPD)


Medical sleep disorders◦ Narcolepsy◦ CPAP adherence

Medically-induced sleep disorders◦ Pain◦ Nighttime caretaking

Parasomnias Infant/toddler sleep disturbance


After infancy, consistent pattern of sleep/wake at night with afternoon naps in young children

Consistent bedtimes Consistent rise times Ability to self-soothe and return to sleep

after brief awakenings Average sleep efficiency 90-95% in

childhood Average sleep onset latency 10-20 minutes


Age Ideal Sleep Duration Sleep Patterns0-2 months 12-18 hours Wide variability3-11 months 14-15 hours Multiple daytime naps1-3 years 12-14 hours Naps consolidate to 1

per day3-5 years 11-13 hours Naps stop around 5

years of age6-11 years 10-11 hours Discrepancy between

school and non-school nights

12-18 years 8.5-9.5 hours Later bedtimes


Iglowstein et al., 2003


10-year-old male “Worrier”◦ Getting in trouble at school◦ Problems with friends◦ Fears of illness

Fears at bedtime◦ Frequent checks

Curtain calls


Target bedtime 9:00 pm Frequent checks leading to delayed sleep

onset Rise time 6:45 am Difficult to awaken Daytime irritability, daytime anxiety


Pervasiveness of the anxiety◦ night-time only vs. throughout the day and night

History of trauma?◦ If yes, treat primary trauma

Reality basis of worries Developmental norms◦ Distinguishing fantasy from reality


Backbone of anxiety interventions Create hierarchy of anxiety-provoking steps

toward going to bed and sleeping independently


Lying in bed in dark alone

Lying in bed with lights on alone

Sitting in bedroom in dark with parents


Backbone of anxiety interventions Create hierarchy of anxiety-provoking steps

toward going to bed and sleeping independently

Flashlight treasure hunts Positive self-talk Positive reinforcement

Pincus et al., 2012


Set aside 15-30 minutes per day to worry. Should be separated from bedtime (before or

after dinner). May worry alone or with a parent present. Express any and all worries for worry time◦ May problem solve

At any other time of the day or night that the child begins to worry, cue to wait for worry time.

Parent does not provide reassurance outside of worry time

Jellesma et al., 2009


Think like a detective Child identifies frequent worries and writes

them down. Look for all evidence for and against the

likelihood of the worry being true. A competing, more positive thought should

be developed for those worries that have the most evidence against them.

Replace fearful statements with positive self-statements.

Gordon et al., 2007


Worry time 2x during the day◦ 15 minutes before school◦ 15 minutes just before dinner

Positive reinforcers for waiting until worry time to seek parental reassurance

During worry time:◦ Identified likelihood of each worry occurring◦ Problem-solved potential responses to each worry


Progressive muscle relaxation◦ Practiced during the day◦ After effective use, began to use at bedtime

Sleep onset latency to 15 minutes Discontinued worry time Improved general worry


7-year-old Asian male New onset of nightmares Precipitated by death of friend Nearly nightly basis Moving into parents’ room Sleeping on parents’ floor or in their bed Pre-sleep anxiety


Occasional nightmares developmentally appropriate

Assess frequency, intensity Fears excessive if last beyond 8 years of age

and/or disrupt family Recurrent nightmares more common in

children with history of trauma◦ Criterion for Post-traumatic Stress Disorder

If PTSD, refer for treatment◦ Can simultaneously treat nightmares


While awake, choose a recent nightmare “You can be the boss of your dreams.” Change the nightmare to have more positive

content Practice newly scripted dream repeatedly In children, modify instructions to include

drawing rather than simply writing, as with adults

When awaken following nightmare, practice in vivo with new, positive content

Simard & Nielsen, 2009


Identified primary dream content◦ Being stepped on or shrunk by giant creatures

Able to draw most recent dream in the visit Re-scripted with new endings◦ Would point a shrink ray at the giant and “shrink

it to the size of an ant” Drew the new dream and hung it above his bed Home practice Nightmares ended within 2 weeks


10-year-old Caucasian male Nephrogenic diabetes insipidus (NDI) ◦ Polydipsia throughout the day and night

ADHD, Primarily Inattentive Type Reading Disorder Methylphenidate Extended Release 18 mg Improved sustained attention in school


Nightly enuresis 3-4 wetting episodes/night No daytime enuresis but urinates

approximately 1 X/hour No reported daytime fatigue or daytime

sleepiness


Thorough physical examination ◦ Rule out enuresis secondary to medical condition

Assess if enuresis is primary or secondary◦ If secondary, assess for psychosocial stressors

and psychopathology◦ If related to stressors/psychopathology, treat

primary disturbance If primary, most likely unrelated to

emotional disturbance


Can improve self-esteem Initiate treatment when child concerned &

motivated Eliminating liquids before bedtime has not

been shown to significantly reduce enuresis

Campbell et al., 2009; Glazener et al., 2005


Imipramine, DDAVP, anticholinergic medications useful in short-term but see recurrence of enuresis when medication is discontinued◦ Unwanted side effects

Urine alarm (1938) most effective treatment Exact action unknown 40% relapse rate after treatment has ended Most can be corrected with additional course of

alarm intervention Overlearning reduces relapse ratesCampbell et al., 2009; Glazener et al., 2005


Mowrer (1938) Child places on underwear prior to bedtime If alarm sounds/vibrates, child is to leave bed to

finish urinating in bathroom◦ Many children will require parents to awaken

them Child should change pajamas and sheets as

independently as possible Maintain record of dry vs. wet nights


Glazener et al., 2005; Hjalmas et al., 2004

**Adding tolterodineslightly improves effect of desmopressin(Kazemi Rashed et al., 2013)


Urine alarm Cleanliness training Positive reinforcement Retention control training Overlearning

Houts, 1996


“Stream interruption”◦ constrict and release urinary muscles repeatedly

while urinating Postpone urination◦ Start with 1 minute◦ Gradually increase to up to 45 minutes

May cause learning to occur more quickly


After 14 dry nights Drink water one hour before bedtime◦ Calculate amount by using 2 ounces per year of age

+ 2 Urinate before going to bed Continue until child achieves 14 additional

dry nights Generally have initial relapse for ~ 1 week Helps decrease relapse rate from ~40% to ~

20% May be difficult to implement


Up to 85% resolution 7-29% relapse rate Usually improves with additional course of

intervention


Alarm intervention after pharmacologic intervention failed

Mom placed his nighttime water in the bathroom

Increased volume of daytime water consumption

Reduced nighttime water consumption Improvements within the first few days Learned how to wake on his own after three

days


After 4 weeks, only one wetting episode per night, with less volume

Consistently occurred just before midnight At all other times, he was waking before the

alarm went off and was successfully going to the bathroom

Hunter is very proud!


14-year-old African American female Excessive Daytime Sleepiness Difficult to awaken in morning Truant Watches TV in bedroom until sleep onset of

2:00-3:00 am On sertraline and bupropion for several

months but still feels “low”


Frequent co-occurring conditions◦ Depression◦ Truancy◦ Substance use/abuse

Psychoeducational assessment for those with school avoidance/truancy


0:00

1:12

2:24

3:36

4:48

6:00

DSWPD Insomnia DSWPD Insomnia

BedtimeSleep Onset Time

Weekday Weekend


Sunday Friday


03:00 13:00


Less focus on intensity and more on wavelength Adequate blue light necessary for phase shift Many now with light-emitting diode (LED) lights No UV exposure Use within 18 inches and 45º of midline of

patient’s visual field Do other activities while in front of the light box 30 minutes in the morning to advance circadian

rhythm

Meesters et al., 2011; Postolache & Oren, 2005


May use chronotherapy if not in school Advance bedtime and rise time by 2 hours

daily Risk of continuing forward progression of

sleep onset time

Lack & Wright, 2007; Weitzman et al., 1981


Stimulus Control Bedtime routine Bedtime 1:30 am Rise time 9:30 am Gradual advance of bed and rise time by 15

minutes every other day Goal of 10:30 pm bedtime; 6:30 am rise time Melatonin 0.5 mg 3 hours before bedtime Bright light therapy School consultationIvanenko et al. (2003); Samaranayake et al. (2010)


Maintaining bedtime of 10:30 pm Rise time of 6:30 am Significant improvement in mood Significant improvement in family

interaction Attending school regularly

Note: At risk for delay of circadian rhythm delay again in the future

diagnostic and treatment challenges in pediatric …...© associated professional sleep societies,...

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