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Sleep and Sleep Disorders in Children and Adolescents Lisa J. Meltzer, PhD a, * , Jodi A. Mindell, PhD b,c a Division of Pulmonary Medicine, The Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA, USA b Saint Joseph’s University, Philadelphia, PA, USA c The Sleep Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA P ediatric sleep disorders are common, affecting approximately 25% to 40% of children and adolescents [1]. Although there are several different types of sleep disorders that affect youth, each disorder can have a significant impact on daytime functioning and development, including learning, growth, behavior, and emotion regulation [2]. Although the relationship between sleep and psychiatric disorders has been established in adults, researchers are only beginning to uncover the interaction between sleep and psychiatric disorders in children and adolescents, including depression, attention-deficit/hyperactiv- ity disorder (ADHD), and autism. The purpose of this article is to review nor- mal sleep and sleep disorders in children and adolescents, the assessment of sleep in pediatric populations, common pediatric sleep disorders, and sleep in children who have common psychiatric disorders. SLEEP IN CHILDREN Parents often ask practitioners how much sleep their child needs. This can be a difficult question to answer as sleep needs not only change with developmental stages, but recent studies and surveys show that there is a large variability in both children’s sleep need, especially in the first few years of life [3], as well as the ac- tual amount of sleep that youth in America are getting [4,5]. Table 1 describes what typically is seen in terms of sleep patterns in children across development. Newborns (0 to 3 Months) There is no clear sleep pattern in the first few weeks of life; however, most new- borns sleep between 10 and 18 hours per day, although this may be longer if infants are premature. This total sleep time is divided into many short sleep pe- riods across the 24-hour clock, with no differentiation between day and night. This polyphasic sleep schedule (multiple sleep periods), although age appropri- ate, often is difficult for new parents. The discrepancy between newborn sleep *Corresponding author. The Children’s Hospital of Philadelphia, 3535 Market Street, 14th Floor, Philadelphia, PA 19104. E-mail address: [email protected] (L.J. Meltzer). 0193-953X/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.psc.2006.08.004 psych.theclinics.com Psychiatr Clin N Am 29 (2006) 1059–1076 PSYCHIATRIC CLINICS OF NORTH AMERICA

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Psychiatr Clin N Am 29 (2006) 1059–1076

PSYCHIATRIC CLINICSOF NORTH AMERICA

Sleep and Sleep Disordersin Children and Adolescents

Lisa J. Meltzer, PhDa,*, Jodi A. Mindell, PhDb,c

aDivision of Pulmonary Medicine, The Children’s Hospital of Philadelphia and Universityof Pennsylvania School of Medicine, Philadelphia, PA, USAbSaint Joseph’s University, Philadelphia, PA, USAcThe Sleep Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA

Pediatric sleep disorders are common, affecting approximately 25% to 40%of children and adolescents [1]. Although there are several different typesof sleep disorders that affect youth, each disorder can have a significant

impact on daytime functioning and development, including learning, growth,behavior, and emotion regulation [2]. Although the relationship between sleepand psychiatric disorders has been established in adults, researchers are onlybeginning to uncover the interaction between sleep and psychiatric disordersin children and adolescents, including depression, attention-deficit/hyperactiv-ity disorder (ADHD), and autism. The purpose of this article is to review nor-mal sleep and sleep disorders in children and adolescents, the assessment ofsleep in pediatric populations, common pediatric sleep disorders, and sleep inchildren who have common psychiatric disorders.

SLEEP IN CHILDRENParents often ask practitioners how much sleep their child needs. This can bea difficult question to answer as sleep needs not only change with developmentalstages, but recent studies and surveys show that there is a large variability in bothchildren’s sleep need, especially in the first few years of life [3], as well as the ac-tual amount of sleep that youth in America are getting [4,5]. Table 1 describeswhat typically is seen in terms of sleep patterns in children across development.

Newborns (0 to 3 Months)There is no clear sleep pattern in the first few weeks of life; however, most new-borns sleep between 10 and 18 hours per day, although this may be longer ifinfants are premature. This total sleep time is divided into many short sleep pe-riods across the 24-hour clock, with no differentiation between day and night.This polyphasic sleep schedule (multiple sleep periods), although age appropri-ate, often is difficult for new parents. The discrepancy between newborn sleep

*Corresponding author. The Children’s Hospital of Philadelphia, 3535 Market Street, 14thFloor, Philadelphia, PA 19104. E-mail address: [email protected] (L.J. Meltzer).

0193-953X/06/$ – see front matter ª 2006 Elsevier Inc. All rights reserved.doi:10.1016/j.psc.2006.08.004 psych.theclinics.com

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patterns and parental expectations and need for prolonged nighttime sleep mayresult in parents stating that their baby ‘‘never sleeps.’’

Infants (3 to 12 Months)Sleep patterns begin to consolidate by 3 months of age, with babies beginningto show a diurnal cycle of sleep at night and wakefulness during the day. In-fants typically sleep approximately 10 to 12 hours at night and up to 3 or 4hours during the day (divided into two or three daytime naps). At approxi-mately 6 months of age, 90% of infants take only two naps, with their nighttimesleep progressively lengthening. It is important to keep in mind that with theonset of each developmental milestone (eg, pulling to standing or walking), chil-dren’s sleep can become disrupted for several nights to weeks before and afterthe milestone occurs [6].

All children wake for brief periods during the night, with many infants ableto return to sleep independently (self-soothers). Parents should be encouragedfrom an early age to put their babies to bed drowsy, but still awake, at bedtimein order for babies to learn how to fall asleep independently. In contrast, infantswho are nursed or rocked to sleep are more likely to develop behavioral insom-nia of childhood, sleep-onset association type, which presents as frequent nightwakings (see later discussion for further description) [2]. Other common sleepdisorders in infants include confusional arousals, bedtime problems, and rhyth-mic movement disorders (RMD).

Toddlers (12 Months to 3 Years)By 18 months of age, the majority of toddlers transition from two daytime napsto one and continue to sleep approximately 10 to 12 hours at night. Approxi-mately 25% to 30% of toddlers have sleep problems [1], with bedtime resistance(behavioral insomnia of childhood, limit-setting type) and frequent night wak-ings (behavioral insomnia of childhood, sleep-onset association type) the twoprimary disorders in this age group. In addition, daytime behavior is markedlyworse in children who are poor sleepers.

Preschool-Aged Children (3 to 5 Years)Sleep amounts in preschool-aged children decrease, mostly the result of the dis-continuation of daytime naps. By the age of 5 years, 75% of children havegiven up their nap and sleep a total of 11 to 12 hours at night. As children de-velop language, cognitive reasoning, and imagination, they also can develop

Table 1Typical sleep need for children and adolescents by developmental stage

Age group Years Total sleep need

Infants 3 to 12 months 14 to 15 hoursToddlers 1 to 3 years 12 to 14 hoursPreschoolers 3 to 5 years 11 to 13 hoursSchool-aged 6 to 12 years 10 to 11 hoursAdolescents 12 to 18 years 8.5 to 9.5 hours

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difficulties initiating sleep. Many children in this age group test limits at bed-time, making bedtime refusal a common sleep complaint by parents. In addi-tion, many children develop fears of the dark and monsters, also resulting inbedtime resistance, and an increase in nightmares. Contrary to the popular be-lief that young children outgrow their sleep difficulties, research has found thatsleep problems in preschoolers can become chronic [7]. Furthermore, two phys-iologic sleep disorders, obstructive sleep apnea and partial arousal parasom-nias, peak during this developmental stage.

School-Aged Children (6 to 12 Years)Almost all children in this developmental stage have a single sleep period atnight, lasting 10 to 11 hours, and are alert and awake during the day, withrare naps. Recent surveys and data indicate that approximately one third ofschool-aged children experience sleep problems [4,8,9]. The most commoncomplaints are bedtime resistance, difficulty initiating sleep because of anxiety,and daytime sleepiness. These symptoms may be a result of obstructive sleepapnea, insufficient sleep, poor sleep hygiene, and/or an anxiety disorder. Sleeprestriction in this age group has been shown to be related to difficulties withattention, memory, learning, and behavior [10–12].

Adolescents (12 to 18 Years)Although adolescents clearly have been shown to need 9 to 9.25 hours of sleepper night through studies conducted in a laboratory setting [13], most get only7 hours of sleep each night [14]. This cumulative sleep debt has many causesand many consequences for daytime functioning. With the onset of puberty,hormonal changes and a shift in melatonin secretion lead to adolescents expe-riencing a 2-hour shift in their circadian sleep phase, resulting in a later sleeponset and morning wake time [13]. In addition, some adolescents experiencea physiologic need for a short sleep period in the early afternoon, especiallygiven their chronic partial nighttime sleep deprivation. These physiologic sleepneeds are in conflict with the early start times of most junior high and highschools, resulting in sleep-deprived adolescents who are asked to learn ata time when their body should be sleeping [15]. In addition, the increased num-ber of demands on adolescents (eg, homework, sports, activities, and work) of-ten results in delaying bedtime further and increasing sleep debt. To help themfunction during the day, 75% of adolescents report relying on caffeinated orenergy drinks [5]. Sleep deprivation can have an impact on mood, attention,memory, behavior, and academic performance [16]. In addition, many adoles-cents report driving drowsy [5], increasing the likelihood of an accident forthese new young drivers. Common sleep disorders in adolescents include de-layed sleep phase syndrome (DSPS), poor sleep hygiene, insomnia, narcolepsy,and restless legs syndrome (RLS)/periodic limb movements in sleep (PLMS).

PEDIATRIC SLEEP DISORDERSAlthough sleep disorders in children and adolescents are common, they arevaried in nature and presentation, ranging from bedtime resistance and

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frequent night wakings that are behavioral in nature to obstructive sleep apneaor narcolepsy, two physiologic sleep disorders. Regardless of the type of sleepdisorder, the majority of pediatric sleep disturbances most likely persist if leftuntreated and can have a significant impact on mood, behavior, development,and functioning. Thus, a careful screening for each of the following disorders isnecessary for all pediatric patients.

Behavioral Insomnia of ChildhoodBehavioral insomnia of childhood manifests most commonly as bedtime resis-tance and/or frequent night wakings [17] and occurs in approximately 10% to30% of infants and toddlers [18]. These sleep difficulties can be linked to an iden-tified behavior in the parent or child, and thus are classified into three subtypes.

Sleep-onset association typeSleep-onset associations are certain conditions that must be present to help chil-dren fall asleep, and without the association, sleep onset may be prolonged andnight wakings more frequent. Positive sleep associations are ones that childrencan facilitate for themselves (eg, sucking the thumb or holding a cuddly object),whereas a negative sleep association is one that involves another person, typi-cally a parent (eg, nursing or rocking an infant to sleep or laying with the tod-dler at bedtime) or external stimuli (eg, riding in the car to fall asleep). As allchildren have a brief arousal 2 to 6 times during the night [19], a child whois dependent on a negative sleep association at bedtime also requires this asso-ciation to be present in the middle of the night, resulting in the parental com-plaint of frequent night wakings.

Sleep-onset association type occurs primarily in infants and toddlers, ages 6months to 3 years [17]. Before 6 months, a diagnosis of behavioral insomnia ofchildhood is not appropriate, as sleeping for an extended period of time isa developmental skill that may not have developed [20]. Although some sleepassociations naturally cease with development (eg, nursing to sleep stops afterweaning), other sleep associations (eg, lying with a child at bedtime) persist;thus, frequent and persistent night wakings may continue. Behavioral treat-ments (eg, extinction, graduated extinction, and positive routines) have beenfound to be highly effective for sleep-onset association type [18,21].

Limit-setting typeThe limit-setting type of behavioral insomnia of childhood typically manifestsas bedtime stalling (eg, repeated requests to use the bathroom or one moregoodnight story) or bedtime refusal (eg, refusal to get ready for bed or stayin bed) at an age-appropriate bedtime [17]. If limits are set, children typicallyfall asleep quickly and easily. As with sleep-onset association type, limit-settingtype occurs in approximately 10% to 30% of toddlers and preschoolers, withthis disorder persisting into childhood, with approximately 15% of parents ofchildren ages 4 to 10 years also reporting problems with bedtime behaviors[1]. Limit-setting type results in prolonged sleep onset, thus, generally a shortertotal sleep time. Once children are asleep, however, their sleep quality typicallyis normal.

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Limit-setting type sometimes is related to normal child development, withyoung children who are learning independence during the day often assertingtheir newfound refusal skills at bedtime. Parents commonly exhibit two typesof responses to these behaviors, either setting no limits (eg, allowing children toset their own bedtime or allowing children to fall asleep in front of television) orsetting unpredictable or inconsistent limits (eg, allowing six books on one nightbut only one book on the next night), often resulting in bedtime temper tan-trums. As children get older, parental involvement with bedtime typically de-creases, reducing the opportunity for problematic behaviors at bedtime.Behavioral approaches also are shown to be highly efficacious in the treatmentof limit-setting type [18,21].

Combined typeThis new diagnostic category recognizes that some children may experienceboth the limit-setting type and sleep-onset association type of behavioral insom-nia of childhood. For example, children who stall and request frequent parentattention at bedtime (limit-setting type) may be unable to go to sleep until a par-ents sits with them at bedtime, and then they have frequent night wakings afterwhich a parent must return to the room to help them return to sleep (sleep-onset association type).

Insufficient or Inadequate SleepThe most common cause of daytime sleepiness in children is insufficient sleep,with adequate sleep sacrificed in order for children to complete their home-work, participate in extracurricular activities, or because of poor sleep hygienehabits (eg, staying up late to watch television). Sleep deprivation can have a cu-mulative effect, resulting in children and adolescents being late or missingschool, falling asleep during school, fatigue, illness, and irritability. Recentpoll data indicate that 28% of high school students report falling asleep inschool at least once a week and 14% report being late to school or missingschool as a result of oversleeping [5]. Furthermore, insufficient sleep can befatal for adolescents who fall asleep while driving.

Although sleep needs vary across the developmental stages, many parentsmay be unaware of either their children’s sleep needs or how much sleep theirchildren actually are getting [5,8]. Signs that children or adolescents are not get-ting enough sleep include (1) needing to be awakened for school or day care inthe morning, (2) sleeping 2 hours more on weekends and vacations comparedwith weekdays, (3) falling asleep in school or at other inappropriate times, and(4) behavior and mood differing on days after getting more sleep. It is impor-tant to address sleep needs and appropriate sleep hygiene with all family mem-bers, as many children and adolescents perceive that their school work oractivity schedule is inflexible, preventing adequate sleep. Alternatively, manyparents model poor sleep practices, including irregular sleep schedules, over-sleeping on weekends, and falling asleep with the television on in the bedroom.Behavioral contracts may be effective in helping children and their families

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target sleep behaviors that need to change (eg, regular sleep schedule) and thesteps that need to be taken to achieve these goals.

Delayed Sleep Phase SyndromeDSPS is seen most commonly in adolescents, although it also can occur inyounger children. DSPS is a circadian rhythm disorder where the habitualsleep-wake times are delayed significantly and persistently by 2 or more hoursbeyond the desired bedtime, interfering with environmental demands (eg,school) [17,22]. In addition, in this chronic condition, sleep patterns are notcoordinated with the environmental cues for sleep and wakefulness (eg,dark and light). Many adolescents report an inability to fall asleep before2:00 AM or 3:00 AM, with any attempts to fall asleep sooner resulting in sleeponset insomnia. If adolescents go to bed at the delayed hour, however, theyfall asleep quickly. Once asleep, adolescents who have DSPS have normalsleep quality. Most adolescents who have DSPS present in clinic with their par-ents complaining about how difficult they are to awaken in the morning. Ap-proximately 5% to 10% of adolescents have DSPS [2,23], with significantnegative effects on academic performance resulting from tardiness or missedschool days.

Treatment for DSPS is difficult and requires highly motivated adolescentswho are willing to keep a consistent sleep schedule 7 nights a week [2,23].When the difference between the actual and desired bedtime is less than 3hours, phase advancement is the best approach. Using this technique, adoles-cents are not to go to bed until the delayed bedtime (eg. 2:00 AM) and then ad-vance their bedtime by 15 minutes every few nights (or once they are fallingasleep quickly at each new bedtime). Chronotherapy, or phase delay, is effec-tive if the phase delay is greater than 3 hours. In this schedule, the bedtime andwake time are shifted 2 to 3 hours later every day until the desired sleepingtime is reached. For example, on day 1 the adolescent should sleep 3:00 AM

to 10:00 AM; day 2, 6:00 AM to 1:00 PM; and so on. Once the desired scheduleis reached, the adolescent must adhere strictly to the new sleep schedule, witheven one night’s deviation potentially returning him/her to the delayed sleepphase pattern. A family systems approach that explores family expectations,problem-solves ways to improve adherence, and discusses of the chronicityof the disorder may be beneficial [23]. This approach, however, has not beenstudied empirically.

The use of melatonin also may be helpful in advancing the circadian clock inadolescents who have DSPS [24]. There is no clear consensus about the timingand dosing of melatonin, and currently melatonin can be purchased only as anover-the-counter supplement, leaving questions about the actual concentrationof melatonin that patients are taking. It has been suggested, however, that mel-atonin should be administered 1 to 2 hours before desired sleep-onset time incombination with the blocking of light exposure in the afternoon and eveningand the increase of exposure to bright light in the morning [23]. In children,a dose of 0.3 to 5 mg has been suggested [23,25,26], but studies on the

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effectiveness and potential side effects of melatonin for children and adolescentsare sparse and inconclusive.

Sleep-Disordered BreathingSleep-disordered breathing (SDB) in children can range from primary snoring toobstructive sleep apnea syndrome (OSAS) and is related to significant cognitiveand behavioral sequelae, including learning, attention, concentration, hyperac-tivity, and aggressive behavior. The incidence of habitual snoring has been re-ported at 3% to 12% of the general pediatric population, with OSAS seen in 1%to 3% of children [2,27]. Although recent evidence suggests that snoring itself isrelated to negative neurobehavioral functioning [28,29], OSAS is a more seriousdisorder that poses significant risk for the developing brain [27].

The clinical presentation of OSAS differs from that in adults, where the typ-ical presentation is obese individuals who snore and are excessively sleepy dur-ing the day. In contrast, children who have OSAS may or may not be obese;the typical cause of this disorder in children is enlarged tonsils and adenoids.Although snoring alone is not indicative of OSAS in children, the AmericanAcademy of Pediatrics recommends that all children who have habitual snoringshould be evaluated for OSAS [30]. Additional symptoms of OSAS in childreninclude restless sleep, sleeping in an upright position or with the neck hyperex-tended (to keep the airway open), noisy breathing, and frequent infections ofthe tonsils or inner ear [27]. Although children may present typical symptomsof daytime sleepiness (eg, difficulty waking in the morning, falling asleep inschool, or frequent naps that are not age appropriate), some children actuallymay be hyperactive, especially as they get more tired. Neurobehavioral prob-lems also may be present in children with OSAS, including mood lability, ag-gression or other acting out behaviors, ADHD-like symptoms (eg, inattentionor hyperactivity), and learning problems [31–33]. Studies find that academicfunctioning improves in children who have OSAS who have been treatedwith adenotonsillectomy compared with children who were not treated [32,34].

OSAS occurs in children of all ages and both genders, although the peakprevalence of this disorder is seen in preschool-aged children (3 to 5 years).Children who have craniofacial abnormalities, Down syndrome, or microgna-thia are at increased risk for OSAS. In addition, with the rise in childhood obe-sity, increasingly more children are at risk for OSAS because of their weight,similar to adults.

For 70% of children, symptoms of OSAS are alleviated with a tonsillectomyand/or adenoidectomy [27,35]. A follow-up overnight sleep study post sur-gery is recommended. For children who are overweight, weight loss is therecommended treatment. Pharmacologic approaches may be indicated forchildren who have chronic nasal congestion that interferes with the qualityof their breathing during sleep. Finally, in children in whom a tonsillectomyor adenoidectomy is contraindicated or unsuccessful, nasal continuous posi-tive airway pressure (CPAP) may be appropriate. CPAP can be a successfultreatment for children and adolescents; however, young children and children

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who have developmental delays may have greater difficulty tolerating thistreatment and may need to participate in systematic desensitization to im-prove compliance with wearing the CPAP during sleep [36].

NarcolepsyNarcolepsy is a chronic neurologic disorder that involves excessive daytimesleepiness, cataplexy (sudden loss of muscle control in response to strong emo-tional stimuli), hypnagogic hallucinations (vivid dreams at sleep onset), sleepparalysis, and fragmented nighttime sleep [17]. Although the onset of narco-lepsy previously was believed to be in late adolescence or adulthood, it nowseems that the symptoms of narcolepsy, most notably excessive daytime sleep-iness, may begin to manifest in some individuals during childhood [37]. Theprevalence of narcolepsy in children is difficult to establish, with retrospectivestudies reporting that approximately 34% of adults who have narcolepsy expe-rienced the onset of symptoms before age 15 [38].

As sleepiness may be the only symptom present in children, the diagnosis ofnarcolepsy is more difficult in children and adolescents than in adults [39]. Thesymptoms of cataplexy and hypnagogic hallucinations may not be present ormay be difficult to elicit in clinic from a child or the parent’s history. Further,in young children, a diagnosis of narcolepsy may be confounded by a child’sdevelopmental need for regular naps. Polysomnography (PSG) with a multiplesleep latency test (MSLT) may provide clear evidence of narcolepsy, but inchildren, results are not always conclusive, and repeat studies may be necessaryfor a final diagnosis.

The current treatment recommendations for narcolepsy in children are sim-ilar to that of adults, and include education, sleep hygiene, and pharmacologicinterventions. Education must be conducted not only with the family but alsothe other systems within which the child functions, including school and peernetworks. Appropriate sleep scheduling is essential, with a consistent bedtime,wake time, and good sleep hygiene (eg, no TV in the bedroom and sleeping ina cool, dark environment). In addition, children and adolescents who have nar-colepsy may benefit from a scheduled daily nap in the early afternoon. Medi-cations commonly are used to target the primary symptoms of narcolepsy:daytime sleepiness and cataplexy. Stimulants are the class of drugs prescribedmost commonly to counteract daytime sleepiness [37,40]. Modafinil (Provigil)also is reported to be effective in improving alertness and improved perfor-mance; however, most studies have been conducted with adults, with few pe-diatric trials completed [41,42]. Cholinergic pathways mediate cataplexy; thus,medications with anticholinergic properties are used to treat cataplexy, includ-ing clomipramine and imipramine. Currently, there are no Food and Drug Ad-ministration (FDA)–approved medications for the treatment of narcolepsy(either the symptoms of daytime sleepiness or cataplexy).

Disorders of ArousalDisorders of arousal, more commonly referred to as partial arousal parasom-nias, are common pediatric sleep disorders that tend to cease with

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development. These events occur during the transition from slow wave sleep(stages 3 and 4) to lighter sleep, rapid eye movement (REM) sleep, or a briefarousal, with transitions most common during the first few hours after sleeponset (at bedtime and during naps). Partial arousal parasomnias include confu-sional arousals, sleep terrors, sleep talking, and sleepwalking [17,43]. Eventsgenerally last a few minutes but can last much longer for some children. Duringan event, although children are asleep, they may appear awake (eyes open),talk, or seem frightened or confused (eg, screaming in the case of sleep terrors).During a partial arousal parasomnia, children may not recognize their parentsand resist attempts to be comforted or soothed, with attempts to wake the childoften prolonging the event. Typical parasomnias resolve spontaneously withchildren rapidly returning to a deep sleep.

A common feature of these disorders is retrograde amnesia, with childrenhaving no recollection of the event in the morning. In addition to the amnesia,partial arousal parasomnias are distinguishable from nightmares by the timingof the events, with sleep terrors occurring in the first part of the evening andnightmares in the early hours of the morning (during REM sleep). Clinically,practitioners often say that when parents are more upset by the episode, it usu-ally is a sleep terror. Alternatively, when a child can recount vividly why he/shewas terrified after waking, the child likely is experiencing nightmares.

There is a strong genetic component to partial arousal parasomnias, with a fam-ily history typically reported [44]. In addition, studies find little evidence thatthese events are related to anxiety, depression, or other psychological problem,although there is an increased rate of psychiatric issues in adolescents whohave sleep terrors [45]. Partial arousals are more likely to be triggered by insuffi-cient sleep, a disruption to the sleep environment or sleep schedule, stress, illness,or certain medications (eg, chloral hydrate or lithium). In addition, SDB is foundin approximately 60% of school-aged children who have sleep terrors [44].

Treatment for partial arousal parasomnias includes providing families withinformation about creating a safe sleep environment (eg, preventing windowsfrom opening or putting alarms or bells on doors to alert if a sleep walker isup), education about the events, and how to interact with children appropri-ately during an event. Finally, as some children may develop a fear of goingto sleep (because they are afraid of having a partial arousal event) and a pro-longed sleep onset in turn increases the likelihood of an event occurring, par-ents should be encouraged to not discuss these events in the morning withthe child or other children in the home. Medications rarely are used to treatthis sleep disorder but may be indicated if partial arousal events are very fre-quent, highly disruptive to the family, or when the child or others in thehome are in danger because of the behavior. Additional information about par-asomnias in general are provided elsewhere in this issue.

Restless Legs Syndrome and Periodic Limb Movement DisorderAlthough the prevalence of RLS and periodic limb movement disorder (PLMD)is not well defined in the general pediatric population, it is worthy of discussion

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because of the strong relationship between these disorders and ADHD (dis-cussed later). RLS manifests as uncomfortable sensations in the legs that worsenin the evening and with long periods of inactivity (eg, long car ride or movie)[17]. Sensations often are described as creepy-crawly or tingling feelings, mostcommonly in the legs, which can be alleviated temporarily with movement.In children, this can include running and jumping around. Symptoms also some-times can be improved if the affected area is rubbed or stretched. PLMD com-monly co-occurs with RLS but also may appear independently. PLMS are briefrepetitive movements or jerks, lasting on average 2 seconds and occurring every5 to 90 seconds during stages 1 and 2 of sleep [17,46]. PLMD occurs whenPLMS are associated with frequent, but brief, arousals from sleep.

Pharmacologic treatment for RLS and PLMD in children and adolescentsmay include benzodiazepine and dopaminergic medications, although thesemedications have not been studied adequately in these age groups. In addition,some children who have RLS or PLMD have low iron/ferritin and many ofthese children and adolescents respond favorably to iron therapy [47]. Atthis time, there are no FDA-approved medications available to treat RLS andPLMD in children.

Sleep-Related Rhythmic Movement DisordersSleep-related RMD include head banging and body rocking and are consideredto be a sleep-wake transition disorder, occurring as children attempt to fallasleep at bedtime, naptime, or after a normal nighttime arousal [17,48]. The eti-ology for RMD is unknown and, although they are common in infants (60% of9 month olds), the behaviors tend to resolve spontaneously with development(only 8% of 4 year olds demonstrate these behaviors), but they can continueinto adolescence and adulthood [49]. Events typically last 5 to 15 minutes,but prolonged events can go for several hours. The rhythmic behaviors gener-ally are benign and self-limiting in normal children, with children rocking sideto side, rocking back and forth while elevated on all four limbs, or bangingtheir head against the pillow.

It is important to ensure that children are safe and protected from injurywhen they engage in these behaviors, and although treatments for this disorderare suggested, most are supported only anecdotally. In cases that result in in-jury, or when the behavior may be highly disruptive to others for a short du-ration (eg, family vacation or overnight sleepover), benzodiazepines may beindicated. For more severe cases or when the behavior persists past the ageof 3 years, however, a thorough psychiatric and neurologic evaluation is rec-ommended to rule out other disorders, such as autism, pervasive developmen-tal disorder, or hypnogenic dystonia.

EVALUATION OF SLEEP PATTERNS AND SLEEP DISORDERSIN CHILDREN AND ADOLESCENTSUnlike the evaluation of sleep problems in adults, information about a child’ssleep and functioning most likely is presented by a parent or other primary

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caregiver. Although in general the sleep history is similar to that of adults (eg,sleep patterns and daytime functioning), the social and environmental contextof a child’s daily life also needs to be considered. This context includes the im-pact of the child’s sleep problems on the family, including parent sleep andfunctioning, and the effects on other siblings in the home. The psychosocial his-tory needs to include questions about parental marital status and living ar-rangements, as children’s sleep patterns are influenced greatly by theirenvironment and inconsistencies in parenting practices or sleeping environ-ments also can disrupt sleep. Finally, daytime sleepiness can present differentlyacross the lifespan, with young children getting more active and seemingly en-ergetic when they get sleepy, while older children and adolescents becomemoody and more fatigued.

A thorough sleep history should cover all areas of a child’s sleep habits, keep-ing in mind that sleep patterns can differ significantly from weekdays to week-ends and from school days to summer vacation and holidays. Starting withbedtime behavior, it is important to assess children’s evening routine, bedtime,sleep environment (eg, cosleeping, shared room or bed, or television in the bed-room), behavior at bedtime (eg, bedtime stalling, bedtime refusal, or difficultiesfalling asleep independently), and sleep-onset latency. Nocturnal behaviorsshould be discussed, including night wakings, symptoms of SDB (eg, snoringor pauses in breathing), sleep terrors or sleepwalking, seizures, and enuresis.Daytime behaviors also should be reviewed, including children’s morningwake time (and difficulty waking in the morning), daytime sleepiness, fatigue,naps, meals, and caffeine or energy drink consumption.

Additional information about daytime functioning also is needed, includingmood, school performance, social interactions, and significant life events. Chil-dren and adolescents are greatly affected by their day-to-day environment, in-cluding home and school, and changes or stressors in either area may affectchildren’s sleep quality and sleep quantity. Events that may have an impacton children’s sleep include the death of a family member, social and peer pres-sure, the birth of a new sibling, a recent move, or marital discord between theparents. In particular, children who ‘‘worry’’ more than their peers are at riskfor difficulties with sleep onset and prolonged night wakings because of rumi-nation over social interactions, academic expectations, family problems, oreven current events (eg, September 11th, Hurricane Katrina, or the war inIraq).

Along with a detailed sleep history, sleep diaries provide a wealth of informa-tion about children’s sleep patterns. If completed on a daily basis, diaries canprovide information about the consistency of a child’s bedtime, duration ofsleep onset, occurrence of night wakings, and whether or not the child over-sleeps on weekends and holiday mornings. In addition, the timing, frequency,and duration of naps can provide additional information about why a childmay have difficulty falling asleep at a given bedtime.

Objective measures of sleep include actigraphy and PSG. An actigraph isa small device the size of a watch worn on a child’s wrist or ankle that measures

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sleep-wake patterns for extended periods of time (eg, 3 days to 2 weeks). Bymeasuring children’s movements and activity levels, a clearer picture of theirbedtime, wake time, night wakings, and naps can be provided (Figs. 1 and 2).The strength of actigraphy is that it can be collected easily for an extended periodof time in children’s natural sleeping environment. The two primary clinical lim-itations for using actigraphy are the need for an accurate sleep diary to interpretactigraphy patterns and the inability of actigraphy to provide information onsleep architecture or underlying sleep disruptors (eg, SDB or periodic move-ments during sleep).

PSG is considered the gold standard for assessing sleep stages and underly-ing sleep disruptors, such as OSA and PLMD. As with adults, the MSLT isused in combination with an overnight PSG for the diagnosis of narcolepsy,although normative values for children and adolescents differ by Tanner stage[37]. Although PSG can be conducted in the home, it is done more commonlyin a laboratory where the child stays overnight. Many physiologic measures arerecorded (eg, electroencephalogram [EEG], electromyogram, electro-oculo-gram, EKG, and oxygen saturation), providing information about the quantityand quality of children’s sleep. PSG has several drawbacks, including cost andavailability. In addition, PSG is only a single night measure, which does notprovide information about sleep patterns over time. In addition, there issome concern about children’s ability to sleep comfortably in a strange environ-ment (in particular young children). Finally, as discussed, PSG is expensive,and laboratories that are child friendly, with appropriately trained technicians,are limited.

Fig. 1. Actigraph printout of consistent sleep onset and offset.

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1071SLEEP DISORDERS IN CHILDREN AND ADOLESCENTS

SLEEP AND PSYCHIATRIC DISORDERS IN CHILDRENSleep difficulties are common in many different populations of children, includ-ing children and adolescents who have developmental disabilities, chronichealth conditions, and psychiatric disorders. The three groups of childrenwho have persistent sleep problems seen most commonly in psychiatric prac-tice are children who have ADHD, autism, and mood/anxiety disorders [50].The following is a brief review of the complex relationship between sleepand these disorders in children and adolescents.

Attention-Deficit/Hyperactivity DisorderSleep problems are common in children who have ADHD, affecting approxi-mately 25% to 50% of children who have this diagnosis [51]. Sleep clearlyhas been shown to differ between children who have and who do not haveADHD. Using parent report, actigraphy, and PSG, children who haveADHD have been found to have greater variability in their sleep patterns,greater difficulty with sleep onset, more activity during sleep, restless sleepand poor sleep quality, shortened sleep duration, and daytime sleepiness. Fur-ther, medications used to treat ADHD (eg, stimulants) can prolong sleep-onsetlatency and result in poorer sleep quality. These studies suggest that ADHDdisrupts a child’s sleep significantly.

The relationship between sleep problems and ADHD, however, is complexand bidirectional [52]. Although children who have ADHD have greater diffi-culties with sleep, children who have SDB display an increase in daytime be-havior symptoms that mimic ADHD or exacerbate underlying ADHD

Fig. 2. Actigraph printout showing inconsistent sleep onset and offset times and daytimenaps.

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symptoms. In studies of children who have SDB, including snoring and OSAS,an increase in hyperactivity, inattentive behaviors, poor emotion regulation,and peer problems is found [28,33,53]. When these sleep disorders weretreated, many of the ADHD symptoms also resolved [54,55]. Finally, higherrates of RLS/PLMD are found in children who have ADHD compared withchildren who do not have ADHD [56,57]. When the PLMD was treatedwith dopamine agonists, sleep quality, sleep quantity, and ADHD symptomsthat previously were resistant to psychostimulants improved [58]. More re-search is needed to help elucidate the relationship between sleep and ADHDin children and adolescents, but this population is at risk for increased sleep dif-ficulties that should be evaluated and treated when appropriate.

Autism Spectrum DisordersSleep problems commonly are reported in children who have autism spectrumdisorders (ASDs), affecting 44% to 83% of children who have ASDs [59–61].The sleep problems reported most commonly include prolonged sleep onset,frequent and prolonged night wakings, early morning wakings, and shorter to-tal sleep time, with differences reported by parent questionnaires and actigra-phy [61–64]. The etiology of sleep problems in children who have ASDs isunclear, although suggested causes include alterations in the timing of melato-nin production, anxiety, abnormal sleep EEG, or brain pathology.

Although knowledge is limited by the few studies conducted, sleep problemsin children who have ASDs seem to be related to daytime functioning. In par-ticular, sleep problems have been shown to be related to more energetic, ex-cited, and problematic daytime behaviors [59]. In addition, shorter total sleeptime is related to social skills deficits and increased stereotypic behaviors in chil-dren who have ASDs [65]. Behavioral interventions have been used, althoughwith limited to moderate success. Pediatric sleep specialists agree that childrenwho have ASDs have a lower response rate to behavioral interventions forsleep problems, and this population recently was identified as the highest prior-ity in terms of clinical trials for the pharmacologic management of pediatricsleep problems [66].

Depression and AnxietyAs with ADHD, the relationship between mood/anxiety disorders and sleep iscomplex and bidirectional. Sleep disturbances (eg, hypersomnia or insomnia)are a symptom of anxiety and depression; at the same time, the consequencesof disrupted or insufficient sleep often exacerbate these disorders. Ninety per-cent of children who have major depressive disorder report sleep disturbances,with insomnia or difficulty initiating sleep the most common complaint [67,68].Hypersomnolence, or sleeping too much, also is a common complaint in de-pressed adolescents [69]. These typically are subjective reports, however, as ob-jective measures of sleep do not always capture these sleep disturbances. Sleepcomplaints also are common in children who have anxiety disorders. Alongwith generalized anxiety, children who experience severe stress reactions,

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adjustment disorders, fears and phobias, or separation anxiety also experienceincreased difficulties with sleep.

As sleep disturbances and mood/anxiety disorders often are comorbid com-plaints, the most effective treatment is a multimodal integrated approach that ad-dresses both the sleep difficulties and the mood/anxiety problems [68]. Whentreating mood/anxiety disorders pharmacologically, it is important to considerthe impact of the medication on a child or adolescent’s sleep, especially assome antidepressants may exacerbate sleep problems. Having a clear and con-sistent sleep routine and schedule helps ensure that children or adolescent’s aregetting sufficient sleep. Relaxation strategies (eg, diaphragmatic breathing or im-agery) also may be used to improve sleep-onset latency and decrease bedtimefears and worries. Finally, the inclusion of a cognitive component (eg, positiveself-statements or restructuring sleep-onset expectations) also can be highly ef-fective in addressing sleep disturbances and mood/anxiety disorder.

SUMMARYSleep disturbances are common in children and range from behaviorally basedsleep disorders, including behavioral insomnia of childhood and DSPS, tophysiologically based sleep disorders, including OSAS, narcolepsy, RLS, andPLMD. Given that children and adolescents who have psychiatric issues com-monly experience sleep disorders, it is critical that child psychiatrists conducta thorough sleep assessment on all patients. Furthermore, not only are sleepdisorders frequently comorbid with psychiatric illness but, in many cases, con-tribute significantly to daytime symptoms and daytime functioning.

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