Assessment and Treatment of Pediatric Insomnia
KYLE P. JOHNSON, MD
PROFESSOR OHSU DIVISION OF CHILD & ADOLESCENT PSYCHIATRY OHSUDIPLOMATE, AMERICAN BOARD OF SLEEP MEDICINE Disclosures
No financial support from industry OHSUNo research grants presently Objectives
The attendee will understand the common presentations of insomnia in children and adolescents
The attendee will understand behavioral OHSUinterventions used to treat pediatric insomnia The attendee will understand the role of medicines in treating pediatric insomnia Disclaimer
There are no FDA approved medicines for pediatric insomnia All medicines discussed in this talk would be “off- OHSUlabel” if used to treat pediatric insomnia Pediatric Insomnia: Consensus Definition
Difficulty initiating and/or maintaining sleep that is viewed as a problem by the child or caregiver Significance of the sleep problem characterized by: Severity, chronicity, frequency, and associated impairment in daytime function in child or family Due to primary sleep disorder or in association with OHSUother sleep/medical/neuropsychiatric disorder
Owens JA, et al, Journal of Clinical Sleep Medicine 2005, 1(1):49-59 Prevalence Rates
Infants and Toddlers (> 6 months of age) 25-50% of infants and toddlers in cross-sectional studies are reported to have night wakings 10-15% experience bedtime resistance
Preschool age children OHSU 15-30% experience difficulties falling asleep and night wakings
Goodlin-Jones BL, et al. 2001; Mindell JA, et al. 2009; Burnham MM, et al. 2002 Prevalence Rates
Elementary school age children Overall prevalence of any parent-reported sleep problem is 25- 40% 15% bedtime resistance 11% sleep-related anxiety Adolescents Lifetime prevalence of insomnia in 13- to 16-year-old OHSUadolescents approaches 11% Up to 35% of adolescents experience insomnia at least several times a month Increased prevalence in girls postpuberty
Blader JC, et al. 1997; Owens JA, et al.2000; Johnson EO, et al. 2006 Types of Pediatric Insomnia
Behavioral insomnia of childhood Sleep-onset association type Limit-setting type Insomnia associated with a psychiatric disorder, neurodevelopmental disorders, and chronic medical disorders Insomnia associated with a sleep disorder Delayed Sleep Phase Syndrome OHSU Restless Legs Syndrome Psychophysiologic Insomnia, aka Learned or Conditioned Insomnia Primary Insomnia Behavioral Insomnia: Sleep Onset Association Type OHSU Case: Behavioral Insomnia Limit-Setting Type
Adam is a 30 month old, typically developing boy referred due to initial insomnia
Insomnia started when moved from crib to bed at 23 months of age
OHSURefuses to stay in bed and often leaves room delaying sleep onset by 2 hours each night Case - Toddler
For the last 2 months, Mother has sat in room with him until he falls asleep
He often wakes in night, comes to parental bed and OHSUfalls quickly to sleep there Case – Toddler
Adam has 5 month old sister, father works full-time and “really needs his sleep” and mother does not work outside the home
Adam described as high-energy and sensation seeking, needing constant parental attention during OHSUthe day Negative Impact on Family
Mother is exhausted and near tears stating “I can’t take it anymore” and OHSU“Please help!” OHSU Limit-Setting Sleep Disorder
Stalling behaviors or refusal to go to bed at the desired time associated with inadequate parental OHSUlimit-setting Behavioral Interventions for Insomnia
Parental and patient education
Infants and Toddlers (> 6 months of age) 25-50% of infants and toddlers in cross-sectional studies are reported to have night wakings 10-15% experience bedtime resistance
OHSU Awakenings during the night are normal
New sleep-onset associations can be taught Behavioral Interventions for Insomnia
Set wake time then determine lights out time
Consider sleep restriction to help with sleep efficiency OHSUSet limits around leaving bedroom Book for Parents OHSU
2005 HarperCollins ISBN: 0-06074256-9 Other Behavioral Interventions OHSU
www.goodnitelite.com Involve Dad! OHSU OHSU Types of Pediatric Insomnia
Behavioral insomnia of childhood Sleep-onset association type Limit-setting type Insomnia associated with a psychiatric disorder, neurodevelopmental disorders, and chronic medical disorders Insomnia associated with a sleep disorder Delayed Sleep Phase Syndrome OHSU Restless Legs Syndrome Psychophysiologic Insomnia, aka Learned or Conditioned Insomnia Primary Insomnia Case – 7 y/o with ASD
7 y/o boy with ASD, verbal with estimated normal intelligence, first grade
Significant anxiety at bedtime, worried about “monsters” recently
OHSUTaking melatonin 1 mg at bedtime with no clear benefit – no other medication trials Case – 7 y/o with ASD
Parents have given up on him sleeping in his own OHSUroom
No sleep apnea symptoms What to Do? OHSU Differential Diagnosis
Anxiety Disorder Always consider trauma
Developmentally normal fears leading to insomnia OHSUInsomnia related to ASD Behavioral Interventions
Move child to his own bedroom with parent present at lights out Parent in room until child asleep or parent sleeps in child’s room
Put child in bed with lights out while drowsy but OHSUawake Bedtime Pass
Best for addressing bedtime struggles Use in 3- to 10-year- old children who have verbal abilities OHSU Tied to rewards Visual schedules clarify bedtime routines
Time for bed
Put on pajamas
Use the bathroom
Wash hands
Brush teeth OHSUGet a drink Read a book
Get in bed and go to sleep
Tailor visual support based on child’s language level Courtesy of Beth Malow Monster Spray OHSU OHSU
www.dawnhuebnerphd.com Book for Parents OHSU
2005 Marlowe & Company ISBN: I-56924-362-X Other Non-Pharmacologic Treatments
Massage therapy (Escalona et al, 2001) Improved sleep problems and stereotyped behaviors OHSUduring the day Qigong Sensory Training Institute www.qsti.org [email protected] OHSU Insomnia in Children with ASD: Pharmacotherapy OHSU
Rossignol DA and Frye RE, Dev Med & Child Neurology 2011; 53(9): 783-792 Meta-Analysis 2011
Meta-Analysis performed on 5 randomized, double-blind, placebo-controlled studies involving melatonin Demonstrated significant improvements with large effect sizes in sleep duration and sleep onset OHSUlatency but not in night-time awakenings Reported side effects of melatonin were minimal to none
Rossignol DA and Frye RE, Dev Med & Child Neurology 2011; 53(9): 783-792 Evidence Base for Melatonin
Several studies (including RCT’s) in typically developing children with sleep –onset insomnia, ADHD, and ASD demonstrate efficacy Appears to be safe Studies in ADHD and ASD have not demonstrated OHSUimprovements in core symptoms/behaviors
Garstang 2006; Van der Heijden, 2007; Anderson, 2008; Wasdell, 2008; Hoebert, 2009; Wright, 2011 Melatonin Dosing Recommendations
Children less than 40 kg, start with 1-1.5 mg and increase weekly by 1-1.5 mg increments to max of 6 mg
Children weighing > 40 kg, start with 1-3 mg and increase by 1-1.5 mg increments until max of 9 mg OHSUalthough unlikely to see improvements > 6 mg Melatonin Recommendations
If certain treating delayed sleep phase syndrome, can give ~ 300 mcg 5-6 hours before present sleep onset time
In treating sleep-onset insomnia, recommend higher OHSUdoses given 30 minutes before lights out Melatonin Recommendations
Melatonin stable in strawberry yogurt, jam, OJ, milk
Tend to recommend melatonin sold in larger pharmacies Natrol, Twin Labs, Rexall, etc. OHSU Can find “pharmaceutical grade” Liquid and controlled release formulations available Not Recommended ! OHSU Insomnia in Children with ASD: Pharmacotherapy
When melatonin does not work Sedating antidepressants Trazodone in girls, mirtazapine in boys or girls Doxepin Can consider non-benzodiazepine, benzodiazepine receptor agonists in teenagers Alpha-2 agonists when hypervigilant from trauma OHSU Risperidone or aripiprazole if considerable irritability/self- injury OHSU Types of Pediatric Insomnia
Behavioral insomnia of childhood Sleep-onset association type Limit-setting type Insomnia associated with a psychiatric disorder, neurodevelopmental disorders, and chronic medical disorders Psychophysiologic insomnia, aka learned or conditioned insomnia OHSUInsomnia associated with a sleep disorder Delayed Sleep Phase Syndrome Restless Legs Syndrome Primary Insomnia OHSU
Created by Daniel Cooper Psychophysiologic Insomnia = Learned Insomnia = Conditioned Insomnia OHSU Case - Teenager OHSU Case - Teenager
16 y/o boy, typically developing, sophomore in high school
Cannot fall asleep until 1 am and has to get up at 6:30 am to get to school on time
OHSUMissing classes, at risk to fail
Taking naps after school Case - Teenager
Sleeping until 12 noon on weekend days
Over the summer, slept from 1 am to to 10:30 am
Screen negative for depression, substance use or OHSUanxiety disorder Delayed Sleep Phase Syndrome
Delay in phase of major sleep period in relation to desired sleep/wake-up time
Chronic or recurrent inability to fall asleep at desired conventional clock time
Inability to awaken at a desired and socially OHSUacceptable time
Normal, stable sleep/wake when on preferred schedule Delayed Sleep Phase Syndrome
Reported prevalence of 7% to 16% in adolescents and young adults
Approximately 10% of patients with chronic insomnia in sleep clinics
OHSUUsually begins in adolescence
Familial – about 40% with family history Delayed sleep phase is common cause of sleep onset insomnia OHSU
Reid KJ, et al, Med Clin N Am 2004, 88: 631-651 Assessment and Treatment of DSPS
Assess motivation of the patient
Determine if family is able to provide support
OHSU Don’t Simply “Make Excuses” for missing school Basic Behavioral and Chronobiologic Interventions OHSU
The Opponent Process Model of Sleep Bright Light Therapy
Useful in treating adolescents with delayed sleep phase syndrome OHSUGive in the morning soon after waking OHSUVs. Improve sleep hygiene
No screen time the hour before lights out
Keep lights low before OHSUbedtime eReaders OHSU eReaders OHSU
Chang AM, et al, PNAS 2015, 112(4):1232-1237 eReaders vs. Print Book
Lux Print book = .91 lux eBook = 31.73 lux
Melatonin suppressed more with eBook vs Print OHSUBook Delay in circadian phase with eBook vs Print Book
Chang AM, et al, PNAS 2015, 112(4):1232-1237 Basic Behavioral and Chronobiologic Interventions
Start with wake time for weekdays/school days Wake time on weekend days should be within 2 hours of weekday wake up time
Determine lights out time based on known sleep needs for youth the age of the patient OHSU Discuss staying out late on weekend nights Basic Behavioral and Chronobiologic Interventions
Teach stimulus control Bed for sleep only
If not able to fall asleep within 20 minutes, get out of bed and sit back in relaxing place WITH LIGHTS REMAINING OFF Listen to books on tape, podcast When eyes get heavy, return to bed and engage in relaxation techniques OHSU If not able to fall asleep in 20 minutes, get out of bed and repeat process Basic Behavioral and Chronobiologic Interventions
Consider sleep restriction Tally the amount of sleep a patient is getting then limit time in bed to this amount by making bedtime later When the patient starts falling asleep within 20 minutes of lights out, start making bedtime gradually earlier by 15-30 minutes OHSU Continue this process until appropriate bedtime reached Naps
Need to be addressed
Educate on benefit of a “power nap” of 20-30 minutes If cannot commit to limiting nap to 20-30 minutes, OHSUthen better not to take nap Pediatric Insomnia OHSUPHARMACOTHERAPY OHSU
Antihistamines – 33% Alpha-2 Agonists – 26% Benzodiazepines - 15%
Antidepressants – 6% Non-benzodiazepines – 1% Pharmacologic Options
Over the Counter Prescribed Medications
Melatonin Benzodiazepines Antihistamines Non-Benzodiazepine, Herbal Benzodiazepine Receptor Agonists OHSU Sedating antidepressants Alpha-2 agonists Antipsychotics Pharmacology of Pediatric Insomnia
Age influences choices Preschool age child Benzodiazepines (clonazepam or lorazepam) Potentially trazodone in female patient Potentially clonidine or guanfacine in child with history of trauma School age child Similar choices as above but also may consider mirtazapine and OHSUdoxepin Clonidine or guanfacine in child with ADHD and significant sleep onset insomnia Pharmacology of Pediatric Insomnia
Adolescent Consider newer hypnotic agents used in adults Zolpidem – immediate release form is now generic must take just as patient gets in to bed; warn about risk of confusion, sleep walking. Zolpidem CR – generic available Zaleplon OHSU Eszopiclone Pharmacology of Pediatric Insomnia
Concerns Overdoses Particularly of clonidine, guanfacine, and doxepin Significant Side Effects Priapism with trazodone Confusion or parasomnias with zolpidem OHSU Do not turn to antipsychotics unless indicated for another condition Insomnia in Children with ADHD
Higher rates of Obstructive Sleep Apnea and Restless Legs Syndrome
Objective measures of sleep (actigraphy and polysomnography) demonstrate minimal or inconsistent differences between children with OHSUADHD and controls except for: Increased movements during sleep More night-to-night variability in sleep patterns
Sadeh A, et al. Sleep Med Rev 2006; Cortese S, et al. JAACAP 2006 Insomnia in Children with ADHD
Other causes of insomnia Comorbid anxiety Oppositional behavior at bedtime Psychostimulant-mediated delayed sleep onset “Rebound” OHSU Intrinsic circadian phase delay Insomnia in Children with ADHD: Pharmacotherapy
Melatonin Shown in several studies to be effective for chronic sleep onset insomnia without significant adverse effects (Weiss M, et al. JAACAP 2006; Van Der Heijden, et al. JAACAP 2007; Hoebert M, et al. Pineal Research 2009) Clonidine Systematic chart review of 62 cases (Prince JB.,et al. JAACAP 1996) 42 children and 20 adolescents Doses ranged from .05 mg to .8 mg used over 1-3.5 months OHSU 85% improvement per clinician with 19% experiencing mild adverse effects 8 week, multicenter, DB PCT Zolpidem dosed at 0.25 mg/kg per day with maximum of 10 mg/day
Two groups of children with ADHD: OHSU 6-11 y/o’s and 12-17 y/o’s Primary measure was latency to persistent sleep between weeks 3 and 6
Blumer JL, et al. Pediatrics, May 2009: e770 – e776 Results: Mean change in latency to persistent sleep at week 4 did not differ between zolpidem and placebo groups Zolpidem in older age group showed improved CGI scores at weeks 4 and 8 No next day residual effects or rebound in insomnia OHSUafter discontinuation 7.4 % discontinued zolpidem dizziness, headaches, hallucinations
Blumer JL, et al. Pediatrics, May 2009: e770 – e776 Insomnia in Children with Anxiety Disorders: Pharmacotherapy
Trauma-Related Anxiety Alpha-2 agonists (clonidine, guanfacine, prazosin) Anxiety Disorders and OCD Sedating antidepressants (added to SSRI if medicine used to treat the anxiety disorder or OCD) Benzodiazepines OHSU Non-benzodiazepine, benzodiazepine agonists in teenagers Insomnia in Children with Major Depressive Disorder: Pharmacotherapy
Sedating antidepressants (added to SSRI used to treat major depressive disorder)
Non-benzodiazepine, benzodiazepine agonists in OHSUteenagers Sedating Antidepressants
Trazodone Priapism risk due to antagonism of alpha-adrenergic receptors Abnormal erectile function estimated at 1/6000 male patients Only slightly faster than fluoxetine in relieving insomnia in adolescents with depressive disorder (Kallepalli et al, J of Child and Adol Psychopharm 1997) Mirtazapine Noradrenergic and specific serotonergic antidepressant 7.5 mg and 15 mg tablets Monitor BP, pulse, lipid profile, CBC and LFTs periodically OHSUDoxepin FDA approved for treating adults with insomnia Silenor (trade name) 3 mg and 6 mg doses Generic: 10 mg capsules and 10 mg/1 ml oral solution Great Reference Book
Written by two experts in the field. Very practical and up-to- date (2010). Includes web access to questionnaires and patient handouts. ISBN: 978-60547-389-5 OHSU(paperback). The End OHSU