Mental Health Care Guide For Primary Care Clinicians Sleep Disorder OPAL-K Oregon Psychiatric Access Line about Kids L: OPAL-K Sleep Disorder Care Guide TABLE OF CONTENTS OPAL-K Assessment & Treatment Flow Chart for Sleep Disorders Page L1 OPAL-K Evaluation for Pediatric Insomnia Page L2 Sleep Disorder Screening, Questionnaire, Suggestions Page L3 OPAL-K Sleep Disorders Treatment Guidelines Page L4 OPAL-K Medication Treatment Algorithm for Sleep Disorders Page L5 OPAL-K Medication Table for Sleep Disorders Page L6 OPAL-K Family Checklist for Sleep Disorders Page L7 OPAL-K Sleep Disorder Resources for Patients Families and Teachers Page L8 OPAL-K Sleep Disorder Resources for Clinicians Page L9 Bibliography- Sleep Disorders Page L10 - L12 L1: OPAL-K INSOMNIA ASSESSMENT & TREATMENT FLOW CHART Identify possible causes of insomnia: behavioral factors, environmental factors, medical illness or medications, psychiatric disorders or substance abuse Behavioral Insomnia of Childhood Criteria: Environmental Causes: Psychiatric Disorders: Medical or Medication - Falling asleep is an extended process - Poor sleep milieu (noise, bright -ADHD Causes: - Sleep onset associations are highly problematic light, etc.) -PTSD -Delayed Sleep phase and demanding -Poor sleep hygiene -Bipolar Disorder syndrome (DSPS) - In the absence of associated conditions sleep is -Family mental illness/Substance -Substance use disorders -Restless Leg syndrome delayed use disorder -Anxiety Disorder (RLS) - Nighttime awakenings require caregiver -Too much caffeine -Major Depression -Asthma intervention -Adjustment Reaction -Cystic Fibrosis - The child has difficulty initiating or maintaining Trauma: -Psychotic Disorder -Pain syndromes sleep -Abuse or neglect - Obsessive Compulsive Disorder -Cancer - Child stalls or refuses to go to bed -Domestic Violence (OCD) -Rheumatic Disorders - The caregiver demonstrates insufficient or -Being bullied at school - Tic Disorders - Medication side-effects inappropriate limit setting -Cyberbullying -Parasomnias and Obstructive - The sleep problem is not better explained by sleep apnea medical, psychiatric, medication, or neurological factors -ADHD Insomnia – treat with alpha 2 -DSPS – usually treated with shifting agonist. Consider evening dose of internal clock using strict schedule, stimulant for rebound light therapy in AM, not light Parental and youth coaching Eliminate/Ameliorate exposure at night, melatonin - Establish a consistent bedtime routine that does not Environmental Causes: -Depression Insomnia – treatment -Restless Leg Syndrome – eliminate include stimulating activities, such as television - Remove stimulating electronic with antidepressant consider (caffeine, nicotine, antihistamines, viewing or video games media from bedrooms mirtazapine or doxepin if SSRI does SSRIs), exercise, and treat possible - Introduce more appropriate sleep associations that - Organize sleeping area to eliminate not resolve insomnia underlying causes like anemia will be readily available to the child during the night, excessive noise or light -Asthma, Cystic Fibrosis – Treat such as use of a transitional object (e.g., blanket, - No caffeinated beverages -Anxiety related insomnia – treat with underlying disorder and causes of air stuffed animal) - Address family mental health hydroxyzine or alpha 2a agonists and hunger - Encourage development of self-soothing skills, that issues/substance problems and make or SSRI -Pain syndromes from Rheumatic is having children fall asleep independently at bedtime appropriate referrals Disorders and cancer - treatment of without parental presence - Address domestic violence issues -PTSD insomnia – alpha 2a agonists underlying disease and proper pain - Practice bedtime fading, which involves temporarily and make appropriate referrals or prazosin if alpha 2as ineffective control setting the child’s bedtime to the current sleep-onset - Identify abuse and or bullying and -Parasomnias & Obstructive sleep time and then gradually advancing bedtime collaborate with mental health -Psychosis/Mania – antipsychotics apnea-refer to sleep specialist - Decrease parental attention for problematic bedtime professional/school on devising a behaviors, such as stalling and additional requests safety plan -Substance use disorders – - Provide positive reinforcement for appropriate abstinence, clonidine can help with behaviors, such as stickers for remaining in bed withdrawal syndromes - Teach self-relaxation techniques and cognitive- behavioral strategies, which can also be beneficial in -OCD- SSRI, Cognitive Behavioral older children. Therapy -Tic Disorders- alpha 2a agonists, antipsychotics L2: EVALUATION FOR PEDIATRIC INSOMNIA • Consider sleep disorders in the differential diagnosis when evaluating children and adolescents with cognitive, emotional and behavioral problems. • Screen all children and adolescents for OSA by asking parents about snoring, apnea, and labored breathing • Ask screening questions for narcolepsy, e.g., cataplexy, sleep paralysis, and hypnagogic hallucinations • Carefully assess sleep schedules and sleep amounts on weekdays, weekends and school holidays. Consider use of a sleep diary • Remember that insufficient sleep is the most common cause of excessive day time sleepiness (EDS) • Assess bedtime routines and sleep-onset associations especially in younger children with behaviorally based sleep disorders • Conduct a physical exam particularly assessing risk factors for Obstructive sleep apnea (OSA) such as craniofacial anomalies, tonsillar size, septal deviation of the nose L3 : OPAL-K Sleep Disorder Screening and Questionnaire BEARS Sleep Screening Algorithm https://depts.washington.edu/dbpeds/Screening%20Tools/ScreeningTools.html Children’s Sleep Habits Questionnaire and scoring Form https://depts.washington.edu/dbpeds/Screening%20Tools/ScreeningTools.html L4: OPAL-K Sleep Disorders Treatment Guidelines • There are no medications FDA approved for pediatric insomnia. • Use sleep hygiene education and behavioral interventions first, (80%-90% of Behavioral Insomnia resolves with behavioral/environmental interventions) before considering use of medications or naturopathic interventions • Youth with psychiatric illness and insomnia should have their psychiatric illness adequately treated before considering use of sleep medications or naturopathic interventions. • More complex psychosocial causes of insomnia may need a multidisciplinary team to adequately address problems such as domestic violence, bullying and substance abuse in the home • Refer suspected cases of Obstructive Sleep Apnea syndromes (OSAS) and narcolepsy to a sleep center for further assessment with Polysonography (PSG) and/or Multiple Sleep Latency Test (MSLT). • The treatment of choice for OSAS is adenotonsillectomy. Continuous Positive Airway Pressure (CPAP) can be used if surgery is not possible or if OSAS persists after adenotonsillectomy. • A follow-up polysomnogram should be done in any child continuing to have OSAS symptoms after adenotonsillectomy. • Delayed Sleep Phase Syndrome (DSPS) is common and can be readily treated with chronotherapy, light therapy and potentially melatonin as long as the patient is motivated. • Educate parents and the youth on sleep needs and hygiene and refer them to appropriate sources of information (see Suggested Readings). • Treat Parasomnias with reassurance and safety measures, using benzodiazepines sparingly for severe, potentially dangerous cases. • Behavioral interventions are the treatment of choice for young children with bedtime struggles and frequent awakenings. Resist using medications unless the child is neuro-developmentally compromised and unresponsive to behavioral treatments. L5: OPAL-K SLEEP MEDICATION TREATMENT ALGORITHM (v.101514) Meds not indicated Premedication Diagnostic evaluation and parent Use non-medical Stage education regarding non-medical and interventions (refer medication treatments to treatment table) Nonmedical interventions have failed Use an Over-the-Counter (OTC) or non- Meds effective Continue prescription medication first such as: melatonin, Treatment Med-Trial 1 or diphenhydramine (Benadryl) Regimen First OTCs ineffective, discontinue. Prescription medications: hydroxyzine (Vistaril), or Trazodone (Desyrel). When psychiatric disorder present consider using alpha 2a agonist for ADHD, atypical antipsychotics for bipolar or psychotic Meds effective Continue Med-Trial 2 disorders, mirtazapine for depression. Treatment Regimen Meds ineffective. Obtain OPAL-K c onsultation to use other meds or refer to child psychiatrist for treatment L6: OPAL-K Sleep Disorder Medication Table (01.06.14) Medication FDA Approval Dosing Comments Melatonin None 0.5-9 mg Some studies report decrease in sleep prior to latencies in youth with ADHD & Autism. desired bedtime Diphenhydramine Available over >12yrs 25- FDA cautions: Do not give to children 2yrs (Benadryl) the counter. FDA 50 mg po and younger approved for qhs 30 allergic reactions minutes 2yrs+ before desired bedtime Hydroxyzine Approved for rx 0.6mg/kg FDA cautions: Do not give to children 2yrs (Vistaril, Atarax) of anxiety, for and younger nausea, and presurgical pruritis in 6yrs+ sedation 25-50mg po qhs for sleep Trazodone FDA approved in Typical Anecdotal evidence that long-term treatment (Desyrel) adults for doses 25- is well tolerated depression 50mg po qhs for adults L7: Sleep Hygiene Checklist for Families with Children Who Can’t Sleep Living with a child who can’t sleep can be very frustrating and at times overwhelming.