Sleep Disorders in Children and Adolescents

Contents

Preface: Pediatric Sleep Disorders: A Unique Opportunity for Child and Adolescent
Psychiatry xv
Jessica R. Lunsford-Avery and Argelinda Baroni

Normal Sleep in Children and Adolescence 1

Alex Agostini and Stephanie Centofanti
Adequate sleep is essential for healthy development in childhood and
adolescence. Healthy sleep contributes to good physical health, immune
function, mental health, and academic performance. The regulation and
architecture of sleep change greatly across childhood and adolescence,
and the ability to obtain sufficient sleep is impacted by a range of factors
that change with maturation. This article describes normal sleep across
childhood and adolescence and discusses some of the most common
barriers to adequate sleep, including early school start times, technology
use, and changes to circadian rhythms, and sleep homeostasis across
puberty.

Sleep and Technology in Early Childhood 15

Amy I. Nathanson
Research suggests that technology use is associated with poorer sleep
outcomes among children less than 6 years of age. These associations
are evident regardless of the type of technology studied, although eve-
ning exposure may have the greatest impact compared with technology
use during other parts of the day. More work is needed, particularly
given that technology use is relatively high among young children. Cli-
nicians should assess patients’ technology exposure, including before
bedtime, to assess whether sleep issues stem from children’s technol-
ogy use. Moreover, clinicians should educate caregivers about the as-
sociation between technology use and sleep problems among young
children.

Neurocognitive Effects of Sleep Disruption in Children and Adolescents 27

Karen Spruyt
A main childhood task is learning. In this task, the role of sleep is increas-
ingly demonstrated. Although most literature examining this role focuses
on preadolescence and middle adolescence, some studies apply napping
designs in preschoolers. Studies overall conclude that without proper
sleep a child’s cognitive abilities suffer, but questions on how and to
what extent linger. Observational studies show the hazards of potential
confounders such as an individual’s resilience to poor sleep as well as
developmental risk factors (eg, disorders, stressors). A better

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 viii Contents

understanding of cognitive sleep neuroscience may have a big impact on

pediatric sleep research and clinical applications.

Classification and Epidemiology of Sleep Disorders in Children and Adolescents 47

Irina Trosman and Anna Ivanenko
Sleep disturbances are common in children and adolescents but still
remain unrecognized and undertreated. Several classification systems
of sleep disorders are available, which include recent attempts to develop
more specific nosologic categories that reflect developmental aspects of
sleep. The prevalence of sleep disorders has been studied across various
samples of healthy, typically developing children and those with special
medical, psychiatric, and neurodevelopmental needs. Sleep disorders
are highly prevalent in children and adolescents with psychiatric disor-
ders, making it important for mental health professionals to be aware of
sleep problems and to address them in the context of psychiatric
comorbidities.

Screening and Evaluation of Sleep Disturbances and Sleep Disorders in Children and
Adolescents 65
Suman K.R. Baddam, Craig A. Canapari, Jenna Van de Grift, Christopher McGirr,
Alexandra Y. Nasser, and Michael J. Crowley
Sleep disturbances and sleep disorders are prevalent in children/adoles-
cents and have a bidirectional relationship with pediatric medical and
mental health disorders. Screening tools and mechanisms for the evalua-
tion and treatment of sleep disturbances and sleep disorders in the pedi-
atric mental health clinic are less well-known; hence, sleep disturbances
and disorders are under-recognized in the pediatric clinics. We present
specific, validated screening and evaluation tools to identify sleep distur-
bances and sleep disorders in children/adolescents. We offer guidance
related to the use of consumer wearables for sleep assessments and
use of sleep telemedicine in pediatric mental health and primary care
clinics.

Medications Used for Pediatric Insomnia 85

Vijayabharathi Ekambaram and Judith Owens
Pediatric insomnia can affect physical and mental health and cause cogni-
tive deficits, social deficits and decrease quality of life. There are no Food
and Drug Administration approved medications approved for pediatric
insomnia. Pharmacologic interventions derive mostly from adult data or
pediatric case reports. This review focuses on Food and Drug Administra-
tion approved prescription drugs (in adults), over-the-counter drugs, and
off-label pediatric insomnia drugs. This review helps the clinician learn
general principles, practice guidelines, and pharmacologic considerations
for medication selection in the pediatric population. Pharmacologic man-
agement should be considered in combination with behavior therapy,
which is proven to have long-lasting outcomes.

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 Contents ix

Behavioral Treatment of Insomnia and Sleep Disturbances in School-Aged Children

and Adolescents 101
Jessica R. Lunsford-Avery, Tatyana Bidopia, Leah Jackson, and Jessica Solis Sloan
Insomnia and related sleep disturbances are prevalent among youth and
are associated with adverse consequences, including poorer psychiatric
functioning. Behavioral sleep interventions, ranging from brief educational
interventions to behavioral therapies (cognitive behavior therapy–
insomnia), are associated with positive outcomes for pediatric sleep
health. In addition, sleep interventions may improve psychiatric health
for children and adolescents with neurodevelopmental and internalizing
disorders. Additional research is necessary to clarify the efficacy of these
interventions over the long-term and across demographic groups; howev-
er, evidence suggests incorporating behavioral sleep strategies may prove
beneficial to pediatric patients with sleep disturbances and related psychi-
atric complaints.

Pediatric Insomnia 117

Madeline Himelfarb and Jess P. Shatkin
Insomnia is the most common sleep disorder among all ages; unfortu-
nately, however, child and adolescent insomnia is infrequently addressed.
Given the importance of adequate sleep for proper brain development, pe-
diatric populations are particularly vulnerable to the negative effects of
insomnia. Therefore, proper clinical assessment and treatment of pediatric
insomnia is crucial. This article is the result of a comprehensive literature
review and serves as a guide to the disorder and how it presents differently
across child development.

The Parasomnias 131

Oliviero Bruni, Lourdes M. DelRosso, Maria Grazia Melegari, and Raffaele Ferri
Parasomnias usually present in childhood and resolve spontaneously.
The diagnosis of non–rapid eye movement–related parasomnias is
mainly based on clinical descriptors and can be challenging. Rapid
eye movement–related parasomnias may index an underlying psychiat-
ric disorder. Even if benign, parasomnias can affect quality of life. Pedi-
atricians and child psychiatrists should be familiarized with these sleep
disorders and suggest adequate sleep hygiene, avoidance of sleep
deprivation, and regular bedtimes even on weekends as the first step
in management of these disorders. Clinicians should pursue the oppor-
tunity for tailoring treatments and consider referral to a sleep expert
when indicated.

Restless Legs Syndrome in Children and Adolescents 143

Lourdes M. DelRosso, Maria Paola Mogavero, Argelinda Baroni, Oliviero Bruni,
and Raffaele Ferri
Children with psychiatric comorbidities frequently are referred for evalua-
tion of sleep complaints. Common sleep symptoms can include difficulty
falling asleep, frequent nocturnal awakening, restless sleep, and

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 x Contents

symptoms of restless legs syndrome (RLS). The understanding of the

sleep condition in relation to the psychiatric comorbidity often is a chal-
lenge to the physician and often sleep disorders remain undiagnosed, un-
treated, or undertreated. Restless legs syndrome has been associated
with psychiatric comorbidities and with certain medications, such as anti-
depressants, antihistamines, and antipsychotics. This article reviews the
presentation of RLS and restless sleep, the association with psychiatric
comorbidities, and treatment options.

Just Let Me Sleep in: Identifying and Treating Delayed Sleep Phase Disorder in
Adolescents 159
Michael A. Feder and Argelinda Baroni
Individuals with delayed sleep phase disorder (DSPD) are unable to natu-
rally fall asleep and awake at conventional times; for this reason, DSPD is
often mistaken for insomnia. However, unlike many patients with insomnia,
those with DSPD struggle to get up at appropriate times. DSPD is associ-
ated with school refusal, academic difficulties, and lower employment rate.
DSPD in youth has prevalence as high as 16%, and is often comorbid with
other psychiatric disorders. Treatments include appropriate light exposure
during the day, melatonin use, developing an evening routine that mini-
mizes arousal-increasing activities, and gradually shifting sleep-wake
times toward more functional ones.

The Associations Between Sleep and Externalizing and Internalizing Problems in

Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical
Findings, Clinical Implications, and Future Research Directions 175
Jenny Dimakos, Gabrielle Gauthier-Gagné, Lanyi Lin, Samantha Scholes, and
Reut Gruber
Sleep problems are common in youth with attention-deficit/hyperactivity
disorder (ADHD). Externalizing and internalizing problems contribute to
dysfunction in youth with ADHD and are amplified by disrupted sleep.
This objective of this article is to synthesize empirical studies that exam-
ined the associations between sleep and internalizing or externalizing
problems in individuals with ADHD. The main findings are that sleep prob-
lems precede, predict, and significantly contribute to the manifestation of
internalizing and externalizing behavior problems among children and ad-
olescents with ADHD. Clinicians should assess sleep and integrate sleep
interventions into the management of youth with ADHD.

Autism Spectrum Disorder and Sleep 195

Kyle P. Johnson and Paria Zarrinnegar
Children and adolescents with autism spectrum disorder (ASD) experience
sleep disturbances, particularly insomnia, at rates much higher than the
general population. Daytime behavioral problems and parental stress are
associated with the resultant sleep deprivation. Behavioral interventions,
parental education, and melatonin are effective treatments. The epidemi-
ology of sleep disturbances in youth with ASD is reviewed in this article
as well as the latest in treatments.

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 Contents xi

Sleep-Related Problems and Pediatric Anxiety Disorders 209

Katherine Crowe and Carolyn Spiro-Levitt
Sleep-related problems are highly prevalent among childhood and adoles-
cent anxiety disorders. The objective of this review was to summarize the
relevant clinical research literature as it pertains to the nature of the asso-
ciation between sleep-related problems and youth anxiety, developmental
factors relevant to this association, and intervention efforts to target co-
morbid sleep challenges and anxiety. Limitations of the literature and
future directions are discussed.

Afraid and Awake: The Interaction Between Trauma and Sleep in Children and
Adolescents 225
Veronica Fellman, Patrick J. Heppell, and Suchet Rao
Traumatic experiences and sleep disturbances are both common in chil-
dren and adolescents. Because of the reciprocal relationship between
sleep complaints and trauma, a mental health evaluation should include
not only an assessment of posttraumatic stress disorder and other trauma
symptoms but also a specific evaluation of sleep-related complaints. Simi-
larly, if a history of both trauma and sleep complaints is identified, an effec-
tive trauma-informed intervention, whether psychological,
psychopharmacologic, or a combination of the two, should directly
address sleep issues.

Sleep and Mood Disorders Among Youth 251

Lauren D. Asarnow and Riya Mirchandaney
This article reviews the literature on mood disorders and sleep disorders
among children and adolescents. Research suggests that sleep plays an
important role in the development, progression, and maintenance of
mood disorder symptoms among children and adolescents. Sleep prob-
lems as early as maternal perinatal insomnia may predict and predate
depression among youth. Children and adolescents who develop comor-
bid mood disorders and sleep problems represent a particularly high-risk
group with more severe mood episode symptoms, higher rates of self-
harm and suicidality, and less responsivity to treatment. Treatment
research supports the idea that sleep problems can be improved through
behavioral interventions.

When Night Falls Fast: Sleep and Suicidal Behavior Among Adolescents and Young
Adults 269
Sara N. Fernandes, Emily Zuckerman, Regina Miranda, and Argelinda Baroni
Sleep disturbances have been linked to suicidal ideation and behaviors in
adolescents. Specifically, insomnia and nightmares are associated with
current suicide risk and predict future ideation. Associations between hy-
persomnia, sleep apnea, and suicide remain inconclusive. Potential bio-
logical mechanisms underlying these relationships include executive
functioning deficits and hyperarousal. Related psychological factors may

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 xii Contents

include thwarted belongingness, perceived burdensomeness, and nega-

tive appraisals. Assessing suicide risk in patients with sleep disturbances,
and vice versa, is needed. Therapeutic interventions such as cognitive
behavior therapy for insomnia and imagery rehearsal treatment, as well
as pharmacologic treatments, show promise in treating sleep disorders
and suicidal behavior.

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