Sleep problems can present several different ways. First, sleep problems occur with many different psychiatric disorders as one of many symptoms within a syndrome. For example, sleep difficulty is one out of 20 possible formal symptoms of posttraumatic stress disorder.
Second, sleep problems can also occur as secondary problems caused by a primary psychiatric disorder. For example, sleep difficulty is not a formal symptom of either autism or attention-deficit/hyperactivity disorder, but it is often seen as a secondary problem caused by the primary problems of those disorders.
Third, sleep problems can occur as primary disorders that are separate from any other psychiatric syndrome (e.g., insomnia disorder, narcolepsy, obstructive sleep apnea, or restless legs syndrome), but these are rarely seen in the routine practice of child & adolescent outpatient mental health practices. These are usually handled by self-help or by primary care doctors.
Sleep Patterns in Very Young Children
Sleep patterns evolve rapidly during the first three years of life. The total amount of sleep needed decreases from 15 hours/day at 1 year of life, to 13 to 14 hours/day by 2 years, and 12 hours/day by 4 years. During the first 3 years of life, short naps occur in the midmorning and early afternoon. The modal duration of naps is about 2 hours. Morning naps disappear first, and then by 3 to 5 years, the afternoon naps gradually disappear. A minority of children nap at 5 and 6 years, and naps usually disappear by age 7 (World Health Organization, 2004, p. 44).
The time it takes to fall asleep gradually shortens and the number of night wakings decreases. After falling asleep, night wakings are normal. Some children wake and put themselves back to sleep and parents never know about the wakings. Other children need their parents to put them back to sleep. Based on research, the following guidelines suggest when sleep may be considered a problem:
(1) Number of minutes needed to fall asleep that may be considered above average:
12-24 months of age: >30 minutes after being put to bed.
After 24 months of age: >20 minutes.
(2) Number of awakenings per night that may be considered above average:
12-24 months of age: 3 or more awakenings per night (combined time >10 minutes)
24-36 months of age: 2 or more awakenings per night (combined time >20 minutes)
After 36 months of age: 2 or more awakenings per night (combined time >30 minutes)
These are guidelines based on group averages (Task Force on Research Diagnostic Criteria: Infancy and Preschool, 2003). For some children their mature sleep pattern does not emerge until early adolescence.
Sleep Apnea in Young Children
Obstructive sleep apnea syndrome deserves special mention. Even though it is uncommon - up to 3% of pre-school children are affected – it can go undetected and cause behavioral problems. Obstructive sleep apnea syndrome is caused by upper airway obstructions during sleep, usually associated with blood oxygen desaturations. The obstructions are often caused by adenotonsillar hypertrophy. The symptoms can be loud snoring, arousals, and unusual sleep positions, such as sleeping on hands and knees. Nighttime bedwetting is common. Because of the sleep disturbance, children are tired in the morning and may develop excessive daytime sleepiness or hyperactivity (World Health Organization, 2004, p. 84).
For a more complete summary of sleep problems see the WHO report, pp 82-102, which is free to download at http://www.euro.who.int/__data/assets/pdf_file/0008/114101/E84683.pdf
Sleep in Middle Childhood (7-12 years) and Adolescence (13-18 years)
By 10 years, children spend 8 to 10 hours in bed and sleep approximately 95% of that time. Prepubertal children are alert throughout the day and daytime naps are rare (Carskadon et al. 1987). Midadolescents sleep on average 8.5 hours/day, and older adolescents, primarily college students, about 7 hours a night (Carskadon et al. 1987).
Older adolescents report staying up to watch television or to do schoolwork on school nights and waking up by alarm in the morning, so they sleep less on school nights compared to non-school nights. The demands of schoolwork increase during adolescence, and parents tend to relinquish control of bedtime
There is no single “magic number” for the duration of sleep needed by children of a certain age because there is significant variability in sleep needs from child to child and across age ranges (Owens, 2012). According to the US National Institute of Health, sleep requirements for teenagers and preteens are estimated to be between 10 hours for 12 years, and 8.5 hours for 18 years.
The simplest and most straightforward way to screen for sleep problems is to keep a daily log over several weeks. One-time questionnaires tend to be inaccurate because of faulty perceptions and unreliable memory.
There are general guidelines to ensure good sleep patterns (otherwise known as sleep hygiene), that apply to all age groups. These include making sure children are active during the day so that they are tired by bedtime, have a routine to prepare for bedtime, go to bed at a regular time, and make the sleeping environment quiet and comforting.
However, because the nature and cause of sleep problems vary so widely throughout development, specific interventions often need to be highly individualized.
In terms of medications for sleep, melatonin is an over-the-counter product that many parents have found long-term success with in the range of 1- to 6- mg per night.
Diphenhydramine (e.g., Benadryl) is an over-the-counter anti-allergy medicine that often makes children drowsy enough to help them fall asleep. Unfortunately, many children have the reverse reaction and become more activated.
For prescription drugs, doctors ought to feel confident that they have reliable reporting from parents before using strong medications.
Sleeping pills (e.g., Ambien and Lunesta) appear to be rarely used in children and adolescents for a variety of reasons. They are not FDA-approved for children, they are not a cure-all, they often have side effects, and so many developmental changes are happening that it seems premature to use a sleeping pill as opposed to searching for an underlying cause.
When using prescription medications, doctors more often use medications that have been approved for other disorders but have a “beneficial” side effect of causing drowsiness or impacting the REM sleep cycle. These include clonidine, hydroxyzine, mirtazapine, trazodone, quetiapine, and others.
If you are a provider who specializes in assessing or treating sleep problems, or know someone who does, please share that information with us by emailing [email protected]
Carskadon, MA, Dement WC (1987). Daytime sleepiness: Quantification of a behavioral state. Neuroscience and Biobehavioral Reviews, 11,3:307-317.