To Sleep

Perchance To Dream
The Diagnosis and Treatment of Children
and Adolescents with Sleep Disorders

Jess P. Shatkin, MD, MPH

Vice Chair for Education
NYU Child Study
New York University School of Medicine
 Outline of Presentation
Review of Normal Sleep Physiology
Neurocognitive Effects of Sleep Disruption
Common Sleep Disorders
Insomnia
Sleep Disordered Breathing
Non-REM Parasomnias
Enuresis
Sleep in Children with Common Psychiatric
Conditions
 Polysomnogram (PSG)

Electroencephalogram (EEG)
Electromyogram (EMG)
Electrooculogram (EOG)
Vital Signs
Other Physiologic Parameters
 Other Methods to Study Sleep
Ambulatory Techniques
Edentrace System (monitors pulse, body position, oro-nasal
flow, chest impedance, breathing noises, and pulse oximetry)
Actigraphy (commonly used, developed in the early 1970s and
has come into increasing use in both research studies and
clinical practice; allows for the study of sleep-wake patterns and
circadian rhythms via the assessment of body movements.
The device is typically worn on the wrist and can easily be
adapted for home use. Reliable and valid for the study of sleep
in normal, healthy populations but less reliable for detecting
disturbed sleep)
Survey Instruments
Many exist for detecting problematic sleep in children and
adolescents, including self-report questionnaires (such as the
Sleep Disturbance Scale for Children, the Child Sleep
Questionnaire, and the Child and Family Sleep History
Questionnaire), sleep diaries, and parent report forms.
 EEG Sleep Patterns
Low Voltage, Random, Fast
Awake
8-12 Hz, Alpha Waves
Drowsy
3-7 Hz, Theta Waves
Stage 1
12-14 Hz, Sleep Spindles and K-Complexes
Stage 2
0.5-2 Hz, Delta Waves, High Voltage, Slow Waves
Stage 3/4

Low Voltage, Random, Fast with Sawtooth Waves

REM
Important Concepts and Terms

Sleep Latency
REM Latency
REM Density
REM Rebound
Sleep Onset REM Period
Non-REM Physiological Changes

Reduced physiological activity

Autonomic slowing
Maintain thermoregulation
Episodic, involuntary movements
Few rapid-eye movements
Few penile erections (little vaginal
lubrication)
Reduced blood flow
 REM Physiological Changes

Increased physiological activity

Autonomic activation
Altered thermoregulation
Partial or full penile erections (significant
vaginal lubrication)
Skeletal muscle paralysis
Rapid-eye movements
 The Sleep Cycle

Cyclic nature of sleep is reliable

REM periods every 90 120 minutes
First REM period is shortest
Most deep sleep (Stage 3 & 4) occurs
early
Most REM occurs late
 Normal Sleep Cycle in Children
Awake
REM
Stage 1
Stage 2
Stage 3
Stage 4

1 2 3 4 5 6 7
Hours of Sleep
Normal Sleep Cycle in Young Adults
Awake
REM
Stage 1
Stage 2
Stage 3
Stage 4

1 2 3 4 5 6 7
Hours of Sleep
 Normal Sleep Cycle in the Elderly
Awake
REM
Stage 1
Stage 2
Stage 3
Stage 4

1 2 3 4 5 6 7
Hours of Sleep
 Sleep Regulation
No clear, single center
Serotonin & Catecholamines (EPI, NOREPI,
DA)
REM off cells
GABA
Acetylcholine
REM on cells
Suprachiasmatic nucleus
25 hour cycle?
Orexin/hypocretin
Pineal gland (melatonin)
Neuroendocrine Activity in Sleep

Growth Hormone
Prolactin
Luteinizing Hormone
Cortisol
Thyroid Stimulating Hormone (TSH)
 Function of Sleep

Restorative/homeostatic
Thermoregulation/energy conservation
Consolidation of learning and memory
Programming of species-specific
behaviors
to sleep, perchance to dream, ay
theres the rub
William Shakespeare (Hamlet)
 Dreams

Sleep hath its own world, A boundary

between the things misnamed Death and
existence: Sleep hath its own world, And
a wide realm of wild reality, And dreams
in their development have breath, And
tears and tortures, and the touch of joy.
Lord Byron
 Dreams

REM dreams
Non-REM dreams
Motor paralysis
Rapid-eye movements
Dream content
Predominantly sad/angry/apprehensive
Primarily visual
 Neurocognitive Effects of Sleep
Disruption: Attention and Memory
Limited data in children; most info based upon the
effects of sleep disordered breathing (SDB) on
daytime performance
Sleep restriction in experimental settings results in
inattention and changes in cortical EEG responses
(even after only 1 hour restriction)
Data are inconsistent on the effects of sleep disruption
on memory performance
Children suffering from Obstructive Sleep Apnea
(OSA), Periodic Limb Movement Disorder (PLMD),
and Restless Leg Syndrome (RLS) with resulting
sleep fragmentation have been shown to suffer
academic deficits, learning problems, and symptoms
that mirror ADHD
In the case of OSA, symptoms are generally reversible after
treatment
 Neurocognitive Effects of Sleep
Disruption: Psychometric Testing

Sleep restriction and total sleep

deprivation have been shown to reduce
computational speed, impair verbal
fluency, & decrease creativity and abstract
problem solving ability
Severe sleep fragmentation (e.g., as seen
in OSA) may result in reduced intelligence
scale scores (IQ)
 Neurocognitive Effects of Sleep
Disruption: Academic Achievement
Children with OSA suffer lower academic
achievement (even when age, race, gender,
SES, and school attended are controlled for)
Treatment of OSA results in significant
improvement in school performance
Children who snore loudly and consistently in
early years are at greater risk for academic
delays in later years, suggesting residual
effects on learning even after resolution of
symptoms
Animal models show increased neuron cell loss in the hippocampus
and PFC in rats exposed to intermittent hypoxia; along with
decreases in special task acquisition and retention and increased
locomotor activity compared to controls
 Sleep Disorders in Children
~25% of children will suffer some type of sleep
problem at some point during childhood
Complaints range from bedtime resistance and
anxiety to primary sleep disorders, such as OSA
and narcolepsy
Research is remarkably consistent, with parents
reporting 50% of preschool children, 30% of
school aged children, and 40% of adolescents as
having sleep difficulties
Self-report among adolescents reveals 14 33%
complaining of frequent or extended nighttime
awakenings, EDS, unrefreshing sleep, early
insomnia, and a subjective need for more sleep
 Sudden Infant Death Syndrome
A worldwide decline in the past decade
Incidence at roughly 0.77 per 1000 live births in Great Britain; incidence
in the United States has dropped by more than 50% from 1.53 per 1000
live births in 1980 to 0.56 per 1000 live births in 2001
Still, SIDS accounted for 8% of all infant deaths in the United States in
2002 and ranks as the third leading cause of infant death in the United
States
The most widely accepted definitions of SIDS require that all other
known possible causes of death be ruled-out by death scene
investigation, review of the clinical history, and autopsy prior to accepting
SIDS as the diagnosis (e.g., intentional or nonintentional injury,
suffocation, etc).
Efforts aimed at reducing modifiable risk factors for infants, such as
sleeping in a prone position, over-bundling, and secondary smoke
exposure, have reduced the incidence of SIDS by more than 60% in
most parts of the world.
Other strategies, such as sleeping solitary in a supine position, not
allowing infants to sleep on their sides, and using a pacifier, may
ultimately reduce the incidence still further.
In the United States, the SIDS rate for African and Native American
infants remains more than twice that of Caucasian infants, reflecting a
long-standing racial disparity.
 DSM IV Sleep Disorders:
Dyssomnias
Primary Insomnia
Primary Hypersomnia
Narcolepsy
Breathing Related Sleep Disorder
Circadian Rhythm Sleep Disorder
Dyssomnia NOS
Primary Insomnia in the General Population
Early and middle insomnia
PSG studies are negative
Sub-clinical symptoms of psychiatric illness
often present
More common w/increasing age and in women
Prevalence: 1 10% in general population; up
to 25% in elderly
Generally sudden onset w/continuation due to
negative conditioning and development of
maladaptive sleep patterns
 Pediatric Insomnia

No clear definition has existed until this

year: Repeated difficulty with sleep
initiation, duration, consolidation, or quality
that occurs despite age-appropriate time
and opportunity for sleep and results in
daytime functional impairment for the child
and/or family.
International Classification of Sleep Disorders-2
 Pediatric Insomnia (2)
Prevalence estimated at 1 6 % in general
pediatric population but considerably higher
amongst those children with neurodevelop-
mental delay and chronic med/psych
conditions
A recent study of 46 children (5-16 y/o) found
that 50% of the those presenting to a
pediatric sleep center for insomnia had a
preexisting psych diagnosis and the
remaining 50% had elevated psych
impairment scores on psychometric
measures & diagnostic interview (Ivanenko et al, 2004)
 Behavioral Insomnia
A recently introduced diagnostic category to
emphasize the sleep difficulties resulting
from inadequate limit setting or sleep
associations:
Rocking
Watching TV
Falling asleep every night in the parents bed
The child is unable to fall asleep in the
absence of these conditions at both bedtime
and following nocturnal awakenings
 Case #1: Insomnia
James is a 15 year-old male with a childhood
history of moderate separation anxiety for which
he never received treatment. He has a history of
mild/moderate sleep disruption (primarily early and
occasional middle insomnia), but over the past 6
weeks he has suffered increasing insomnia
concurrent with an increase in school stressors.
He presents to you with complaints of a two hour
sleep onset latency 4x/week and nightly nocturnal
awakenings with difficulty falling back to sleep.
How do you proceed?
 Treatment of Insomnia: Sleep
Hygiene
Identify the cause or other Axis I disorder (if
possible) and treat
Set a sleep/wake schedule
Exercise daily but not at night
Avoid caffeine, cigarettes, alcohol, and drugs
Invent a relaxing bedtime ritual (e.g., bathing,
reading, watching TV, etc.)
Use the bed for sleeping or sex, nothing else
Wake up to the sun, exposing yourself to
morning sunshine
Adjust the room temperature as desired
Treatment of Insomnia (2): Medication
No FDA approved treatments
Sedatives are short-term solutions
A shorter half-life is typically preferred
Sedating antihistamines (diphenhydramine,
hydroxyzine, cyproheptadine)
Alpha-2 agonists (clonidine, guanfacine)
Sedating antidepressants (Trazodone, Serzone,
Remeron, TCAs,)
Benzodiazepines and similar agents (Sonata, Ambien,
Lunesta, Rozarem) preferred over barbiturates
Tolerance to somnolent effects of Benzos develops in about 4
weeks (not anxiolytic effects)
HM/DS: Melatonin, Kava, Valerian, L-tryptophan,
chamomile, passion flower, lavender, etc
Sleep Disordered Breathing (SDB)

Primary Snoring
regular snoring without changes in sleep
architecture, alveolar ventilation, or
oxygenation
Upper Airway Resistance Syndrome
Similar to OSA but UARS does not result in
blood oxygen desaturations
Obstructive Sleep Apnea
Results in blood oxygen desaturations
 SDB: Epidemiology

Primary Snoring
*Prevalence = 7 12%
Upper Airway Resistance Syndrome
*Estimates difficult to ascertain
Obstructive Sleep Apnea
*Prevalence = 1 2%
 SDB Clinical Presentation
Parents complain of:
Snoring
Frequent awakenings
Excessive Daytime Sedation
Poor academic performance
Irritability
Poor executive function
Inattention/general cognitive impairment
 SDB Evaluation and Treatment
Labs show:
A reduction in airflow and Hgb saturation
Increased total Hgb
Cardiac arrhythmias (sinus arrhythmias, PVCs,
AV block, sinus arrest)
Stage 1 >> 3,4 & REM
Physical Examination shows:
Adenotonsillar enlargement
Pectus excavatum & rib flaring
More commonly in adults: obesity, >17 neck
size, HTN, cor pulmonale
 Treatment of Sleep Apnea
Weight loss
Sleep on sides (and stomach)
CPAP (Continuous Positive Airway
Pressure) prevents obstruction by soft-
tissue and keeps airway open
Surgical intervention (e.g., enlarged
tonsils, deviated septum)
Avoid sedatives (which can prevent
reawakening to breathe)
 DSM IV Sleep Disorders:
Non-REM Parasomnias
Somnambulism
Sleep/Night Terrors
Somniloquy
Enuresis
Sleep Related Involuntary Movement
Disorders
PLMD
Body Rocking
Bruxism
Enuresis: Epidemiology & Diagnosis
Occurs in approximately 30% of 4 y/o, 10%
of 6 y/o, 5% of 10 y/o, 3% of 12 y/o, and 1%
of those 15 y/o and over
Although not satisfying DSM-IV criteria for
diagnosis, 10 20% of 5 y/o continue to
have a least one episode of nocturnal
enuresis/month
DSM-IV requires:
Frequency at least 2x/week for at least 3 months
age at least 5 years
 Enuresis: Etiology

Primary enuresis (never consistently dry)

Multifactorial etiology w/difficulties in: bladder
musculature stability, CNS arousability,
pontine reflex function, internal sphincter tone,
functional bladder capacity, nocturnal urine
production, & maturational delay in ADH
secretion
Secondary enuresis (previously dry for 6
mo)
UTI, diabetes mellitus, psychological factors
 Associated Features

Nocturnal enuresis is associated with poor

self-image, diminished achievement in
school, and an increase in the time spent
by families compensating, both financially
and personally, for the symptoms.
Risk factors (twice as common in
boys>girls, family history, lower SES,
black race)
 Case #2: Enuresis
Ryan is a 10 y/o male with a history of mild MR,
ADHD (CT), and severe ODD with a rule-out of
Bipolar D/O NOS. He also suffers nightly
enuresis. Current medications include Concerta
54 mg qAM and Risperdal 0.25 mg BID. His
parents have tried numerous behavioral
interventions with no success. Ryan has
previously been treated with desmopressin
acetate to 4 mg hs and imipramine to 50 mg hs.
What questions do you have?
How would you proceed?
 Enuresis: Treatment (1)

Full history (e.g., nature of behavioral

treatments tried, how medications were
used)
Psycho-education for family and patient
Discontinue all caffeine and EtOH
Restrict late night fluid intake
Afternoon nap (to decrease Stage III/IV)
Brief awakening for toileting at midnight
 Enuresis: Treatment (2)

Behavioral Treatments:
Bedwetting alarm (highest cure rate, lowest
relapse rate)
Bladder training to increase capacity
Reward systems
Cognitive & motivational therapy
Pelvic floor muscle training
Biofeedback
 Enuresis: Treatment (3)
Medications:
Desmopressin acetate (DDAVP)
Intranasal (10 60 mcg) vs. oral (0.1 0.6 mg)
Imipramine or amitriptylene
25 50 mg
Anticholinergic (antispasmodic) agents
Oxybutinin (Ditropan) 2.5 5 mg or tolterodine
(Detrol) 0.5 1 mg
Combination treatment
DDAVP + oxybutinin or DDAVP + TCA
Atomoxetine (Strattera)
Non-REM Sleep Disorders and
Unconscious Actions

Doctor: You see, her eyes are open.

Lady-in-Waiting: Ay, but their sense are
shut.
William Shakespeare (The Tragedy of
MacBeth)
 Non-REM Sleep Parasomnias:
Shared Features
1 30 minutes
Retrograde amnesia
Family/personal history
High potential for injury to self and others
Occur during slow-wave sleep
More common in childhood
Attempts to awaken are fruitless
Psychopathology rare in children
Non-REM Sleep Parasomnias:
Precipitating Factors
Dyssomnia
Sleep deprivation
Medications
Magnesium deficiency
Hormonal factors
 Sleep Terrors
Infrequent occurrence
Prevalence 36.5% in children, 12.6% in
adults
Autonomic activation
30 seconds 3 minutes
Complete amnesia
Gender preference
Males typically in childhood
Females possibly more common in adulthood
 Sleepwalking

Common occurrence
Prevalence 6-17% in children; lifetime
incidence 40%
Prevalence 2.5% in adults
Generally docile
Often coupled with enuresis
No consistent gender differences
Complete amnesia
May engage in complex behaviors
 Confusional Arousal

Epidemiology unclear
4% incidence in Stockholm study
No gender differences noted
Hallmarks include irrational acts, poor
judgment, incoherence, and disorientation
Autonomic arousal
Complete amnesia
Premeditated acts believed impossible
 Case #3: Non-REM Parasomnia vs.
Suicide Attempt
Tracy is a well adjusted 12 y/o girl from an intact
and loving family with no psychiatric history.
One summers evening, an hour after going to
bed, she was awoken with a severe sore throat.
She stumbled to the mirror to find her throat cut
wide open to her trachea with two 5 horizontal
lacerations extending the breadth of her neck. A
bloodied box cutter was found at her bedside;
she had no memory of the event.
How would you make a diagnosis?
How would you treat this case?
Treatment of Non-REM Parasomnias:
Psychosocial Interventions
Repeat of a violent episode is rare
Family/patient education
Avoid possible precipitants
Avoid sleep disruptions
Loud noises, limit evening oral fluid intake
Safeguard the home
Movement sensors, locks on windows, remove
potentially lethal objects, etc.
Enforce afternoon naps with Sleep Terrors
Treatment of Non-REM Parasomnias:
Medication

Benzodiazepines with long half-lives

Clonazepam, Diazepam
Tricyclic antidepressants
SSRIs and Trazodone
Barbiturates
possible use in REM sleep disorders
 DSM IV Sleep Disorders:
REM Parasomnias

REM Sleep Behavior Disorder

Sleep Paralysis
Nightmare Disorder
 Sleep in Children with Common
Psychiatric Conditions

ADHD
Pervasive Developmental Delays
Mood Disorders
Anxiety Disorders
 ADHD: Epidemiology
All variety of sleep disorders are more
common amongst children with ADHD than
healthy controls, controls with other psych
illness, and health siblings by 5x
The DSM-III considered excessive
movements during sleep to be a criterion for
hyperactivity in children
It is estimated that up to 25% of children
with severe sleep problems in infancy will
later qualify for a diagnosis of ADHD
 ADHD: Clinical Presentation
Greater variation in sleep onset time, wake
time, and sleep duration
Significantly more bedtime struggles with
parents
Habitual snoring is 3x more common in
children with ADHD
Greater frequency of PLMD and SDB have
also been frequently reported
ADHD: Treatment Recommendations
Enforce sleep hygiene
Lower the dose or change the stimulant
Change to a shorter acting preparation
Add a low dose of stimulant (if insomnia
appears due to hyperactive rebound)
Change to an entirely novel agent (e.g.,
atomoxetine)
Use adjunctive agents: antihistamines,
clonidine, sedating antidepressants, &
melatonin
 PDD: Epidemiology
44 88% of children with frank autism are
reported to suffer sleep difficulties as are 44
86% of children with Autism Spectrum
Disorders
Younger children and those with more
severe cognitive delay/disability tend to
demonstrate increased problems
Sleep problems are often long-standing; a
recent study of adults with Aspergers
demonstrated that 90% complain of
frequent insomnia
 PDD: Clinical Presentation
Most frequently reported problems are
difficulty falling asleep, frequent awakenings
with difficulty returning to sleep, early
morning awakening, irregular sleep/wake
patterns, shortened duration of sleep,
dyssomnias & parasomnias
Etiology may have to do with failure to
recognize environmental and social cues,
poorly developed circadian rhythms (b/c of
social deficits), altered melatonin
production, and abnormalities in the HPA
axis
 PDD: Treatment
Sleep hygiene & behavioral treatments
Chronotherapy +/- light therapy for those
with circadian rhythm problems or phase
shifting
Unstudied medications: antihistamines,
sedating antidepressants, alpha-2 agonists,
benzodiazepines, antipsychotics
Melatonin
Sedative
Synchronizing sleep to environment
 Mood Disorders: Epidemiology
2/3 of depressed children have early &
middle insomnia and 50% report late
insomnia
Up to 88% of depressed adolescents report
sleep disturbances (primarily insomnia) with
up to 25% of these reporting hypersomnia
Approximately 10% experience continual
insomnia after the depression has lifted
One study of bipolar children found 40%
had a dramatically reduced need for sleep
(vs. controls and those with ADHD)
Mood Disorders: Clinical Presentation
Children may demonstrate bedtime
resistance, bedtime anxiety, early & middle
insomnia, desire to co-sleep, enuresis,
nightmares, sleep-walking, early morning
awakening, and EDS
Adolescents report difficulties with early and
middle insomnia (w/extended awakenings),
EDS, unrefreshing sleep, and up to 50%
report early morning awakening
Sleep difficulties in adolescents appear to be
chronic and affect girls more than boys
Mood Disorders: Clinical Presentation (2)
Adolescents who report sleep problems are
much more likely to report symptoms of
depression, anxiety, poor self-esteem,
lethargy, irritability, and emotional lability
Adolescents who report sleep problems are
also much more likely to consume caffeine,
nicotine, and alcohol
Thus, sleep problems should be viewed as a
potentially easy marker for adolescents at
risk of developing some sort of
psychopathology
 Sleep in Adults with Depression

Reduced REM latency

Increased percentage of REM
REM distribution shifts to earlier in sleep
cycle
Reduction in REM sleep useful in
treatment
REM is preferentially selected in sleep
deprived and/or depressed state
 Mood Disorders: Treatment

Identify and treat the primary Axis I disorder

Sleep hygiene and medications as indicated
No clear data on whether or not to treat the
symptom of insomnia independent from the
mood disorder
Borrowing from adult studies, this may make
sense for pediatric bipolar disorder
 Anxiety Disorders: Epidemiology
Anxiety and sleep are intimately tied in
childhood
Sleep problems by age 4 are correlated with
later onset depression and anxiety by 15
Nighttime fears are common (up to 75%
report)
Sleep problems typically follow for those
children with DSM-IV anxiety disorders
(PTSD, OCD, school refusal, etc.)
 Anxiety Disorders: Clinical
Presentation
Nighttime fears commonly take the form of
animals, fictitious characters (e.g., witches
& monsters), being kidnapped, or being
teased by peers
Anxiety is believed to predispose children to
parasomnias and nightmares
Occasional nightmares occur in 80% of
children
15% report frequent nightmares (>1/month)
69% of children report that the content of their
nightmares is influenced by frightening material
viewed on TV or at the movies
 Anxiety Disorders: Treatment

Identify and treat the primary Axis I disorder

Sleep hygiene and medications as indicated
No clear data on whether or not to treat the
symptom of insomnia independent from the
anxiety disorder