Although sleep problems occur frequently in the pediatric population, with rates between 25%–40%, they too often go unrecognized and untreated (Sheldon S, Ferber R, Kryger M., Principles and Practice of Pediatric Sleep Medicine. Philadelphia, PA: Elsevier; 2005). In his Q&A interview in this issue, Dr. Rafael Pelayo nicely addresses how common sleep disorders are in children and adolescents; he also reviews some of the signs and symptoms you should look for. In this article, I describe in more detail some of the more common sleep disorders of childhood.

As Dr. Pelayo emphasizes, the cornerstone for diagnosing pediatric sleep disorders is obtaining a detailed and accurate history followed by a comprehensive physical exam that includes screening for developmental delays and cognitive dysfunction. This approach should be developmentally focused and problem driven, starting with, “Is this child waking up refreshed?” If the answer is no, you should follow- up by asking about the variables noted in the table “Assessing Sleep Problems in Young Patients.”

Sleep-disordered breathing
Sleep-disordered breathing in children ranges from primary snoring to obstructive hypoventilation to obstructive sleep apnea syndrome (OSAS). The condition can be subtle or overt. Your clinical suspicion should be high in any child with behavioral problems who wakes up unrefreshed. Any cessation of airflow at the nose and/or mouth causes disrupted sleep, transient hypoxemia (low levels of blood oxygen), and hypercapnia (high levels of CO2). The prevalence of OSAS is between 4% and 11% (Marcus CL, Am J Respir Crit Care Med 2001;164(1):16–30), and it becomes gradually more common from the ages of 2 through 8 years old, coinciding with the increased prevalence of enlarged tonsils.

As is true in adults, symptoms of OSAS in children include frequent loud snoring, observed breathing pauses, restless sleep, nighttime sweating, and choking/gasping/snorting during sleep. Almost all children with OSAS snore, but not all children who snore have OSAS. Children with sleep apnea may sleep in positions that help open the airway (hyperextending the neck or sleeping upright). Daytime symptoms of OSAS include mouth breathing and dry mouth due to enlarged adenoids, chronic nasal congestion, hypo-nasal speech, difficulty swallowing related to enlarged tonsils, morning headaches, frequent episodes of otitis media, and sinusitis. Children can also exhibit mood changes (depression/anxiety), increased somatic complaints, social withdrawal, aggression, impulsivity, hyperactivity, and other ADHD-like symptoms such as inattention, poor concentration, and distractibility.

As a psychiatrist, your main job is to identify the possibility that a sleep disorder exists in your patient, and then refer to a sleep specialist (Pediatrics 2002;109(4):704–712). Specialists will often start with an overnight polysomnogram, the gold standard test for diagnosing OSAS. Treatments range from tonsillectomy/adenoidectomy to nasal continuous positive airway pressure. For milder cases, specialists may prescribe drugs such as montelukast (trade name Singulair, often used for asthma) and intranasal corticosteroids such as fluticasone spray.

Insomnia
Pediatric insomnia is defined as difficulty with sleep initiation, duration, or quality that occurs despite age-appropriate time and opportunity for sleep and results in daytime functional impairment for the child and/or family (American Academy of Sleep Medicine. The international classification of sleep disorders: Diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005).

Behavioral insomnia of childhood 
The most common type of insomnia in the pediatric population is behavioral insomnia of childhood (BIC), which presents as bedtime problems and/or awakenings. There are 3 types of BIC: sleep-onset association, limit-setting insomnia, and combined. In sleep-onset association, children have trouble falling asleep on their own, because they have learned to associate falling asleep with specific circumstances. Some common examples of such circumstances include being in the parents’ bed or having the parents nearby, feeding from a bottle, being rocked, and watching television. In limit-setting insomnia, the child simply refuses to go to bed and the parents have trouble setting limits. The “combined” category indicates that both sleep association and limit-setting issues are relevant.

The best solutions for BIC are behavioral strategies, which are effective in about 80% of children (Mindell JA et al, Sleep 2006;29(10):1263–1276).

Primary insomnia
Primary insomnia is common in youth, with 9%–13% of adolescents experiencing chronic insomnia and 35% experiencing insomnia at least several times a month. The prevalence in pre-pubertal boys and girls is equivalent; however, there is an increased prevalence in post-pubertal girls. Common complaints are difficulty falling asleep/maintaining sleep, worrying about being unable to sleep, and decreased daytime functioning. Treatment of primary insomnia involves changing dysfunctional sleep behaviors (irregular sleep-wake schedule, daytime napping, and negative sleep perceptions). Behavioral strategies can include relaxation, sleep restriction, stimulus control, and cognitive behavioral therapy. Practicing sleep hygiene is a crucial component in treating pediatric insomnia. This includes setting a consistent, age-appropriate wake-up time and bedtime. The timing and duration of naps should also be consistent. Although pharmacological treatments have been studied in adults, there are no hypnotics that are FDA-approved for insomnia in children and adolescents.

Delayed-sleep-phase syndrome
Delayed-sleep-phase syndrome is a circadian disorder characterized by a shift in the sleep cycle to progressively later bedtimes and corresponding difficulty waking up early enough to fulfill social responsibilities. It is one of the most common sleep disorders of adolescence and is often caused by a tendency to stay up late and sleep in on the weekends. The sleep habit then carries over to weekdays. Successful treatment requires motivation from the adolescent, which is not a foregone conclusion. Both light therapy and melatonin can be helpful.

Disorders of arousal
Disorders of arousal (also known as parasomnias) include sleepwalking, sleep terrors, and confusional arousals (Mason TB and Pack AL, Sleep 2007;30:141–151). They are more common in young children and tend to decrease during the second decade of life, when slow-wave sleep declines. Treatment consists of educating parents regarding the causes and generally benign nature of these parasomnias. Safety should be the primary concern for children, and safety precautions should be instituted to prevent accidental injury. Avoidance of triggers such as insufficient sleep, stress, and anxiety also is helpful.

Restless legs syndrome
Restless legs syndrome (RLS) is a primary neurological disorder, characterized by uncomfortable sensations in the lower extremities that are accompanied by an almost irresistible urge to move the legs (Piccheietti MA and Picchietti DL, Semin Pediatric Neurol 2008;(15)2:91–99). A unique feature of RLS is the timing of symptoms; it appears to have a circadian component, often peaking in the evening.

The initial complaints by parents of children with RLS may be delayed sleep onset and/or daytime behavior or attention problems. Children will describe RLS symptoms as squeezing, tingling, wiggling, itching, popping, funny feelings, shaking, tiredness, arching, or pulling/tugging of the legs. Parents of RLS children may complain that their children are restless and need to kick/stretch their legs often. The consensus pediatric criteria for the diagnosis of RLS include the adult criteria plus a description of the symptoms in the child’s own words. The diagnosis is more complicated in children with limited verbal abilities.

Iron supplementation for children with RLS is a reasonable choice if the ferritin level is <50. Selective serotonin reuptake inhibitors (SSRIs), metoclopramide, diphenhydramine, sleep deprivation, nicotine, caffeine, and alcohol have all been shown to either promote or aggravate RLS, so they should be avoided if possible (Picchietti MA and Picchietti DL, Semi Pediatric Neurol 2008;(15)2:91–99).There is limited experience regarding the use of dopaminergic medications in children. Although ropinirole (Requip) and pramipexole (Mirapex) are FDA-approved medications in adults with RLS, there is no approved medication for the pediatric population. Other medications, including benzodiazepines, anticonvulsants, alpha-adrenergic agonists, and opioid medications, have not been adequately studied in children. Clonazepam is commonly used for treatment of RLS and PLMD in children; however, it may aggravate hyperactivity in young patients.

Insomnia due to lifestyle issues
Treating children for insufficient sleep can be challenging because of the increased pressure to succeed in life: Children these days have more pressure to get things done in a short period of time. Most children have after-school responsibilities such as sports, extra tutoring, or other activities, and then homework. Anecdotally, homework is taking longer to complete, a finding that may be linked to the pervasive use of smartphones: Children are finishing their homework by group texting. The child who finishes the homework fastest usually feels the obligation to help the rest of the group finish the homework as well. However, finishing homework in a group setting can sometimes be laboriously slow. In addition, more children have their cell phones on all the time and can receive text messages late into the night or early in the morning. With the pervasiveness of social media, more children have the fear of missing out (FOMO). They feel they need to be included in social networking (Facebook, Instagram, Snapchat, etc.), lest they miss an opportunity for social interaction, a novel experience, or satisfying event.

Conclusion
There are many good reasons to ask about sleep disorders in your psychiatric evaluations of children. Since adults with sleep disorders often report decades of suffering before their problem is addressed, identifying and treating children and adolescents with sleep disorders should be viewed as preventive medicine.

The core strategies for children who have trouble sleeping aim to reduce arousal at bedtime: sleep hygiene education, progressive muscle relaxation, stimulus control, and cognitive behavioral therapy techniques such as thought stopping, increasing positive thinking, and journaling “worries” at bedtime. Child psychiatrists and psychologists are in a unique position to nip these problems in the bud before they become chronic.