Rafael Pelayo, MD.
Clinical Professor in the Department of Psychiatry and Behavioral Sciences, Stanford Center for Sleep Sciences and Medicine at the Stanford University School of Medicine, Stanford, CA.
Dr. Pelayo has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CCPR: What are some of the main challenges child psychiatrists face when evaluating kids with sleep problems?
Dr. Pelayo: What I teach is to always think of sleep in terms of 4 components. For patients who come to you with sleep concerns, you have to think about: 1. the amount of sleep; 2. the quality of their sleep; 3. the timing of their sleep; and 4. their state of mind. These are key areas you need to cover when getting a patient’s history.
CCPR: Let’s start with amount of sleep. I know many of us think between 8–10 hours, depending upon age. Is this actually correct? Does less sleep than the recommended amount automatically raise a red flag for you?
Dr. Pelayo: The more important issue is not so much the number of hours of sleep; it’s whether the child wakes up refreshed or not. Sleeping is about restoring the brain. Think about why we tell kids they have to sleep: to make themselves feel better or to recharge their batteries. That’s the way we need to look at it. When I asked one 3-year-old patient, “Why are you here?” he looked me in the eye and said, “Doctor, sleeping makes me tired.” The mother of another child said, “I don’t know what’s wrong. He sleeps more than the other kids. He still naps. Some of his friends have stopped napping already. He’s always tired.” It turns out that although this kid was logging a lot of sleep hours, the quality was bad because he had undiagnosed sleep apnea: The more hours he slept, the worse he was breathing, the more tired he felt.
CCPR: So what’s a better approach than asking how much sleep a patient is getting?
Dr. Pelayo: I ask the parents (or the patient if it’s a teenager), “Do you ever wake up refreshed, or are you always tired?” If they say, “If I can get enough hours of sleep, or if I’m on vacation, I sleep better,” then there is a behavioral component. But, if they always wake up tired no matter how many hours they sleep, there may be an organic issue going on, and you’re almost automatically going to order a sleep test, because you want to measure the quality of their sleep. A sleep study is not to study their sleep habits, it’s to determine the quality of their sleep once they are asleep. It’s also important to think about the entire family’s sleep when you consider amount and quality of sleep aspects.
CCPR: Why is that?
Dr. Pelayo: It’s a mistake to just hone in on the child’s sleep, because they don’t sleep in a vacuum; they sleep in a family. For many families, the only break parents get is when the child is sleeping. The more impaired the child is with sleep, the greater the pressure to sleep in a predictable pattern to take stress off the family. Parents often feel guilty, knowing it’s not the child’s fault; sometimes they blame themselves. On the other hand, sometimes the child is sleeping fairly well, but the parents are complaining because they themselves have unaddressed sleep problems. For example, parents who have occasional bouts of insomnia may be unable to return to sleep if their child wakes up and then wakes them up, so the parents’ insomnia worsens. Along that same vein, you might have a parent who has unaddressed sleep apnea with already brittle sleep that is easily interrupted by the child waking up. So I always think about the overall picture of the entire family’s sleep dynamics.
CCPR: So we discussed the amount and the quality of sleep. The third component you mentioned is the timing.
Dr. Pelayo: The timing often gets overlooked. When you get a history, you need to know whether the person sleeps differently on weekdays or weekends, and also whether parents have unusual sleep patterns. For example, a shift worker may come in late from work and want to spend time with the child—that throws off the cycle. Or, if the parents are divorced, a kid may have different sleep routines and patterns at each home. Regarding timing of sleep, I focus more on the wake-up time than the time of sleep onset. A lot of times parents will say, “Well, I let the child sleep in if he’s had a bad night of sleep, because we all need our rest.” But that means the wake-up time is varying, and you want to lock in a regular wake-up time.
CCPR: What about the fourth component, state of mind?
Dr. Pelayo: What trumps everything is the child’s state of mind. You have to ask the parent, “Does your child look forward to sleeping?” and, “Do they dread the next day?” And ask the child, “Are you scared of sleep?”
CCPR: Can you give us an example?
Dr. Pelayo: Sure. One of my patients was a child who had trouble falling asleep certain nights of the week. It turned out that, in this family, as in many families of children with psychiatric problems, putting the child to bed was not a pleasurable experience; it was a chore, so parents took alternated nights. It turned out that the father was a stickler about how the kid brushed his teeth, and on those nights, instead of looking forward to sleeping, the child got apprehensive and could not sleep well. Things like this will happen, especially if you have a nonverbal kid, such as a child with severe autism. Autistic kids may have plenty of neurological or psychiatric issues, but they can also, like any kid, have a simple fear of the dark or a fear of being alone. So I suggest asking, “Does this child enjoy going to bed?” and, “As it gets closer to bedtime, does the kid seem to get excited or tense, or does the kid seem to look forward to it, yawning and pointing to the bed or the crib?” It’s also important to ask about the experience of getting out of bed in the morning. I always ask the parents, “What’s your child’s motivation to get out of bed? Are they looking forward to their day, or do they dread it? Do they like school?”
CCPR: Where do you go from here?
Dr. Pelayo: Once I get the history that encompasses the 4 sleep components, I address the chief complaint: The child is tired, doesn’t sleep at night, is irritable, and so forth.
CCPR: There are various sleep disorders such as sleep apnea and restless legs syndrome that we may not normally think of as being problems in kids. Should child psychiatrists pay more attention to these?
Dr. Pelayo: Yes, obstructive sleep apnea is very common in kids, particularly in kids with psychiatric or neurologic impairments. A lot of parents associate snoring with the loud adult sounding noise. What you really want to ask is, “Can you hear the child breathing? Does the child sleep with an open or closed mouth?” Normally, children sleep with their mouths closed, their breathing is silent, and they are tucked in a little ball. But, if the child has any degree of a breathing disorder, the mouth will be open and you will hear breathing, and the head will be arched backwards, because that naturally opens up the airway. Sleep apnea will mimic a lot of behavioral issues; it will mimic sleep terrors and aggravate nightmares. So parents may say, “Oh, he was prescribed this medication, but it gave him bad nightmares.” But maybe what the medication really did was make the sleep apnea worse, and that’s causing the nightmares. You also want to ask if the child is really restless while asleep, which is another sleep apnea clue.
CCPR: What about restless legs syndrome in children?
Dr. Pelayo: Restless legs syndrome (RLS) is more common than we realize. My youngest diagnosis was a two-year-old child with restless legs. RLS causes a creepy-crawly feeling that the kid may not be able to describe. Parents will often call it “growing pains.” So if any child has growing pains, it should be a red flag about RLS. One way of helping to make the diagnosis if you’re not really sure is finding out if the birth mother had RLS, because it runs strongly in families and will often flare up during pregnancy. You want to go backwards and ask carefully about siblings and other relatives, because some people have a really mild version and don’t realize it. By the way, a lot of the tricyclics and SSRIs will aggravate restless legs, which is something to keep in mind.
CCPR: So let’s say you’ve ruled out the major organic causes of insomnia, such as sleep apnea and RLS. What can we do behaviorally to help poorly sleeping kids get back on track?
Dr. Pelayo: My approach is to first figure out what the parents want, because in the end with all of these sleep issues, the parents have to live with this child. Then, with the child, I lock in a wake-up time that makes sense for the family. It’s easier to force somebody to wake up than to force somebody to fall asleep. Once we establish the wake-up time, I do the math backwards to set a bedtime. Sometimes I have the child wear an actigraph, or the parents can keep a sleep log and figure out how many hours the child is really getting.
CCPR: Sounds like a reasonable plan. Any advice on how parents can get their kids to actually fall asleep at the new bedtime?
Dr. Pelayo: A lot of times parents start the bedtime routines at an earlier hour, but the more you encroach on the second-wind alertness effect, the more you have to fight with the kid to settle down. The better approach is actually to delay the bedtime; make him go to bed later and let the homeostatic drive for sleep kick in so the kid really wants to sleep and is actually craving that bed. Even if the child has a bad night sleep, you still lock in that same wake-up time. Often, if you ask parents to do this kind of thing, you may hear right off the top, “I’ve tried this sleep hygiene stuff already, and it didn’t work.” But if you question them further, they may admit they only tried it for 3 or 4 nights and then gave up. You really have to do it for about 2 months. So, you say to the parents, “Listen, I need you to do this for at least several weeks before you tell me it’s not working.” And by then it will have clicked.
CCPR: When do you turn to medications, and what do you use?
Dr. Pelayo: Before talking about specific medications, it’s important to understand how to time hypnotics so they don’t simply sedate kids but actually help them fall asleep.
CCPR: I’m not sure I understand the difference.
Dr. Pelayo: I’ve often had the experience of meeting with parents who tell me, no matter what I suggest, “We already tried that medication; we already tried this.” In these cases, I take the time to work my way backwards and ask, “When you tried that medication, what conditions did you try it under?” It’s possible that the child was underdosed, which a lot of parents do because they are scared about overdosing or giving their kid a hangover. The problem with underdosing is that the child does not fall asleep but instead becomes disinhibited or may have a frightening experience in between wakefulness and sleep, like a hypnagogic hallucination. Another issue is the timing of a hypnotic. For example, zolpidem (Ambien) only helps you fall asleep about 20 minutes faster than usual compared to placebo. Both kids and adults get a circadian second wind in the evening, meaning they are most alert at that time. So let’s say that the kid has been falling asleep at midnight, but the parents want the child to fall asleep at 10 pm. No medication can shorten the sleep latency by 2 hours; the best we can do is 20–30 minutes.
CCPR: So how do you handle this?
Dr. Pelayo: The more effective way to use these medications is to say, “You’ve been falling asleep at midnight. I want you to fall asleep at 10 pm. Let’s have you take this medication at 11 pm and have you asleep by 11:30 pm for a week. Then you’ll take it at 10:30 pm and we’ll wait another week and we’ll get you to sleep by 11 pm.” And so on, working your way backwards from there.
CCPR: Are there any specific hypnotics that you prefer or avoid?
Dr. Pelayo: Assuming that there is not an underlying organic sleep disorder, and assuming they’ve agreed to sleep hygiene techniques, I’m very flexible about what medications to use. I first ask, “Can this kid swallow pills?” For those who can’t, I like to use clonazepam, because it comes in wafers that dissolve under the tongue; a low dose such as 0.25 mg or 0.5 mg will work. I also use low-dose doxepin (Silenor) in kids, either 3 or 6 mg. It’s amazing how well that works. Doxepin is more for sleep maintenance, not for sleep-onset insomnia. I’m not averse to using conventional hypnotics like zolpidem (Ambien) or zopiclone (Lunesta), but the thing to know about those medications in children is that hepatic clearance is faster than in adults, so these kids actually need higher dosages. In an adult, you might prescribe 5 or 10 mg of Ambien; in a kid, you may have to go up to 15 or 20 mg (Blumer JL et al, Clin Pharmacol Ther 2008;83(4):551–558).
CCPR: A common medication that child psychiatrists use is clonidine, particularly in the setting of autism or in the setting of ADHD, where they are taking stimulants. Is this something that you prescribe for sleep?
Dr. Pelayo: I personally don’t prescribe clonidine, in part because I work with children and adults and I don’t think there’s a big difference in the pathophysiology between adult insomnia and childhood insomnia. We don’t prescribe clonidine for adults with insomnia—it’s a blood pressure medication. It is more a sedating substance; it doesn’t produce a really refreshing sleep for the kid—the same thing with quetiapine (Seroquel) and trazodone. If the parents say they have him on trazodone or clonidine and are comfortable with it, it’s okay for them to do that. But what I really want them to do is start locking in that wake-up time and a falling-asleep time.
CCPR: Sounds like good advice. Thank you for your time, Dr. Pelayo.
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