• Subscribe
  • Register for free Content
  • Cart
  • Login
  • Browse by Topic
    • 13 Reasons Why
    • ABA
    • Abstinence
    • Acamprosate
    • Addiction
    • Addiction Treatment
    • Addyi
    • Adhansia
    • Adhansia XR
    • ADHD
    • ADHD Attention Deficit Hyperactivity Disorder
    • ADHD Rating Scale-5
    • ADHD-RS-5
    • Adherence
    • Adjunct treatment
    • adolescents
    • Aducanumab
    • Aduhelm
    • Adult ADHD
    • Adverse Childhood Experiences (ACES)
    • adverse events
    • affective disorders
    • Affordable Care Act (ACA)
    • aggression
    • Agitation
    • Aid to capacity evaluation (ACE)
    • AIMS test (Assessment of Involuntary Movement)
    • air pollution
    • Akathisia
    • Alcohol
    • alcohol abuse
    • alcohol dependence
    • Alcohol Poisoning
    • Alcohol related liver disease
    • Alcohol Use
    • Alcohol use disorder
    • Alcoholism
    • Alpha Agonists
    • Alternative treatments
    • Alzheimers
    • Amantadine
    • amino acids
    • amphetamine
    • Amphetamines
    • anabolic steroids
    • Andro
    • Androstenedione
    • Anorexia
    • Anorexia Nervosa
    • Anti-NMDA Receptor Encephalitis
    • Antibiotic
    • Anticholinergic burden scale
    • Anticholinergics
    • Antidepressant
    • Antidepressant Augmentation
    • Antidepressants
    • Antipsychotic
    • Antipsychotics
    • Anxiety
    • Anxiety Disorder
    • anxiety disorders
    • APA CE Post-Test
    • Applied Behavioral Analysis
    • Aptensio
    • Aripiprazole
    • ArModafinil
    • Asenapine
    • Assault
    • Assent
    • Assessment
    • asthma
    • atamoxetine
    • Athletic performance
    • Ativan Challenge Test
    • Atomoxetine
    • Atomoxetine (ATX)
    • Atropine
    • attention
    • Attention Deficit Hyperactivity Disorder
    • Atypical Antipsychotics
    • Austedo
    • Autism
    • Autism Spectrum Disorder
    • Autism Spectrum Disorder
    • Autism Spectrum Disorder autism spectrum disorder
    • Behavior therapy
    • Behavioral addiction
    • Behavioral therapy
    • Behavioral treatment
    • Belsomra
    • Benzodiazepine
    • Benzodiazepines
    • Benzphetamine
    • Beta-blockers
    • Billing
    • Bipolar Depression
    • Bipolar Disorder
    • Bipolar II
    • Black youth
    • Bleeding
    • Board Certification
    • Borderline Personality Disorder
    • Boredom
    • BPD
    • BPSD (behavioral and psychological symptoms of dementia)
    • Brain Devices
    • Breastfeeding
    • Brexpiprazole
    • Brief psychotherapy
    • brief pulse
    • Brief Strategic Family Therapy (BFST)
    • Bulimia Nervosa
    • Bullying
    • Bumetanide
    • Buprenorphine
    • Buprenorphine Induction
    • Bupropion
    • Bush-Francis Scale
    • Buspirone
    • C-Reactive Protein
    • Caffeine
    • CAM Treatments
    • Cancer
    • Cannabidiol
    • Cannabis
    • Capacity
    • Caplyta
    • Carbamazepine
    • Cardiovascular
    • Cariprazine
    • Catatonia
    • CATIE
    • CBT
    • CBTi
    • Central Alpha Agonists
    • CGI
    • Chantix
    • Child and adolescent
    • Child Psychiatry
    • Child Psychiatry
    • childcare
    • children
    • children and adolescents
    • Chlorpromazine
    • Chokroverty
    • Chromosomal Microarray
    • circadian system
    • Citalopram
    • Clinical Global Impressions
    • Clinical practice
    • Clinical Practice Guidelines
    • Clozapine
    • CME Post-Test
    • co-morbidities
    • Co-occurring disorders
    • Cocaine
    • Cognition
    • Cognitive Behavioral Therapy
    • Cognitive Behavioral Therapy for Insomnia
    • Cognitive Behavioral Therapy for Insomnia (CBTi)
    • Cognitive Decline
    • Cognitive functioning
    • cognitive impact
    • Cognitive impairment
    • Cognitive Rehabilitation Therapy (CRT)
    • Collaboration
    • Collaborative care
    • Collateral data
    • Combination treatment
    • Combined Pharmacotherapy
    • Commitment
    • community trauma
    • Comorbidity
    • complementary medicine
    • Complementary treatments
    • Complimentary Medicine
    • Complimentary treatments
    • compulsions
    • Computer addiction
    • Computers in Psychiatric Practice
    • Conduct Disorder
    • Confidentiality
    • Connect
    • Connection
    • Connections
    • Consensual
    • Consent
    • Contagion
    • Contempla
    • contingency management
    • contraceptive services
    • control group
    • Coronavirus
    • Cosmetic pharmacology
    • Countertransference
    • court hearings
    • COVID-19
    • COVID19
    • craving
    • creatine
    • creatine monohydrate
    • Creativity
    • Crime
    • Criminal behavior
    • Crisis intervention
    • Crocus Sativus
    • CRP
    • Cultural Competence
    • Culture
    • custody agreement
    • Cymbalta
    • CYP2C19
    • CYP2D6
    • DASH diet
    • Dayvigo
    • De-escalation
    • Debriefing
    • Decisional Capacity
    • Degarelix
    • Deliberate foreign body ingestion
    • Delirium
    • Delusional Disorder
    • Dementia
    • Deplin
    • Deprescribing
    • Depression
    • Depressive Disorder
    • designer drugs
    • Detoxification
    • Deutetrabenazine
    • Developmental Relationship Based Intervention
    • DFBI
    • Diabetes
    • diabetes insipidus
    • Diagnosis
    • Diagnostic Testing
    • diet
    • Dietary Approaches to Stop Hypertension (DASH)
    • Diethylpropion
    • Diphenhydramine
    • Disaster
    • Discrepancies
    • Disparities
    • Dispositional capacity
    • Disruptive Mood Dysregulation Disorder (DMDD)
    • Disulfiram
    • Divalproex
    • Diversity
    • Divorce
    • DMDD
    • Dopamine
    • Dosage Timing
    • Dose Response
    • Dosing
    • double blind
    • DRBI
    • Drooling
    • Droperidol
    • drug misuse
    • Drug-assisted psychotherapy
    • DSM
    • Dual diagnosis
    • Duloxetine
    • duty to protect
    • duty to warn
    • Dyanaval
    • Dyslexia
    • Dysregulation
    • E-Cigarettes
    • Eating Disorders
    • eating restriction
    • eCigarettes
    • ECT
    • effect size
    • Effexor
    • efficacy
    • EHR
    • Electroconvulsive therapy
    • Electronic Health Records
    • electronic use
    • Emergency
    • Emergency Department
    • emergent suicidality
    • emotion dysregulation
    • Emotional dysregulation
    • Encephalitis
    • End of Life Care
    • Engagement
    • Equine Assisted Psychotherapy
    • Equine therapy
    • Escitalopram
    • Esketamine
    • Estrogen
    • Eszopiclone
    • eTNS
    • Evekeo
    • excessive exercise
    • Exercise
    • Existing marijuana
    • expressed emotion
    • extended dosing
    • extended-release
    • Falls
    • Family Separation
    • Fast-acting
    • FDA
    • FDA Warnings
    • Female hypoactive sexual desire disorder
    • Female Issues in Psychiatry
    • fentanyl
    • fetal effects
    • First Generation Antipsychotics (FGAs)
    • fluid restriction
    • Fluoxetine
    • Folate
    • Folic Acid
    • Fragile X
    • Free Articles
    • gabapentin
    • GAD
    • GAMC
    • Gastroenterology
    • GDD
    • Gender
    • Gender & Sexuality
    • Gender Affirming Medical Care
    • Gender Diverse
    • Gender Dysphoria
    • Gender Dysphoric Disorder
    • Gender Identity
    • Generalized Anxiety Disorder
    • Generics
    • GeneSight
    • Genetic Testing
    • Genetics and Psychiatry
    • Geriatric
    • Geriatric Psychiatry
    • Geriatrics
    • Ginkgo
    • Good Psychiatric Management
    • Guanfacine
    • Hair loss
    • Haloperidol
    • Harm reduction
    • Head Trauma
    • Health Apps
    • Healthy aging
    • Hearing loss
    • Heart health
    • Heart rate
    • Hemorrhagic
    • Hepatitis
    • Heroin
    • Higher-calorie refeeding
    • HIPAA
    • Histamine
    • HIV
    • Hormone Replacement Therapy
    • Hospital policy
    • HRT
    • huffing
    • hydroxymethyl butyrate (HMB)
    • Hydroxyzine
    • hypersalivation
    • hypersexual behaviors
    • Hypnotics
    • Hypomania
    • Hyponatremia
    • IDEA
    • Incarceration
    • Inclusion
    • Inclusion strategies
    • Independent Educational Plan (IEP)
    • induction
    • infant
    • Inflammation
    • Ingrezza
    • Inhalants
    • Innovations
    • Inpatient Psychiatry
    • inquiry
    • Insomnia
    • Insulin resistance
    • Insurance
    • intermittent fasting
    • Internet
    • interpersonal stressors
    • Interpreter
    • Intervention
    • Intra-cerebral hemorrhage
    • Intra-nasal
    • involuntary civil commitment
    • Irritability
    • IV immunoglobulin therapy (IVIG)
    • Jornay PM
    • Keppra
    • Ketamine
    • l-methylfolate
    • Laboratory Testing in Psychiatry
    • lactation
    • Lamictal
    • Lamotrigine
    • Language
    • Lavender
    • Learning & Developmental Disabilities
    • Least Restrictive Environment
    • Legal issues
    • Lemborexant
    • Levetiracetam
    • Lewy Body Dementia
    • LGBT
    • LGBTQ+
    • Life coaching
    • Life expectancy
    • Light and Dark Therapy
    • Light therapy
    • Lightbox
    • Liraglutide
    • Literacy
    • Lithium
    • Longevity
    • lorazepam taper
    • Low calorie refeeding
    • Low libido
    • low sodium
    • Lumateperone
    • Lurasidone
    • Lyrica
    • maintenance ECT
    • Malingering
    • Malnourishment
    • Management
    • Mania
    • Mania on Antidepressants
    • MAOIs
    • Marijuana
    • MDMA
    • Media
    • Medical Comorbidities
    • Medical incapacity hold
    • Medication
    • Medication adherence
    • medication capacity hold
    • Medication for Opioid Use Disorder
    • Medication for Opioid Use Disorder (MOUD)
    • medication of opioid use disorder (MOUD)
    • medications
    • Melatonin
    • Memantine
    • memory loss
    • Mental Health
    • Meta-analysis
    • Metabolic syndrome
    • Metformin
    • Methadone
    • Methamphetamines
    • methylfolate
    • methylphenidate
    • Micronutrients
    • Mind-Gut Connection
    • Mindfulness
    • Minocycline
    • Minority
    • Mirtazapine
    • Mixed Features
    • Modafinil
    • Mood
    • mood disorders
    • Mood stabilizer
    • Mood Stabilizers
    • Mortality
    • Motivational Interviewing
    • MTA
    • MTHFR
    • muscle dysmorphia
    • Mydayis
    • Naloxone
    • Naltrexone
    • Narcolepsy
    • Natural Medications
    • natural treatments
    • Naturalistic Developmental-Behavioral Intervention
    • NDBI
    • Negative Symptoms
    • Negative symptoms of schizophrenia
    • Netflix
    • neuroleptic malignant syndrome
    • Neurology
    • Neuroscience in Psychiatry
    • Neurotoxicity
    • New York
    • newborn
    • News of Note
    • nicotine
    • Nightmares
    • NMDA
    • NNH
    • NNT
    • Nomogram
    • Non-pharmacologic
    • Non-suicidal self-injury
    • Norepinephrine
    • Nortriptyline
    • Novel drug
    • Novel Medications
    • Nuedexta
    • null hypothesis
    • number needed to harm
    • number needed to treat
    • Nuplazid
    • Nurses
    • Nutrition
    • Nuvigil
    • Obesity
    • observational study
    • obsessions
    • Obsessive Compulsive Disorder
    • Obsessive compulsive disorder/OCD
    • OCD
    • olanzapine
    • Omega-3
    • Online Learning
    • online therapy
    • Open Label
    • Opioid antagonist
    • Opioid epidemic
    • Opioid Use Disorder
    • Opioids
    • oppositional behavior
    • Oral Contraceptives
    • Orexin
    • Orthostasis
    • Osmolality
    • Osteporosis
    • Outcome tracking
    • Outcomes
    • Outpatient
    • Over the counter
    • Over the counter medication
    • Overdiagnosis
    • Overdose
    • Oxcarbazepine
    • p-value
    • Pain
    • pandemic
    • Panic Disorder
    • Parent Training
    • Parenting Strategies
    • Parents
    • Parkinson’s
    • Parkinson’s Disease
    • Paroxetine
    • Particulate matter
    • Patch
    • Patient relationship
    • pediatric
    • Pediatric Acute Onset Neuropsychiatric Syndrome (PANS)
    • Pediatric Autoimmune Neurologic Disorder Associated with Streptococcus (PANDAS)
    • Pedophilic Disorder
    • Performance Enhancing Substances
    • Perseveration
    • Perseverative Behavior
    • Personality Disorders
    • Pharmaceutical Industry
    • Pharmacogenomics
    • Pharmacology
    • Pharmacology Tips
    • Pharmacotherapy
    • Pharmacy
    • Phendimetrazine
    • Phentermine
    • phonemic awareness
    • Phonics
    • Physician assisted suicide
    • Pica
    • PICOT
    • Pimozide
    • Pitolisant
    • Podcast
    • polypharmacy
    • post traumatic stress disorder
    • post-exposure prophylaxis
    • Post-hoc Analysis ADHD Rating Scale-5
    • Post-menopausal
    • Post-stroke depression
    • Posterior Probability
    • Postpartum Depression
    • Potency
    • Practice management
    • Practice Tools and Tips
    • Practice Tools and Tips
    • Pramipexole
    • Prazosin
    • Pregabalin
    • Pregnancy
    • pregnancy testing
    • Prepubescent children
    • prescribing patterns
    • Prescription costs
    • prevalence
    • Prevention
    • Primary care
    • primary outcome
    • Prison
    • Privacy
    • Prodrome
    • Prolactin
    • Prolonged exposure
    • Promethazine
    • Promotoras
    • Pronouns
    • Provigil
    • Prozac
    • pseudobulbar affect
    • Psilocybin
    • Psychedelics
    • Psychiatric interviewing
    • Psychoanalysis
    • Psychodynamic therapy
    • Psychological First Aide
    • Psychopharm Myths
    • Psychopharmacology
    • Psychopharmacology Tips
    • Psychosis
    • Psychotherapy
    • Psychotherapy
    • Psychotic Agitation
    • Psychotic Depression
    • psychotic disorders
    • Psychotropic medication
    • PTSD
    • Public health
    • Qelbree
    • Quality of care
    • quality of life
    • Quetiapine
    • Quillivant
    • Race
    • Raloxifene
    • Randomized controlled trial
    • randomized discontinuation design
    • rapid naming
    • Rapid-acting
    • RCT
    • Reading
    • Reading disorder
    • Reading Disorders
    • Reading remediation
    • recovery time
    • Red Cross
    • Refeeding syndrome
    • Registered Articles
    • Relationships
    • Remediation
    • Repetitive Behavior
    • Repetitive behaviors
    • replication
    • reporting requirements
    • Research
    • Research Update
    • Research Updates
    • Respectful Care
    • restrictive dieting
    • retarded vs excited catatonia
    • retention
    • Retirement
    • retrograde amnesia
    • Riluzole
    • Risk
    • Risk Management
    • Risk of Addiction
    • Risperidione
    • Risperidone
    • Ritalin
    • rTMS
    • safety
    • Safety Planning
    • Saffron
    • SAMe
    • Samidorphan
    • Saphris
    • Schizoaffective disorder
    • Schizophrenia
    • School Phobia
    • School Refusal
    • ScreeninGeg
    • Seasonal Affective Disorder
    • Second Generation Antipsychotics (SGAs)
    • secondary outcome
    • Secuado
    • Self-injury
    • Self-Regulation
    • Semaglutide
    • Separation
    • Separation Anxiety
    • SERM (Selective Estrogen Receptor Modulator)
    • Serotonin
    • Serotonin Norepinephine Reuptake Inhibitors
    • Serotonin Specific Reuptake Inhibitors
    • Serotonin Specific Reuptake Inhibitors (SSRIs)
    • Sertraline
    • Sex offenders
    • Sex Therapy
    • Sexual Abuse
    • Sexual Dysfunction
    • sexual intercourse
    • Sexual Side Effects
    • SIADH
    • Side Effects
    • Silexan
    • Skype
    • Sleep
    • Sleep Apnea
    • Sleep Disorders
    • Sleep Onset Insomnia
    • Smoking Cessation
    • Smoking Cessation Agents
    • smoking cessations
    • SNRIs
    • Social Anxiety
    • Social Anxiety Disorder
    • social cohesion
    • sodium supplementation
    • Somnambulism
    • Special populations
    • Specific Phobia
    • SSRIs
    • statistical significance
    • Statutes
    • Stereotypical Behavior
    • steroids
    • STI screening
    • Stigma
    • stimulant
    • Stimulant Medications
    • Stimulant treatment
    • Stimulant use disorder
    • Stimulants
    • Stroke
    • structured literacy
    • Suboxone
    • Substance Abuse
    • Substance Abuse
    • Substance Use
    • Substance Use Disorder
    • Substance use disorders
    • Suicidality
    • Suicide
    • Sundowning
    • Supplements
    • Surrogate decision-maker
    • Suvorexant
    • Swallowing
    • Symptom Assessment
    • Symptom Management
    • Systematic review
    • Tags
    • Tantrums
    • Tarasoff
    • Tardive dyskinesia
    • Technology
    • Teen
    • teens
    • Telehealth
    • Telemed
    • Telemedicine
    • Telepsychiatry
    • test cme quiz
    • testifying
    • Tetrabenazine
    • TFCBT
    • TGD
    • Therapy during medication appointment
    • Therapy with Med Management
    • tics
    • TMS
    • Tobacco
    • tobacco research
    • Tobacco use disorder
    • Top 10 Podcasts of 2021
    • Topiramate
    • Toxic Stress
    • Transcranial Magnetic Stimulation
    • Transdermal
    • Transgender
    • Translator
    • Trauma
    • Trauma Informed Care
    • Traumatic Brain Injury (TBI)
    • Trazodone
    • treatment
    • treatment efficacy
    • treatment pediatric
    • Treatment planning
    • Treatment-Resistant Depression
    • Trigeminal Nerve Stimulation
    • Trintellix
    • unblinded
    • Understanding Psychiatric Research
    • unilateral vs bilateral
    • urinary difficulties
    • Valbenazine
    • Valproate
    • Vaping
    • Varenicline
    • Venlafaxine
    • verbal de-escalation
    • videogaming addiction
    • Viloxazine
    • Violence
    • Vitamin B6
    • Vitamin D
    • Vitamin E
    • VMAT2 Inhibitors
    • Vortioxetine
    • Vyleesi
    • Waist circumference
    • Wakix
    • water intoxication
    • water restriction
    • Weed
    • Weight gain
    • Weight Loss Medications
    • Weiss Functional Impairment Rating Scale-Parent (WFIRS-P)
    • Wellbutrin
    • whey protein powders
    • Whole Genome Sequencing
    • Wilderness Therapy Programs
    • Withdrawal
    • Women's Issues in Psychiatry
    • Women’s Issues in Psychiatry
    • Working With Families
    • workplace
    • Xenazine
    • Youth
    • Zenzedi and ProCentra
    • Ziprasidone
  • HOME
  • STORE
  • CME CENTER
  • Blog
  • Podcast
  • NEWSLETTERS
    • The Carlat Psychiatry Report
    • The Carlat Child Psychiatry Report
    • The Carlat Addiction Treatment Report
    • The Carlat Hospital Psychiatry Report
    • The Carlat Geriatric Psychiatry Report
  • Archive
  • Archive
  • Archive
  • Archive
  • Archive
  • The Carlat Child Psychiatry Report
  • Overarousal in Children and Adolescents (Oct/Nov/Dec)
  • Tools to Help Kids and Teens to Sleep Better

Tools to Help Kids and Teens to Sleep Better

The Carlat Child Psychiatry Report, Volume 12, Number 7&8, October 2021
https://www.thecarlatreport.com/newsletter-issue/ccprv12n78/

From The Carlat Child Psychiatry Report, October 2021, Overarousal in Children and Adolescents

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Assessment | CBTi | circadian system | Cognitive Behavioral Therapy for Insomnia | Sleep | treatment

Print Friendly, PDF & Email

Rafael Pelayo, MD, FAASM

Clinical professor and Associate Division Chief for Community Commitment and Engagement for the Sleep Medicine Division, Stanford University School of Medicine. President, California Sleep Society. Author of How to Sleep: The New Science-Based Solutions for Sleeping Through the Night (Artisan, 2020).

Dr. Pelayo has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

 

Sasha is a 13-year-old whose grades are slipping. She reports trouble concentrating in school, and her parents are worried she might have ADHD. On taking a history, you learn that Sasha stays up late and gets up early, obtaining about six hours of sleep per night.

Adolescents have been reporting less sleep over the past 20 years in what’s been termed “The Great Sleep Recession” (Keyes KM et al, Pediatrics 2015;135(3):460–468). Although recommended sleep is 9–12 hours for children ages 6–12 and 8–10 hours for teens ages 13–18 (Paruthi S et al, J Clin Sleep Med 2016;12(6):785–786; Hirshkowitz M et al, Sleep Health 2015;1(4):233–243), many kids do not get these amounts. Fifty-eight percent of middle school students and 73% of high school students experience short sleep duration, with girls more sleep deprived than boys (76% vs 70%) (Wheaton AG et al, MMWR Morb Mortal Wkly Rep 2018;67(3):85–90).

Consequences of sleep deprivation in adolescents
A meta-analysis with over 500,000 participants found an inverse relationship between sleep duration and suicidality in adolescents. The risk of suicide plans decreased by 11% for every one-hour increase in sleep duration (Chiu HY et al, Sleep Med Rev 2018;42:119–126). Other research linked sleep deprivation in adolescents to automobile accidents and cognitive difficulties (Mason GM et al, Sleep Med Rev 2021;57:101472). Inadequate sleep may mimic ADHD and aggravate mood disorders. This can lead to a vicious cycle since medications commonly prescribed for ADHD often interfere with sleep. Lack of sleep also leads to greater risk-taking behavior, including substance use, and is associated with obesity, diabetes, sports injuries, and poor academic performance.

Assessing sleep problems in children and adolescents
There are four essential components of sleep history that you should review when assessing a sleep problem: 1. Sleep amount; 2. Sleep quality; 3. Sleep timing; and 4. State of mind related to sleep.

Sleep amount
Pin down how much sleep your patient is getting. Sleep-deprived adolescents are grumpy, have difficulty concentrating, and often sleep in excessively on weekends. Younger children and adults rarely do this. The patient’s recall may be inaccurate, so ask families to keep a daily record over at least a couple of weeks or use electronic sleep tracking devices such as wearables or smartphone-based applications. Although electronic sleep trackers are far from perfect, they can show trends in sleep. Some versions have been recently validated, including Fatigue Science Readi­Band, Fitbit Alta HR, Garmin Fenix 5S, and Garmin Vivosmart 3 (Chinoy ED et al, Sleep 2021;44(5):zsaa291).

Sleep quality
Get a sense of how effectively your patient is sleeping. Kids may sleep poorly despite adequate sleep time. Children who snore or sleep with their mouth open may have sleep apnea—the more they sleep, the less they are breathing. If you suspect sleep apnea or some other physiological disorder, contact the patient’s primary doctor to arrange a sleep assessment. Note that home-based sleep studies are not well validated in children or adolescents, and they are not typically reimbursed by insurance companies.

Sleep timing
Figure out when your patient sleeps. Sleep timing may reveal a circadian sleep disorder. The circadian system synchronizes biological rhythms to the day/night cycle. It’s harder for people to simply “go to bed earlier” unless they are very sleep deprived. Teens may find it easier to go to bed later and sleep later when possible rather than falling asleep earlier, but sleeping in or oversleeping in a child is a sign of sleep deprivation. The COVID-19 pandemic has disrupted kids’ sleep, with classes alternating between virtual and in-person lessons and changing school start times. Establish a consistent wake-up time first to anchor the circadian system and make nighttime sleep easier.

State of mind
Ask who prompted the patient to come see you. Was it the parents’ idea or the child’s? Parents may recognize the connection between sleep and other problems. Children or teens who want help with sleep may be suffering from internalizing problems such as depression or anxiety that are harder for parents to recognize. Determine the child’s motivation to go to sleep and get out of bed. Do they look forward to going to sleep? Are they dreading the next day? Waking up is biological, but getting out of bed is volitional. I explain to my patients and their families that their lives are reflected in their sleep, and vice versa.

As you assess Sasha’s sleep, you learn that she gets plenty of exercise, does not drink caffeinated beverages, and avoids electronics after dinner. On weekends Sasha tries to catch up on sleep, often sleeping until early afternoon.

Techniques to improve sleep: CBTi
Conversations about sleep often center on sleep hygiene rules such as “turn off and put away the electronics two hours before bed” and “don’t lay awake in bed.” Patients, parents, and clinicians are aware of these rules. But according to the American Academy of Sleep Medicine’s clinical practice guidelines, relying solely on sleep hygiene is usually ineffective (Edinger JD et al, J Clin Sleep Med 2021;17(2):255–262). A more comprehensive approach is cognitive behavioral therapy for insomnia (CBTi), which has a good track record in adults and has been adapted for children and teens. It may be more helpful for our patients.

CBTi is cognitive behavioral therapy that is specific to the thoughts, behaviors, and emotions related to sleep (Mindell JA et al, Sleep 2006;29(10):1263–1276). Referral to a more specialized practitioner is challenging, as the small number of these clinicians cannot meet the clinical demand. You can use basic CBTi in your office, but keep in mind that it can take weeks to implement.

Here are some typical CBTi techniques (see box below):

  • Sleep restriction/delayed bedtimes:
    Assess how much time the patient spends actually sleeping in bed, and adjust to reduce the amount of time in bed awake. The goal is to make the time devoted to sleeping more ­efficient.
  • Stimulus control:
    Strengthen the connection between bed and sleep by changing the location of other activities so that the bed is only used for sleeping.
  • Gradual extinction:
    For a young child in a parent’s bed, take a slow stepwise approach to moving the child to their own bed. More steps are more effective.
  • Cognitive restructuring:
    Identify distorted thoughts about sleep and challenge, replace, or reframe them.
  • Address barriers to sleep hygiene:
    Individualize the implementation of usual recommendations. For example, create a workable plan for restricting evening electronics.
  • Relaxation techniques:
    Teach progressive muscle relaxation (PMR), deep breathing, and visualization. To gain proficiency, the patient should practice these techniques while they are not trying to sleep. Many scripts and videos cover PMR for kids. See www.tinyurl.com/rfk4axu6 and www.tinyurl.com/ayruumtk for some resources.

 

Table: Examples of Cognitive Behavioral Therapy for Insomnia (CBTi) Techniques

Table: Examples of CBTi Techniques

(Click to view full-sized PDF)

 

You determine that Sasha is not getting enough sleep during the school week and that she and her family need to prioritize her sleep. As part of the initial plan, you talk with Sasha and her family about sleep deprivation and tell her parents to have her stop sleeping in on weekends. You explain that this will make Sasha’s sleep more predictable and help her get more sleep during the week.

Medications?
There are no FDA-approved hypnotics for children. We recommend avoiding hypnotic medications when possible in children and teens. Off-label use of medications such as guanfacine or clonidine is best done as a time-limited approach. Medications may have a role in insomnia, narcolepsy, parasomnias, and sleep-related movement disorders; however, parents and healthcare providers often use hypnotic medications without adequate application of behavioral techniques and without taking into account circadian modulation of alertness.

Keep in mind that people are more alert for about two hours before sleeping. If a medication shortens sleep latency by only 20 or 30 minutes, patients may report that the medication “makes things worse” or that it causes a child to act strangely, perhaps experiencing hypnagogic hallucinations. This can occur especially if the family gives the medication early because of fear of next-day sedation. Similarly, giving a low dose may result in the child being disinhibited but not falling asleep. The same medication given at a more appropriate circadian time and/or dose may be effective. Also note that if a child is not expecting or wanting to sleep, they may resist the drowsy feelings or become upset. Consider short-term use of a melatonin supplement (1–3 mg) 90 minutes before bed.

Sasha returns in three weeks and reports having more energy during the day. She gets about 7.5 hours of sleep per night, her homework is done earlier, and her grades are up. Her parents are glad to avoid using medications and will let you know if there are difficulties in the future.

CCPR Verdict: Sleep problems have lifelong complications. The sleep medicine field has matured and can help most of our patients. Screen for sleep disorders in all patients at every visit. Consider using CBTi to effect meaningful change rather then relying on generic sleep hygiene rules, and try to avoid using medications. If you need to refer to a sleep specialist in behavioral sleep medicine, try: www.behavioralsleep.org/index.php/united-states-sbsm-members

Suggested Articles

  • Assessing Feedback From Multiple Sources January 31, 2022 We talk about the importance of gathering data from multiple sources as part of a…
  • Practical Issues with Prescribing ADHD Meds March 24, 2022 There are so many newer medications for ADHD. Should we be trying them out sooner…
  • Managing Video Gaming in Children and Teens October 30, 2020 So many families struggle with videogaming addiction and other overuse of electronics, maybe more so…

Powered by Contextual Related Posts

Share this page!
Subscribe
Register for free content

Register For Free Articles

Register to receive free email newsletters with concise, practical advice for busy clinicians. You will also have access to select article content on the website and you will receive notifications of new books and special discount offers.




Courses and Book CME
Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)
2022 Carlat Psychiatry Report Self-Assessment Course
Prescribing Psychotropics: From Drug Interactions to Genetics
The Child Medication Fact Book for Psychiatric Practice (2018)
Issues Archives

2022

  • ADHD in Children and Adolescents (April/May/June)
  • Assessment in Children and Adolescents (January/February/March)

2021

  • Overarousal in Children and Adolescents (Oct/Nov/Dec)
  • Substance Use in Children and Adolescents (Jul/Aug/Sep)
  • Autism in Children and Adolescents (April/May/June)
  • Clinical Complexity With Children and Adolescents (Jan/Feb/Mar)

2020

  • Esketamine (January)
  • Telepsychiatry (May)
  • Mind-Gut Connection (January)
  • Practical Psychotherapy (November/December)
  • Mood and Menopause (October)
  • When to Use Lithium (September)
  • Traumatic Brain Injury (August)
  • Borderline Personality Disorder (June/July)
  • Psychopharmacology Algorithms (April)
  • Bipolar II (March)
  • Inflammation and Depression (February)

2020

  • Mood Disorders in Children and Adolescents (Oct/Nov/Dec)
  • Identity & Culture in Children and Adolescents (July/August/September)
  • Psychosis in Children and Adolescents (April/May/June)
  • ADHD in Children and Adolescents (Jan/Feb/Mar)

2020

  • Harm Reduction (January/February)
  • Substance Use in Health Professionals (March/April)
  • Alternative Treatment in Addiction (November/December)
  • Social Aspects of Addiction (September/October)
  • Opioid Use Disorder Treatment (July/August)
  • Emerging Risks for Old Medications (May/June)

2019

  • Depression (May)
  • Adult ADHD (November/December)
  • Mental Health Apps (October)
  • How to Talk about Medication (September)
  • Side Effects Part II (August)
  • Side Effects Part I (June/July)
  • Sleep (April)
  • Parenting, Pregnancy, and Prevention (March)
  • Dark and Light Therapy (February)
  • Deprescribing (January)

2018

  • Drug Metabolism (November/December)
  • Working With Transgender Patients (October)
  • Emergency Psychiatry (September)
  • Treatment-Resistant Depression (July/August)
  • Neurobiology (June)
  • Anxiety (May)
  • Neurofeedback (April)
  • Antipsychotics Update (March)
  • Working With Families (February)
  • Bipolar Disorder (January)

2017

  • PTSD (December)
  • Retirement (November)
  • Intellectual Disability (September/October)
  • Antidepressants (July/August)
  • Personality Disorders (June)
  • Dementia (May)
  • Cognitive Behavior Therapy Techniques (April)
  • Pharmacogenetics (March)
  • Treating Psychosis (February)
  • Adult ADHD (January)

2016

  • Complementary and Alternative Medicine in Psychiatry (November/December)
  • Side Effects (October)
  • Pain Management (September)
  • Medication in Pregnancy (July/August)
  • Psychoanalysis in Modern Psychiatry (June)
  • Correctional Psychiatry (May)
  • Antidepressant Roundup (April)
  • Burnout (March)
  • Private Practice (February)
  • Bipolar Disorder (January)

2015

  • Psychiatry and General Medicine (November/December)
  • Biomarkers in Psychiatry (May)
  • Telepsychiatry (October)
  • Sleep Disorders (September)
  • Interventional Psychiatry (July/August)
  • Eating Disorders (June)
  • Psychotherapy Updates (April)
  • Topics in Geriatric Psychiatry (March)
  • Antipsychotics Update (February)
  • Risk Management (January)

2014

  • Bipolar Disorder (November/December)
  • Pharmacogenetics (October)
  • Keeping up in Psychiatry (September)
  • Research in Psychiatry (July/August)
  • Marijuana (June)
  • Psychiatric Diagnosis (May)
  • Issues in Psychopharmacology (April)
  • Schizophrenia (March)
  • Women’s Psychiatry (February)
  • Ethics in Psychiatry (January)

2013

  • Military Psychiatry (December)
  • Depression (November)
  • Treatment of Dementia (October)
  • Anxiety Disorders (September)
  • Natural and Alternative Treatments in Psychiatry (July/August)
  • Autism Spectrum Disorder (June)
  • Practice Tips (May)
  • Substance Abuse (April)
  • Medicolegal Topics (March)
  • End of Life Care (February)
  • Antipsychotic Update (January)

2012

  • Screening Tools and Tips (December)
  • Medical Comorbidities (November)
  • Devices in Psychiatry (October)
  • Eating Disorders (September)
  • Bipolar Disorder (July/August)
  • Risk Management (June)
  • Antidepressant Roundup 2012 (May)
  • Gender and Sexuality (April)
  • Personality Disorders (March)
  • ADHD (February)
  • Natural Treatments in Psychiatry (January)

2011

  • Electronic Medical Records (December)
  • Insomnia (November)
  • Psychotherapy (October)
  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Joshua D. Feder, MD

Dr. Joshua Feder studied mathematics and medicine at Boston University, Psychiatry at Naval Regional Medical Center San Diego, serving the first gulf war in child and adolescent psychiatry fellowship at Tripler Army Medical Center in Honolulu, and eventually becoming Chief of Child Psychiatry at the National Naval Medical Center in Bethesda, MD. Dr. Feder now practices in Solana Beach, California and serves as Medical Director at Positive Development, providing relationship-based support for families, with research at UCSD, SDSU, Fielding Graduate University, An Najah National University, Quicksilver Software, Autism Is inclusion program, and Programmatic Lead for the International Networking Group on Peace Building with Young Children, with projects in the US, Northern Ireland, and the Middle East. Dr. Feder co-authored the first American Academy of Child & Adolescent Psychiatry Practice Parameter on Autism and serves on the Disaster & Trauma Committee and the Resource Group on Youth at the Border. Dr Feder was founding policy chair for the California Association for Infant Mental Health, and advocates worldwide on access to care, climate policy, and peacebuilding. His recent books include Child Medication Fact Book for Psychiatric Practice (2018) and Prescribing Psychotropics (2021).

Full Editorial Information

About

  • About Us
  • CME Center
  • FAQ
  • Contact Us

Shop Online

  • Subscriptions
  • Books
  • Online Courses

Newsletters

  • The Carlat Psychiatry Report
  • The Carlat Addiction Treatment Report
  • The Carlat Child Psychiatry Report
  • The Carlat Hospital Psychiatry Report

Contact

  • info@thecarlatreport.com
  • 866-348-9279
  • PO Box 626, Newburyport MA 01950

Follow Us

© 2022 Carlat Publishing, LLC and Affiliates, All Rights Reserved.

Please see our Privacy Policy and the Hardware/Software Requirements to view our website.

×