NEUROLOGIC DISORDERS: DEVELOPMENTAL AND BEHAVIORAL SEQUELAE 1056-4858/99 $8.00 +90 DEVELOPMENTAL FEATURES OF SLEEP Jodi A. Mindell, PhD, Judith A. Owens, MD, MPH, ‘and Mary A. Carskadon, PhD Sleep disorders are common in children and adolescents who present for psychological or psychiatric evaluation. A thorough understanding of sleep and. sleep disorders is important for psychiatrists and other mental health profession als, a6 there is offen a relationship among sleep, medical, and psychiatric is- ‘sues. Not only may sleep disorders be mistaken for psychiatric or psychologi- al disorders, but medical and psychiatric disorders can cause sleep disturbances. The purpose ofthis article is o provide detailed information about sleep and its evaluation, discuss the most common sleep disorders seen in children and adolescents, and provide an understanding of the relationships ‘among sleep disturbances and medical and psychiatric disorders. SLEEP PHYSIOLOGY AND DEVELOPMENT Sleep is a complex process involving multiple physiologic systems. To understand sleep and sleep disorders in children and adolescents, knowledge about sleep stages and development is important. Sleep comprises two distinct States: rapid eye movement (REM) sleep and non-REM sleep. Non-REM sleep is further divided into Stages 1, 2, 3, and 4. Stages 3 and 4 are often referred to as delta sleep or slow-wave sleep, which constitutes the deepest level of sleep. This deep non-REM sleep occurs in the first 1 to 3 hours after sleep onset, and children have greater amounts of deep slow-wave sleep than adults. Stages 3 and 4 sleep arise during the first year, achieve their highest levels in early From the Department of Payshology, St. Josephs University, Philadelphia, Pennsylvania GAM); it of Pediatrics (JO) and the nt of atry and SKaneh‘Bchevr (AC), Bown Univaray Scan! of dice; and Geparseat of CCheonabiology, EP. Brady Hospital (MAC), Providence, Rhode istand (CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA [VOLUME 8+ NUMER & + OCTOBER 198 695696 MINDeLL es at childhood, decrease by about 4% across adolescent development, and. decline sone gradually in adulthood. Iie dificult to awaken a Git from this deep Sleep and onctavvakened the cild soften diodented and confused. Confused Darl arousal including slepwalking and sleep troy arise from deep Sage {Thon REM sleep. Rapid eye movement sleep incorporates aspects of both deep sleep ond light sleep. Repid eye movement sleep is associated with an active supprestion of peripheral musele tone, marked decine In thermoregulatory function, and {nteased variability In te rgslation of blood pressure, Heat Tat, and respira tion. Cortical brain function is extremely active in REM sleep. The majority of dreaming occurs during REM sleep, and when avakened a person i quickly Slert. Epbodes of REM occur in cycles of 60 fo 90 mints in adults (Cphiy Tonger in children), velth increasing duration Uwoughout the night. Thus, dhe longest REM epinodes occur nthe eatly toring fst prior Yo awakening making nightmares most key to our in the second hall ofthe sleep period ‘Another important aspect of sleep tat neads toe recognized that afousals ‘cour droughout the sleep Period. There short episodes of wakefulness typically fccur five t seven times aright during normal skep. Children usuolly return to sleep quiely and have no recall of the avrakening “The regulation ofeleep in aduls is described as depending on two major biologie processes (I) a sleep-wake homeostatic process and (2) the creadian fining sfotom, These factors are likely to play similar roles in children and certainly in adolescents: The homeostatic processzometimes called procs ‘Sm ie modeled ae controling the depth and length of sleep as a fanclon of por waking. This proces offen is indexed by the quantity of electrouncephalo- tram (BEG) slowewave activity (SWA) during slp. Slow-wave ecivity and Stages 3 and 4 sep, which are identified viswlly based on ERG slow waves, fre most prooinent early in te sleep phase and are potentiated by prior slows loss Elcrooncephalogeam SWA is generated Sulasicaly, and the thalamic ting of sensory activity may account for the high arousal threshold ding eae eae sleep following sleep loss Recent evidence from cats bas indicated that local increases in adenosine concentration particularly in the basal forebrain—are Conrsated with the homeostatic drive for sleep™ Other neurotransmitter sys tems, including histamine, serotonin, glutamate, neuropeptides, and neuroan- ‘iunochemcal substances, have been shovra to modulate Ron-REM sleep. Lite tvidence exists for a specific circadian regulation of SWA, although the length thd timing of sleep per ae are strongly circadian The timing of REM slep is more clearly regulated by cigcadian dining suacarismay adbhough tomattate mguon isco cher in tat REM clo Eipprenion leads 19 REM sleep tabound. The pesk propensity for REM sleep Colncides withthe tough of te ceadian temperature thy.” " Rapid eye ‘ovement sleep is also cylic over a shorter (ltadian) tne fame, allemating with non-REM' sleep across the night This nor-REM-REM cycle aries from 8 Welldousibed reciprocty of neuronal discarge In the bran stem. Rapid eye movement sleep may be characterized as a pontine process, and it has been Eggested that “the pone i both necessary for generating and sullcent (0 {generate the principal phenomena of REM sieep.""" Rapid eye movement arses Into pontine nude, the lateral dorsal tegmental (DD pontine mle! andthe Pedunculopontine tegmental PPT) auclt The LOTPPT neurons are cholnesple End ate dhe REMLON units; that ls, their fring occuts prior to ond throughout REM sleep, recruiting other pontine regions to complete the REM “process,”DEVELOPMENTAL FEATURES OF SLEEP 697 eee eee eee eta eeeeaeaat toto The ulsadian non REM-REM cycle arises fom the respec ofthe LDT: ver HEN-On newont wit the RENGOM neue lose in econ ‘Ephe nmtlel andthe nomdienorge niclevs lors coma. Acti of Be ‘clotonegc and norsdrenegc netrong i avacated wih te einai of EM step episode. The vacprocal latonhipof tase neural popslaton in Bron terns inves inhbtion by cortonertc and oredsonnpe cl groupe ef the LBEPET glo anf excaoof te phe and cls cus cures by the cholinergic UMOn LDPFPT These newcophysiotogil ond nearochem Gi ineractons acount for te wolanown phanhacoepc atone on REM Siep, uch a REM suppression by inany anipresanis a REM petition Ey Sisters: agent lege REM infucon by ecole or physovigine) Tiga iltate Remon RENT and REMI seg pats te Waeton Wake Stage 1 Stage 2. SWS. Age 12| Wake, — Stage | Stage 2 SWS. REM. ty nmzoemeiii2 5 4 5 6 7 Time of Night Figure 1. Nen-REM and REM sleep pattems in the rans from late childhood to cay adolescence. V » fights out. a'= Hghts 00,698 MANDELL etal from late childhood to eanly adolescence. The normal transition of waking to snon-REM sleep and then fo REM sleep is clearly evident in all duce graphs, os fs the declining interval from sleep ination fo REM sleep across this age span. The developmental progression of REM sleep from bint early cidhood fe even more striking, Pulte newborn humans steep approdmataly two titds of the ime, equally divided between acive and guitt sep, which are the Immature precursors of REM and non iIEM sleep. The newhosn enters sleep Shoup activ ep nana] proses at ral Gangs over tf year Eatency from sleep onset to REM sleep in the older child is quite long—on the order of 3 hous. In early adolescence, this delay tothe fast REM sleep episode is reduced to about 90 to 110 minutes, with a more gradual decline stcompanying adulthood. The cieadian pattem of REM sleep propensity mani fests as longer REM episodes Inte in the tight near the Sine of the body femperatare minimum. TF the latency t0 REM sleep depends on the pressure for SWA, then develop- rental trends in REM slep late relate tothe maturation of nonsREM sleep tnd SWA. An the newborn brain matures, sleep spindles (12 Wo 1d cycles per Second nonsREM sleep EBG activity) and SWA begin to appear from 9 to 6 ‘months of age. The emergence ofthese thalamicaly generated cortical EEG signs ely depends on an adequate cortical "superstructure," indexed by some as coral symapte dy” ees ceding ep pnts ney chi hood, and Stages 3 and 4 dedine markedly (approximately 40%) acose the second decade" This developmental tend ie evident in Figure 1. Sloep-vake activity continues to diminish gradually across the lifespan, and stage 4 sleep may be very minimal in the ededy, particulary men. The hometstatclly regulated incease in SWA, hovrever, fs maintained, even in the aged” ™ Wilh Chronic sleep resuition—as inthe ineulicient sleep pattern cominon among Adolescente SWA may be quite pronounced ‘Age-related (developmental) processes also affect sleep regulation, These developmental factors affect bath slep physiology and sleep consolidation and duratian. The primary physiologic change isin the proportion of REM versus nor-REM slp. During the newbom period, REM sleep (eferred t0 a active sleep during this age) accounts for approximately 60% of slep and gradually redicen overtime fo adult levels of 54 to 30%. This decrease in REM sleep is also accompanied by'a dramatic decrease in delta sleep, expedally following Paberty, which is the reason most children grow out of fleepovaliing. and Steep terrors. “bleep requirements alo change across age. Newboms sleep approximately 16hours a day in - to hour episodes. Sleep consolidation oocbrs gules with most sleep occurring during the night by @ months of age. At 1 year of age, thildren sleep on average Tt hours at night and take two naps totaling 2.5 hours. By 3 years of age, the average cid gels 10.3 hours of sleep at night plus one LShour map. And, by dor 5 years of age, moat childcen have given up dayne naps, with all sleep Secusring at night By 18 years of age, sleep actounts for proximately hours a cay. eis important to note that these sleep requiretments are generalizations and sigaicant individual diferenes exis CLASSIFICATION OF SLEEP DISORDERS. Before discussing specific sleep disorders, it is important to outline the classification system, Sleep disorders are classified into two major categories, the dyssomnias and the parasomnizs, as delineated by the Intemational Classifica-DEVELOPMENTAL FEATURES OF SLEEP 699) tion of Sleep Disorders (ICSD}.® The dyssormnias include those disorders that result in difficulty either initiating or maintaining slecp, or involve excessive daytime sleepiness. The parasomnias, on the other hand, are disorders that disrupt sleep after it has been initiated and are disorders of arousal, partial ‘arousal, or sleep-stage transitions. They are disorders that intrude into the sleep process, but usually do not result in complaints of insomnia or excessive sleepiness. Note that these terms, as they are defined by the ICSD, differ slightly from their use in the fourth edition of the American Psychiatric Association's Dingnostic and Statistical Manual of Mental Disorders (DSM-IV) The DSM-IV defines dyssomnias as those sleep disorders in which the predominant distur- bance is in the amount, quality, or timing of sleep. The parasomnias are de- seribed as sleep disorders that involve abnormal behavioral or physiologic ‘events occurring in association with sleep, specific sleop stages, or sleep-wake transitions. Both methods of defining these terms, however, result in the same classification of specific disorders PREVALENCE OF SLEEP DISORDERS Surveys have found that approximately 20% fo 25% of children expezience some type of sloap disturbance. "=" For example, Salzarulo and Cheve- lier interviewed the families of 218 children 2 to 15 years of age who were referred for pediatric or child psychiatic consultation, and found that sleep talking wes guite common (32%), followed by nightmares (3170), aking at night (25%), Wouble falling asleep (23%, enurasis (17%), bruxism (10%), sleep rocking (79), and night terrors (7%). In Dollinger’s 1982 survey of mothers referring their children to a university lini the most common sleep problems (among 3 to 15-year-old children) were sleep talking (53%), restless sleep and bedtime refusal both 42%), and refusing to g0 to sleep without a nightlight (400%). Other sleep problems included bad dreams (35%), difficulty In going to sleep (26%), erying out in sleep (16%), and nightmares (11%). Another study of healthy preadolescens, 8 t 10 years of age, found that 43% ofthe children were experiencing a sleep problem that had lasted more than 6 months." Looking at specific sleep disorders, parasomnias were present in 2% of the children, with enuresis), sleep walking (5), and night fears (15%) reported HOW TO EVALUATE PEDIATRIC SLEEP COMPLAINTS {A thorough evaluation of pediatric sleep complaints is essential. The first stop in evaluating a child or adolescent for asleep disorder isthe completion of a thorough sleep history. All aspects ofthe sleep-wake eycle need to be reviewed. ‘A review of slep hnbils needs to be conducted, including co-sleeping, sleep schedules (both weekday and weekend), and iniake of caifeinated beverages Information should be collected about bedtime routines, inluding evening ach ties, bedtime stalling or ofusal behaviors, and the latency to slaep onset. Details about nocturnal behawiers and other abnormal events during sleep should be detailed, such es night tesvors,confusional arousal, seizures, and enuresis. The number and duration of nighitime awakenings need to be evaluated. Informa- tion about common symptoms rated to sleep-disordered breathing should be assessed, including snoring, breathing pauses, restiess sleep, sleeping, in abnor- ‘mal positions, sweating, mouth breathing, and carly morning headaches. Furthermore, information about dlumal behaviors, such as dificlly to700 MENDEL tat awaken, daytine sleepine, fatigue, naps, meals, cafeine intake, medications and feoings of ansiey and depression should be reviewed. Additional informa: ton about daytime functioning and sgalicant Ife events should be collected Daytime functioning noes to incorporate all aspects including school perfor ‘mance, coca! zlaionships, and fanly funconng, Problems in any of these seas can be indlative of seep. problema and con also contribute 10 sleep Aifalties, given that adjustment Slep problems are common following suck events as death of a family member change in school, or a recent move More subtcisbues ean also lead to slep problems. For example, family nancial problems can result in ele cisturances in children, even if Uke parens do not Fieve thatthe chil is aware of such problems. Often children, and expectlly adolescents are much more aware offal tensions than parents kro. ‘The second step in the evaluation of sleep problema isthe callection of sleep diaren. A typical sleep diary includes information on the tine to bed, latency fo sleep onset, number and duration of nighttime awakenings, time of waking tla sleep tine, and duration and tive of aps. Two weeks of baseline sleep diane aro urually adequate to delinat seep pater. "he thind step isto determine whether an overnight sleep study ie needed In cates concerning a peciic underiying physiologic problem, nocturnal poly: sommography (PSG) s.an esseriial component of aseasment, A PSG. is wate ranted prielpaly to diagnose sleep-diaordered breathing, expecially obstructive Sloop apnea; fo investigate slep-rlated causes of excessive daytime sleepiness, Such at narcolepsy of sleep fragmentation due to frequent nactural susals (euch as periodic limb movement disorder, and occasionally to delineate the ‘use of episodic noctimal phenomena or example, parasonilas Vs. nocturnal seine) Polysomnography typically involves recordings of EEG, elecrooculogram (806), Cecnookyobcm EMG), oxygen saturn ase and orl aon th rade nd abdominal piratory movements, and Hin muscle activity. Most ‘overnight studies are done in the sleep laboratory, although home studies may be'requested. Laboratory studies have the benebt of increased validity and ‘clusion of behavioral observation, In edaition, home and nap studies have a high false-negative rate forslaep- disordered breathing. Ae an adjunct to a noc: tusnal PSG, a multiple sleep latency test (MSL) is often conducted to objectively evaluate an iuividua's Wvel of daytime sleepiness and slep ons! stctuze, Slihough no widely accepted norms for children curently exet. The MSLT onsets of four 20-minute nap opportunities piven at Zhou intervals. The test iS evaluated for speed of fling selec and latency 10 REM sloop ‘Sleep can afso be assessed through estimation from activity dats. Longeterm ambulatory monitoring with a weistorn (or in patients less than 3 years of age, anklo-worn) acigraph ean provide excellent information acros nights Stn woos” Actgrpy from actinty tn hatte ones cols sey Counts on a minute fosminto base around the clock, where the later coll total activity courts for lenger spans of ine, for example, an entire day. Wh actigraphy, Valid and reliable estimates of the times of sleep onset and sleep ost, a5 well ag total amount of sleep and sleep Interruptions, ate posible. Computer algorithms validated versus PSG show that acigraphy—pariclaly fn combination with a behavioral report such a3. sleep diary or parental repontprovides avery useful estate of sleep’ A oniniznam of five ight of Acigraphy provides rable estimates for mary sloop variables! The measures stained from actigraphy do not incde asessinent of nom REM and REM sleep, however. On the Otter hand, reliable, objective estimates of the lengthDEVELOPMENTAL FEATURES OF SLEEP 701 and timing of sleep over the course of the school week can be very useful for clinical assessment. DIFFERENTIAL DIAGNOSIS Ditferential diagnosis is important because many sleep disorders present with similar symptomatology, stich as difficulty sleeping or excessive daytime sleepiness. Differentiation between a sleep disorder and other medical or psycho- logical problems is also important. For example, a child with apparent night terrors may actually have a seizure disorder. In other cases, difficulties at bed- time may be symptomatic of a more general problem with noncompliance. Nighitime fers may be jut one of many extensive fears in an extremely Furthermore, itis important to keep in mind that some children may have ‘more than one sleep disorder, especially the frequent coexistence of medical and. behavioral sleep disorders."* For example, a child may have both obstructive sleep apnea and behavioral issues with bedtime refusal. Once a sleep disorder is identified, a thorough evaluation for all other sleep disorders should still be ‘conducted. If not, sleep problems may continue, even with successful treatment Last, because sleep disorders can be associated with physical illness or another psychological disorder, an evaluation of other factors may be essential. IMPACT OF SLEEP DISTURBANCES: A mumber of studies, largely in adults, have documented the pervasive Impact ofslep disturbances in a variety of domains. These studies have consis. tently found negative mood changes and significant decrements in cognitive fonctioning and performance decements related to excosive daytime sleep ness. Several mechanisms likely account for these negative effets of sleep Glistusbances, The first posible cause ip the actual sleep deprivation, that 3, shortened sleep or lack of sleep, which may occur with sleep disorders resulting in sleep onset delay, such a8 delayed sleep phase syncirome. In general, even partial sleep deprivation has been shown to result in diminished performance, Expecially if it occurs on 2 recurring basis. Dahl” proposes thatthe sleep loss Incurred fiom inadequate or dishubed sleep in cildren influences prefrontal corter functioning, resulting in decrements in executive functioning involved in the control of attetion and emotions. Sleep fragmentation, or sleep interruption, is'a second mechanism. Slep fragmentation occurs with such sleep disorders a obstructive sleep apnea and periodic limb movements in sleep, when sleep 1s periodically interrupted throughout the night. Finallya third general mechanism Eos been proposed related fo the CNS effects of hypoxemia, and. possibly hhypereazbia, in sleep-disordered breathing "From the findings with adults, it an be extrapolated that similar effects are expected in children and adolescents, although there is a paucity of research on the impact of sleep disturbances on children’s functioning. The most empiric suppor, and the most consistent findings, arc based on cimcal observation and parental report, which indicate that slop problems in children result in changes In mood and behavior" These changes offen are paradoxe in nature, with Younger children presenting as iritable and overactive, with a short attention Joan These symptoms can be similar to those soen with attention deficit hyper active disorder (ADHD).702 YaNDELL eat ‘The second arwa of impact concems neuropsychological functioning. The few studies conducted, similar to those found with adults, have found that children experiencing sleep disturbances have difficulties with focused attention, vigilance, reaction time, executive functioning, and, to a certain extent, mem ory”-*"s8 0 Finally, it is expected that sleep problems affect overall Functioning in the child’s naturalistic setting, both in regard to the short-term and long-term effects of sleep disturbance. Initial studies have found that sleep problems can be related to academic functioning” It is ikely that sleep problems also affect social functioning, as supported by mostly anecdotal evidence. ‘Additional support for the previous conclusions has been found in studies looking at the impact of treatment of inadequate or disturbed sleep. For example, significant improvements in cognitive performance and behavior have been reported following the treatment of obstructive sleep apnea” and young chil- dren's sleep disturbances.” Furthermore, itis worth mentioning that sleep disturbances can also have a significant impact on the family. A number of studies have documented negative effects on parental sleep and subsequent impairment of daytime func- tioning related to sleepiness in families with children who have clinically sig- nificant sleep disturbance." Additionally, another study found improvements in parents’ mood, marital satisfaction, and total sleep time following treatment ‘of their young child’s sleep disturbances.) PEDIATRIC SLEEP DISORDERS Excessive Daytime Sleepiness and Hypersomnolence Complaints of excessive sleepiness during the day or a greater sleep requize- ‘ment than expected at a given age are common. These fwo symptoms may indicate of a wide range of sleep problems. Five of the most common sleep disturbances are reviewed subsequently, Inadequate Amounts of Sieep A frequently overlooked cause of excessive daytime sleepiness in children, and adolescents is lack of sufficient sleep. Late evening activities, early moming. school start times, and erratic sleep schedules can all contribute to inadequate sleep time. Answers to general questions about “usual” sleep sehediulas during a sleep history can be misleading. Reports often- overestimate the amount of ‘sleep the child or adolescent is achieving. By asking more directly about time in. bed’ on specific nights, shorter sleep times are often described. Furthermore, parental reports about time to bed, especially with adolescents, are often inaccu- rate and can overestimate total sleep times. Information about weekdays versus ‘weekends can also be helpful. Late sleep onsets and long hours in bed on ‘weekends are often indications of erratic schedules and inadequate sleep on ‘weekdays. Sleep diaries and actigraphy are also helpful in elucidating actual sleep patterns. ‘The issue of insufficient sleep has been examined most carefully in adoles- cents, in whom surveys, field studies, and laboratory assessments converge to indicate that many obtain inadequate sleep, and 2 minority are markedly im- paired by excessive sleepiness. Much less is known in younger childzen, al- ‘though if is important to address the issue in any chile presenting, with excessive sleepiness. Sleep need varies across individuals and appears to be more com-DEVELOPMENTAL FEATURES OF SLEEP 703 monly underestimated than overestimated. Thus, parents may assume that 8, 9 {10 hours of sleep are sufficient fora pieadolescent and not realize that a slrone sleep defet may accumulate overtime if sleep nest is not met. Older adolescent likely do not need les sleep than preadolestens, In one kngitadinal Study of 10-to 16-year-old cldven the average sleep length at every age (given an identical 10-hour sleep opportunity over the course of thnve nights) showed ho significant change with age. The mean was about 925 hours At the same time, these boys and gils were more Hkely fo waken spontaneously at unger (prepubertal ages than when older. Furthermore, at mi to lte puberty, adoles- ers bogan to manest a mudday augmentation of sleepiness despite claular levels of noctumal sleep These findings indicote that sleep need does not decline with age ecrcs this span. ‘swith many other health behaviors achieving changes in sleep habits can be dificule and requires diligence by ciniians, parents, and the cd or cols. cent. Children and adlesceni may resist change because thay perceive thls Sorial, work, and school schedules as inflexible. Behavioral contracts can be successful if clear consequences for both sucess and ‘allure ate outlined. This approach is essential when daytime sleepiness affects school performance oF 5d functioning Obstructive Steep Apnea Obstructive sleep apnea syndrome (OSAS) is part of the spectrum of sleep- disordered breathing that also includes primary snoring (snoring without respi- ratory compromise) and upper airway resistance syndrome (usually in children, due to adenotonsillar hypertrophy).** During sleep, increased upper airway resistance and the inability to maintain airway patency leads to a pattern of repeated partial (hypopnea) or complete (apnea) cessation of airflow. These ‘obstructive events result in two major consequences: repeated episodes of hyp- ‘oxia and hypercapnia; and frequent arousals from sleep, leading to sleep frag ‘mentation and subsequent behavioral and neurocognitive evidence of sleep disruption. Common symptomatology in children includes loud, disruptive, chronic snoring, breathing pauses, snorting or gasping respirations, mouth ‘breathing, restless sleep, sleeping in unusual positions, and excessive sweating, during sleep. There may be a history of chronic problems with tonsils and adenoids, or ear infections. Impact on daytime functioning may present as ‘excessive sleepiness or excessive activity. ‘The prevalence of OSAS is estimated at 1% to 3%, and the peak age for development of symptoms is 2 to 6 years. There also appears to be an increased. pt symp y risk of OSAS in early to midadolescence that more closely resembles adult O5AS. in clinical presentation and in its frequent association with obesity. Many chil: dren with OSAS have a positive family history of sleep-disordered breathing. (Childzen at particularly high risk for sleep apnea include those with maxillofacial abnormalities, mi a history of cleft palate, neuromuscular disease or hypotonia, and Down syndrome. Children who are morbidly obese (greater than 150% ideal body weigh, including those with Prader Willi syndrome, are also at increased risk for O8AS* ‘Sleep apnea in children can be difficult to diagnose based on clinical history ‘The degree of adenotonsillar hypertrophy does not necessarily correlate with, clinical symptomatology or severity of apnea as defined by polysomnographic variables, including the apnea-hypopnea index (number of breath stoppages or partial obstructions per hour of sleep), and symptomatology also may not be predictive of OSAS. Numerous studies have attempted to develop predictiveTOL MINDELL eat sodlels of OSAS in childzen based on symptomatology, but all have had litle fuccess2» "90" Therefore, overnight polysomnography is considered to be the “gold standard” inthe diagnosis of OAS in chldren and adolescents Severe OSAS can rs in pulmonary Hypertension, right hear failure, and cor pulmonale, as well as growth fulure and systemic hypertension. Milder SAS may simply result in Bequent bie azousels fom seep, which enable the airway to open ard breathing to sesume. Thee frequent arotals, of which both parents an chicven may besmawrare, can lead to significant daytime sleepiness nd consequently «hast of intemalizing and extemalzing belavior problems and academe difculies, including itablity aggressiveness, dstactbilty iatention, and hyperactivity, “The most conuon tvatment of pediatric OSAS is tonsillectomy or adenoid- ectomy, which relieves symptoms it about 70% of all pediatric caves*™ = Weight lose, if appropriate, shoud be sttongly recommended. Porthermore nasal continuous postive airway pressure (CPAP) is succesful in the treatment Of obstructive sleop apnea in adults, and Js being used more equenty as 3 teen’ for sme chien with sep pmo epecily eset wham Surgical intervention it inappropriate or only cessful The wtty tthe teatment modalies sed for OSAS in als, auch as denial devices nd tivulopalatopharymgoplasty (UPPP), has not been wrell studied in chien Nereolepsy Narcolepsy is «chron dsondor characterized by excusive sleypinss often presenting a repeated episodes of raps or lapses ino sleep of stot dation Broughout the day» “<* The clase symptoms of nascolepy include exces sive daytime sleepiness, cataplesy (he sudden loss of russe tne following a strong emotion), sleep paralysis, and hypnogogic hallacinations. Ail individuals with narcolepsy experience excessive daytime sleepines, with some or ll of the other symptoms. Cataplexy, a pathognomonic symptom of narcolepsy, i trig gered by a song emotion, suchas laughter, anger, or fae nd sett in lose of EMateral muscle tone. Tt can be as mild a foling of wealsnns in the knees OF t= dramatic as faling to the floor and being unable to move. Episodes of atapleny lst from a few seconds ta few minutes, with complete secovery. ‘Gotsining a history of catapexy and other symptoms Consistent with narcolepsy con be difcalt, expecially in children and adolescents, Nescolepay isnot rate, with an incidence of approximately 1 in 10,000. The typical age of onset is late adolescence or easly adulthood lshough docuztented {ates have been found in prepubertal children ®"™ The emergence of symptoms ff narcolepsy in duldeen and adolescents can occur in any combination, with some experiencing such symptoms as hypnogogic halucinaions prior to the onset of daytime sleepiness. Diagnosis of nereolepsy requlzes overnight PSG, ‘which usally includes a MSLE Brly-onset REM periods a bedtime and during haps, fragmented nighttime sleep, and objective. documentation of excessive daytime sleepines ave all characteviatics of narcolepey. Repeat stadies in younger individuals are ofen roquired. ‘Narcolepsy is neurologic disorder with a song genetic predispsition Most ilentifed cases of narslepey have HLA-DR antigen. Ite important fo "ote, however, thatthe prevalence of nareclepay is much ese han the prevalence Of this HLA marke: (0.05% compared with 35%). A family history of narcolepsy tad exes deepiness cn be pl nconiaing a agro, ahaugh not found in many ences. “Treatment of narcolepsy includes echcation about the disorder fr the childDEVELOPMENTAL. FEATURES OF SLEEP 705 for adolescent andi the family, adherence to a regular schedule that allows the hid fo obtain optimal sleep with good sleep habits (ofen including scheduled zaps), use of short-acting stimulant medication for treatment of daytime sleepi- ness, and use of REM-suppressant medications (euch as protriptyline) for symp- toms of cataplexy. Unfortunately, no controlled treatment trials have focused on children or adolescents with naicolepsy, thus more research is needed. ‘diopathic Hypersomnotence ‘A small percentage of children and adolescents have significantly increased. sleep needs without evidence of the REM sleep abnormalities seen in narcolepsy, a condition called hypersomnolence. Most individuals with idiopathic hyper- somnolence nap daily for 1 to 2 hours, but in contrast to narcoleptics do not find short naps refreshing. Idiopathic hypersommolence offen occurs with a family history of excessive sleep needs. Adolescents with an idiopathic hyper somnolence may sleep 12 hours each night and stil show clear objective sleepi- ness in MSLT studies. Polysomnography and MSLT studies are necessary 0 differentiate idiopathic hypersomnolence from narcolepsy. Furthermore, @ psy- chiatric evaluation should be conducted, as depression can be a cause. These disorders also are treated frequently with planned naps and stimulant medica- tion. Family education is important because idiopathic hypersomnolence can have significant effects on daytime functioning. Teacher education is also essen- tial, as hypersomnolent adolescents are often considered a problem in school, with many labeled as “lazy” or “belligerent.” Academic performance and social functioning can be greatly affected by idiopathic hypersamnolence. Kieine-Levin Syndrome Keine® and Levin’ first described symptoms of hypersomnolence, hyper sexuality, and compulsive overeating in a group of adolescent boys. In addition, mental disturbances, including irritability, confusion, and occasional auditory oF ‘visual hallucinations, have been reported. This syndrome (with moze than 100 published cases) occurs three times more frequently in boys than in girls." Symptoms typically begin during adolescence, either gradually or abruptly. In about half the cases the onset follows a flu-like illness or injury with loss of consciousness. Frequently, there is an episodic nature to the symptoms, with symptoms lasting 12 hours to 3 weeks and recurring at intervals of weeks to ‘months. The syndrome usually resolves spontaneously during late adolescence cor early adulthood, ‘Laboratory tests, imaging studies, FRGs, and endocrine measures do not appear to be helpful in making the specific diagnosis of Kleine-Levin syndrome. Differential diagnosis in these cases includes organic causes, such as a hypothala- mic tumor, localized CNS infection, or vascular accident. The presence of neuro- logic signs, evidence of increased CNS pressure, abnormalities in temperature regulation, abnormalities in water regulation, or other endocrine abnormalities also point to an organically based problem. Bipolar illness should also be consid- cred if there isa family history of bipolar illness or other signs suggesting early- ‘onset bipolar disorder. Stimulant medications, such as amphetamines, methyl: phenidate, or pemoline, have been reported to be helpful in individual cases, but typically only for brief periods of a few hours at most. Lithium carbonate also may be used preventatively.706 MuNDELL et Restless Legs Syndrome and Periodic Limb Movement Disorder Reales legs syndrome (RIS) is asleep disorder that manifests itelf as tuncosfortable sensations inthe legs (Aysenthesiag), with the urge to move the legs. The sensations are woise when inactive and typically ate aggravated dlring the evening of night, with some temporary nile with activi Adulte commonly shake their les, pace, or “bicycle” their legs. Children, however, may jump or run. Periodic Ln movements in sleep (PLMS) typically accom pany RLS. Thab brief repetitive jerks, lasting an average of 2 sands, ypialy ecu every 5 to 90 seconds during stages 1 and 2 of sleep. When PLM a7e accompanied by symptomatic seep disturbance, the dsonder is refered to ts periodic limb movement disorder (PLMD). Periodic limb movement disorder can. fcc with or without RLS. “tle has ben reported on PLMD an RLS in children and adolescents, but both are dlorders that ae being scoped more in these populations. Patenis often describe their child a¢ constantly fidgeting while avake, whereas other Aleserbe ELS as. “roving pains.” Picclet and’ Walters” reported on five ‘lildren with diagnosed RLS" All ve children had chrome sleep-onset problems Sand three of the five had sleep maintenance problems. Restless sleep was commonly reported, and no cll was descbed to have daytime sleepiness, Sithough most "looked tied." The authors noted that these lldren had oth insufficient quantity of sleep (averaged 72.minates les nighttime sleep) and 1 ep (averag a ) distubed sleep quality Treatment rested in significant iaxprovement in both Sleep quantity end quality and in improved daytime behavior "reatment for RLS and PLMD is typically mullifacete, chiding establish- sent of a vgid sleep schedule and ote of fuhavioral management for appro. Plate sleep behaviors. Caffeine reslion is imporlant, because chldren and Eolescene vith RLS inay be sensiive to calfenes effect on slp. Medication also may bu necessary. Chondine can be an effective agent. Dopamine antago nists such as levodope-cabidopa, have been successfl with adult, but ies Keown about thls ute in cldten and adolescents Delayed Sleep Phase Syndrome Adolescents often stay up late at night. Delayed sloop phase syndrome {DSPS), however, differs from this developmental trend because it involves a very large and intractable shift in sleep-wake schedule. Delayed sleep phase syndrome may occur at any age, but is most common in adolescents and young adults. Ie begins with a tendency to stay up late at night, to sleep Tate in the ‘moming, or to take a late aftemoon nap, especially on weekends, holidays, or summer vacations, The pattern becomes problematic when it interferes with ‘waking in the mornings for school or work. Entrainment to the 24-hour day is evident in DSPS. Thus, the timing i consistent from day to day-—consistently te. Adolescents with DSPS may complain of sleep-oncet insomnia and extreme difficulty waking in the morning, even for desirable activities. To cope, many adolescents with DSPS take lengthy afternoon naps or catch up with extended and delayed sleep on weekends and days off. With DSPS, even highly motivated adolescents are unable to shift their sleep back to an earlier time without assistance. Their attempts may even run counter to the process, leading to appropriate phase resynchronization. The prevalence of DSPS is approximately 17% for adolescents, and although rare, it can also be found in prepubescent chil- deen.DEVELOPMENEAL FEATURSS OF SLEEP 707 ‘Treatment for DSYS ivolves siting circadian shyéhms so that sleep occurs st the destable ime. Two methods are posible, "The ft i 1 shift Beims snd waketimes cate by 15 minutes day, beginning with the tine thatthe Adolescent usually goes to bed without clffculy. The second method, called Groner swe for more diel cases and involves delaying bein and wake time by 2 to 3 hours daly. Tiss ian adolescent uslly goes to bed at 5800 aus en the Ses day of eatment bedtime fy seeded for 70 ate the second day 10:00 and so forth antl the desired ane achieved In adiion to the change in slecptimes a reomponiation ofall sleep habits is necessary, Inluding such things as developing postive sleep routines and avoiding caf feine. Adolescents typeally do well dering the fst phase ofthis treatment, as they often perceive Iialy that they are being allowed to stay up later each day; with suifcient motivation it does not require parental input, te patents sre usually trod atthe echedled sleep time, an they receive postive attention fortheir suocenex Witheither method naps must be avokied ard the solescent ‘must maintain consistent slep schedule both on weekdays. and weekends ‘Adaitonally, exposure fo bright pht on waking is bone To both achieve Sucease and maintain changes, highly motivated adolescent ia seguir. The tore dificult aspect of treatment isthe maintenance of te new sleep schedule [All takes sone weekend or vacation in which old habits ae esd to uno all achievements, Sehavioral contact often are necesary and psychological and family sooues may need tobe addressed if resistance wo change Ts encounters, as is experienced frequently Once the new schedule fly entenced a ccasonal late nights permitted, but the adolescent should nol elep more than 1Tor.2 hours later than his or her usual weekday wake tne Achieving success in seaiging an adolescent's sleep schedule canbe diff calt As mentioned previously it segues @ great deal of motivation an the Sppor ofa sable home envizonment. issaes sch as the motivation of he hl frradolesceni, the family resources, and the existence of any. poychistve OF Substance bce problems all need to be addressed before suc can be ox pected Sulicient motives to institute change must be explored. Similar fo mony Ether behavioral interventions, a welldeveloped plan i essential to akieve suc os Parasomnias As discussed previously, parasomnias are behaviors that occur during sleep, ‘Three such behaviors ane addressed, including partial arousals, nightmares, and enuresis. Partial Arousals Sleepwalking, confusional arousal, and sleep terrors ace all variations of paral arusals rom deep skep wally Stages 3 snd As dncused previously Fost children have a deep period of slow-wave Heep 1 to 3 hours afer ekep ‘onset, followed by a tancion to lighter sleep” REM sleep, of a brief arousal ‘This tension often is accompanist hy briet unusual Bchavios, such a strange movement, mumbling or grimacing. In more dramatic ccs, ovrever, these transion episodes const ofsleepalkng,slepwalkin,confased pasta routs, or # sleep terror Throughout the event, te child emai eserally Sleep and as no memory of the event in the morning. The episodes can last from seconds to 30 snus, ith the majority lasing som 2 40 10 inst,708 MINDELL etal “These events, partcuany alep tenor, can be distressing for parents, as the child often coe not recognize the parent, reset comfort, and i incohcen. In Aramatie cates, children appear tered, scream, dash wildy, and bolt sway from paren. A partial zoveal event usually terminates spontaneously, wits the child feturning fo deep slp. Paral etousile are quite common in cilren. Chronic leptin occurs in approximately ik to 6% of children, ithe many’ a8 20% ofall Cdn having had at least one such episode Sep terrors are less frequent with stimates ranging from Ivo = The ducepancies among reported zea Of partial arousal may result Srom the dificlly in measuring the occurence of thor events which the cldren do ot remember and the pacents may. not serve. This, these sates are likly f0 underestimate the tne prevalence of these disorders Most partial arouals ae a developmental phenomenon, with resolution a8 the child gets older Ax delta sleep devine ih adolneence, the frequency of these detested events decrenes, Shacies indicate a faa component 0 these sleep lsturbances, wiih postive hbtores common in Sst or eocond- degre relstiven" Many parents sosume 2 psychological bass fr these event either an ansety-provoking evento depression, but sich Is rarely the ease 2°30 Pant arouaals can be exacerbated Ina susceptible individual by enviton mental facto that fragment seep, such as fevet, intercurrent ings, «ull Bladder, and certain madicatons, sich a lth, prin, and desipramine Furthermore slep deprivation contributes tothe occurrence of pari arosals, demonstrated by'a starp rise in thei occurence in conjunction with chaotic sleep schedules, on the nights of recovery sleep following sleep los, or in conjunction witha change in schedule orf lag, These episodes also may occur folowing stessil episodes, not as tect fesult of fe stressful event but Indieelly fom concomitant sleep loss Diagnosis of petal arousal can usualy be made by clin! history alone Although parents ofenidenily sleep torors se “nightmares,” the wo Gistnct ccarrences ae eanily discernible (able 1) The primary difeences are that Paral arousal events oscar carly rather than Inte during the nigh are accompa ied by confusion rether than clarity, are forgotten by the child rather than Carre as vivid memory resolve in a quick fetumn to deep seep rather than prolonged awakening, and are more fequent following sleep les. Underlying Heep daropters that may tagger sleepwalking or skep toes should slo be evaluated. For example, childsen with Gbetructive sleep apnea have an increased Iheltood of paral soesns: These csturbanoss can rest in sleep deprivation, increas slow-wave sleep, and tore frequent atousa. Finally thee events Should be diferentated fom nocturnal seizures, which ate characterized by Storeotypic, repetitive movements oectting at any Hie of night (ve Tale ‘nce diagnosed, treatment of petal srousale involves numberof steps. ‘The ist steps penal education Zbout what hese episndes ae and what they are not Family reassurance is one of the most important roles ofthe clinician, ‘The next step i fo ensure adagute taety forthe dul, Gate shouldbe erected across stair and all windows and doors should be locked snd bolted so tat the dld or adolescent is unable to leave the house The third sep iso evaluate the chil’ or adolescent’ sleep schedule Maintaining a consistent sleep sched ‘le that includes sn adequate mount of tine in bed can result In signfcant diminution in the fequency ancl severy of sleepwalking or sheep teres. Fourth patents should be instructed not fo attempt to awaken the child dusing an event, as this nay actully exacerbate or prolong the episode. Las, othersoxanyeq 0}0W ofa An, EO 6/1 3591 0 PN ‘SeroUNUIN suo fo apr Sarge Soundooys sume, penpucu dag a < WeLON days yo 38015 ‘vowo> ar “ovnbang we a Aanfur xoy yenusiog oh ‘ove es esomy ano jo wap [ousyemn j posnyuco Asn ao agence 7 SIIEMEA — URpoKA ag eur eed Goamays aA Bee yo 6/1808 "900 dogs ye waye ou uy ‘seenowy jemed ‘seunzieg jeusnyoon ‘SEUVWLHOIN GNY ‘STVSNOUY TWiLM¥a 'SEUNZISS TNUNLOON 4O STUNLVA OUSTERLOVEWHO "> e1a0L710 MINDELLct a sleep darupters, such as slep-disordered breathing or other nighttime awalen- ing need fo be treated (Other potential trestmnents for partial arousal include hypnoss, celaxation strategies, and positive zenforcement: Initial sucreso with echedaled avraken- ings, which involves waking the child for a number of nights prior t the ime ofa usual event, has been shown! * The se of medications, including a benzodiazepine sich clonazepam or diazepam ora trcycic antidepressant sich as imipramine, may be warranted = " "1" These medication: significantly decrease SWA’and ace indicated in cates in which the events are extemely feequent, cause significant family disruption, or when the child or adolescent is a danger to himself or herself or others. When the medication is st However, dhe often 1s rebound delta and an increase in paral arousal therefore weaning off mediation Is recommended. The efacy of phasic therapy, relaxation taining, hypnosis, and scheduled awakenings, hoveever, is Alificalt to assess Few randomized clinical tals have been performed, and sponancous remission rats are unknown, Nightmares Nightmare are commonly experienced by children, and occur in about 10% to 50%e of children between 3 antl 6 years of age. They typically decrease in frequency over time, with a small percentage of children continuing to have them Uoughout adolescnce and even into adulthood. kn contrast to sex terre, nightmates occur during REM slep and hve are much more Iikely #0 happen during the second half of the night. When waking from a nightmare, the child alt andl can cleanly describe detailed scones and iightening ianages ‘The child usually has difficulty going back to sleep and secks comfort Children will emember and tale about thet nightmares te folowing moming, I ls Usually eney to distinguish nightmares from might torre (ec Table 1) iv older luldren and adolescents although is more dificil in younger hldven who have limited verbal abies “The mest coenmon images during nightmares involve fears of attack, falling, fe ee eee Dightmares. For example, distressing or frightening events such as anaifomobile daccident of the death of a relative aze associated with nese. ightmare incidence. Nightmares algo are associated with posttraumatic stress disorder, and thus evaluation for this ansety disorder should be conducted in children With frequent nightmares. Sleep deprivation also can inctesse the likelihood of Zightmare, becmuse vivid dreams are more contmon on extended night of recovery from sleep Toss. One study surprisingly found that paren most Common catsalaitebution for nightmares was “overtiedness”with “stress” not highly rated as a faclor™ In aditon, certain medications are assoriated ‘with mighnares, including some frblockers and antidepressants, Other medica Hons such as alcohol, barbiturates, and benzodiazepines, produce nightmares 2 withdrawal symptoms 1, Ones of etme for ihtmae if nce tl ep tine ane ‘slogp schedule for children who undergo frequent sleep depriva- IEE. Poychoterpy can ab be ester wih treatment ocacd on the provoking events Effective anxiety reduction techniques indude masation snd Imagery, offen combined with ofner behavioral strategies such as systematic decenatization response prevention ™ or dream reorganization ™” Dram £00 ganization invelves systematic desensitization with coping slfstatements and ‘Buided rehearsal of mastery endings to dream content. Tor most fares, hvDEVELOPMENTAL FEATURES OF SUEEP 711 ever, reassurance that nightmares are part of normal child development is all that is necessary. Enuresis nuresis is diagnosed when persistent bedwetting occurs after 5 years of age. Estimates indicate that bedwetting occurs in approximately 25% of boys and 15% of girls at 6 years of age, with 8% of boys and 4% of giels continuing, to be enuretic at 12 years of age.° The spontancous rate of remission after 6 ‘years of age is about 15% per year. Primary enuresis, referring to those who have had a continuous enuretic condition, comprises 70% to 90% of all enuresis, cases. Secondary enuresis, in which the child has had at least 3 to 6 months of dryness, accounts for the remaining 10%-30% ofall cases. Etiologic factors that contribute to enuresis include family history, maturation, and functional bladder capacity. A number of physiopathologie factors can also cause enuresis, such as lusinary tract infection, bladder instability, epilepsy, and sleep apnea. In contrast, psychopathology does not contribute to entuesis, although psychological prob- Jems may result from consistent bedwetting in an older child. Enuresis requires 2 multifaceted assessment. Following an interview with the child and parents, a physical examination is conducted to rule out physical anomalies. urine culture to test for specific gravity, glucose, protein, blood, and any signs of infection is also important. A complete sleep history is necessary to rule out obstructive sleep apnea, ‘Most physicians treat enuresis pharmacologically. The two most common classes of medications are tricyclic antidepressants and antidiurctics. Imipra- ‘mine, prescribed in doses between 25 and 75 mg taken at bedtime, is successful in controlling enuresis in up t0 70% of cases when taken regularly” On ‘withdrawal from the medication, however, few children stay dry. Furthermore, ‘because of imipramine's potential cardiotoxic effects and the high relapse rate following withdrawal, iti often not recommended for long-term use.“® Another ‘compound that has been used with success is desmopressin (DAP), an ana~ logue of the antidiurectic hormone vasopressin.” Approximately 70% of cases have persistont resolution of bedwetting when maintained on desmopressin, minimal side effects. Unfortunately, it too almost always leads to relapse following discontinuation. Although desmopressin is much more expensive and has higher relapse rates than other treatments, it may be the treatment of choice ‘when used on a short-term or as needed basis (eg,, ovemight camp, staying at a fiend’ house) Several behavioral treatments have high proven success rates. The most popular and effective technique is an alarm system. The original bell-and-pad system, which sounds a bell or buzzer when bedwetting occurs, was developed ‘by Mowrer and Mowrer in 1938." Many such systems now attach directly to the child's pajamas or underwear, resulting in even more immediate feedback ‘when voiding begins, Reported success rates for this technique have been as high a5 75%," with the best results in children over 7 years of age Relapse rales are also low, at approximately 41%, although relapse rates as low as 17% have been found with intermittent alarm schedules. The alarm has been found to be superior to imipramine, DDAVP, and other skills-based treatments. (Other treatment approaches for enuresis include bladder training." re- ‘sponse prevention and contingency management)” hypnosis;* and dietary con- trol, such as a reduction in caffeine intake. A comprehensive treatment program is typically used, incorporating 2 number of components such as bladder- stretching exercises, visual sequencing, a nightly waking schedule, positive prac-7A2— MINDELLet at tice, and an alarm activated by wetness, Overall, the literature indicates that enuresis is highly amenable to behavioral treatment and should be considered a ‘realable disorder. SLEEP AND MEDICAL ISSUES Children with a varicty of medical issues offen have concomitant sleep problems. These sleep problems may be the result of the medical problem, may bbe the cause of the presenting symptomatology, or the two conditions may exacerbate each other. Tourette's Syndrome ‘Tourete’s syndrome isa disorder of multiple motor or vocal tics with a ctuldhood anset’ Data indieate that approximately 50% of dren with Toure tes syndrome have seep distubaness’™ ™ In alti, this movement disorder reoults in movements throughout all stages of sleep. Thus, children and adoles- cons with Toureiee syndrome are at isk for parzomnis, inluding ssp walking and sleep teers, and they have a higher incidence of enn Test sent of Tourette's syndrome can seduce sleep disturbances In addition, teal ment with clonidine ot clonazepam ‘near bedtime can improve sleep with a Alecrease in EEG aroutals, and behavioral interventions to incesse nighttime Sleep ate alo of wiity™ Respiratory Disease Children and adolescents with respiratory diseases are at increased risk for sleep-disordered breathing. Asthma (reactive airways diseases) and cystic fibro- sis (CF) are two such respiratory diseases. Astiuma is a common childhood disease, and many children experience exacerbations at night during sleep. This effect is primarily related to circadian variations in lang Function rather than a direct impact of sleep. The end result, however, is significant sleep disruption Reductions in Stage 4 sleep and increased awakenings and arousals during sleep are found in children with asthma compared with controls.” Thus, medical treatment of asthma needs to take into account the likelihood of increased poverty during sleep. A thorough seep evaluation, with an emphasis on sleep fragmentation and symptomatology consistent with sleep -dicordered breathing, is important. Medication management needs to include a plan for nighttime control of astnma symptoms. This plan should incorporate longer-acting medica tions for nighttime control, but ones that do not interfere with sleep itself. ‘Theophylline is sometimes recommended as the best medication for nighttime asthma symptoms, although the propensity for significant side effects must be taken into consideration." The use of prophylactic medications, however, such as Cromolyn, which have few behavioral side effects, is more common. Cortico: steroids, also used frequently for asthma, may also disrupt sleep.” Control of, environmental allergens should also be considered, as well as treatment of any ‘other underlying sleep disrupters. Finally, children with atopic dermatitis (eg. ‘eczema), frequently associated with asthma, tend to have increased sleep-onset difficulty, night wakings, decreased sleep duration, and increased daytime sleep-DEVELOPMENTAL FEATURES OF SLEEP 713 {ness related to pruritus and treatment medications such as antihistamines and corticosteroids.” Cystic fibrosis, a chronic lung disease that begins in infancy, leading to premature death, can result in nocturnal hypoxemia® In addition, those with CCE can have decreased sleep efficiency, increased sleep state changes, increased awakenings, and decreased REM sleep. Some of these changes in sleep may result from coughing. The development of nasal polyps that may obstruct airflow may also contribute to increased prevalence of obstructive sleep apnea. ‘Treatments that improve physiologic functioning and sleep include supplemental ong during lee, nisl CPAP, and adequte toainent of ineton end coughing, Solzures ‘As many 25 20% to 40% of scizutes occur during sleep with another significant pordon present at sleep-wake tanstions. Some seizure disorder, Such as benign lence eplepay and frosa-iobe eplepey usually oceut during Sloop. Not only do seizures commonly occur during seep bt sleep deprivation Can tigger a sebure Furthermore, anieplepie medications cam also sigh cantly sifectslep™ Whereas some anticonvulsants cause drowsiness and re ced sleep latency, other medicavons (eg, flbamate,adzenocortiotopic hor ‘mone, and eatbamazepine) can lesd to complains of ireomnia with slap onset an sieep maintenance problems. Phencbarital Is known to teuce sleep le tency, nighttime srous, and REM sleep, with no effect on slow-wave seep Resteaness azo occurs during the second part ofthe might, Differentiating sleep problems irom eplepsy can be difcl. For example, ute disorders are Known to result in Gaye sleepiness, asleep is en disrupted by seizure activity. Thus, fa child or adolescent presents with daytine sleepiness with no apparantundetiying sleep disruptor of narcolepay, a inure inorder should be considered. Seizures may slo be difcalt to fterentate from parasomnias. Table 1 provides the moet common distinguishing factors betwetn seizures and partial arousal disorder. 1 should also be note that = seizure disorder cannot be diagnosed from ovecright PSG) another study that includes additonal BSG channels equied Blindness Sleep problems are frequently experienced by cildcen and adolescents who axe blind. Sleep distubancis include dficuly filing asleep at a desied Sie, frequent nightime awakenings, daytime fatigue, and frequent nape. The major. ity of sleep problems in the blind are ttt to ceadian shythm disturbances ‘Although no studies have bas conducted with bling children between the ages of and 15, prevalence studies have been conducted with Boh younger childeen Snd adults In preschool age children, sleep disturbances were move conaon in 2 group of Mind children compared with «control group.™ Furthermore in a Survey of bind adults, 7% ported sleep-wake disturbances” ‘Attempts to regulate the sleep-wake fycle by maintaining a strict day-night routine have produced mixed results, Mindell tall founda strict outine to be beneficial ‘with a totally blind 2yearold child, but attempts with older chuldren andl adults have had more lined succes, Medications such as coral hydrate or benzodiazepines can be helpful, primarily to promote sleep onset at714 MINDELL ett bedtime. Initial success has also been achieved with melatonin in this population, although the majority of studies have been conducted with adults. An important cautionary note is that the long-term effects of melatonin on children and adolescents are unknown. Chronic tliness Children with chronic ilinesses or acute medical disturbances can also experience sleep difficulties.“ ™ '® For example, children with severe burns offen experience nightmares." Several preliminary studies have addressed. the issue of sleep disturbance in children with juvenile theumatoid arthr GRA) and other theumatologic conditions, ‘These studies have documented increased arousals from sleep, leading to sleep fragmentation and daytime sleepiness in JRA," similar to what has been found in adults with rheumatoid arthritis The sleep disturbances and impairment in daytime functioning ap- peared to comelate more closely with reported pain levels than with disease ‘activity. Chronic fatigue syndrome, which includes a variety of theumatologic ‘and somatic complaints in association with debilitating fatigue, has buen re ported in children and adolescents, as well as in adults, to be associated with a ‘arity of sleep complains, including insomnia, hypersomnolence, and excessive daytime sleepiness ® and with objective PSG findings of increased sleep onset latency and decreased sleep efficiency.” Excessive daytime fatigue has been reported in children with sickle cell disease. ** In addition, the significant medical complications of comorbid OSAS in sickle cell disease has been deseribed in several studies," Hypoxemia and hypercerbia associated with OSAS in these children may lead to increased Frequency and severity of vaso-ocelusive crises, as well as to an increased risk. ‘of perioperative morbidity with adenotonsillectomy:" There is also increased morbidity as well as an increased prevalence of sleep-disordered breathing in children with a variety of neuromuscular diseases, including Duchenne’s muscu Jar dystrophy and congenital myopathies.“° The underlying pathophysiology likely relates to a combination of extrapulmonary restrictive lung disease ro sulting fom such associated conditions as scoliosis, from respiratory muscle ‘weakness, and from reduced central ventilatory drive. Hospitalization Not only do childcen with chronic Hinesses experience sleep problems, but ss do those who are hospitalized. Hospitalized children often experience an adjustment sleep disorder. Hospitals, and all that goes with a hospitalization, ‘an be a major disrupter of sleep, and not surprisingly hospitalized children ‘often develop sleep problems. Hospitalization also may exacerbate preex- isting sleep difficulties Hagemann® found that hospitalized children, 3 to 8 ‘years of age, lose up to 25% of their normal sleep time because of difficulties falling asleep and delays in sleep onset. Methods to help hospitalized children {get more sleep include instructing the nursing staff to institute structured bed- times for the children and to modify the hospital environment (eg., dimmed lights, reduced noise, television off) to reduce sleep interference. Surprisingly, several studies have found that parental presence and reminders of home canDEVELOPMENTAL FEATURES OF SLEEP 715 lead to greater difficulty falling asleep." Mild sedatives also may be useful for hospitalized children experiencing sleep problems." Medications Though less well documented in children than in aduls, many paychintsic medications have been shown to have sigraicant effets on sleep, most offen insomnia or daytime sedation. Table 2 ist sleep disturbances commonly assoc. aed with psycholtopic medicabons that are suently used in cldton and Adolescents. The distinction between sleep disturbances elated tothe underlying Psvchiatric disorder and those sacondaty to the medication used to Weal the Scorder fs not always clea however. For example, the prolonged sleep onset latency frequently described by parents of children with ADHD may’ bein some chien, past of the ADHD syndrome itself rather than the eet of psychestimilantindced azousal or tebound resulting from withdrawal of 8 Psvchostimatant2 Some of the paycholropc medications listed in Table 2 have actually been used to treat sleep disorders in chien for example, antihistamines ar benzo™ dlazepines used for sleep induction in insomnia Trimeprasine has en sed on a short-term basis i connction with behavioral techniques i. several studies for both sleep-onset delay® and night waking™ in infants and young children. The rationale for use in sleeponset delay is the attention of the etincion-burst ying often occuring atthe beginning ofa behavioral treatment progam Choral hydrate a commonly wd dg or sedating dn pe { dlagnasicprocedares, i oceasionally prescibed by pediatrics for ren with severe sleep-onset delay: howevet, eports of powible ks of hepatotoxic ity and respiratory complications in the setting of comorbid sleep disordered breathing rales concems about the safety ofthis policy. Clonidine has been sted succeseflly for ADHD.assocated sleep disturbances owing tots Righly Seating effect and reduction of ADHD symptoms, but concems about the safety af donddine-peychostimulant combinations have been raised In general, the use of hypnotes and sedatives to tet sleep disturbances in childrens problem atic and should be discouraged. Potential concerns include the development of folerance to sedating effect, paradoxie reactions, sues of dependence and withdrawal, and lack of information about longterm side effects At best, these medications should be used as an adjunct to, and not in Hew of, behavioral techniques. nal the recent upsurge in interest in maton asa treatment for cond- tions ranging from insomnia and jet to aging has led to its increased trmapervised wee inten and atclescnt Alough melatonin Fas been Sccetefully used for Greadlan tytn deorder in blind snd severely neurolog cally impaired children,” is use ota preventative tcalment for jt lag aad for Sleep induction in children has not been well stadiod. Possible interaction with other drugs, impre preparations, and the possiblity tht sudden withdraval ould trigger the onatt of precocious puberty in light of melatonin’ elects on the reproduction axio™ ar just some of the cautonaty notes that should be tached tothe use of melatonin fr sleep disturbances. "Not only do prescription medications affect sleep, but co do other types of drugs. Alcohol which often faiitates slop onset can lead to decrensed REM Sleep and sleep disruption. Withdrawal from stimulants, alcohol, and marijuana Gan lead f0 severe, although shortlived, slocp disturbances, Caffeine, which716 MANDEL eta Table 2. SLEEP DISTURBANCES ASSOCIATED WITH PSYCHOTROPIC MEDICATIONS Medication Poychostimulants “Methylphenidate ‘Dextroamphelanine Pemoline Hierceyatic antidepressants ‘Amitptyine teste Doncpin Noweepyline Dexpramine selective etoninreupake inhibitors ia Paci Fuvoxamine Fluoxetine Serine her antdepressnts/inood Sabilzce Veriaxine Trazadone Bupropion Monoamine oxidase inhibitors Lithium coAgonists Clonidine Guanfacine Neuroleptics Aswial Benzodiazepines J} Sleep onset latency [sate TST, | REM Daytime sedation REM supression. 1 Stage 2 sleep Daytime sedation’™=! Middle insomnia 1st, 1 SE 1 REM Daytime sedation” Incomnia Daytime sedation 1 RRM, | SWS Insomnia Insomnia Re Daytime sedation REM suppression 11ST Daytime sedation Ni ‘Midsleep awakenings Daytime sedation y ist A Sleep onsot latency Highdevel daytime Sedation ‘Sleep Effects ‘Comments “Tolerance to slp eftcts may ‘increase over ime; ‘Pemoline has te least tect on sep Listed mot fo lost ‘eating! Paroxetine most activating 10% of children discontinue due to sedation side effects Sedation may improve after ‘ot weeks Sedation often worse in ‘afemoon”™ Guanfacine less sedating ‘Tansdertal patch form of ‘lonidine say be less sedating Low-potoncy agents (chlorpromazine, thorydazine)™ most seitng moderate potney ‘Sittin: Nehpotency Sinn: talopet9 more ag hope sedating a ckment ination ‘Used to tat Stage 1V roel disorders (night tertor sleep walking)DEVELOPMENTAL FEATURES OF SLEEP 717 ‘Table 2. SLEEP DISTURBANCES ASSOCIATED WITH PSYCHOTHOPIC MEDICATIONS Continued Wedication Steep Erects Comments "Antistamines Tighseve dayume May develop toloanes may Sedation have pardon excatory cect Blockers Daytime fatigue Toma Nightmares Buspirone Daytine sation 20% ls sedating than seemating "pneodlaepines reported’ “TST = Total lp tine SE people often use to counteract daytime sleepiness, can cause difficulties falling asleep. ‘SLEEP AND PSYCHIATRIC ISSUES AAs in adults, skep disturbances and psychiatric disorders show complex zelationships in children and adolescents One reason for this complexity ithe bidirectional nature of the relationship. ‘That is, sleep disruption is strongly associated with emotional and behavioral problems, and many psychiatie pob- Jems are associated with sleep disturbances, Four psyctiatie sues are ad dressed, including depression, stess, anvety disorders, and ADHD. Depression Reports of slep disturbances are extemely common in children and adoles cents with depression. One study found that 75% of children and adolescents with major depressive disorder (MDD) reported insomnia, with 20% descrbing Severe insomnia.” In addition, about 258% of the depressed adolescents com Planed of hypersonnia. Many of these complaint, however, appear to be Subjective in nature, with Limited objective supporting evidences One study indicated thet although a group of depressed adolescents took 0 minutes to fll aslep in comparison with 15 minites in a group of controls, 30% of the depressed adolescents reports sleep-onset durations of greater than 30 mintes. In addition to the impact of MDD om sleep, symptom of depression can be linked to lack of sleep. That, feelings of fatigue, stability, and slaggishness say simply be the mtu of sleep depvation. I eel in thee ces eat Boh the mand donde and the sleep disturbance, Regularization ofthe sleep-wake eycle in some children adolescents will lead to improvements in tood ancl decreases in depres Symptomatology. Addiionaly, eatment of depression is hikely to improve sleep, both objetively and subjectively718 MINDELL st ‘Stress and Anxiety Disorders Stressful an traumatic experiences can have sgnfcan effects on the sexp- wake ele Such experiences can run the gamt from war and natural dis ters to Such common events as changes ia school or eeporation from siblings or paren" Concomitant sleep problems have boon documented as they relate {oa number of hse seston. Tor ample, seep disturbances are frequently experienced by children and adolescents following abuse, especially sexual Sbuse’* "= % Following both the San Francisco Bay area earthquake and the Hurricane Hugo disaster refusal fo go to bed or sleep alone were the most frequent symptoms reported by parents ™ Nightmares are lso common after natucal dlnsers, although more ao in younger children. Conflicing prevalence data have been feported reganding sleep problems fn dren exposed to war and terrorist activites. One study investigating the fshermath of an event in which 86 children Were held hostage, wih 22 killed Sind 6 injared during a release operation, found that 75% of survivors suffered from percent nightinares and insomnia In contest, nother study reported fewer bad dreams and longer sleep mes in children living in an area subject to intermittent femoris activities contpared with thos living In safe areas Tt has ben proposed by Sade that in these types of situations the actual proximity for level of expoaure to the disaster may be the important issue. Furthermore, the lack of sleep problems during long ferm stesful evens, such as living in @ War zone, may'be the result fom habitation or the development of suecessul coping tate ‘As mendioned previously, le events may not need to be as dramatic as sewual abuse or wat to result in sleep problems. For example, steep problems fan be seen in toddlers on graduating t0 a new class in preschool Sess fractions may not only reslt in nightmares and insomnia, but also in bruxism, rinding, or clenching tcth during slep. Althowgh there i litle direct evidence fan underving poychological dsordey, bruxism often inroases during times ‘oF stress, such asthe night prior toa major fest or during problems with fiends * 'Not only may stress result in sleep disturbances, but anxiety disorders may also contribute f0 sleep problems in children and adolescents. Posttraumatic Stress disorder, 8s dictated previously, has been assodated with a variety of sleep problems, incioding recurrent nightmares, difily fling asleep, and Fragmented night sleep "Another anxiety relased problem that affect sleep 1s rte er Fea ofthe dk ia normaly devopmenta acute Young Ghuldren, and can significantly affect a child's ability to fall asleep. Many su Sespiuping fear eared ugh simple contoning™ Tor eran the bedroom may be a source of anvily for some ciliren espesally fhe tedroom is the place where the child is ent as punishment. Alo, if te child Fas a nightmare or awakens distressed in the midale of We alght, a parent cally Gomes into the room and turns on the ight Ths, chil ay associate Tight with comfort and darkness with distress or nightmares, Several studies have successfully treated nighttime fears in children using cognitive behavioral techniques, by incorporating relaxation traning self-mon fonng of nightie behavior, verbal self-control trainin, ancl positive reinforce thent to decrease severe nighttime fears***" Ollendick etal found that rein forcement for engaging in appropriate nighttime behavior and self-contol procedures were succesful in reducing nighttime fear in two children. In their ‘dy they Yound that the most important component of tealment was contin- gent reinforcement. Although most chldren will outgrow their fears, in severe ses psychological treatments ae effective.DEVULORMENTAL FEATURES OF SUP 719 It is important to understand that some sleep problems that appear to be anxiety-related are not. Particularly in the case of sleep terrors of nightmares, just because a child looks anxious does not indicate that the primary contributing, factor for the sleep problem is psychological. In most cases, such sleep problems aus not the result of underyng peychopthology, but are physiologically or behaviorally based. A careful evahiation of the sleep problem and daytime functioning will help differentiate the contributing factors. Attention Deficit-Hyperactivity Disorder Many have speculated on the relationship between ADHD and sleep distur- ‘bances, particularly given the consistent parental reports of significant sleep disturbances in comparison to controls Controlled studies using objective ‘measures of sleep, however, find few differences"! Several studies have noted, however, that sleep deprivation can exacerbate ADHD symptoms, partic- ularly irritability, distractibility, and difficulties with focused aitention:® As in the case of childhood and adolescent depression, sleep complaints in ADHD may reflect phenomena requiring beter characterization ofthe participants and the sleep assessment Specific sleep disorders may also be more prevalent in children and adoles- cents with ADHD. For example, children with ADHD have been reported to have high rates of RLS and PLMS. Furthermore, higher prevalence rates for obstructive sleep apnea have also been found in this population *" Following. treatment of the primary sleep disorders, improvements in ADHD symptoms were observed” In evaluating a child or adolescent with ADHD, it is worth considering sleep issues as an underlying disrupter of daytime functioning, as well as potentially exacerbating daytime behavior. Thus, increasing or improving night- time sleep may help in the management of daytime symptoms of ADHD. ‘SUMMARY In sum sleep disorders are common problems for chldeen and adolescents, ith estimates indicating that approvimately 20% to 25% ofthe pedlatre popula tion experiences some typeof seep distrbence: Funhermore, cnicane show be aware tat sleep divtuances aay not only exist in olan, But eam be ‘ated to psychiatric or medical nues. Althovgh mich appesrs fo be known about sleep disorders inthe pediatric population, our knowledge ofthis area i sulin is infancy. Adkliional mesearc i sll needed to investigate diferencee in dlnial presentation of specifi sleep disturbances among diferent age groups Gey chien, adolescents, sds, and elderly), to deveiop the most appreprate tsiments for even popuiaton and Wo sic he eee of xp trance on Function Given the prevalence ofthese problems in the child and adolescent popula tion and its lkly impact on cognitive and behavioral functioning, heath profes Sonals need to bocome increasingly avare of and knowedgenbe about sleep {nd sleep disorder: Weal spend shout one thd of our ive sleeping, oe tying, fo sloop thus, we shoul understand as much as we can about it720° MINDELL et at References 1. Acsbo C, Sadch A, Siler R, et al: Estimating sleep paticrs with activity monitoring Jn children and adolescents How many nights are necessary fo reliable moasures? Seep 2255, 1999 2, Akmnann PA, Waltonen SJ, Olson KA, et al: Plaebo-controlled evaluation of ritalin side effects. 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Arch Podaie Adolesc Ned 148457, 154 163, Zamis G, Pres J Tal Ayo aloe feagmentation in caren with verte thea toid artis} Rheumatol 254191 1998 et, Zuccon! 4, Stambi LE Pestlorsa G, et al Habitual snoring and obstructive sleep pen syndrome in children: Elects of early tonal surgery In} Pedate Oorhinola yoo! 26255, 1953, 16, Zaley | Dipbution of REM sep in entrained 24 hour and free unsing sleep-wake ‘jean Seep 2377, 180 Ms, lin Hypn 17270, Aires reprint requests to Jodi A. Mindol, PRD ‘Department of Paychology ‘St Joesph’ University "5400 City Avene Philadelphia, PA 19131,