Returning to Katie’s story, careful assessment revealed no evidence for active ADHD or binge eating, but instead, a significant predisposition to anxiety and high levels of intrafamilial hostility. In keeping with Katie’s own goals, we discussed ways to improve sleep and maintain school performance, while looking for opportunities to decrease family discord. Her methylphenidate ER was tapered to reduce early insomnia. The possibility of tolerance to diphenhydramine and its side effects, including increased appetite, led to a plan to taper this medication while titrating citalopram, one of the more soporific SSRIs, to reduce worry thoughts that might disrupt sleep onset. Education was provided about the circadian shift in adolescence that leads to later bedtimes and rising times with an ongoing need for about 8 hours of sleep nightly. Her behavior plan addressed increased daytime exercise, meditation as part of a pre-bedtime routine, and meeting with a nutritionist to regulate dietary variety and portion sizes without a focus on weight loss. Individual and family therapy were recommended, and Katie seemed to benefit from support and learning to talk back to her anxious automatic thoughts.The assessment and treatment of pediatric insomnia may require several visits to complete. But, given growing knowledge of how much sleep contributes to learning, longevity, and well-being, and the consequences of sleep deprivation with regard to safety, irritability, poor concentration, disordered metabolism and appetite, etc., the potential benefits seem well worth the time.
Dr. Rosenfeld is assistant professor of psychiatry at Vermont Center for Children, Youth & Families, at the University of Vermont Medical Center, and the University of Vermont, Burlington. He has received honorarium from Oakstone Publishing for contributing board review course content on human development.
