Assistant Professor of Clinical Psychiatry and Behavioral Neuroscience
Julia N. Stimpfl, MD
PGY-1 Resident in General Psychiatry
Jeffrey R. Strawn, MD
Professor of Psychiatry, Pediatrics, and Clinical Pharmacology
• • • •
University of Cincinnati College of Medicine
Cincinnati, Ohio
Disclosures
Drs. Hamill Skoch and Stimpfl report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products. Dr. Strawn has received research support from AbbVie, Neuronetics, Lundbeck, Otsuka, PCORI, and the National Institutes of Health. He has provided consultation to Intra-Cellular Therapies and the FDA. He receives royalties from Springer Publishing and UpToDate and received material support from Myriad. He has also received honoraria from CMEology, Genomind, Neuroscience Education Institute, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry.
Behavioral interventions should be implemented before considering pharmacotherapy
Children and adolescents who do not receive sufficient sleep can experience worsening inattention, daytime fatigue, and cognitive and behavioral difficulties. Assessment and treatment of insomnia and other sleep difficulties in young patients is critical as poor sleep increases their risk for depression, self-harm, and suicide.
In Part 1 of this article (Pediatric insomnia: Assessment and diagnosis, Current Psychiatry, December 2021, p. 9-13,24-25), we described sleep architecture, sleep in healthy youth and in those with certain psychiatric disorders, and how to assess sleep in pediatric patients. In Part 2, we focus on psychotherapeutic and psychopharmacologic interventions for youth with insomnia, and describe an effective approach to consultation with pediatric behavioral sleep medicine specialists.
Psychotherapeutic interventions
Regardless of the source of a child’s insomnia or co-occurring disorders, healthy sleep practices are the first line behavioral treatment, including for youth with attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, obsessive-compulsive disorder, and depressive disorders.
Healthy sleep practices/sleep hygiene
Developmentally appropriate bedtimes and routines(Table). Helping children establish a regular, consistent bedtime is key in promoting healthy sleep. Ideally, the bedtime routine involves 3 to 4 activities each night in the same order, and these activities should be relaxing and soothing (eg, taking a bath, putting on pajamas, reading books). Setting age-appropriate bedtimes also is important. If an older child is asked to go to bed at 8 pm but cannot fall asleep for an hour, they may not have insomnia but instead a developmentally inappropriate bedtime. Several studies found that children younger than age 10 should go to bed no later than 9 pm. Bedtimes later than 9 pm for young children are correlated with shorter sleep duration.1
Consistent sleep schedules.Another important aspect of healthy sleep is working with parents to enforce a consistent bedtime and wake-up time, including weekdays and weekends. Ideally, bedtime on weekdays and weekends should not vary by more than 1 hour. Helping children wake up at the same time each day helps to set and regulate their circadian rhythm. Keeping these schedules consistent on vacations and school holidays also is helpful. For adolescents, the weekday/weekend bedtimes can vary by up to 2 hours because adolescents have a delayed circadian rhythm and wake-up times for high school can be early.
Environmental factors.An important piece of parental education is stimulus control and the ingredients of healthy sleep. Healthy sleep ingredients include a dark, quiet, consistent, and cool bedroom; a comfortable bed, the child feeling safe, and limited environmental stimuli.
Continue to: Cognitive-behavioral therapy for insomnia...
