The literature on child and adolescent sleep disturbance increasingly recognizes the impact of psychological and social factors on sleep profiles in this, and other, age groups (Hsieh et al, 2019; Wang et al., 2016). We have recently seen and experienced this in very tangible ways because of the significant psychological, social, and economic impacts that have arisen in consequence of the Covid-19 pandemic. Changes in sleep profiles have been a component of the response for many, both because of the increased stress overall, but, additionally, the dramatic shifts in our daily routines, activities and schedules consequent to the stay at home guidance appear to be significant factors in altering sleep profiles as well.
Beyond these acute (albeit seismic) stressors, we are also increasingly aware of the broad negative impact that adverse childhood experiences and other chronic psychosocial stressors (e.g., poverty, racism, health disparities, lack of community safety, food insecurity, etc.) have on the physical and emotional development of children and adolescents. These more chronic factors increase the risk of youth experiencing sleep disruptions and increase the risk of developing more pervasive dyssomnias, often in association with co-occurring behavioral health problems.
With these considerations in mind, potential contributing factors to sleep disturbance must be carefully assessed in their own right, as well as, in the context of other suspected behavioral health and medical problems. Medical causes of sleep problems can include medication side effects (ADHD medications, in particular), GERD, asthma, congenital heart disease and other conditions. In the mental health arena, it is critical to screen for trauma (PEARLS screener), depression (PHQ-9), anxiety (GAD 7) and other psychological factors, such as maladjustment and/or resiliency. Guidance on sleep hygiene should take these factors into account. Whenever feasible, providers should explore the patient’s and the family’s perspective on any environmental factors, with empathy and sensitivity. While these issues may or may not be amendable to intervention within the primary care setting, acknowledging the reality that societal and environmental factors may be at work in causing sleep (and other) difficulties and can be of help in guiding families on managing risks and understanding the potential benefits of various interventions.
For all patients experiencing sleep difficulties, guidance as to standard sleep hygiene practices should be provided. When indicated, encouraging linkage to relevant supports and services in the community can have significant benefit in improving both sleep and overall functionality.
Medications:
Medications in general, should be considered second line. Melatonin has been fairly well studied and found to be effective at doses of 1 – 5 mg in children and adolescents. More studies are needed for the evaluation of safety and efficacy long-term use (Zwart et al., 2018). In general, it is reasonable to consider discontinuation of pharmacological agents at a regular interval.
There appears to be role for psychopharmacology to treat underlying anxiety (SSRIs), depression (SSRIs), as well as active trauma symptoms, all syndromes that may be associated with sleep problems that should be considered in the ongoing management of affected patients. For adolescents experiencing trauma associated nightmares, prazosin 1 – 4 mg, has shown to decrease nightmares and improve sleep. Trazodone and Mirtazapine have shown some anecdotal benefit at low to moderated dosing, but there is not strong evidence in the literature.
The role of benzodiazepine and Z-class medications, should be considered second-line, and are discouraged as long term options because of dependency and potential abuse considerations with adolescents and, because of potential disinhibition responses in children, . They may, nonetheless, be helpful for very brief periods of time, particularly in the face of acute stressors.
Akinsanya, A., Marwaha, R., & Tampi, R. R. (2017). Prazosin in Children and Adolescents with Posttraumatic Stress Disorder Who Have Nightmares: A Systematic Review. Journal of Clinical Psychopharmacology, 37(1), 84–88. https://doi.org/10.1097/JCP.0000000000000638
Hsieh, Y. P., Lu, W. H., & Yen, C. F. (2019). Psychosocial Determinants of Insomnia in Adolescents: Roles of Mental Health, Behavioral Health, and Social Environment. Frontiers in Neuroscience, 13(August), 1–9. https://doi.org/10.3389/fnins.2019.00848
Janjua, I., & Goldman, R. D. (2016). Sleep-related melatonin use in healthy children. Canadian Family Physician Medecin de Famille Canadien, 62(4), 315–317. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27076541%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4830653
Wang, Y., Raffeld, M. R., Slopen, N., Hale, L., & Dunn, E. C. (2016). Childhood adversity and insomnia in adolescence. Sleep Medicine, 21, 12–18. https://doi.org/10.1016/j.sleep.2016.01.011
Zwart, T., Smits, M., Egberts, T., Rademaker, C., & van Geijlswijk, I. (2018). Long-Term Melatonin Therapy for Adolescents and Young Adults with Chronic Sleep Onset Insomnia and Late Melatonin Onset: Evaluation of Sleep Quality, Chronotype, and Lifestyle Factors Compared to Age-Related Randomly Selected Population Cohorts. Healthcare, 6(1), 23. https://doi.org/10.3390/healthcare6010023