"Ah, To Sleep… Perchance To Dream" Sleep Disorders Throughout ...
To Sleep Perchance To Dream The Diagnosis and Treatment of Children and Adolescents with Sleep Disorders Jess P. Shatkin, MD, MPH Vice Chair for Education NYU Child Study New York University School of Medicine Outline of Presentation Review of Normal Sleep Physiology Neurocognitive Effects of Sleep Disruption
Common Sleep Disorders Insomnia Sleep Disordered Breathing Non-REM Parasomnias Enuresis Sleep in Children with Common Psychiatric Conditions
Polysomnogram (PSG) Electroencephalogram (EEG) Electromyogram (EMG) Electrooculogram (EOG) Vital Signs Other Physiologic Parameters Other Methods to Study Sleep Ambulatory Techniques Edentrace System (monitors pulse, body position, oronasal flow, chest impedance, breathing noises, and pulse oximetry) Actigraphy (commonly used, developed in the early 1970s
and has come into increasing use in both research studies and clinical practice; allows for the study of sleep-wake patterns and circadian rhythms via the assessment of body movements. The device is typically worn on the wrist and can easily be adapted for home use. Reliable and valid for the study of sleep in normal, healthy populations but less reliable for detecting disturbed sleep) Survey Instruments Many exist for detecting problematic sleep in children and adolescents, including self-report questionnaires (such as the Sleep Disturbance Scale for Children, the Child Sleep Questionnaire, and the Child and Family Sleep History Questionnaire), sleep diaries, and parent report forms.
Stage 2 12-14 Hz, Sleep Spindles and K-Complexes Stage 3/4 0.5-2 Hz, Delta Waves, High Voltage, Slow Waves REM Low Voltage, Random, Fast with Sawtooth Waves Important Concepts and Terms Sleep Latency
REM Latency REM Density REM Rebound Sleep Onset REM Period Non-REM Physiological Changes Reduced physiological activity Autonomic slowing Maintain thermoregulation Episodic, involuntary movements Few rapid-eye movements Few penile erections (little vaginal lubrication) Reduced blood flow
REM Physiological Changes Increased physiological activity Autonomic activation Altered thermoregulation Partial or full penile erections (significant vaginal lubrication) Skeletal muscle paralysis Rapid-eye movements The Sleep Cycle Cyclic nature of sleep is reliable REM periods every 90 120 minutes First REM period is shortest
Most deep sleep (Stage 3 & 4) occurs early Most REM occurs late Normal Sleep Cycle in Children Awake REM Stage 1 Stage 2 Stage 3 Stage 4 1 2
3 4 Hours of Sleep 5 6 7 Normal Sleep Cycle in Young
Hours of Sleep 5 6 7 Normal Sleep Cycle in the Elderly Awake REM Stage 1 Stage 2
Stage 3 Stage 4 1 2 3 4 Hours of Sleep 5
6 7 Sleep Regulation No clear, single center Serotonin & Catecholamines (EPI, NOREPI, DA) REM off cells GABA Acetylcholine REM on cells
Suprachiasmatic nucleus 25 hour cycle? Orexin/hypocretin Pineal gland (melatonin) Neuroendocrine Activity in Sleep Growth Hormone Prolactin Luteinizing Hormone Cortisol Thyroid Stimulating Hormone (TSH) Function of Sleep Restorative/homeostatic
Thermoregulation/energy conservation Consolidation of learning and memory Programming of species-specific behaviors to sleep, perchance to dream, ay theres the rub William Shakespeare (Hamlet) Dreams Sleep hath its own world, A boundary between the things misnamed Death and existence: Sleep hath its own world, And a wide realm of wild reality,
And dreams in their development have breath, And tears and tortures, and the touch of joy. Dreams REM dreams Non-REM dreams Motor paralysis Rapid-eye movements Dream content Predominantly sad/angry/apprehensive Primarily visual
Neurocognitive Effects of Sleep Disruption: Attention and Memory Limited data in children; most info based upon the effects of sleep disordered breathing (SDB) on daytime performance Sleep restriction in experimental settings results in inattention and changes in cortical EEG responses (even after only 1 hour restriction) Data are inconsistent on the effects of sleep disruption on memory performance Children suffering from Obstructive Sleep Apnea (OSA), Periodic Limb Movement Disorder (PLMD),
and Restless Leg Syndrome (RLS) with resulting sleep fragmentation have been shown to suffer academic deficits, learning problems, and symptoms that mirror ADHD In the case of OSA, symptoms are generally reversible after treatment Neurocognitive Effects of Sleep Disruption: Psychometric Testing Sleep restriction and total sleep deprivation have been shown to reduce computational speed, impair verbal fluency, & decrease creativity and abstract problem solving ability
Severe sleep fragmentation (e.g., as seen in OSA) may result in reduced intelligence scale scores (IQ) Neurocognitive Effects of Sleep Disruption: Academic Achievement Children with OSA suffer lower academic achievement (even when age, race, gender, SES, and school attended are controlled for) Treatment of OSA results in significant improvement in school performance Children who snore loudly and consistently in early years are at greater
risk for academic delays in later years, suggesting residual effects on learning even after resolution of symptoms Animal models show increased neuron cell loss in the hippocampus and PFC in rats exposed to intermittent hypoxia; along with decreases in special task acquisition and retention and increased locomotor activity compared to controls Sleep Disorders in Children ~25% of children will suffer some type of sleep problem at some point during childhood Complaints range from bedtime resistance and anxiety to primary sleep disorders, such
as OSA and narcolepsy Research is remarkably consistent, with parents reporting 50% of preschool children, 30% of school aged children, and 40% of adolescents as having sleep difficulties Self-report among adolescents reveals 14 33% complaining of frequent or extended nighttime awakenings, EDS, unrefreshing sleep, early insomnia, and a subjective need for more sleep Sudden Infant Death Syndrome A worldwide decline in the past decade
Incidence at roughly 0.77 per 1000 live births in Great Britain; incidence in the United States has dropped by more than 50% from 1.53 per 1000 live births in 1980 to 0.56 per 1000 live births in 2001 Still, SIDS accounted for 8% of all infant deaths in the United States in 2002 and ranks as the third leading cause of infant death in the United States The most widely accepted definitions of SIDS require that all other known possible causes of death be ruled-out by death scene investigation, review of the clinical history, and autopsy prior to accepting SIDS as the diagnosis (e.g., intentional or nonintentional injury, suffocation, etc). Efforts aimed at reducing modifiable risk factors for infants, such as sleeping in a prone position, over-bundling, and secondary smoke exposure, have reduced the incidence of SIDS by more than 60% in
most parts of the world. Other strategies, such as sleeping solitary in a supine position, not allowing infants to sleep on their sides, and using a pacifier, may ultimately reduce the incidence still further. In the United States, the SIDS rate for African and Native American infants remains more than twice that of Caucasian infants, reflecting a long-standing racial disparity. DSM IV Sleep Disorders: Dyssomnias Primary Insomnia Primary Hypersomnia Narcolepsy Breathing Related Sleep Disorder
Circadian Rhythm Sleep Disorder Dyssomnia NOS Primary Insomnia in the General Population Early and middle insomnia PSG studies are negative Sub-clinical symptoms of psychiatric illness often present More common w/increasing age and in women Prevalence: 1 10% in general population; up to 25% in elderly
Generally sudden onset w/continuation due to negative conditioning and development of maladaptive sleep patterns Pediatric Insomnia No clear definition has existed until this year: Repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite ageappropriate time and opportunity for sleep and results in daytime functional impairment for the child and/or family. International Classification of Sleep Disorders-2
Pediatric Insomnia (2) Prevalence estimated at 1 6 % in general pediatric population but considerably higher amongst those children with neurodevelop-mental delay and chronic med/psych conditions A recent study of 46 children (5-16 y/o) found that 50% of the those presenting to a pediatric sleep center for insomnia had a preexisting psych diagnosis and the remaining 50% had elevated psych impairment scores on psychometric measures & diagnostic interview (Ivanenko et al, 2004)
Behavioral Insomnia A recently introduced diagnostic category to emphasize the sleep difficulties resulting from inadequate limit setting or sleep associations: Rocking Watching TV Falling asleep every night in the parents bed The child is unable to fall asleep in the absence of these conditions at both bedtime and following nocturnal awakenings
Case #1: Insomnia James is a 15 year-old male with a childhood history of moderate separation anxiety for which he never received treatment. He has a history of mild/moderate sleep disruption (primarily early and occasional middle insomnia), but over the past 6 weeks he has suffered increasing insomnia concurrent with an increase in school stressors. He presents to you with complaints of a two hour sleep onset latency 4x/week and nightly nocturnal awakenings with difficulty falling back to sleep. How do you proceed?
Treatment of Insomnia: Sleep Hygiene Identify the cause or other Axis I disorder (if possible) and treat Set a sleep/wake schedule Exercise daily but not at night Avoid caffeine, cigarettes, alcohol, and drugs Invent a relaxing bedtime ritual (e.g., bathing, reading, watching TV, etc.) Use the bed for sleeping or sex, nothing else Wake up to the sun, exposing yourself to morning sunshine Adjust the room temperature as desired
Treatment of Insomnia (2): Medication No FDA approved treatments Sedatives are short-term solutions A shorter half-life is typically preferred Sedating antihistamines (diphenhydramine, hydroxyzine, cyproheptadine) Alpha-2 agonists (clonidine, guanfacine) Sedating antidepressants (Trazodone, Serzone, Remeron, TCAs,) Benzodiazepines and similar agents (Sonata, Ambien, Lunesta, Rozarem) preferred over barbiturates
Tolerance to somnolent effects of Benzos develops in about 4 weeks (not anxiolytic effects) HM/DS: Melatonin, Kava, Valerian, L-tryptophan, chamomile, passion flower, lavender, etc Sleep Disordered Breathing (SDB) Primary Snoring regular snoring without changes in sleep architecture, alveolar ventilation, or oxygenation Upper Airway Resistance Syndrome Similar to OSA but UARS does not result
Poor academic performance Irritability Poor executive function Inattention/general cognitive impairment SDB Evaluation and Treatment Labs show: A reduction in airflow and Hgb saturation Increased total Hgb Cardiac arrhythmias (sinus arrhythmias, PVCs, AV block, sinus arrest) Stage 1 >> 3,4 & REM Physical Examination shows:
Adenotonsillar enlargement Pectus excavatum & rib flaring More commonly in adults: obesity, >17 neck size, HTN, cor pulmonale Treatment of Sleep Apnea Weight loss Sleep on sides (and stomach) CPAP (Continuous Positive Airway Pressure) prevents obstruction by soft-tissue and keeps airway open Surgical intervention (e.g., enlarged tonsils, deviated septum) Avoid sedatives (which can prevent
reawakening to breathe) DSM IV Sleep Disorders: Non-REM Parasomnias Somnambulism Sleep/Night Terrors Somniloquy Enuresis Sleep Related Involuntary Movement Disorders PLMD Body Rocking Bruxism
Enuresis: Epidemiology & Diagnosis Occurs in approximately 30% of 4 y/o, 10% of 6 y/o, 5% of 10 y/o, 3% of 12 y/o, and 1% of those 15 y/o and over Although not satisfying DSM-IV criteria for diagnosis, 10 20% of 5 y/o continue to have a least one episode of nocturnal enuresis/month DSM-IV requires: Frequency at least 2x/week for at least 3 months age at least 5 years
Associated Features Nocturnal enuresis is associated with poor self-image, diminished achievement in school, and an increase in the time spent by families compensating, both financially and personally, for the symptoms. Risk factors (twice as common in boys>girls, family history, lower SES, black race) Case #2: Enuresis Ryan is a 10 y/o male with a history of mild MR, ADHD (CT), and severe ODD with a rule-out of
Bipolar D/O NOS. He also suffers nightly enuresis. Current medications include Concerta 54 mg qAM and Risperdal 0.25 mg BID. His parents have tried numerous behavioral interventions with no success. Ryan has previously been treated with desmopressin acetate to 4 mg hs and imipramine to 50 mg hs. What questions do you have? How would you proceed? Enuresis: Treatment (1) Full history (e.g., nature of behavioral treatments tried, how medications were
used) Psycho-education for family and patient Discontinue all caffeine and EtOH Restrict late night fluid intake Afternoon nap (to decrease Stage III/IV) Brief awakening for toileting at midnight Enuresis: Treatment (2) Behavioral Treatments: Bedwetting alarm (highest cure rate, lowest relapse rate) Bladder training to increase capacity Reward systems Cognitive & motivational therapy
Combination treatment DDAVP + oxybutinin or DDAVP + TCA Atomoxetine (Strattera) Non-REM Sleep Disorders and Unconscious Actions Doctor: You see, her eyes are open. Lady-in-Waiting: Ay, but their sense are shut. William Shakespeare (The Tragedy of MacBeth)
Non-REM Sleep Parasomnias: Shared Features 1 30 minutes Retrograde amnesia Family/personal history High potential for injury to self and others Occur during slow-wave sleep More common in childhood Attempts to awaken are fruitless Psychopathology rare in children Non-REM Sleep Parasomnias:
Complete amnesia Gender preference Males typically in childhood Females possibly more common in adulthood Sleepwalking Common occurrence Prevalence 6-17% in children; lifetime incidence 40% Prevalence 2.5% in adults Generally docile Often coupled with enuresis
No consistent gender differences Complete amnesia May engage in complex behaviors Confusional Arousal Epidemiology unclear 4% incidence in Stockholm study No gender differences noted Hallmarks include irrational acts, poor judgment, incoherence, and disorientation Autonomic arousal Complete amnesia
Premeditated acts believed impossible Case #3: Non-REM Parasomnia vs. Suicide Attempt Tracy is a well adjusted 12 y/o girl from an intact and loving family with no psychiatric history. One summers evening, an hour after going to bed, she was awoken with a severe sore throat. She stumbled to the mirror to find her throat cut wide open to her trachea with two 5 horizontal lacerations extending the breadth of her neck. A bloodied box cutter was found at her bedside; she had no memory of the event.
How would you make a diagnosis? How would you treat this case? Treatment of Non-REM Parasomnias: Psychosocial Interventions Repeat of a violent episode is rare Family/patient education Avoid possible precipitants Avoid sleep disruptions Loud noises, limit evening oral fluid intake
Safeguard the home Movement sensors, locks on windows, remove potentially lethal objects, etc. Enforce afternoon naps with Sleep Terrors Treatment of Non-REM Parasomnias: Medication Benzodiazepines with long half-lives Clonazepam, Diazepam Tricyclic antidepressants
SSRIs and Trazodone Barbiturates possible use in REM sleep disorders DSM IV Sleep Disorders: REM Parasomnias REM Sleep Behavior Disorder Sleep Paralysis Nightmare Disorder Sleep in Children with Common Psychiatric Conditions ADHD
Pervasive Developmental Delays Mood Disorders Anxiety Disorders ADHD: Epidemiology All variety of sleep disorders are more common amongst children with ADHD than healthy controls, controls with other psych illness, and health siblings by 5x The DSM-III considered excessive movements during sleep to be a criterion for hyperactivity in children It is estimated that up to 25% of children with severe sleep problems in infancy
will later qualify for a diagnosis of ADHD ADHD: Clinical Presentation Greater variation in sleep onset time, wake time, and sleep duration Significantly more bedtime struggles with parents Habitual snoring is 3x more common in children with ADHD Greater frequency of PLMD and SDB have also been frequently reported ADHD: Treatment Recommendations
Enforce sleep hygiene Lower the dose or change the stimulant Change to a shorter acting preparation Add a low dose of stimulant (if insomnia appears due to hyperactive rebound) Change to an entirely novel agent (e.g., atomoxetine) Use adjunctive agents: antihistamines, clonidine, sedating antidepressants, & melatonin PDD: Epidemiology 44 88% of children with frank autism
are reported to suffer sleep difficulties as are 44 86% of children with Autism Spectrum Disorders Younger children and those with more severe cognitive delay/disability tend to demonstrate increased problems Sleep problems are often long-standing; a recent study of adults with Aspergers demonstrated that 90% complain of frequent insomnia PDD: Clinical Presentation Most frequently reported problems are difficulty falling asleep, frequent
awakenings with difficulty returning to sleep, early morning awakening, irregular sleep/wake patterns, shortened duration of sleep, dyssomnias & parasomnias Etiology may have to do with failure to recognize environmental and social cues, poorly developed circadian rhythms (b/c of social deficits), altered melatonin production, and abnormalities in the HPA axis PDD: Treatment Sleep hygiene & behavioral treatments Chronotherapy +/- light therapy for those
with circadian rhythm problems or phase shifting Unstudied medications: antihistamines, sedating antidepressants, alpha-2 agonists, benzodiazepines, antipsychotics Melatonin Sedative Synchronizing sleep to environment Mood Disorders: Epidemiology 2/3 of depressed children have early & middle insomnia and 50% report late insomnia Up to 88% of depressed adolescents report
sleep disturbances (primarily insomnia) with up to 25% of these reporting hypersomnia Approximately 10% experience continual insomnia after the depression has lifted One study of bipolar children found 40% had a dramatically reduced need for sleep (vs. controls and those with ADHD) Mood Disorders: Clinical Presentation Children may demonstrate bedtime resistance, bedtime anxiety, early &
middle insomnia, desire to co-sleep, enuresis, nightmares, sleep-walking, early morning awakening, and EDS Adolescents report difficulties with early and middle insomnia (w/extended awakenings), EDS, unrefreshing sleep, and up to 50% report early morning awakening Sleep difficulties in adolescents appear to be chronic and affect girls more than boys Mood Disorders: Clinical Presentation (2) Adolescents who report sleep problems
are much more likely to report symptoms of depression, anxiety, poor self-esteem, lethargy, irritability, and emotional lability Adolescents who report sleep problems are also much more likely to consume caffeine, nicotine, and alcohol Thus, sleep problems should be viewed as a potentially easy marker for adolescents at risk of developing some sort of psychopathology Sleep in Adults with Depression Reduced REM latency Increased percentage of REM
REM distribution shifts to earlier in sleep cycle Reduction in REM sleep useful in treatment REM is preferentially selected in sleep deprived and/or depressed state Mood Disorders: Treatment Identify and treat the primary Axis I disorder Sleep hygiene and medications as indicated No clear data on whether or not to treat the symptom of insomnia
independent from the mood disorder Borrowing from adult studies, this may make sense for pediatric bipolar disorder Anxiety Disorders: Epidemiology Anxiety and sleep are intimately tied in childhood Sleep problems by age 4 are correlated with later onset depression and anxiety by 15 Nighttime fears are common (up to 75% report) Sleep problems typically follow for those children with DSM-IV anxiety disorders
(PTSD, OCD, school refusal, etc.) Anxiety Disorders: Clinical Presentation Nighttime fears commonly take the form of animals, fictitious characters (e.g., witches & monsters), being kidnapped, or being teased by peers Anxiety is believed to predispose children to parasomnias and nightmares Occasional nightmares occur in 80% of children 15% report frequent nightmares (>1/month)
69% of children report that the content of their nightmares is influenced by frightening material viewed on TV or at the movies Anxiety Disorders: Treatment Identify and treat the primary Axis I disorder Sleep hygiene and medications as indicated No clear data on whether or not to treat the symptom of insomnia independent from the anxiety disorder
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