5 - SLEEP DISORDERS
Insomnia is defined
as difficulty falling asleep, difficulty staying asleep, or
short sleep duration, despite having an adequate opportunity
for sleep. It is the most common sleep complaint, affecting
approximately 30-40% of the adult population. Even when more
stringent criteria are required, such as daytime impairment
or marked distress, insomnia disorders have a prevalence of
approximately 10%. Evidence suggests that insomnia has significant
consequences on quality of life, healthcare utilization, and
subsequent psychiatric disorders. Efficacious short-term behavioral
and pharmacologic treatments for insomnia are available, and
progress has been made in epidemiology and risk factor identification,
in identification of adverse outcomes, and in identifying effective
However, there is
still much we do not know regarding the causes, characterization,
consequences, and optimal management of insomnia disorders.
For instance, we do not have a consistent phenotype(s) for insomnia
disorders that could be applied to human and animal studies.
Despite major advances in the neurobiology of sleep and circadian
rhythms (Section I), the implications of these findings for
insomnia have not been carefully investigated. Instead, the
pathophysiology of insomnia has been examined from a number
of clinically derived theoretical frameworks, with little replication
of the findings reported in individual studies. Effective treatments
for Insomnia have been developed, but important issues still
remain. For instance, the exportability of behavioral treatments
to usual care settings and the effectiveness (as opposed to
efficacy) of insomnia treatments have yet to be determined.
Finally, there is a need to develop novel pharmacologic treatments
based on new findings in sleep neurobiology.
In The Last Five Years
- The efficacy and
durability of standardized behavioral treatments for insomnia
have been demonstrated in a number of well-controlled clinical
- The epidemiology
of insomnia in adults has been well described. Consistent risk
factors, such as psychological symptoms, medical illness, and
female sex, have been identified.
- Independent studies
have demonstrated that insomnia is a risk factor for subsequent
development of psychiatric disorders, and for worse outcomes
among individuals with concurrent psychiatric disorders.
- A small but growing
body of evidence has demonstrated "hyperarousal" among
patients with insomnia, including increased central nervous
system activation (indexed by increased high-frequency EEG activity),
sympathetic nervous system activation, and hypothalamic-pituitary-adrenal
- Basic and pre-clinical
studies are needed that focus on the neurobiology of insomnia.
These should include (1) the development of animal models of
insomnia with specific insomnia phenotypes, (2) the application
of neurophysiological, neurochemical, neuroanatomic, and functional
neuroimaging approaches to human studies, and (3) genetic, genomic,
and proteomic studies.
treatment studies are needed to define the efficacy, safety,
abuse liability and role of long-term hypnotic treatment. Priority
should be given to studies defining the optimal duration and
pattern of administration of traditional hypnotic medications,
including investigations of their use in populations with high
rates of utilization such as with psychiatric disorders. Studies
are also needed on widely used but poorly-documented treatments,
such as sedating antidepressants, and on the development and
testing of novel pharmacologic agents based on neuroscience
findings (e.g., drugs affecting corticotropin release, adenosine,
or hypocretin systems).
- Insomnia phenotypes
need to be characterized. This includes (1) development and
validation of clinical phenotypes (e.g., define diagnostic criteria),
(2) physiological characterization and biomarkers (which may
include measures of EEG, HPA axis, sympathetic nervous system,
and functional neuroanatomy using neuroimaging techniques),
and (3) indices of discriminant validity versus mood and anxiety
disorders. Definition of insomnia phenotypes should also address
subjective-objective discrepancies in sleep measures, as well
as the relationship between insomnia and co-existing sleep,
psychiatric, and physical disorders.
- Further studies
of behavioral/ psychological treatments are needed. These studies
should include (1) the use of behavioral/ psychological treatments
in routine care settings (e.g., primary care offices), (2) the
development of alternative delivery methods (e.g., simplified
treatment regimens, computer or Internet administration), (3)
studies in patients with medical or psychiatric comorbidity,
and (4) large-scale effectiveness studies. Priority should also
be placed on investigating the specific efficacious components
of these behavioral treatments.
- More precisely
define the potential physical health risks, morbidity, and functional
consequences of insomnia, distinct from the morbidity and consequences
of associated medical and psychiatric conditions.
- Examine the extent
of use, efficacy, and adverse effects associated with alternative
treatment approaches, including nutritional supplements, herbal
remedies, and non-pharmacological treatments.
Difficulties in initiating
and maintaining sleep are extremely common in children. The
overall prevalence of sleep onset delay/bedtime resistance has
been reported to be in the range of 15 - 25% in healthy school-aged
children and even higher in adolescents. However, because behaviorally-based
sleep problems in children are often defined by caregivers,
the range of sleep behaviors that may be considered "normal"
or "pathologic" is wide and the definitions highly
variable. In addition, population-based normative data on sleep
patterns across childhood are lacking, creating further challenges
in defining "abnormal" sleep in infants, children,
and adolescents. Thus, a common nosology for defining sleep
disorders in children needs to be developed and evaluated.
Insomnia in Special
in pediatric special needs populations are extremely common,
and often a source of considerable stress for families. Prevalence
of sleep problems in children with severe mental retardation
has been estimated to be as high as 80%, and to be 50% in children
with less severe cognitive impairment. The prevalence of sleep
problems in autism is estimated to be 50 to 70%.
with initiation and maintenance of sleep, shortened sleep duration,
irregular sleeping patterns, and early morning waking have been
reported in many neurodevelopmental disorders, including autism
and pervasive developmental disorder, Asperger's syndrome, Smith-Magenis
syndrome, Angelman's syndrome, tuberous sclerosis, San Filippo
syndrome, Rett syndrome, and William syndrome. Other studies
have suggested that similar rates of sleep problems also occur
in both younger and older blind children, the most common concerns
being difficulty falling asleep, night wakings, and restless
The types of sleep
disorders in these children are not unique to this population,
but are more frequent and more severe than in the general population,
and often reflect the child's developmental level rather than
chronological age. Multiple sleep disorders are also likely
to occur simultaneously. The incremental impact of disrupted
and/or inadequate sleep on cognitive, emotional, and social
development and behavior in these already at-risk children is
Little is understood
about the interaction between sleep disorders and acute and
chronic health conditions such as asthma, diabetes, and juvenile
rheumatoid arthritis on either a pathophysiologic or behavioral
level. In chronic pain conditions, these interactions are likely
to significantly impact morbidity and quality of life.
In The Last 5 Years
- In addition to
risk factors such as social and communication developmental
abnormalities and cognitive impairment, a primary arousal dysfunction
in children with neurodevelopmental disorders may contribute
to sleep problems.
- There may also
be a primary disturbance of melatonin production and synchronization
in autistic children, and some autistic children seem to respond
to treatment with exogenous melatonin. Studies have documented
improvements in sleep onset delay, night wakings, early morning
waking and total hours of sleep using a small dose (0.3-0.5
to 2.5-5 mg) of melatonin approximately one hour before desired
bedtime in up to 80% of children with disorders such as cortical
blindness, Rett syndrome, autism, tuberous sclerosis, and Asperger's
syndrome. However, melatonin is not effective in all developmentally
delayed children with sleep problems and little is known overall
about long-term side effects.
- A few studies have
examined the role of sleep disturbances in chronic medical conditions
of childhood such as sickle cell disease and asthma, disorders
particularly common in high risk and minority populations. The
interaction between sleep and physical and emotional dysfunction
in acute and chronic pain conditions such as burns and juvenile
rheumatoid arthritis has also begun to be explored. Additional
factors such as the impact of hospitalization, family dynamics,
underlying disease processes, and concurrent medications are
also important in assessing the bi-directional relationship
of insomnia and chronic illness in children.
- Clinical psychology
and pediatric studies have examined the efficacy of empirical
behavioral treatment for sleep problems in small samples. Most
of these studies have relied on parental assessment of treatment
success. Additional outcomes research to systematically assess
efficacy of various treatment modalities for sleep disorders,
including behavioral management protocols, is needed to generate
recommendations for "best practices."
- Pharmacologic intervention
in conjunction with behavioral techniques has been shown to
be effective in some cases. However, little is known overall
about the safety and efficacy of pharmacologic interventions
for sleep disturbances in children, alone or in combination
with behavioral therapy. Medications used to treat insomnia
in children include diphenhydramine, chloral hydrate, trazadone,
clonidine, and benzodiazepines. Hypnotic medications, however,
can result in unpredictable side effects, development of tolerance
necessitating increasingly higher doses, paradoxical effects
(agitation instead of sedation), and withdrawal effects. Rebound
sleep onset delay on discontinuation and morning "hangover"
can be significant problems as well. Little is known about the
scope and patterns of use of pharmacologic interventions in
pediatric sleep disorders, about possible indications, and about
potential target populations for short-term use of hypnotics
in conjunction with behavioral interventions.
- Develop a common
definition and document the prevalence and functional impact
of pediatric insomnia across the age spectrum in the general
population, and in high-risk populations such as special needs
children (e.g., neurodevelopmental disorders, sensory deficits)
and children with chronic medical conditions (e.g., diabetes,
asthma). Normative data will need to be collected regarding
sleep practices and patterns in order to define "abnormal"
sleep. Studies will need to examine the developmental aspects
of insomnia in children, including the role of early sleep patterns
and behaviors, parenting practices, temperament, and genetics,
and risks and protective factors for the persistence of insomnia
into adolescence and adulthood.
- Develop and evaluate
optimal evidence-based treatment strategies and management protocols
for pediatric insomnia:
> In otherwise
healthy children, using standardized measures for such outcome
variables as sleep quality and quantity, sleepiness/alertness,
mood, behavior, academic functioning and parental stress.
> In children
with special needs, including evidence-based behavioral and
pharmacologic treatments for insomnia and circadian rhythm disturbances,
and including outcome measures such as neurocognitive performance
measures and assessment of impact on quality of life for children
- Examine the interrelationships
between insomnia and chronic medical conditions in children,
including effects on disease processes, pain management, quality
of life and caregiver well being.