Need for better understanding of appropriate treatment choices for children with insomnia: Study

A new survey of child psychiatrists indicates that insomnia is a major problem among children in mental health treatment and at least a quarter of these patients are given sleep medication. The results of the survey, conducted by Judith Owens, MD, a sleep expert with Hasbro Children's Hospital, and colleagues, suggests that management of insomnia in this population is a common practice, although the clinical approach varies widely. The study is published in the August 2010 edition of Sleep Medicine.

Nearly 1,300 members of the American Academy of Child and Adolescent Psychiatry completed a survey to examine the clinical practice patterns regarding non-prescription and prescription medication for insomnia by child and adolescent psychiatrists. Based on their responses, Owens and her fellow researchers determined insomnia is a significant clinical issue among nearly one-third of the psychiatrists' school-aged and adolescent patients.

To address the issue, an overwhelming 96 percent of the clinicians recommended at least one prescription medication in a typical month and 88 percent recommended an over-the-counter medication. The sleep medications prescribed ranged from antihistamines to sedating medications for Attention Deficit-Hyperactivity Disorder (ADHD), such as alpha agonists (clonidine), to antidepressants like trazodone. They also included medications from a number of other categories, such as antipsychotics and anticonvulsants, depending on the psychiatric or behavioral diagnosis of the child.

Owens, who is also an associate professor at The Warren Alpert Medical School of Brown University comments, "The most important rationale for the use of sleep medication among child psychiatrists is to manage the effects of sleep disruption on daytime functioning. It is important to note, however, that concerns about side effects and the lack of evidence regarding their effectiveness were cited as significant barriers to their use." Owens adds, "Despite the high frequency of use and the wide range of medications chosen, practitioners also expressed a number of significant concerns about the appropriateness of sleep medication in general for children."

The respondents to the survey indicated that over 75 percent of the patients in their practices were children or adolescents and they saw an average of 70 children per month, the majority of whom were age 6 or older. The percentage of patients who were identified with insomnia was substantial and also increased with age. Overall, the results suggest that among children receiving psychiatric care, more than 20 percent of preschoolers and almost one-third of school-aged children and adolescents are affected by insomnia.

The researchers report that past studies have found that behavioral treatments such as relaxation techniques, sleep restriction and cognitive behavioral therapy are effective for childhood insomnia, and multiple studies conducted in the United States and abroad indicate that sleep disturbances are one of the primary indications for psychotropic medication in children. This is true despite the fact that little data exists about the safety and effectiveness of pharmacotherapy for the treatment of insomnia and other sleep disturbances in children and adolescents. In addition, there are currently no medications specifically approved for use as hypnotics in children under the age of 18. Lead author Owens says, "Yet treatment of insomnia symptoms with both over-the-counter and prescription medication is a common clinical practice, particularly for children and adolescents with special needs and co-morbid psychiatric disorders."

The authors point out that virtually all psychiatric and neurodevelopmental disorders in children - including depression, ADHD and autism spectrum disorders - can be associated with delayed sleep onset and sleep disruption and, as a result, with significant daytime sleepiness and fatigue that may further exacerbate psychiatric symptoms. Because of that, Owens says, "That is why child psychiatrists may be potentially more likely than pediatricians to prescribe medication for insomnia. Furthermore, use of other psychotropic medications, which can have significant negative effects on sleep in this population, frequently complicates clinical management of sleep issues in child psychiatry patients"

Owens and her colleagues had previously surveyed a national sample of 670 community-based pediatricians regarding use of medications for insomnia; almost 75 percent of the practitioners recommended non-prescription medications and more than 50 percent had prescribed a sleep medication in the previous six months for children with insomnia. Most commonly, the clinicians reported recommending medication for children with insomnia who had mental retardation or developmental delays, ADHD, autism spectrum disorders and mood/anxiety disorders.

Based on their findings, the researchers recommend the development of clinical trials of sleep medications in children to determine relative efficacy, effective dosing ranges, and safety and tolerability issues. The researchers also note the measures should include the impact of the specific drug on mood and daytime functioning. Finally, they call for a systematic evaluation of the impact of psychotropic medications commonly used in children.

Owens concludes, "Mental health professionals responsible for the care of children should set as a goal the establishment of an evidence-based understanding of appropriate treatment choices for insomnia. In addition, we need a more comprehensive understanding of insomnia in the context of psychiatric disorders in general and the impact on quality of life and long-term prognosis in these patients."