How increased awareness of behavioral sleep medicine could be a game-changer for children.
By Lindsey Nolen
Sleep is essential to healthy child development, yet one in five young children and preadolescents have symptoms of insomnia.1 Pediatric insomnia can result in difficulty falling asleep, bedtime resistance, and night wakings and has been linked to insomnia in adulthood, mental health disorders such as depression and anxiety, and alcohol use. Pediatric insomnia can easily impact the functioning of the whole family.
Prescription medication is commonly used to treat pediatric insomnia. Still, behavioral sleep medicine has shown great promise as a first line of treatment, and more people are becoming aware of this option.2 Unfortunately, few well-controlled studies examine behavioral interventions, and no formal nonpharmacological clinical management guidelines exist for pediatric insomnia.
Sleep professionals are now advocating for the use of behavioral sleep medicine and the development of treatment guidelines for pediatric insomnia patients.
Behavioral Sleep Medicine as First-line Treatment
Erin Leichman, PhD, NCSP, executive director of the Pediatric Sleep Council and a senior research psychologist at Saint Joseph’s University, says environmental modifications, improving sleep hygiene, and other behavioral changes—in addition to cognitive-behavioral approaches once a child is old enough to understand those methods—are some of the primary intervention strategies that can treat pediatric insomnia.
“These approaches can include changing routines, caregiver-child interactions for naps, bedtime, what’s around a child when they sleep, where a child sleeps, how they fall asleep, what the child and caregiver do at bedtime and during the night, and/or how families/children/teens think about sleep, among other things,” she says.
When employing behavioral treatment, Leichman says a clinical provider should be involved to help rule out (or treat as necessary) any specific medical or physiological problems that may be disrupting sleep.
In specific cases, certain developmental concerns could lead a physician to consider pharmacological approaches in conjunction with behavioral strategies. “These decisions are typically made on an individual basis and should be considered by a provider who specializes in pediatric sleep medicine when possible,” Leichman says.
There are currently no US Food and Drug Administration-approved medications for pediatric insomnia, says Lisa Medalie, PsyD, DBSM, founder of tech-enabled insomnia treatment company DrLullaby, and the data on the use of melatonin is mostly seen in special populations, such as children with autism or attention deficit hyperactivity disorder.
“Why not empower parents and children to learn research-backed, healthy habits rather than become dependent on an external substance that is not necessarily the first-line recommendation?” she asks.
There are, of course, reasons that contribute to this situation. According to Medalie, one such reason is insufficient access to behavioral sleep medicine due to so few providers with formal training. Additionally, parents often want a “quick fix.”
Recognizing these challenges, she launched DrLullaby as a way to address access-to-care by having board-certified clinicians train new providers. “We tried to offer services for pediatrics, but the referrals paled in comparison to adult patients referred. We believe this was because parents are so frequently turning to melatonin,” Medalie says.
Parent Perspective
Clinical psychologist Jason Ong, PhD, DBSM, director of behavioral sleep medicine at Nox Health and adjunct associate professor of neurology at Northwestern University Feinberg School of Medicine, says research has shown behavioral interventions have reliable and lasting benefits in reducing bedtime problems and nighttime awakenings, particularly in infants and young children.
Emerging evidence also suggests cognitive behavioral therapy for insomnia (CBT-I) can reduce insomnia symptoms in adolescents. But implementing behavioral strategies requires discipline and consistency on the part of the parent/caretaker, which can be difficult to sustain, Ong says.
Also, Ong says some parents discount their child’s sleep problem as a regular part of development without considering the long-term effects. For example, parents may feel a young child coming to their bed at night is “normal.” But if the parent allows it repeatedly, they inadvertently reinforce this behavior. This could then hinder the child’s ability to develop skills for self-soothing and perpetuate the sleep problem beyond what is age-appropriate, resulting in pediatric insomnia, Ong says.
Keshia M. Prince, PsyD, DBSM, a postdoctoral fellow completing behavioral sleep medicine training with Medalie, adds that pediatric insomnia can result in maladaptive sleep habits, which could elevate the risk for chronic sleep problems as an adult. Sleep loss from pediatric insomnia can contribute to developmental, academic, behavioral (such as irritability and acting out), executive functioning (such as concentration), and health problems (such as poor immune system functioning and obesity), along with childhood injuries (such as more falls).
“Pediatric insomnia typically manifests in problems with initiating sleep and problems remaining asleep in 20% to 30% of infants, toddlers, and preschoolers; in bedtime resistance in 15% of elementary-aged children; and 11% of adolescents struggle with insomnia,” Prince says. “Pediatric behavioral sleep medicine is still a fairly new field, so parents underreport insomnia as a ‘problem’ and more so expect sleep issues with their children, so many times the problem goes undiagnosed.”
Collaborating with Pediatricians
Although an increasing number of kids have trouble sleeping (especially since the pandemic), pediatricians are simply not always equipped to treat insomnia, says Jared Saletin, PhD, co-chair of the biennial Pediatric Sleep Medicine Conference sponsored by Brown University and assistant professor of psychiatry and human behavior at Brown University. Saletin says, “There’s a lot of psychological roots to insomnia, including anxiety and other changes with mental health stressors in one’s environment.”
Saletin does not treat patients himself, but his broad perspective on pediatric insomnia stems from his work in a behavioral health environment. This perspective is why he believes the sleep medicine subspecialty can improve pediatric insomnia identification by first ensuring that more sleep clinicians are trained in pediatric sleep medicine. Better communication between sleep medicine providers and primary care pediatricians is essential to achieving such improvement, he says.
In Medalie’s experience, pediatric sleep physicians can identify these patients but often do not have a place to refer them. Prince adds, “Sleep medicine can continue to team up with primary care, to focus on proactive solutions regarding early identification to prevent an issue from becoming chronic. Psychoeducation is so important in making the public aware of poor signs of sleep, as well as providing resources to assess and treat sleep-related problems. Behavioral sleep medicine is a newer field, so with time, more people will know there is more that can be done to prevent and treat insomnia effectively, without necessarily jumping to the use of melatonin.”
The Future of Pediatric Insomnia Treatment
While guidelines exist for adult insomnia,3 no clinical guidelines have been written for treating insomnia in children and adolescents. The Society of Behavioral Sleep Medicine (SBSM) is now sponsoring the first-ever guidelines for the behavioral treatment of insomnia in school-aged children and adolescents, which it expects to publish as two papers in the journal Behavioral Sleep Medicine by December 2024. One of these manuscripts will describe the review of the literature, and the other will be clinical practice guidelines.
Stacey Simon, PhD, who is on the SBSM board of directors, as well as an associate professor at the University of Colorado Anschutz Medical Campus and practitioner at Children’s Hospital Colorado, says these pediatric insomnia guidelines will be the first set of clinical guidelines developed by SBSM.
“We’ve convened a working group of some expert clinicians and researchers in the field of pediatric insomnia,” Simon says. “We also have some patient and parent representatives, [meaning] folks who have the lived experience of having a child or being a teenager with insomnia. This group will review all the existing published research and make recommendations on best practices for treating pediatric insomnia.” Junior investigative researchers will systematically review the literature to help inform the recommendations.
SBSM deliberately included individuals from a variety of backgrounds and experiences to get multiple perspectives. “For example, we have some individuals with training in clinical psychology in nursing and public health from the US as well as internationally,” Simon says. “We’re excited about that.”
From there, Simon already has one idea of where pediatric insomnia investigations could go in the future. “We need more research into effective interventions for children with co-occurring medical conditions, children with neurodevelopmental disorders (such as ADHD and autism, as well as children from historically minoritized populations),” Simon says. “Most of the existing intervention literature really focuses on children with insomnia but who are otherwise healthy, or from non-diverse samples. That’s why I think this is a really important area for focus going into the future.”
References
- Calhoun SL, Fernandez-Mendoza J, Vgontzas AN, et al. Prevalence of insomnia symptoms in a general population sample of young children and preadolescents: gender effects. Sleep Med. 2014 Jan;15(1):91-5.
- Vriend J, Corkum P. Clinical management of behavioral insomnia of childhood. Psychol Res Behav Manag. 2011;4:69-79.
- Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021 Feb 1;17(2):255-62.
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