Insomnia disorder is part of a cluster of diagnoses called the sleep-wake disorders. Sleep-wake disorders are a group of psychiatric conditions that include:
These disorders are broadly characterized by disruptions in sleep and wakefulness. Individuals with insomnia disorder have frequent difficulty falling asleep or staying asleep. Individuals with hypersomnolence disorder feel excessively sleepy during the day, despite obtaining what for most people would be a full night of sleep. Individuals with parasomnias such as non-rapid eye movement sleep arousal disorder and nightmare disorder experience unusual behaviors while sleeping, such as sleep walking, or vivid and disturbing dreams or night terrors.
Some sleep-wake disorders, including insomnia disorder and hypersomnolence disorder, are associated with disturbances in the amount of time the individual spends asleep (too much or too little) or the times at which the individual sleeps (often outside of the desired sleeping window). Other disorders, such as the parasomnias, are not associated with disturbances in the quantity or timing of sleep per se, but are instead associated with behavioral disturbances during sleep or frequent highly distressing dreams.
The exact epidemiology of insomnia disorder is unknown, but approximately 10 - 25% of children and adolescents report at least some insomnia symptoms and approximately 5% report chronic insomnia. Insomnia disorder is characterized by a dissatisfaction with the quantity or quality of sleep related to one or more of the following:
Occasional sleep difficulties are fairly common in children and adolescents. Therefore, insomnia disorder is diagnosed only when the sleep difficulty occurs at least three nights per week for a period of three months or longer. Insomnia disorder often co-occurs with medical conditions and other mental disorders. Insomnia disorder should only be diagnosed if the insomnia is not adequately explained by the co-occurring condition and if the insomnia is severe enough to warrant independent clinical attention. Finally, insomnia disorder is diagnosed only if the child is significantly distressed or impaired by the insomnia or resulting daytime symptoms.
Insomnia disorder severity can range from mild to severe. In the short term, insomnia disorder can lead to daytime symptoms such as irritability or impaired concentration that may impair school performance. In the long term, severe untreated insomnia disorder can lead to physical and mental health complications, including major depressive disorder and cardiac disease.
Some children and adolescents with insomnia disorder experience comorbid physical and/or mental health conditions, which may be exacerbated by the insomnia disorder or share a bidirectional causal relationship with insomnia.
Insomnia disorder has been linked to abnormalities of brain function which are thought to contribute to symptoms. In particular, evidence points to hyperarousal in the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and central nervous system. In addition, cognitive factors (such as worrying excessively about sleep or its negative consequences) and behavioral factors (such as inconsistent bedtimes and bedtime routines in children and phase delayed circadian rhythms in adolescents) have been proposed to contribute to insomnia. The disorder has a genetic component, although having a genetic predisposition to insomnia disorder does not necessarily mean that someone will develop insomnia disorder.
Insomnia disorder is treatable. Task force consensus guidelines include those published in the journals Pediatrics and Pediatric Clinics of North America.
Clinical research and consensus guidelines suggest that the following treatments are effective:
There is limited data for the pharmacological treatment of pediatric insomnia. However, consensus guidelines suggest that pharmacotherapy may be considered when the child does not respond to behavioral interventions or when the parent is unable to implement these interventions. Importantly, medication is not considered a first-line treatment for pediatric insomnia and interventions should be short-term in nature. Additionally, adolescents should be screened for the presence of substance use disorders before medications are prescribed due to the potential for abuse and drug-drug interactions. With these caveats in mind, the following treatments have been identified as potentially efficacious for children with chronic insomnia:
The hypnotic medication zolpidem has demonstrated efficacy in treating adult insomnia, but failed to show a benefit in a trial for pediatric insomnia. At present, there is insufficient data to recommend the use of antidepressant medications for treating pediatric insomnia. The American Academy of Pediatrics recommends against the use of chloral hydrate to treat pediatric insomnia.
For more information about drug prescribing in insomnia disorder, click here.
Additional Treatments to Consider
Preliminary evidence suggests that yoga, while not a substitute for the more well-validated treatments described above, might also be considered.
Clinical research and consensus guidelines suggest that the following treatments are effective:
There is limited data for the pharmacological treatment of pediatric insomnia. However, consensus guidelines suggest that pharmacotherapy may be considered when the child does not respond to behavioral interventions or when the parent is unable to implement these interventions. Importantly, medication is not considered a first-line treatment for pediatric insomnia and interventions should be short-term in nature. Additionally, adolescents should be screened for the presence of substance use disorders before medications are prescribed due to the potential for abuse and drug-drug interactions. With these caveats in mind, the following treatments have been identified as potentially efficacious for children with chronic insomnia:
The hypnotic medication zolpidem has demonstrated efficacy in treating adult insomnia, but failed to show a benefit in a trial for pediatric insomnia. At present, there is insufficient data to recommend the use of antidepressant medications for treating pediatric insomnia. The American Academy of Pediatrics recommends against the use of chloral hydrate to treat pediatric insomnia.
For more information about drug prescribing in insomnia disorder, click here.
Additional Treatments to Consider
Preliminary evidence suggests that yoga, while not a substitute for the more well-validated treatments described above, might also be considered.