Elsevier

Sleep Medicine

Volume 5, Issue 3, May 2004, Pages 253-259
Sleep Medicine

Original article
Psychiatric symptoms in children with insomnia referred to a pediatric sleep medicine center

https://doi.org/10.1016/j.sleep.2004.02.001Get rights and content

Abstract

Background and purpose: To assess the frequency and nature of clinical and psychiatric symptoms in children referred to a pediatric sleep center for evaluation of insomnia.

Patients and methods: A retrospective chart review of all children referred to the pediatric sleep medicine was conducted. Children presenting exclusively with sleep initiation and/or maintenance problems underwent a structured clinical psychiatric interview and their parents completed the behavioral assessment system for children (BASC), pediatric symptom checklist, the clinical attention problem scale and a detailed sleep questionnaire.

Results: Twenty-three of 46 children (50%) with persistent insomnia had a professional diagnosis of another psychiatric disorder. In the remaining 50%, although parents denied any previous psychiatric history, 40% displayed psychiatric symptoms as documented by psychometric measures and clinical interview. A significant positive correlation was observed between depressive BASC score and sleep onset latency and an inverse correlation was present with REM sleep latency.

Conclusion: The vast majority of children presenting with persistent insomnia exhibit clinical symptoms of an accompanying psychiatric disorder, suggesting that comprehensive psychometric assessments are warranted in this population.

Introduction

A growing body of research suggests a strong relationship between sleep and emotional and behavioral development in children [1], [2], [3], [4], [5]. Furthermore, the prevalence of sleep complaints has been assessed in the general pediatric population [6], [7], as well as in children with special needs, such as pediatric populations with chronic neurodevelopmental [8], [9], psychiatric [10], [11], [12], and medical disabilities [13]. Population-based surveys on sleep combined with behavioral assessment instruments have also been widely utilized, and have thus far revealed a strong association between sleep problems (e.g. difficulties initiating and maintaining sleep, sleep-disordered breathing, parasomnias, and abnormal involuntary movements) and behavioral and emotional symptoms in children [1], [5], [14], [15].

Despite compelling evidence on the wide prevalence of pediatric insomnia in the primary care setting, this problem is poorly studied and understood. Furthermore, since symptoms of pediatric insomnia greatly overlap with ongoing developmental changes in sleep habits and are reported mainly by the caregivers rather than by the patients themselves, no clear consensus on the definition of insomnia in children exists, even among pediatric sleep experts. A number of behavioral sleep disorders in children present with difficulty settling in bed and delayed sleep onset and are greatly influenced by parent–child interaction and other environmental factors (for reviews see Refs. [16], [17], [18]). However, no research evidence is available on the issue of primary or idiopathic insomnia in children, and in fact, insomnia in children is viewed as a symptom rather than as a diagnostic entity. Glaze et al. [18] have recently proposed Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV)-adapted criteria for identification and assessment of insomnia in children. These criteria require that the subjective report of sleep disturbance should be accompanied by functional daytime impairment in mood, behavior or learning, and that it does not occur in the presence of another intrinsic sleep disorder, parasomnia, or drug use/abuse [18].

Approximately 35% of adult insomniacs suffer from an underlying psychiatric disorder [19]. Moreover, insomnia serves as an early marker and as a major risk factor for development of depression [20]. A recent study of sleep problems in children indicated that 13.2–28.6% of children who report trouble sleeping exhibit symptoms of anxiety and depression [2]. Taken together, these findings raise the possibility that insomnia is an early sign of emotional distress or that, in susceptible individuals whose sleep homeostasis is poorly preserved by intrinsic biological mechanisms, insomnia is causally implicated in the mood disturbance.

To the best of our knowledge, no studies are available examining psychiatric symptoms in children with insomnia. Thus, the primary goal of this study was to investigate the psychiatric status and clinical characteristics of children referred to a Pediatric Sleep Medicine Center with the chief complaint of sleep initiation and/or maintenance problems.

Section snippets

Subjects

A retrospective chart review was conducted of all children consecutively referred to Kosair Children's Hospital Sleep Medicine and Apnea Center in Louisville, KY during the years 2002–2003 with a chief complaint of difficulties initiating and/or maintaining sleep. The criteria used for definition of initiation or maintenance insomnia were those recently published by Glaze et al. [18] and included: “the complaint is significant difficulty (defined by frequency, severity, and/or chronicity)

Results

Based on the demographic, medical, and psychiatric information routinely obtained during their initial consultation at the Sleep Clinic, 46 children having no other previously diagnosed sleep disorders were identified as presenting with a complaint of initiation or maintenance insomnia. Patients ranged from 5 to 16 years, with a mean age of 9.2±3.6 years. Thirty-one subjects were male and 37 were Caucasian. Two subgroups became apparent: those with a current or previous history of psychiatric

Discussion

This study describes for the first time the psychiatric and clinical characteristics of children, evaluated at a Pediatric Sleep Medicine Center, whose major complaint was insomnia related to sleep initiation and/or maintenance. Due to the lack of consensus on the definition of pediatric insomnia, we adopted the criteria recently proposed by Glaze et al. [18], and only children meeting such criteria were included.

Analysis of the demographic and clinical characteristics revealed that 50% of the

Acknowledgements

This research was supported by NIH grant HL-65270, Centers for Disease Control and Prevention Grant E11/CCE 422081-01, and The Commonwealth of Kentucky Research Challenge Trust Fund. We thank the parents and children for their co-operation in this study.

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