Child Psych Sleep/Wake Disorders

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Suggested amount of sleep by the American Academy of Pediatrics based on age: 3 to 5 years of age

10 to 13 hours

Suggested amount of sleep by the American Academy of Pediatrics based on age 6 to 12 years of age:

9 to 12 hours

Suggested amount of sleep by the American Academy of Pediatrics based on age 13 to 18 years of age:

8 to 10 hours

A comprehensive developmental and psychiatric history is necessary to help determine a timeline of the sleep-wake disorder, possible contributing factors, and comorbidities.

BEARS

What does BEARS stand for?

Bedtime, Excessive Daytime Sleepiness, Awakenings, Regularity, Snoring

What is the duration criteria for insomnia disorder according to the DSM?

3 nights per week or more and have been present for 3 months or more

Insomnia lasting 1 to 3 months

Episodic

Insomnia lasting longer than 3 months

Persistent

Insomnia lasting 2 or more episodes in the last 12 months

Recurrent

Sleep in early childhood: most infants are sleeping through the night with about 50% having irregular patterns and may wake during the night throughout first 12 months.

6 to 9 months

Sleep in early childhood: some problems with nighttime awakening, taking more than 30 minutes to fall asleep, and are afraid of the dark.

18 to 36 months

Define Hypersomnolence Disorder

Self-reported complaints of excessive sleepiness despite 7 hours of sleep at night with one or more of the following symptoms: -Recurrent periods of sleep within the same day -A prolonged sleep episode of more than 9 hours per day that is not refreshing

What is the frequency and duration of Hypersomnolence Disorder?

At least 3 times per week for at least 3 months

What is the average age on onset for hypersomnolence disorder?

17 to 24 years

Recurrent periods of a need to sleep, lapsing into sleep, or napping occurring within the same day.

Narcolepsy

Frequency and duration of narcolepsy

Occurs at least 3 times per week for the past 3 months.

A sudden, bilateral loss of muscle tone without loss of consciousness. Usually happens after laughing.

Cataplexy

How does narcolepsy manifest in children?

Spontaneous grimaces, spells with jaw opening and tongue thrusting, or global hypotonia without apparent emotional triggers are present

This is measured in the CSF. Hypocretin-1 immunoreactivity less than or equal to 110pg/mL. Not as a results of acute brain injury, inflammation, or infection.

Hypocretin deficiency

What is the first peak of onset of narcolepsy?

First peak between 15 to 25 years of age

Abrupt onset in childhod narcolepsy is associated with?

Obesity and premature puberty

Early symptoms of narcolepy include?

Sleepiness, hypnagogic hallucinations, vivid dreams, and REM sleep behavior disorder

When does sleep paralysis develop in narcolepsy?

Puberty

Risk factors for developing narcolepsy

An autoimmune response, such as Group A strep, influenza, winter infections, head trauma, and disrupted sleep-wake patterns

Differences of symptoms of OSA in children vs adults

Odd sleep postures such as sleeping on hands and knees

Nighttime symptoms of labored breathing and apneas are reported more often than behavioral issues

OSA in children < 5 years old

Daytime sleepiness, behavior problems, ADHD, learning difficulties, and morning headaches are more common.

OSA in children > 5 years old

What causes OSA to peak in children around 3 to 8 years old?

Growth of airway and regression of tonsillar tissue

A persistent pattern of sleep disruption due to an altered circadian system or a misalignment between circadian rhythm and sleep-wake schedule.

Circadian rhythm sleep-wake disorders

Delay in timing of desired sleep period of more than 2 hours, resulting in insomnia and excessive sleepiness. Symptoms include difficulty waking in the morning, morning confusion, and daytime sleepiness.

Delayed Sleep Phase Type

What genes are associated with circadian rhythm sleep-wake disorders

PER3, CKIe

(wrist monitor to detect motor activity) x 7 days

Actigraphy

Incremental adjustments to bedtime

Chronotherapy

Age range for parasomnias

2 years of age through adolescence

The child is difficult to awaken and does not respond to communications because they are still partially asleep while they are up walking around

Sleepwalking

Abrupt terror during sleep, often starting with panic and screaming. Accompanied by intense fear and autonomic arousal (mydriasis, tachycardia, tachypnea, and diaphoresis). The child is generally unresponsive to the comfort of others.

Sleep terrors

Can last a few minutes up to 30 minutes. Spells occur within 3 hours of the child falling asleep. Occurs during Stage 3 and 4 of delta (NREM) sleep.

NREM sleep arousal disorder (sleepwalking type)

Last 1 to 10 minutes and occur during Stage 3 and 4 of delta (NREM) sleep. While the child is distressed during the event, they typically fall back to sleep and have no recall in the morning. Parents are typically more distressed than the child

NREM sleep arousal disorder (sleep terror type)

Name some triggers for night terrors

Poor sleep, illness, discomfort, a full bladder, and medications

If a child has a night terror what should you do?

Plan scheduled awakenings prior to expected episode

Repeated episodes of dysphoric and memorable dreams usually involving a threat to survival, security, or physical integrity occurring during the second half of sleep.

Nightmare disorder

Acute nightmare disorder

1 month or less

Subacute nightmare disorder

1 to 6 months

Persistent nightmare disorder

6 months or longer

Mild nightmare disorder

Less than 1 episode per week

Moderate nightmare disorder

1 to 6 nights per week

Severe nightmare disorder

7 nights per week

Frequency and duration of RLS

Occurs at least 3 times per week over the course of at least 3 months

What sleep conditions are more common in males and females?

NREM sleep terror type is more common in males, and RLS is more common in females

Associated with genetic variants of MEIS1, BTBD9 (80% risk), MAP2K5 on chromosomes 2p, 6p, 15q, iron deficiency anemia, and European decent

RLS

Diagnostics: PSG indicates increased sleep delays and higher arousal index

RLS

Non-pharmacological Treatments for RLS:

Hot baths, massaging legs, applying hot or cold packs, avoiding caffeine and alcohol, engaging in regular exercise, acupuncture

What diagnostic tests are the most useful for diagnosing substance/medication induced sleep disorder?

2-week sleep diaries and actigraphy

Can cause symptoms similar to a hoarding disorder with the individual experiencing distress when discarding items and possessions

TBI

In complex partial epilepsy, symptoms may be autonomic, cognitive, a change in affect, or automatisms including blushing, stomach fullness, a change in respiration, dream-like episodes, déjà vu, presence of an aura, fear, panic, anxiety, depression, elation, lip smacking, rubbing, or chewing.

Preictal

Disorganized and uncontrollable behaviors. An EEG will show focalized activity in 25% to 50% of patients. A normal EEG is not enough to exclude a diagnosis of epilepsy. Often a 24 to 72-hour EEG is needed.

Ictal

Amnesia may be present. Difficulty talking, writing, and walking. Feeling fatigued and weak. Headaches or migraines. Nausea. An urge to urinate.

Postictal

Personality changes are the most common psychiatric issues between seizure episodes, with the most prevalent being increased emotionality or a focus on religion. There may be changes in speech including slowed, serious, tangential, and circumstantial conversations. Children who have onset of complex partial epilepsy prior to puberty may be hyposexual and not be interested in sex as they get older. Some psychotic episodes are seen in temporal lobe epilepsy and are more prevalent if seizure onset is during puberty. Occasionally violence is noted but occurs rarely. Episodic mood disorders such as depression and mania may occur.

Interictal

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