INSOMNIA IN CHILDREN AND TEENS: IMPACT, TYPES AND SLEEP MANAGEMENT TIPS

While often overlooked, sleep is a highly essential component of optimal health and well-being. Sleep disturbances and disorders are frequent amongst the global population, with children and teenagers being particularly vulnerable to the effects of sleep loss.

The following article attempts to surmise current data on insomnia, focusing primarily on the effects of sleep loss in children and teens, as well as what can be done to improve sleep health outcomes in this population. Along with the types of child and teen insomnias, suggestions for improving sleep and treatment options are also reviewed below.

Impact of Childhood and Teen Insomnia

Insomnia refers to sleep difficulties in general. Symptoms and presentations of insomnia can vary from being unable to fall asleep, problems with maintaining consistent sleep, frequently waking up during the night or waking up too early without being able to fall back asleep.

Impact on Health and Well-Being. For general health and wellbeing, sleep is essential, particularly with regard to learning, memory consolidation, emotional regulation^[1], energy balance and brain waste removal. Sleeping difficulties are known to alter blood sugar levels, increase anxiety, reduce one’s ability to think or focus and affect temperature regulation. In children and teens, insomnia can increase the risk for developmental abnormalities, comorbid disease, and learning deficits, with the most common ones being anxiety disorders, ADD/ADHD^[2] and depression. The impact of sleep deprivation on energy balance also promotes increased food intake in some children and bears associations with obesity.^[3]

Prevalence. Despite being so important for overall health and childhood development, insomnia in children and teenagers is often underestimated and overlooked. Insomnia is prevalent in as much as 30% of the American population, whereas up to 20-30% of children and teens globally are known to suffer from sleep-related disorders. Some reviews have suggested that infantile insomnia is prevalent in up to 30% of infants and that after the age of 3, the prevalence is closer to 15% among children. As much as 80% of children and teens with psychiatric or neurodevelopmental disorders are known to suffer from insomnia.

Optimal Nightly Sleep Durations Per Age Group. There is no set length of time considered optimal for sleep. However, the below sleep durations are known to facilitate optimal health, with room for variance. Insomnia generally refers to sleep that consistently falls below the acceptable range of variance (the time in brackets):

• Newborns (0-3 months) need 14-17 hrs sleep per day (with 11-19 hrs considered acceptable)
• Infants (4-12 months) need 12-15 hrs (10-18 hrs acceptable)
• Toddlers (1-2 years) need 11-14 hrs (9-16 hrs acceptable)
• Preschoolers (3-5 years) need 10-13 hrs (8-14 hrs acceptable)
• School-aged Kids (6-13 years) need 9-11 hrs (8-12 hrs acceptable)
• Teens (14-17 years) need 8-10 hrs (7-11 hrs acceptable)
• Adults (18-64 years) need 7-9 hrs (6-10 hrs acceptable)
• The Elderly (>65 years) need 7-8 hrs (5-9 hrs acceptable)

Common Types of Child and Teen Insomnia

Small amounts of sleep disruption are common occurrences in infants, children and teenagers, especially around developmental milestones in infants^[4]. When sleep disruption becomes chronic, it increases the risk of multiple health conditions and disorderly sleeping during adulthood. As sleep disturbances are common in these age groups, chronic insomnia can be completely dismissed and left untreated until it is too late.

Infantile and Childhood Insomnia. During the first years of life, insomnia presents as recurring difficulties falling asleep, sleep disruption during the night, parasomnias and sleep-related breathing problems such as obstructive sleep apnea. There are three common forms of childhood insomnia, which often spontaneously resolve before adolescence^[5]:

• Sleep Onset Association Disorder refers to a type of infant insomnia in which the infant battles to fall asleep without extremely specific conditions such as an object (e.g. a toy, blanket) or circumstance (e.g., night light). The infant often wakes up several times and requires the parent to check in on them and restore the specific condition in order for them to fall back to sleep. The condition usually resolves by the time the infant is 3-4 years old.
• Limit-Setting Sleep Disorder is another common insomnia condition that transiently affects preschool and school-age children. In this condition, the child battles to fall asleep or wakes up and battles to fall back to sleep. It is characterized by waking up 3-5 times a night with total sleep time being reduced by 1-2 hours. The reason for delayed sleep onset is often coupled with an excuse from the child, such as wanting to hear another bedtime story. This condition usually resolves with the implementation of a strict bedtime routine and occasionally with the short-term use of pharmaceutical sleep medications until the child has adjusted to maintaining their routine.
• Parasomnias refer to a group of sleep disorders with unusual motor, verbal, or behavioural events that affect children more frequently than adults. Examples include sleepwalking, sleep paralysis and night terrors. These disorders are the result of disruptions in the first and second phases of sleep, during the transitions from sleep to waking, or during Rapid Eye Movement (REM) cycles^[6]. Sleepwalking is the most common parasomnia seen in children, usually affecting kids aged between 8 and 12^[7]. Confusional arousal commonly affects kids below the age of 5. These conditions, alongside sleep terrors and recurring nightmares, usually spontaneously abate with age^[8]. Circadian signaling (delayed or insufficient deep sleep) and neurologic components of sleep (REM and restless leg syndrome) are more likely to be components of insomnia in older children and teens.

Teen Insomnia. In teens, insomnia is usually characterized by poor sleep hygiene, delayed sleep phase insomnia, or insomnia induced by psychophysiological factors, as described briefly below^[9]:

• Delayed Sleep Phase Insomnia may occur as a result of hormonal changes and is often associated with entering puberty. It is defined as a delay at any point in the sleep cycle that leads to waking up later than usual and is thought to be a circadian rhythm disorder. It can occur during adulthood as well for different reasons that result in hormonal circadian fluctuations. Most teens with delayed sleep phase insomnia battle to fall asleep at the prescribed time and battle to wake up the following morning. Symptoms include sleep deprivation, hyperactivity or daytime sleepiness, increased aggression and potential learning deficits. Napping during the day or being lenient with sleep times on the weekend tends to result in more delayed sleep during the evening. Treatment usually consists of readjusting the sleep cycle, promoting optimal metabolic (and hormonal) health and often, the affected teen benefits from the short-term use of melatonin.
• Inadequate Sleep Hygiene or Insomnia. Besides hormonal perturbations, teens go through several other changes that can lead to inadequate sleep hygiene and symptoms of insomnia. Social habits, late-night electronic device use, stimulants, and an increase in the social, family, or academic obligations are all associated with having an effect on sleep hygiene in teenagers. These can promote going to bed after 11 pm and waking up after 8 am, having an irregular sleep cycle between weekdays and weekend and/or a completely inverted sleep-wake cycle. Education on sleep hygiene, implementation of a strict routine and sometimes melatonin are often used to correct this form of teen insomnia.
• Psychophysiological Insomnia occurs when the teen has a history of battling to fall asleep and is characterized by anxiety, a mild obsession with sleep, trying to get to sleep and not being able to sleep. Stress management and sleep hygiene often serve to correct this type of insomnia.

Possible Causes and Mechanisms of Sleep Disturbance

In the absence of straightforward causes of sleep deprivation, chronic insomnia is traditionally known to be a complex condition with many possible underlying causes. While much research has focused on insomnia, relatively little is known about it.

General Mechanisms. Insomnia may be the result of another health condition (often related to severe stress) and/or to disrupted circadian signaling. Hormones, neurotransmitters, brain electrical activity, metabolic cues and inflammation can all affect circadian signaling.

Sleep-Wake Hormonal Imbalance. Imbalances between hormones that promote either sleepiness (GABA, serotonin, melatonin, prostaglandin D2 and adenosine) or wakefulness (corticoids, noradrenaline, orexin, catecholamine, histamine, glutamate) are common to insomniacs. Orexin may play a primary role in promoting insomnia as it is associated with increased firing in the wake-promoting areas of the brain and decreased firing in sleep-promoting areas.

Insomnia as a Catch-22 Condition. Studies have shown that insomniacs tend to have higher degrees of brain inflammation (sometimes a result of lesions, traumatic injuries, diseases or infections) and reduced blood flow to various brain regions, which are known to differ between individuals with sleep problems. In this context, insomnia itself can contribute towards perpetuating more of itself, especially as deep sleep is required to drain the brain of most of the toxins it accumulates throughout the day. Toxin accumulation due to sleep deprivation can result in excessive inflammation, swelling, reduced blood flow and neurotransmitter imbalances that can predispose the individual to more sleep loss.

Child and Teen Insomnia Risk factors

The following factors are known to increase the risk for childhood and teen insomnia:

• Parent Behaviours. Parents can contribute to childhood and teen insomnia through their behaviours, health profiles and attitudes toward sleep. If the child wakes up during the night and the parents encourage the child to fall back to sleep while being cradled or in their lap, it can increase the risk for infantile insomnia. Night-feeding and sleeping with the parents in the same bed can also increase the risk. Parents with a history of depression or other psychiatric disorders are also more likely to have children that are prone to insomnia. Parents are also required to educate their children on the importance of sleep hygiene and enforce an adequate healthy routine. The enforcement of such should not be stressful or aggressive.
• Reduced Natural Light Exposure. Daylight and its absence play a major role in setting the circadian rhythm that dictates the sleep-wake cycle. Epidemiological studies reveal a link between lower natural light exposure and insomnia, which is evident more in urban contexts versus rural settings.^[10] Missing light in the early morning after waking appears to be an important factor for stabilizing the circadian rhythm. Furthermore, optimal daytime light exposure is important for ensuring optimal vitamin D conversion is taking place in the body. Vitamin D3 deficiency and reduced sun exposure are both risk factors for the development of insomnia.
• Childhood Adversity was shown to double the risk for insomnia amongst children and teens and is also linked to depression, anxiety, and PTSD.^[11] This follows from a body of research that highlights stress as a main factor involved in depression, anxiety, circadian disruption and sleep loss.
• Puberty and Hormonal Fluctuations. The highest prevalence of insomnia in pre-adolescent children was found in girls aged 11-12. This is believed to be the result of hormonal fluctuation prior to puberty onset.
• Geographic Location. Light exposure is vital for optimal sleep and circadian functioning. Adolescents in Norway, where there is less sun exposure on average, were shown to be at a much higher risk for insomnia and related conditions than in many other areas of the world. One population study suggested that the average sleep duration of Norwegian adolescents averaged 6 hrs 25 mins and that roughly 65% displayed difficulty falling asleep, taking more than 30 mins to do so.
• Asthma and Breathing Difficulties. Sleep apnea is a common cause of sleep disturbances and is closely related to respiratory problems, asthma and obesity. When one is unable to maintain an adequate oxygen supply to the brain during sleep, the body often wakes up spontaneously. Improving either breathing or quality of sleep has been shown to improve overall health and the quality of life in children with asthma.^[12]
• Infections can promote sleep disturbances by detracting from breathing and giving rise to changes in core body temperature. Fevers, temperature disruptions and inflammation during the night can also lead to night sweats, waking up and difficulty in getting comfortable or returning to sleep. Confusional arousal was also shown to be related to fevers^[13].
• Temperature. Fluctuations in core body temperature are known to be involved in regulating the quality of sleep and vice versa. Under healthy circumstances, the body cools when entering sleep and heats back up closer to the time of waking, in line with metabolic processes. It is noted that melatonin surges are linked with body cooling prior to sleep and that the opposite is true for waking. This process relies on adequate blood flow to the extremities and skin. Children have smaller bodies than adults, with different metabolic rates and thermal regulation. School-aged boys were shown to have a higher core body temperature than their fully grown counterparts and were more sensitive toward ambient temperature increases during sleep. School-aged girls were shown to be more sensitive to cold during sleep. Children were shown to be more likely to sleep without covers, which enhances the surface area of the skin for body temperature cooling.^[14]
• Comorbidities. Sleep disorders in children are often linked to other health conditions, including infantile colic, GERD, allergies, asthma and other respiratory conditions, anemia, obesity, neurologic muscular diseases, epilepsy, ADD/ADHD, autism, anxiety and depression. Depression is thought to be associated with the highest prevalence of child and teen insomnia among all comorbidities, occurring in roughly 75% of patients in this age group. While these health conditions increase the risk for insomnia, sleep deprivation is also known to promote their occurrence in children and teens. As a result, treatment of these conditions often serves to enhance sleep quality and maintaining good quality sleep is also often employed as part of a treatment protocol to help.
• Genetics. There is limited information on genetics that directly precipitates a heightened risk for insomnia. However, many genes are associated with inducing comorbidities to insomnia and may increase the risk indirectly. Insomnia was also noted to be higher in the children of parents with psychiatric disorders or with mothers who experience postpartum or other kinds of depression.

11 Tips for Improving Sleep Hygiene and Quality in Kids and Teens

Signs of insomnia in children and teenagers may not indicate a full-blown disease and may be transient as a result of developmental changes or other life factors. In light of this, treatment should only be considered if insomnia does not resolve after several months of trying to improve the child or teen’s sleep. The following tips may be of use in this scenario:

1. Day and Night Activity Variance. It was noted in preliminary studies that day and night contrasts between light exposure, the environment, body posturing and overall activity patterns served to improve circadian signaling, sleep and temperature regulation.
2. Physical Activity. Physical activity is known to improve sleep hygiene in a number of different ways. It tends to improve cardiovascular and neurologic health, both of which contribute to optimal blood circulation, metabolic signaling and thermal control. Just before bedtime, gentle exercises and stretches can help to stimulate body cooling mechanisms as well as relax the nervous system. During cold, and rainy weather, physical activity typically dwindles, coupled with an increased need for foods that promote warmth as well as more exposure to artificial light.^[15] Finding ways to include exercise in colder weather can help to facilitate better temperature control and sleep.
3. Bedtime Regularity. Setting a stable bedtime promotes a stable metabolism which facilitates optimal thermal and hormonal signaling and sleep. When one’s sleeping time varies, so do the metabolic cues that govern hormones and temperature control.
4. Keeping Strict Tabs on a Bedtime Routine. While it is well-understood by many parents that children need to get to sleep on time, it is not often easy to ensure. Creating and maintaining a routine that helps children to ease into sleep can help to promote a stable sleep cycle, the benefits of which may be lifelong for the child. The routine should be distinctly different from daytime activities and overt stimulation or excitement ought to be avoided up to 3 hours prior to bedtime (up to 1 hour for older children and teens). This extends towards eating before bed (especially stimulant foods or beverages), energetic play, staying up with bright artificial light sources, or using an electronic device. Gentle conversation, calming bedtime stories and lullabies can all help younger children to relax and may improve sleep quality. If the child is prone to being restless before bedtime as they mature, the parent may wish to teach them relaxation techniques that they can practice on their own to help them fall asleep with confidence.
5. Timing of Bedtime Medications and Activities. Making a list of the activities and medications that can raise core temperature and promote wakefulness before bed is crucial for creating a healthy sleep routine. Examples include spending time on electronic devices, consuming hot drinks, cooling the face, hands and feet too much (more of a concern during warmer weather conditions) and taking medications that increase the metabolism. These should be spaced at least an hour and a half or more before bedtime for the best results. 
6. Parental Management of Child Sleep Disruptions. The parent’s involvement is crucial for the development of the child at all phases of life. As highlighted above, various behaviours of the parent in terms of child sleep management can increase the risk for chronic insomnia in the child. Consistency is vital to success and emphasis ought to be placed on the child’s independence and confidence in their ability to sleep well and on their own. If the child wakes up during the night, the parent should not be tempted to allow the child to fall asleep while in their arms, their beds or on their person, and aim instead to place them in their own beds or cribs while still awake. For infants, bottle-feeding till the baby is asleep ought to also be avoided. This can help them to develop surety in their own ability to fall asleep and be on their own during the night. It also helps the child to fall asleep without needing anything to do so.
7. Maintaining a Stable, Cooler Core Temperature at Night. Parents ought to ensure that children are able to sleep in a cooler environment at night, particularly when the weather is warm. The hands, feet and neck are vital for ensuring optimal temperature control. It is important for the temperature of these extremities not to become too cold, as the cold in these areas can restrict body cooling and reduce the efficacy of sleep. If the child battles to maintain an optimal cooler body temperature for easing into sleep, then it may be a good idea to incorporate a hot shower or bath roughly an hour before bedtime. Clothing and bedding ought to be weighed against the ambient temperature to ensure sleep occurs within the optimal temperature range.
8. Arrange a Babysitter for Night-Time Social Occasions. Night-time activity in the household is one of the best known factors that can contribute to pediatric sleep disruption. Where and if possible, it is good to arrange a babysitter for social occasions who can make sure the child is able to fall asleep without a hitch.
9. Parent-Child Communication. A lack of understanding and communication between parent and child can contribute to the development of childhood insomnia. It is essential that children understand the importance of sleep and that if they can not sleep, they need to seek out assistance from their parents or guardian. The better the communication between parent and child, the easier it is to catch early warning signs for full-blown sleep disorders and manage them effectively.
10. Optimal Nutrition. Many children and teens with a combination of insomnia and other developmental disorders such as ADD/ADHD or autism were shown to benefit from nutritional supplementation. Vitamin D3 is known to be a prominent feature of sun exposure and circadian regulation. Studies have shown that supplementation helps improve sleep parameters in children and teens with sleep disorders^[16]. Omega-3 alone^[17] or in combination with omega-6 fats, zinc and magnesium were shown to reduce the time it took for children with and without ADHD to fall asleep, as well as to improve concentration during the day^[18]. Other antioxidants have also been noted to improve sleep in conjunction with stable eating patterns that ensure balanced energy levels and metabolism.^[19] Some children and teens may benefit from consuming a diet higher in plant-based protein as well as from an elimination diet or from omitting common allergenic foods, such as wheat/gluten, dairy, soy, corn and peanuts.
11. Other Suggestions. Various other strategies for promoting optimal sleep in children and teens have been used with varying degrees of success. Calming music, touch therapy, massage, acupuncture^[20] and acupressure^[21] may help some children to fall asleep and to have a better quality of sleep. However the evidence is low and the results are mixed.^[22] Weighted blankets may be an option for children and teens who suffer from chronic anxiety or who have ADD/ADHD. While there is no compelling evidence to suggest that weighted blankets are effective for treating insomnia, they may help to reduce bedtime anxiety^[23] and may help some children and teens to place a more positive emphasis on maintaining optimal sleep hygiene^[24].

Possible Treatment Options

Treatment options ought to be considered for children and teens with chronic insomnia that does not spontaneously resolve after several months of maintaining optimal sleep hygiene. A skilled practitioner or pediatrician will be able to assess the overall health of the child and investigate underlying contributions towards the problem that can be then treated, such as comorbid health conditions. Together with the child’s doctor, a treatment strategy can be devised to help restore sleep as much as possible.^[25]

The below treatment options are commonly employed and tailored to suit the child or teen’s unique needs.

• Circadian Entrainment. School-age children with circadian disturbances were shown to benefit from 6-8 weeks of circadian rhythm therapy. This included being in bed with the lights off at 9 pm, getting early morning sunlight between 6-7 am and engaging in some form of light physical activity every day, such as a 20-30 min walk. The intervention helped to improve sleep onset, quality and duration, as well as lower core body temperature, which was shown to be slightly higher than average at the beginning of the trial.^[26]
• Non-Invasive Ventilation and Oxygen Therapy. Children who have sleeping problems coupled with respiratory issues may benefit from either non-invasive ventilation techniques or mild hyperbaric oxygen therapy. Ventilators or oxygen masks at night help to maintain oxygen levels and keep the airways open, thus helping to promote sustained sleep and deeper quality of sleep.^[27] They have been used with success to improve sleep health outcomes in children and teens with these conditions. Hyperbaric oxygen administers oxygen to all tissues of the body, including the brain and can help to improve breathing in those with respiratory ailments. Oxygen therapy may also help to lower pain in those with musculoskeletal disorders and other pain-related disorders, as well as reduce anxiety, which may enhance sleep.
• Melatonin has proven to be a safe and effective treatment option for improving sleep quality, duration and onset in children and adolescents^[28]. It is usually the first medication to be prescribed or suggested for treating insomnia in children and teens, as it can often serve to reset the circadian rhythm without posing any side effects or withdrawal symptoms^[29]. As melatonin is associated with a lower core body temperature and antioxidant reductions in inflammation, it may be able to improve sleep onset time through mechanisms other than circadian signaling. It is most commonly prescribed in the short term at 1mg for several nights in a row until a healthy sleep cycle has been re-established. Those with ADD/ADHD, neurodevelopmental or psychiatric disorders, or who suffer from extreme insomnia without a known cause may benefit from a higher dose (3-10mg) taken within several hours of bedtime.^[30] It is important to discuss the dosage and length of intervention with a pediatrician or skilled physician.
• Pharmaceutical Interventions. A doctor may decide to prescribe pharmaceuticals to help enhance sleep in children and teens. The medication and dosage will depend on the child, their developmental stage and their health. Antihistamines, antidepressants, and sedative agents are all considered by the doctor and weighed against their respective side effects and withdrawal symptoms. The doctor should prescribe medications that are able to treat any other comorbidities the child may have as well, such as using antidepressants for treating depression-induced insomnia or antihistamines for allergy-related sleep disruption. Be sure to ask about the side effects, the duration of treatment and what to expect when the child is required to withdraw from the medication.^[31]

Conclusion

Insomnia is a complicated, often multi-factorial health condition that affects all parameters of daytime functioning, growth, development, learning, memory, mood and more. For these reasons, children and teenagers are particularly vulnerable to the negative effects of insomnia. Sleep disruption occurs naturally from time to time in this population group, which contributes to the dismissal of chronic sleep disturbances that may lead to insomnia. The role of the parent is invaluable in guiding the child’s relationship with sleep, setting up a stable bedtime routine and in helping the child establish confidence in sleep. Working out an optimal day and night structure that promotes healthy circadian signaling goes a long way toward ensuring sleep stability, as does an open line of parent-child communication, adequate nutrition and physical activity. If insomnia ensues despite the maintenance of optimal sleep hygiene, treatment should revolve around the management of comorbidities and resetting the sleep cycle through melatonin and other pharmacologic agents. Consult with a skilled pediatric specialist who can assess the child’s case and devise a comprehensive treatment plan for the best results.

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