Our children aren't sleeping and we're medicating them

A new survey of child psychiatrists indicates that insomnia is a major problem among children in mental health treatment and at least a quarter of these patients are given sleep medication. The results of the survey, conducted by Judith Owens, MD, a sleep expert with Hasbro Children's Hospital, and colleagues, suggests that management of insomnia in this population is a common practice, although the clinical approach varies widely. The study is published in the August 2010 edition of Sleep Medicine.

Nearly 1,300 members of the American Academy of Child and Adolescent Psychiatry completed a survey to examine the clinical practice patterns regarding non-prescription and prescription medication for insomnia by child and adolescent psychiatrists. Based on their responses, Owens and her fellow researchers determined insomnia is a significant clinical issue among nearly one-third of the psychiatrists' school-aged and adolescent patients.

To address the issue, an overwhelming 96 percent of the clinicians recommended at least one prescription medication in a typical month and 88 percent recommended an over-the-counter medication. The sleep medications prescribed ranged from antihistamines to sedating medications for Attention Deficit-Hyperactivity Disorder (ADHD), such as alpha agonists (clonidine), to antidepressants like trazodone. They also included medications from a number of other categories, such as antipsychotics and anticonvulsants, depending on the psychiatric or behavioral diagnosis of the child.

Owens, who is also an associate professor at The Warren Alpert Medical School of Brown University comments, "The most important rationale for the use of sleep medication among child psychiatrists is to manage the effects of sleep disruption on daytime functioning. It is important to note, however, that concerns about side effects and the lack of evidence regarding their effectiveness were cited as significant barriers to their use." Owens adds, "Despite the high frequency of use and the wide range of medications chosen, practitioners also expressed a number of significant concerns about the appropriateness of sleep medication in general for children."

The respondents to the survey indicated that over 75 percent of the patients in their practices were children or adolescents and they saw an average of 70 children per month, the majority of whom were age 6 or older. The percentage of patients who were identified with insomnia was substantial and also increased with age. Overall, the results suggest that among children receiving psychiatric care, more than 20 percent of preschoolers and almost one-third of school-aged children and adolescents are affected by insomnia.

The researchers report that past studies have found that behavioral treatments such as relaxation techniques, sleep restriction and cognitive behavioral therapy are effective for childhood insomnia, and multiple studies conducted in the United States and abroad indicate that sleep disturbances are one of the primary indications for psychotropic medication in children. This is true despite the fact that little data exists about the safety and effectiveness of pharmacotherapy for the treatment of insomnia and other sleep disturbances in children and adolescents. In addition, there are currently no medications specifically approved for use as hypnotics in children under the age of 18. Lead author Owens says, "Yet treatment of insomnia symptoms with both over-the-counter and prescription medication is a common clinical practice, particularly for children and adolescents with special needs and co-morbid psychiatric disorders."