Mental Health: Sleep in Childhood With a Focus on Trauma

Column Author: Theodore Brisimitzakis, DO | Clinical Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine

Column Editor: Trent Myers, MD | Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine

Background

Sleep is a foundational component of physical and mental health. In children, approximately 25% experience some level of sleep problem, 3.7% are diagnosed with a sleep disorder and 6.1% are on a medication for treatment.¹ A systematic review and dose-response meta-analysis between sleep duration and suicidality in adolescents showed a U-shape association between sleep duration and the risks of suicidal ideation and attempts. The risk of suicide plans decreased by 11% for every one hour increase in sleep duration, with the lowest rate of suicide attempts observed with a sleep duration of eight to nine hours per day.²

In patients with underlying psychiatric diagnosis and struggles, insomnia is especially prevalent. In a meta-analysis of children with a history of child maltreatment, kids with child maltreatment had increased insomnia symptoms (OR 3.91), shorter sleep duration of ~12.1 minutes, and increased nightmares (OR 3.15) compared with a control group with “no alleged experiences of maltreatment.”³ In an Ontario cross-sectional study, child maltreatment was linked to increased time falling asleep (10 minutes), nighttime awakenings, and decreased sleep duration on weekdays.⁴

Non-Pharmacologic Treatment Approaches

Given the importance of sleep, it is important to understand both the behavioral and medication treatments that can aid in sleep. According to one review of several meta-analysis and systemic reviews, common behavioral interventions include the following¹:

• Sleep Education: Combination of general education (what sleep is and its benefits) plus sleep hygiene tips (limiting sugar, caffeine, and electronics before bed, etc.).
• Behavioral Change Methods: Sleep routine, rewards and active ignoring.
• Relaxation Techniques: Progressive muscle relaxation, listening to music.
• Cognitive Behavioral Therapy: Includes identifying and changing thoughts, feelings and behaviors that negatively impact sleep.
• “Mind-Body Interventions:” Meditative techniques plus physical exercise (e.g., tai chi), typically in adults.
• Later School Start Interventions: Delayed start time of 60+ minutes compared to controls.

Of these techniques, behavioral change methods, mind-body exercise and later school start times demonstrated increased evidence for sleep duration and/or quality improvement.¹

Pharmacologic Treatment Approaches

While non-pharmacological methods can be effective regarding insomnia treatment, there are evidence-based treatments for insomnia in children. According to a systematic review by McDonagh et al. looking at the effectiveness and negative effects of medication treatment for sleep disorders in children and adolescents, the following was reported⁵:

• Melatonin: Superior to placebo during short-term duration (one to 13 weeks) and significantly benefits sleep latency, duration and nighttime awakenings; the highest efficacy in sleep latency was found for children with autism spectrum disorder.
• Diphenhydramine: While the data is limited, there were minimal but significant improvements in sleep latency or sleep duration.
• Eszopiclone and zolpidem: Although these medications are utilized, they were not shown to be effective for sleep disorders in children with attention-deficit/hyperactivity disorder and had adverse effects.⁵

Other Pharmacological Treatments:

• Prazosin: Adjunctive treatment to “evidence-based trauma focused psychotherapies” (e.g., trauma-focused cognitive behavioral therapy) for nightmares and sleep disturbances in children with post-traumatic stress disorder. According to Keeshin et al., prazosin was well tolerated and associated with significant improvement in nightmare frequency, nightmare severity and sleep problems.⁶
• Trazodone: For sleep onset and maintenance; notable side effects include priapism (medical emergency) and increased suicidality (psychiatric emergency).
• Clonidine Immediate Release: For sleep onset.
• Hydroxyzine: For sleep onset and as needed medication for anxiety or irritability.
• Mirtazapine: Useful for both sleep onset and appetite stimulation, and lower doses are more efficacious for sleep and appetite; notable side effects include Stevens-Johnson syndrome (medical emergency) and increased suicidality (psychiatric emergency).

In conclusion, given the limited data supporting efficacy of pharmacological treatments, it is generally advised to maximize the non-pharmacological techniques and then trialing medication on an as-needed, short-term basis.

References:

1. Albakri U, Drotos E, Meertens R. Sleep health promotion interventions and their effectiveness: an umbrella review. Int J Environ Res Public Health. 2021;18(11):5533. PMID: 34064108. PMCID: PMC8196727. doi:10.3390/ijerph18115533
2. Chiu HY, Lee HC, Chen PY, Lai YF, Tu YK. Associations between sleep duration and suicidality in adolescents: a systematic review and dose-response meta-analysis. Sleep Med Rev. 2018;42:119-126. PMID: 30093362. doi:10.1016/j.smrv.2018.07.003
3. Schønning V, Sivertsen B, Hysing M, Dovran A, Askeland KG. Childhood maltreatment and sleep in children and adolescents: a systematic review and meta-analysis. Sleep Med Rev. 2022;63:101617. PMID: 35313257. doi:10.1016/j.smrv.2022.101617
4. Turner S, Menzies C, Fortier J, et al. Child maltreatment and sleep problems among adolescents in Ontario: a cross sectional study. Child Abuse Negl. 2020;99:104309. PMID: 31838226. doi:10.1016/j.chiabu.2019.104309
5. McDonagh MS, Holmes R, Hsu F. Pharmacologic treatments for sleep disorders in children: a systematic review. J Child Neurol. 2019;34(5):237-247. PMID: 30674203. doi:10.1177/0883073818821030
6. Keeshin BR, Ding Q, Presson AP, Berkowitz SJ, Strawn JR. Use of prazosin for pediatric PTSD-associated nightmares and sleep disturbances: a retrospective chart review. Neurol Ther. 2017;6(2):247-257. PMID: 28755207. PMCID: PMC5700900. doi:10.1007/s40120-017-0078-4