- Chronic insomnia includes difficulty with sleep initiation and/or maintenance despite adequate opportunity for sleep and reasonable sleep environment, as well as an associated impairment in daytime function (e.g., sleepiness, irritability, impaired memory or attention etc.) that is causing distress to individual or familial function. This distress is usually focused on the potential impairment to daytime function as a consequence of insufficient sleep.
- Those who suffer from insomnia have global levels of hyperarousal physiologically and cognitively.
Amanda's Story
Amanda is a 10 year old girl who presents with frequent awakenings during sleep. She also states that she has trouble going to sleep and can’t sleep when she wants to sleep.
Her mother brings her into the provider today because her teacher at school has noticed that she has had difficulty focusing during class and seems to have frequent meltdowns, more so than her peers. Academically, she has always been high achieving. She is not falling asleep nor does she appear sleepy at school.
Because it has taken progressively longer for Amanda to fall asleep at night, her parents have started putting her to bed earlier hoping that she will fall asleep earlier and sleep for longer.
Expert Insights
BEARS Screening for Pediatric Insomnia
As part of the clinic’s routine protocols all patients are screened with a BEARS assessment tool. Open the categories below to review some of the history that was obtained from Amanda and her mother.
Bedtime Problems
Amanda currently is going to bed at 8PM, but unable to fall asleep until 11PM. She will repeatedly come out of bed and room and express concerns about not being to fall asleep. She returns to bed without much resistance, but states she is not able to fall asleep. She will frequently check on what her parents are doing. She states she thinks about “everything” during that time.
- On a recent vacation, when bedtime was later, she continued to have difficulties falling asleep although seemed to take her much less time to eventually fall asleep (closer to one hour).
Expert Insights
- Spending 3 hours in bed on a nightly basis and failing at achieving the desired goal of sleep onset provides consistent negative reinforcement of failure, worsening levels of hyperarousal and anxiety surrounding sleep.
- Seeing a gap in desired bedtime and physiologic sleep onset time may suggest physiologic circadian shifting which occurs in adolescence, although most with typical delayed sleep phase syndrome do not complain of awakenings once asleep.
Excessive Daytime Sleepiness
When asked, Amanda denies daytime sleepiness at all. She does not nap and does not fall asleep in class or during car rides.
Expert Insights
- In many children, particularly pre-pubertal in age, the primary manifestations of excessive daytime sleepiness are not overt sleepiness, but rather impairments in focus, academic performance, worsened mood and emotional lability.
- Providers need to know age appropriate manifestations of daytime sleepiness in order to best ask caregivers, parents, and teachers the questions that will more accurately reflect the impact of insomnia.
Awakenings
Amanda says she is a light sleeper and wakes up to everything. Her mother describes that Amanda can hear somebody close a car door on the street and wake up to it. Amanda also knows what times she wakes up since she looks at her clock a lot overnight, concerned that it may be time to get up without having been able to fall asleep at all.
Expert Insights
- Hyperaoursal associated with long standing insomnia includes ability to disrupt sleep maintenance, with low thresholds of arousal to environmental factors such as noise. Hypervigilance to not miss anything while asleep is a common description.
Regularity & Duration
Amanda states that she wakes up almost every night a few times, but cannot recall farther than 1-2 days the timing of these awakenings and how long she is awake. She states that she thinks she is awake for hours. Mom however feels that Amanda is awake only for a few minutes and then falls back asleep quickly.
Expert Insights
- Paradoxical insomnia is when more sleep is being achieved than perceived by the patient, who continues to have the same distress and subjective impairment of insufficient sleep as those with true insomnia. There may be secondary gain to the complaints which then continue to reinforce the perceived experiences.
Sleep-Disordered Breathing / Snoring
Amanda quickly becomes worried that maybe she does snore. However, her mom does not recall that she snores, and on a recent vacation when they were sharing a hotel room she did not hear Amanda snore. She has never had problems with allergies, asthma, or chronic congestion.
Expert Insights
- Many parents are not aware of whether or not their tween or teen snores as they do not frequently sleep in the same room.
Amanda's Evaluation & Diagnosis
What evaluation & diagnostic protocol should be used diagnose Amanda?
Check all that apply:
The evaluation protocol strategies we recommend for Amanda's case are:
- Determine child's sleep history
- Perform physical exam
- Complete a Sleep Diary
Elements of Amanda's Sleep History
| Sleep History | Case Specific Information | Amanda's Evaluation Results |
|---|---|---|
Nighttime Routine |
Please describe the bedtime routine at the beginning of the night. |
Amanda will read in bed after 7:30 in hopes of becoming drowsy, and turns off the lights at 8. She tosses and turns and worries that she is not sleeping and leaves her room frequently to seek her mom. Sometimes she will turn the light back on or use a flashlight and read again in bed until 11. |
Review timing of events at night (bedtime/wake time) |
Please describe what happens after Amanda first falls asleep through the rest of the night. |
Amanda states that she has frequent awakenings, and says that they can occur at any time. Mom states that Amanda will leave her bedroom frequently and seek parental reassurance until about 11PM, when they believe she falls asleep. After 11, Amanda does not seek her parents but states she is awake in her room for long periods of time at night. |
Screen for other sleep issues (OSA, restless leg syndrome) |
|
Amanda denies any growing pains or restless leg symptoms. No reported snoring. No nocturnal cough or history of asthma. |
Safety concerns |
Amanda does not typically leave her room and is scared of being outside at night so mom does not believe she would try to leave the house. |
|
Review of medications (antidepressants, seizure medications, and antihistamines all have impacts on sleep) |
Use of medications both prescription and over the counter for sleep aid? |
Amanda’s mom states that she has given her Benadryl on occasion, and once gave her a ½ dose of her husband’s melatonin that he uses when he travels for business. They both seem to help her fall asleep quicker, though Amanda reports she still had awakenings during the night. |
Assess for family history of sleep disorders |
Does insomnia run in the family? |
Amanda’s mom notes that “she is just like me” and that she has had insomnia since “forever”. |
Perform a Physical Exam
| Information to obtain includes: | Case Evaluation Results |
|---|---|
A physical exam should include height, weight, BMI, cardiovascular exam, HEENT, respiratory and neurological exam. |
Amanda is a thin for age girl who is very articulate and conversationally mature for age. She is Tanner stage 2. She otherwise has a normal exam. |
Sleep/Other Diary
| Information to obtain includes: | Case Evaluation Results |
|---|---|
Typical sleep onset and offset times, any napping during the day, and arousal frequency and duration over a 2 week period. The sleep diary would allow for a more comprehensive assessment of Amanda’s sleep and wake times to allow for restriction as potential treatment in the future. |
Amanda’s sleep diary reveals on average a 3 hour latency with frequent arousals ranging from 2-5 arousals per night, though most are short (<10 minutes) to 1.5 hours in duration. There does not seem to be a pattern to her arousals. In the last 2 weeks there have been 3 mornings where she has awoken early at 4:30 AM and been unable to go back to sleep. |
Options that are Not Recommended
Order Labs/Other Diagnostic Tests
There is no need to order other labs or diagnostic tests.
Sleep Study
A sleep study is not recommended in this case.
Refer to a Specialist
A referral to a specialist is not recommended in this case.
Red Flags
- Suspicion of comorbid depression with suicidal ideation
- Reported total sleep time of <6 hours per night
When evaluating a child for possible insomnia, consider how other health care providers may also need to be involved.
Expert Insights: Triggers for Insomnia
- As with all insomnias, triggers can be categorized into three groups
- Predisposing: temperament, development, genetics, co-morbid condition
- Precipitating: an acute event, particularly impactful poor outcome from insufficient sleep
- Perpetuating: ongoing poor sleep hygiene, anxiety
Evaluation & Diagnosis
What factors are contributing to Amanda's insomnia?
Check all that apply:
- Poor sleep efficiency
- Poor stimulus control
- Hyperarousal and possible anxiety
- Poor sleep hygiene
All of the above factors are contirubuing to Amanda's insomnia.
Amanda’s diagnosis is consistent with chronic insomnia, likely due to a combination of her temperament, family history and worsened by recent failure to improve the situation by moving her bedtime earlier.
Amanda's Treatment & Referrals
Now it’s time to recommend treatment options for Amanda's insomnia.
Check all that apply:
The following treatment strategies are recommended for chronic insomnia:
- Sleep hygiene & routine
- Sleep restriction
- Stimulus control
- Cognitive restructuring
When to consult a sleep specialist or refer to another discipline:
- When the above interventions are not successful or suspicion for another comorbid condition exists.
Interdisciplinary Treatment Components
Amanda's Results:
Good news! Amanda’s difficulty sleeping has improved with treatment.
Treatment strategies and results for chronic insomnia:
- Sleep Hygiene and Routine. First, an age appropriate bedtime was identified which was closer to 9 PM rather than 7:30 or 8 PM. Clock was removed from the room, blackout shades were placed on windows.
- Stimulus control. Amanda was encouraged to read before bed, but outside of her bed. A “nook” was created in her room with a bean bag chair and non-LED light where she could read if not sleepy, and where she read at the beginning of the night. However, she did not prepare for bed until after having read for a while in the evening.
- Sleep restriction. Amanda had clearly gotten into a vicious cycle of being too awake and too hyperaroused during the three hours she was awake and lying in bed, failing at going to sleep. Sleep restriction involved setting her bedtime at 11, which is when she was falling asleep. In addition, a “cease-fire” was employed between mom and Amanda, such that when and if she sought her presence during times that she could not sleep that mother would not penalize her or “yell” at her which had frequently been the case in the past. Once Amanda was routinely falling asleep quickly (<20 minutes), successfully and independently at 11PM, she stated she was “so tired” that she was sleeping throughout the night more reliably without prolonged awakenings. After a week of successful sleep onset at 11 PM, Amanda’s bedtime was moved 15 minutes earlier each week progressively until it reached 9 PM. Once she was sleeping longer hours, her focus improved and anxious tendencies decreased.