Keywords

FormalPara Case Vignette

Karl is a 10-year-old boy with history of high-functioning autistic disorder, mild intellectual disability, and hypothyroidism who came to the clinic with his parents due to excessive morning sleepiness. He lives at home with his parents and 13-year-old sister.

He has a regular bedtime routine that he follows and is to be in bed at 8 PM. Detailed review of nightly routine reveals Karl following a schedule of getting dressed, brushing his teeth, saying prayers, and reading for 20 min. Parents reported that Karl was taking too long in completing his routine: he counted the times he brushed his teeth, and if for any reason he “didn’t do it right,” he started the process again, delaying his bedtime. Once in bed, he prayed, and his parents noticed he was also extending his prayer time. When asked about this, Karl reported he “has to” include more people in his prayers because “so many bad things happen to them” and he wanted to make sure they “get help.” After he was done reading, the lights were turned off and his parent would leave. Karl said he then tried to fall asleep, but the “bad things that happen keep coming.” He described images and information from the news that “come into my head, like pictures from the TV news.” Although Karl was good at following rules and knows to stay in bed, he was scared and tired at the same time. Finally, Karl described his muscles as being in “knots,” which did not let him rest. At school, he was tired, experienced difficulty concentrating, and became irritable at times, which affected both his academic performance and peer interactions.

Karl’s parents reported they had the news on in the background while eating dinner and never expected him to understand or pay attention to it. In completing the psychiatric review of systems, Karl worried about “the world coming to an end” and his parents’ safety.

Karl was diagnosed with generalized anxiety disorder. He responded well to treatment for anxiety symptoms in the form of cognitive behavioral therapy that included relaxation techniques in combination with parent psychoeducation regarding discussion of current events with him. Karl’s sleep pattern then returned to normal.

Diagnosis of Psychiatric Illnesses in Intellectual Disabilities

Having an intellectual disability (ID) does not exempt anyone from psychiatric illness. Both children and adults with ID who have comorbid psychiatric illnesses often have their psychiatric symptoms miscategorized/misidentified as attributable to their ID such that they do not receive appropriate treatment. As such, they can fairly be considered an underserved population [1]. In a typically developing population, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is used to facilitate psychiatric diagnosis; however, many of the criteria listed there do not apply easily to individuals with ID, due to inability to communicate symptoms that often are subjective in nature and/or require detailed responses to very specific questions. As a result, the National Association for the Dually Diagnosed (NADD) in association with the American Psychiatric Association developed the Diagnostic Manual: Intellectual Disability (DM-ID-2): A Textbook of Diagnosis of Mental Disorders in Persons with Intellectual Disability (DSM-ID) [2].This manual includes a description of each psychiatric disorder and lists symptoms adapted to individuals who might not otherwise be able to report accurately on criteria needed for diagnosis, including sleep-related symptoms. The use of appropriate criteria is crucial in order to accurately diagnose children with ID.

Medication Effects on Sleep

Psychoactive medications frequently used in individuals with neurodevelopmental disabilities might have undesirable effects in sleep that might be an issue of concern for caregivers. Excessive sleepiness is frequently observed with mood stabilizers (valproic acid, lithium carbonate), anti-seizure medications (lamotrigine), antipsychotics (risperidone, aripiprazole), benzodiazepines (diazepam, lorazepam, alprazolam), alpha-agonists (guanfacine, clonidine), and antidepressants (trazodone, sertraline). Sleep disruption, usually in the form of delayed sleep initiation, can occur with stimulant medications (amphetamines, methylphenidate). For example, in children with attention-deficit/hyperactivity disorder, the use of stimulant medication leads to a longer sleep latency, worse sleep efficiency, and shorter sleep duration. It is also important to consider the doses, the administration time, and the formulation of the stimulants administered (extended release versus immediate release) [1]. Judicious use of these drugs is paramount to avoid worsening sleep problems that these patients may already have.

How to Approach Sleep Disturbances in Children with Psychiatric Problems?

Symptoms seen in psychiatric disorders can be secondary to medical disorders and medications. For example, sleep apnea and thyroid abnormalities may lead to symptoms of ADHD and depression, respectively [3]. Symptoms can also be secondary to medications such as mania that can result from steroid administration. Treating the underlying psychiatric disorder may correct much of the sleep abnormality that’s present. But, frequently, medications are used to help correct continued sleep disturbances.

Because sleep disturbances are present in many children with psychiatric problems, their identification and treatment are important to improve children’s quality of life and clinical outcomes (Table 24.1). The management of primary sleep disorders is very important as they can occur in addition to psychiatric problems [5]. Conversely, treatment of a primary psychiatric disorder may actually improve a child’s sleep disturbance and should be undertaken. Sleep hygiene recommendations and behavioral interventions are at the heart of management. Behavioral interventions in children who have problems with initiation of sleep (especially with need for co-sleeping) such as firm schedules or modification of the hour to go to bed, depending on the case; rewards; establishment of limits; avoidance of scary movies or television shows; as well as instillation of positive thoughts and routines are all helpful [5,6,7]. Discipline and structure are very relevant. Breathing exercises and relaxation techniques can also be helpful [8].

Table 24.1 Psychiatric diagnoses in DSM-5 and pertinent sleep abnormalities [4]
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In terms of medication specifically for sleep, it is important to remember that there are no US Food and Drug Administration (FDA)-approved drugs for insomnia in children. Moreover, effects vary: while some antidepressants (serotonin reuptake inhibitors such as fluoxetine) can have negative effects on sleep patterns, causing insomnia or hypersomnia, trazodone, in comparison, appears to be more effective improving insomnia [9, 10]. Other drugs such as mirtazapine and ramelteon may be effective, but data on their use are scarce [11]. Melatonin may be well tolerated and effective in some children with autism spectrum disorders and neurodevelopmental disabilities, improving sleep duration and decreasing sleep latency [11, 12]. Hypnotics should probably be avoided due to lack to data in children [6]. Indeed, the actual success of many interventions for sleep is unknown due to very limited data [6].

Evaluation of Sleep Abnormalities Frequently Seen in Children with Psychiatric Disorders

When evaluating sleep disorders in patients who are typically developing and in children with neurodevelopmental disorders, in addition to the workup for sleep disorders detailed in the earlier chapters in this book, the following steps can be added. The psychiatric history of family members should be assessed. The child should be screened for psychiatric disorders that can present with sleep abnormalities, since sleep abnormalities can result from a primary psychiatric disorder that is comorbid with a neurodevelopmental disorder. Drug and alcohol abuse can also interfere with sleep quality, and although there is little research literature about this, having a developmental disability doesn’t preclude substance use or abuse, which should always be queried as part of a mental health evaluation. Sleep complaints are often present in psychiatric illness, not necessarily as part of formal diagnostic criteria but often as a manifestation of another symptom (i.e., fear of the dark in anxiety). Therefore, a psychiatric review of systems should include details of duration and quality of sleep. Questions about sleep initiation, maintenance, middle-of-the-night awakening, nightmares, early awakening, and daytime sleepiness are important. The presence and timing of daytime naps should be documented, especially in younger and nonverbal children. Parental expectations of total amount of sleep should also be part of the evaluation. Information should be obtained from the child, parents, and other caregivers including school personnel, daycare providers, and babysitters. A sleep journal is highly recommended and should also include any perceived changes in mood and energy (Table 24.2).

Table 24.2 Tools to assess pediatric sleep
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Mood Disorders

Sleep is part of the diagnostic criteria of depression and bipolar disorder; as such, details about its quality and quantity are always part of the psychiatric review of systems (see Table 24.1). These criteria apply to both children and adult regardless of their developmental functioning [4].

Prevalence of major depressive disorder (MDD) from early childhood to adolescence ranges from 1% to 8% [18]. MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) lists insomnia or hypersomnia in its symptom criteria in addition to depressed mood, loss of interest in pleasurable activities, weight changes, psychomotor agitation or retardation, fatigue, feelings of worthlessness, diminished concentration, and recurrent thoughts of death or suicide [4]. Symptoms specific to children include irritability and excessive mood reactivity; however, MDD presents in children in a similar fashion to older patients. According to the DSM-5 criteria used for the diagnosis of major depressive disorder, insomnia or hypersomnia are occurring nearly every day [4]. Interestingly, sleep disturbances correlate with other symptomatology. For instance, agitation and insomnia go together just as hypersomnia tends to be associated with fatigue, hopelessness, and helplessness [19]. Furthermore, there is an impairment in sleep architecture, such as decrease in REM latency and other REM sleep abnormalities [20]. Also, sleep disturbances early in life correlate with the risk of developing MDD later in life [21].

Further, sleep problems correlate not only with symptoms and risk of complications but also with poor response to therapy [22]. In fact, adult patients who attempt suicide are more commonly affected by sleep disturbances [23, 24], and insomnia may be a risk factor for suicidal thoughts [25].

The prevalence rate of pediatric bipolar I and II disorders is difficult to establish. DSM-V lists a combined prevalence rate of 1.8%, for the pediatric population [4]. The mean onset for the first manic, hypomanic, or major depressive episode is approximately 18 years for bipolar I [4]. Decreased need for sleep is a very common complaint from parents with children with neurodevelopmental disabilities but also of typically developing adolescents with bipolar disorder. Often parents identify sleep disruption retrospectively as a prodromal symptom of bipolar disorder [26, 27]. Bipolar disorder is classified in the DSM-5 as bipolar I disorder and bipolar II depending on the presence of mania or hypomania. Both can present with disordered sleep (decrease need of sleep, e.g., feels rested after only 3 h of sleep) which must be present as a criteria to fulfill diagnosis. With the development of DSM-V, the definition of bipolar disorder is very clear in adults, and the diagnosis in children and adolescents requires taking into account the child’s developmental level to better identify the criteria needed for diagnosis. An example of this might be the presence of “grandiosity” as part of mania and the expression of this abnormality of thought being different in a full functioning adult versus a 5-year-old child in which fantastic role-play is normal; the same applies for sleep patterns. Increased sleep-onset latency, multiple episodes of awakening, and decreased need for sleep are also commonly seen in children with bipolar disorder [28, 29]. While acute manic episodes are characterized by decreased need for sleep, it has also been reported that sleep deprivation might play a part in relapse of mania [20]. In fact, sleep disturbances occur in the large majority of children during both manic and hypomanic episodes [30]. During depressive episodes, insomnia and hypersomnia are present [4, 31].

Very few studies have been published regarding characteristics of sleep in children with bipolar disorder. The findings of these studies suggest that children with this condition have more stage 1 sleep and a trend toward reduced stage 4 sleep [32]; lower sleep efficiency, less REM sleep, and a trend toward more awakenings [33]; and decreased sleep efficiency and duration, as well as increased nocturnal activity [34] and longer slow-wave sleep [35]. Sleep disturbances are also present in children of parents with bipolar disorder when compared with controls [36].

Anxiety Disorders

Sleep disorders are seen often in patients with anxiety disorders, and as these are among the most common psychiatric disturbances in children, adolescents, and young adults, it can be inferred how relevant is to recognize and address this problem. Prevalence of anxiety in children and adolescents is 10–20% [37]. The sleep complaints reported in the literature vary according to development, ranging from bedtime refusal, separation anxiety, resistance to sleeping alone, and fear of the dark (directly related to sleep and bedtime routine) to poor academic performance, daytime sleepiness, and irritability (secondary to poor sleep) [31]. Severity of anxiety correlates to functional impairment and sleep disruption and predicts escalating anxiety symptoms [38, 39]. As with MDD, persistent sleep disorders at an early age correlate with the development of anxiety disorders in adulthood [21].

The most common anxiety disorder in children is separation anxiety disorder. Insomnia, nightmares, and refusal to sleep alone are all associated with separation anxiety and as such should be considered in these children [40].

Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is also associated with sleep disturbances. PTSD is becoming a more recognized health problem in our youth. PTSD consists in the development of symptoms following exposure to one or more traumatic events. The clinical presentation varies from fear-based responses to dysphoric mood (DSM-V) [41]. Although now a separate category in DSM-5 from anxiety disorders, PTSD is highly related to and usually comorbid with anxiety. It now belongs to a category named “Trauma and Stressor-related Disorders” [42]. In children, for example, a child suffering from physical abuse can experience fragmentation on his sleep and nightmares [43].

Obsessive-Compulsive Disorder

Children suffering from obsessive-compulsive disorder (OCD) may also be at high risk for sleep disturbances due to anxiety. Shorter total sleep times often characterize children with OCD [35]. OCD-related behavior can interfere with bedtime routines in young children as in the case described above, the need for completing rituals (counting, following a certain order) and the presence of intrusive thoughts of anxious nature keep them awake, and if those thoughts are obsessive and distressing in nature, the diagnosis changes from GAD to OCD [40, 44]. In fact, it appears that in these children, the presence of depression can play an important role in their sleep health [45].

Tourette Syndrome

Ghosh et al. reported on 123 young patients with Tourette syndrome (TS) with and without attention-deficit/hyperactivity disorder (ADHD) aging 21 years and under [46]. Sleep was a frequent issue, with 65% of children in the Tourette-only group and 64% of the group with comorbid ADHD having symptoms suggestive of a sleep disorder [46]. Insomnia was more common in those with TS and ADHD than in TS-only, but even in the TS-only group, primary insomnia was the most common sleep disorder, affecting 32% [46]. Sleep talking also appears to be common in patients with TS [47]. Sleep disturbances in these patients may also be caused by intrusive thoughts and other emotional disturbances [48, 49].

Schizophrenia

Due to the typical age of onset of schizophrenia in adolescence or young adulthood, it is not a common problem in children. However, sleep disturbances are quite common in patients with schizophrenia, especially insomnia [49]. Individuals with schizophrenia have problems with sleep initiation and maintenance. In patients with schizophrenia, obstructive sleep apnea can be seen as a consequence of the use of neuroleptic drugs, given that these drugs can cause significant weight gain, a risk factor for the development of sleep apnea [50].

Neurodevelopmental Disabilities

Sleep disturbances often are present in children with neurodevelopmental disabilities (as high as 86%) but can be misunderstood and underdiagnosed [11, 51]. Some children who are blind have increased susceptibility to sleep problems due to their difficulty recognizing the changes in light that characterize day and night [11].

Conclusions

Having a neurodevelopmental disability of any kind does not exempt a child from having a comorbid psychiatric disorder. Symptoms that reflect impairment in quality of life should be reviewed carefully and addressed. The identification and treatment of comorbid psychiatric conditions are necessary to address disordered sleep. A psychiatric diagnosis in a nonverbal person is certainly more complicated than in the typically developing population and requires obtaining collateral information from parents or other caregivers, as full participation in a review of systems by the affected individual might not be possible. This should include a review of the daily routine, details of sleep schedule, medical history, and any medications being administered. More studies are needed in children and adults with neurodevelopmental disorders, including longitudinal studies that incorporate clinical interviews, sleep diaries, questionnaires, and multiple informants. These will allow for creation of effective practice guidelines as to how to assess for psychiatric disorders in individuals with sleep symptoms.