Paeds · respiratory-sleep-and-airway
Behavioural insomnia and circadian rhythm disorders
Also known as Behavioural insomnia of childhood · Bedtime problems and night wakings · Delayed sleep phase syndrome · Delayed sleep-wake phase disorder · Circadian rhythm sleep-wake disorders in children
Fellowship guide to behavioural insomnia of childhood and the circadian rhythm sleep-wake disorders: the sleep-onset association and limit-setting subtypes and their diagnosis on a picture of difficulty sleeping despite adequate sleep opportunity, the two-process and melatonin physiology behind the adolescent phase delay, the sleep history, diary and actigraphy, behavioural treatment as first-line, timed morning bright light and correctly timed low-dose evening melatonin for delayed sleep-wake phase disorder, the special place of melatonin in neurodevelopmental disability, and the families and populations that change the plan.
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Red flags
- Persistent daytime sleepiness severe enough to threaten safety — a drowsy adolescent who drives, or a child falling asleep in class every day — needs urgent schedule correction and a search for a coexisting disorder rather than reassurance
- Delayed sleep-wake phase disorder that presents as school refusal with low mood demands active screening for depression, anxiety and suicidal ideation, because circadian disruption and mood disorder feed each other
- A child who snores, gasps or has restless legs is not simply a behavioural insomniac — an organic sleep disorder such as obstructive sleep apnoea or restless legs must be excluded before the problem is called behavioural
- Melatonin prescribed as a bedtime hypnotic at the wrong time or dose will fail in delayed sleep-wake phase disorder — the drug is a chronobiotic that must be given hours before habitual sleep onset to shift the clock
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Board mappings
- Behavioural insomnia and circadian rhythm disorders in children
- Paediatric behavioural insomnia and circadian rhythm sleep-wake disorders: assessment and management
- Sleep problems in children: behavioural insomnia and delayed sleep phase
- Long case: the adolescent with delayed sleep-wake phase disorder and school refusal
- Short case: the toddler with bedtime problems and night wakings
- Behavioural sleep problems and circadian rhythm disorders
- Community: the child who will not sleep
- Developmental-behavioral pediatrics: behavioral insomnia and circadian rhythm disorders
- Patient Care: pediatric behavioral insomnia and circadian rhythm sleep-wake disorders
- Medical Expert: paediatric behavioural insomnia and circadian rhythm disorders
Overview & Definition
Two very different families sit at the exhausted end of most sleep referrals, and the examiner wants them separated at once. The toddler who cannot fall asleep without being rocked, and wakes the household four times a night, has behavioural insomnia of childhood: a learned problem of settling and staying asleep. The teenager who lies awake until two in the morning and cannot be roused for school has a circadian rhythm disorder: a body clock set to the wrong time. [1] [8]
The unifying definition of behavioural insomnia of childhood is difficulty initiating or maintaining sleep that arises from behaviour and learning, occurs despite an adequate opportunity to sleep, and produces daytime consequences for the child or the family. The circadian rhythm sleep-wake disorders, by contrast, are a persistent mismatch between the internal clock and schedule child needs to keep. Both are common, both are treatable, and both are frequently mismanaged with a hypnotic instead of the right behavioural or circadian plan. [1] [8]
References11ShowHide
- [1]Mindell JA; Kuhn B; Lewin DS; Meltzer LJ; Sadeh A Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep, 2006.PMID 17068979
- [2]Morgenthaler TI; Owens J; Alessi C; Boehlecke B; Brown TM; Coleman J; et al Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep, 2006.PMID 17068980
- [3]Meltzer LJ; Mindell JA Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. J Pediatr Psychol, 2014.PMID 24947271
- [4]van Geijlswijk IM; van der Heijden KB; Egberts ACG; Korzilius HPLM; Smits MG Dose finding of melatonin for chronic idiopathic childhood sleep onset insomnia: an RCT. Psychopharmacology (Berl), 2010.PMID 20668840
- [5]van Geijlswijk IM; Mol RH; Egberts TCG; Smits MG Evaluation of sleep, puberty and mental health in children with long-term melatonin treatment for chronic idiopathic childhood sleep onset insomnia. Psychopharmacology (Berl), 2011.PMID 21340475
- [6]Bruni O; Alonso-Alconada D; Besag F; Biran V; Braam W; Cortese S; et al Current role of melatonin in pediatric neurology: clinical recommendations. Eur J Paediatr Neurol, 2015.PMID 25553845
- [7]Gringras P; Gamble C; Jones AP; Wiggs L; Williamson PR; Sutcliffe A; et al Melatonin for sleep problems in children with neurodevelopmental disorders: randomised double masked placebo controlled trial. BMJ, 2012.PMID 23129488
- [8]Auger RR; Burgess HJ; Emens JS; Deriy LV; Thomas SM; Sharkey KM Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med, 2015.PMID 26414986
- [9]Crowley SJ; Wolfson AR; Tarokh L; Carskadon MA An update on adolescent sleep: New evidence informing the perfect storm model. J Adolesc, 2018.PMID 29908393
- [10]Micic G; Lovato N; Gradisar M; Ferguson SA; Burgess HJ; Lack LC The etiology of delayed sleep phase disorder. Sleep Med Rev, 2016.PMID 26434674
- [11]Saxvig IW; Wilhelmsen-Langeland A; Pallesen S; Vedaa O; Nordhus IH; Bjorvatn B A randomized controlled trial with bright light and melatonin for delayed sleep phase disorder: effects on subjective and objective sleep. Chronobiol Int, 2014.PMID 24144243