Insomnia In Children And Adolescents: A Definition And Some Issues

Exhausted and frustrated parents and children would agree that paediatric insomnia is a complex issue that has "unmet medical needs". Pediatrics has published Pharmacologic management of insomnia in children and adolescents: consensus statement. Following a 2-day conference on the current status and future role for pharmacologic management of insomnia in children and adolescents (November, 2004), the group agreed a definition of paediatric insomnia as:

repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite age-appropriate time and opportunity for sleep and results in daytime functional impairment for the child and/or family.

Those with a sense of deja vu will recognise that this definition is modified from the International Classification of Sleep 2 for adults; e.g., the inclusion of "functional" and "child and/or family". The group also collated and developed consensus recommendations for clinical trials in this area:

• high-priority patient populations for research
• inclusion/exclusion criteria
• outcome measures
• ethical considerations unique to clinical trials involving children and adolescents
• priorities for future research that will enhance the understanding of pediatric insomnia.

The conference participants are said to have "unanimously agreed" on the need for pharmacologic management of paediatric insomnia. However, the participants acknowledged that in the absence of pharmacological trials that have collected safety and efficacy data about sleep or psychotropic medications for children, there is what they characterise as a knowledge gap about the appropriate medication to use for the management of paediatric insomnia, hence the proposals for clinical trials.

The conference participants identified that priority should be given to the study of insomnia in children with attention-deficit/hyperactivity disorder and those with pervasive developmental disorders/autism spectrum disorder. I am in strong agreement with this priority. The paper does not provide a description of sleep-quality and the impact of sleep-disordered breathing or how pharmacological management is thought to influence those conditions.

It was not the theme of the conference but I believe that drugs are usually part of the solution in complex issues like insomnia, they are not the complete solution. The complex aetiology and consequences of paediatric insomnia are reflected in the recognition of "daytime functional impairment" for the family as a stimulus for treatment. However, many doctors are cautious about prescribing sleeping pills to adults albeit that the participants claimed that pharmaceutical solutions would only be considered after the usual behavioural techniques had been tried and found to be unsuccessful. Nonetheless, I think that it would be useful if the trial designs included adaptations of behavioural techniques that have been approved in trials with adults: e.g., Espie reports that "CBT is clinically and durably effective for persistent insomnia in routine practice". However, Morin has recently argued that combining CBT and pharmaceutical interventions is not necessarily superior because long-term effects vary between patients.

Which treatment to initiate first, or whether to run treatments concurrently, depends on factors such as the nature of the insomnia, treatment history, comorbid conditions, acceptability of treatment to the patient, and treatment cost or availability.

There have been comparatively few studies of interventions for paediatric insomnia, so the trial recommendations are to be welcomed. There is extensive research on the phenomenon of sleep-disordered breathing in children and suggested links to physical, cognitive and emotional disturbances: even tentatively, I would like to see a willingness to consider behavioural interventions for that and other sleep-related disorders. In the interim, the advice for parents seems to be to try the usual recommended behavioural management techniques for controlling bed-time and sleep onset: but if they fail to work, to discuss pharmaceutical management.