Sleep problems can present several different ways. First, sleep problems occur with many
different psychiatric disorders as one of many symptoms within a syndrome. For
example, sleep difficulty is one out of 20 possible formal symptoms of
posttraumatic stress disorder.
Second, sleep problems can also occur as secondary
problems caused by a primary psychiatric disorder. For example, sleep difficulty is not a formal
symptom of either autism or attention-deficit/hyperactivity disorder, but it is
often seen as a secondary problem caused by the primary problems of those
Third, sleep problems can occur as primary disorders that
are separate from any other psychiatric syndrome (e.g., insomnia disorder,
narcolepsy, obstructive sleep apnea, or restless legs syndrome), but these are
rarely seen in the routine practice of child & adolescent outpatient mental
health practices. These are usually
handled by self-help or by primary care doctors.
Sleep Patterns in
Very Young Children
Sleep patterns evolve rapidly during the first three
years of life. The total amount of sleep
needed decreases from 15 hours/day at 1 year of life, to 13 to 14 hours/day by
2 years, and 12 hours/day by 4 years. During the first 3 years of life, short
naps occur in the midmorning and early afternoon. The modal duration of naps is
about 2 hours. Morning naps disappear first, and then by 3 to 5 years, the afternoon
naps gradually disappear. A minority of children nap at 5 and 6 years, and naps
usually disappear by age 7 (World Health Organization, 2004, p. 44).
The time it takes to fall asleep gradually shortens and
the number of night wakings decreases.
After falling asleep, night wakings are normal. Some children wake and
put themselves back to sleep and parents never know about the wakings. Other
children need their parents to put them back to sleep. Based on research, the following guidelines
suggest when sleep may be considered a problem:
(1) Number of minutes needed to fall asleep that may be
considered above average:
12-24 months of age:
>30 minutes after being put to bed.
After 24 months of age: >20 minutes.
(2) Number of awakenings per night that may be considered
12-24 months of age: 3 or more awakenings per night
(combined time >10 minutes)
24-36 months of age: 2 or more awakenings per night
(combined time >20 minutes)
After 36 months of age: 2 or more awakenings per night
(combined time >30 minutes)
These are guidelines based on group averages (Task Force
on Research Diagnostic Criteria: Infancy and Preschool, 2003). For some
children their mature sleep pattern does not emerge until early adolescence.
Sleep Apnea in
Obstructive sleep apnea syndrome deserves special mention. Even though it is uncommon - up to 3% of pre-school
children are affected – it can go undetected and cause behavioral problems. Obstructive
sleep apnea syndrome is caused by upper airway obstructions during sleep,
usually associated with blood oxygen desaturations. The obstructions are often
caused by adenotonsillar hypertrophy. The symptoms can be loud snoring,
arousals, and unusual sleep positions, such as sleeping on hands and knees.
Nighttime bedwetting is common. Because of the sleep disturbance, children are
tired in the morning and may develop excessive daytime sleepiness or
hyperactivity (World Health Organization, 2004, p. 84).
For a more complete summary of sleep problems see the WHO
report, pp 82-102, which is free to download at http://www.euro.who.int/__data/assets/pdf_file/0008/114101/E84683.pdf
Sleep in Middle
Childhood (7-12 years) and Adolescence (13-18 years)
By 10 years, children spend 8 to 10 hours in bed and
sleep approximately 95% of that time. Prepubertal
children are alert throughout the day and daytime naps are rare (Carskadon et
al. 1987). Midadolescents sleep on average
8.5 hours/day, and older adolescents, primarily college students, about 7 hours
a night (Carskadon et al. 1987).
Older adolescents report staying up to watch television
or to do schoolwork on school nights and waking up by alarm in the morning, so
they sleep less on school nights compared to non-school nights. The demands of
schoolwork increase during adolescence, and parents tend to relinquish control
There is no single “magic number” for the duration of sleep needed by
children of a certain age because there is significant variability in sleep
needs from child to child and across age ranges (Owens, 2012). According to the US National Institute of Health, sleep
requirements for teenagers and preteens are estimated to be between 10 hours
for 12 years, and 8.5 hours for 18 years.
The simplest and most straightforward way to screen for
sleep problems is to keep a daily log over several weeks. One-time
questionnaires tend to be inaccurate because of faulty perceptions and
There are general guidelines to ensure good sleep
patterns (otherwise known as sleep hygiene), that apply to all age groups. These include making sure children are active
during the day so that they are tired by bedtime, have a routine to prepare for
bedtime, go to bed at a regular time, and make the sleeping environment quiet
However, because the nature and cause of sleep problems
vary so widely throughout development, specific interventions often need to be
In terms of medications for sleep, melatonin is an
over-the-counter product that many parents have found long-term success with in
the range of 1- to 6- mg per night.
Diphenhydramine (e.g., Benadryl) is an over-the-counter
anti-allergy medicine that often makes children drowsy enough to help them fall
asleep. Unfortunately, many children
have the reverse reaction and become more activated.
For prescription drugs, doctors ought to feel confident
that they have reliable reporting from parents before using strong medications.
Sleeping pills (e.g., Ambien and Lunesta) appear to be
rarely used in children and adolescents for a variety of reasons. They are not FDA-approved for children, they
are not a cure-all, they often have side effects, and so many developmental
changes are happening that it seems premature to use a sleeping pill as opposed
to searching for an underlying cause.
When using prescription medications, doctors more often
use medications that have been approved for other disorders but have a “beneficial”
side effect of causing drowsiness or impacting the REM sleep cycle. These
include clonidine, hydroxyzine, mirtazapine, trazodone, quetiapine, and others.
If you are a provider who specializes in assessing or treating sleep problems, or know someone who does, please share that information with us by emailing firstname.lastname@example.org.
Carskadon, MA, Dement WC (1987). Daytime sleepiness:
Quantification of a behavioral state. Neuroscience and Biobehavioral Reviews,
Owens, JA (2012). A letter to the editor in defense of
sleep recommendations. Pediatrics, 129,5:987-988.
Task Force on Research Diagnostic Criteria: Infancy and
Preschool (2003) (Scheeringa, chair and primary author). Research diagnostic
criteria for infants and preschool children: The process and empirical support. Journal of the
American Academy of Child and Adolescent Psychiatry, 42:1504-1512
World Health Organization (2004). WHO technical meeting
on sleep and health. Copenhagen, Denmark: WHO. Accessed 11.28.2018 at http://www.euro.who.int/__data/assets/pdf_file/0008/114101/E84683.pdf