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The Psychological Effects of Childhood Insomnia

Paediatric or childhood insomnia is defined as significant difficulty initiating or maintaining sleep, which causes significant impairment in the child’s functioning as reported by the child or caregiver (Glaze, Rosen, & Owens, 2002). Paediatric sleep problems are extremely common, affecting approximately 20 to 30 percent of children during infancy and early childhood, and about 35 percent of adolescents (Glaze et al., 2002; Owens & Mindell, 2011; Paiva, Gaspar, & Matos, 2015; Tikotzky & Sadeh, 2010). The most common include bedtime and night-waking problems, which are classified as behavioural insomnia of childhood, of which there are three types (Glaze et al., 2002; Owens & Mindell, 2011). Sleep-onset association type refers to difficulty falling asleep or resuming sleeping after night-time waking without special assistance by the caregiver. Limit-setting type refers to the child’s refusal to go to sleep, accompanied by lack of limit-setting by the caregiver. The combined type has characteristics of the other two types. Older children and adolescents may be affected by psychophysiological insomnia, which is a state of sleeplessness characterised by heightened physiological arousal combined with learned sleep-preventing associations (Owens & Mindell, 2011). Childhood insomnia may also coexist with neurodevelopmental, psychiatric, and chronic physical disorders, in which case insomnia may be secondary to the disorder or use of medication (Owens & Mindell, 2011).

Psychological Effects

Sleep deprivation leads to changes in the prefrontal cortex, which is responsible for executive functioning; basal ganglia, which is responsible for reward anticipation; and amygdala, which is responsible for emotional reactivity (Maski & Kothare, 2013). Dahl (1996 a, b) found that these arousal, attention, and emotional regulatory systems are modulated and integrated in the prefrontal cortex. When the child does not get sufficient sleep, this leads to an impairment of prefrontal cortical function, which leads to impaired ability to self-regulate attention, emotion, and goal-directed behaviour (Dahl, 1996a, b). This connection helps to explain both the short- and long- term adverse effects of childhood insomnia on daytime functioning, behaviour, and emotion (Liu et al., 2007).

I. Short-term effects

Family/social dysfunction. Childhood insomnia has a multidirectional relationship with parental/family dysfunction and emotional and behavioural problems (Baglioni, Spiegelhalder, Lombardo, & Riemann, 2010; Dahl, 1996a; Reid, Hong, & Wade, 2009). In adolescents, insufficient sleep leads to sleepiness, tiredness, irritability, moodiness, and low tolerance for frustration, all of which contribute to social problems at school and at home (Dahl, 1999, 2001). Emotional problems. Longitudinal studies have demonstrated that chronic insomnia contributes to the development of depression and anxiety in children, which may persist into adulthood (Baglioni et al., 2010; Gregory et al., 2005; Gregory & O’Connor, 2002; Gregory, Rijsdijk, Lau, Dayl, & Eley, 2009; Roberts, Robert, & Chen, 2002). Emotional lability may modulate the relationship between insomnia and the development of emotional disorders (Baglioni et al., 2010; Nixon et al., 2008). Among children aged 6 to 12 years, decreased levels of vagal suppression (an indicator of emotion regulation) and high levels of emotional intensity have been associated with sleep problems (El-Sheikh & Buckhalt, 2005). Sleep deprivation for one to three nights leads to increased negative affect and anxiety in adolescents (Talbot, McGlinchey, Kaplan, Dahl, & Harvey, 2010). Attention problems. Insomnia and sleep deprivation can lead to or worsen symptoms of ADHD, including distractibility, impulsivity, and inattentiveness (Dahl, 1999, 2001; van der Heijden et al., 2005a, b, c). Among adolescents, one night’s sleep deprivation has been demonstrated to result in significant deleterious effects on sustained attention, reaction speed, cognitive processing speed, and subjective sleepiness (Louca & Short, 2014). School performance. A meta-analysis of studies with children and adolescents concluded that sleepiness, poor sleep quality, and low sleep duration are significant predictors of impaired school performance (Dewald, Meijer, Oort, Kerkhof, & Bögels, 2010). Disrupted among children ages 6 to 12 years has been demonstrated to moderate the relationship between emotional insecurity at home and school performance (El-Sheikh, Buckhalt, Cummings, & Keller, 2007). In adolescents, school performance is affected when insufficient sleep leads to decreased motivation, impairments in attention and performance, and impairments in performing dual tasks and creative and flexible thinking (Dahl, 1999, 2001).

'''II. Long-term effects'''

Behavioural problems. The impairment of daytime neurobehavioral functioning caused by childhood insomnia often results in long-term behavioural issues (Maski & Kothare, 2013). Over time, chronic insomnia contributes to poor academic outcomes, the development of challenging behaviours, substance abuse, depression, anxiety, and suicidality (Maski & Kothard, 2013). In adolescents, the symptoms of chronic insomnia contribute to risk of daytime micro-sleeps which may contribute to accidents, use of stimulants, lack of motivation affecting goal-directed behaviour, mood lability leading to anger and aggressiveness, and problems with peers, parents, and teachers (Dahl, 1999, 2001). Mood disorders. Sleep-deprivation effects on mood can also result in a spiral effect whereby depression and anxiety cause further problems with sleep, which in turn worsens symptoms of depression and anxiety (Dahl, 1999, 2001). Insomnia is highly prevalent among children with clinical depression and anxiety, and symptoms of depression and anxiety are significantly worse among children with insomnia (Liu et al., 2007). Chronic insomnia may lead to altered frontal-limbic neuronal activity, which may contribute to the development of depression (Liu et al., 2007). Circadian sleep disturbances may lead to cycles of insomnia and hypersomnia, affecting mood among both healthy and depressed children (Liu et al., 2007). Among adolescents, sleep deprivation is associated with health-related quality of life, fatigue, and health complaints, especially headaches (Paiva et al., 2015). Family dysfunction. Behavioural insomnia is very common in childhood and, if not treated, may become more persistent, affecting the child’s cognitive and emotional functioning in addition to family dynamics (Glaze et al., 2002; Owens & Mindell, 2011). Although this may be a bidirectional relationship, with family dysfunction contributing to lack of consistent bedtime routines, parental sleep deficits may have deleterious effects of parents’ mood, behaviour, and interactions with the child; the resolution of childhood insomnia often leads to increased parental well-being and improved family dynamics (Glaze et al., 2002).

Interventions

I. Cognitive-behavioural interventions

Cognitive-behavioural interventions include cognitive approaches that aim at changing thoughts, attitudes, and beliefs, with behavioural approach that aim at changing behaviours based on learning theory (Tikotzky & Sadeh, 2010). Cognitive-behavioural interventions are highly effective in decreasing both short-term and long-term sleep-related problems (Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006). Outcomes include increased quality and quantity of sleep, improved child behaviour and well-being, and increased parental well-being (Hiscock, Bayer, Hampton, Ukoumunne, & Wake, 2008). With infants and young children, interventions are targeted at parents’ beliefs and behaviours, while direct work is generally done with older children and adolescents (Tikotzsky & Sadeh, 2010). Parents of infants are generally educated in techniques that reduce their night-time to promote the development of self-soothing skills (Mindell et al., 2006). Older children who are affected by bed refusal and night-time fears are treated with a variety of cognitive-behavioural techniques including muscle relaxation and breathing control, systematic desensitisation, positive self-talk and positive reinforcement, and guided imagery (Gordon, King, Gullone, Muris, & Ollendick, 2007). Among adolescents, treatment is similar to that of adults, including relaxation techniques, sleep restriction, reduction of physiological reactivity, and methods of coping with worry (Tikotzky & Sadeh, 2010). Among young children, there has been empirical support for the efficacy of several behavioural interventions in reducing bedtime problems and night wakings (Meltzer & Mindell, 2014). These include: (1) unmodified extinction, which requires caregivers to ignore all negative behaviour from bedtime until a set waking time; (2) graduated extinction (which requires the caregiver to check on the child at gradually lengthening intervals, but ignore negative behaviour); and (3) parent education/prevention (Meltzer & Mindell, 2014). For children affected by spontaneous nocturnal awakening, scheduled awakenings with comforting are expected to aid in consolidation (Meltzer & Mindell, 2014). There is also a variety of effective bedtime fading/positive routines which include establishing a positive bedtime routine, and stimulus control techniques, and gradually changing the bedtime to match when the child naturally falls asleep (Meltzer & Mindell, 2014). Sleep hygiene has been shown to be cultural, affecting the sleep quality of children and adolescents (LeBourgeois, Giannotti, Cortesi, Wolfson, & Harsh, 2005). Sleep hygiene refers to a set of behavioural practices that are conducive to quality sleep, adequate sleep duration, and daytime alertness (LeBourgeous et al., 2005). Procedures include setting and maintaining a consistent bed time and awakening time; setting and maintaining a positive bedtime routine; avoiding mental, emotional, or physical excitement before bedtime; sleeping in a quiet, comfortable environment; avoiding late-afternoon naps; and avoiding substances including caffeine, tobacco, and alcohol in the latter part of the day (LeBourgeous et al., 2005; Weiss et al., 2006).

'''II. Melatonin'''

Melatonin, which moderates natural sleep-wake rhythms, has been demonstrated to be effective in improving sleep and health status in children with idiopathic chronic sleep-onset insomnia (Smits et al., 2003). This treatment has been studied among children with ADHD and initial insomnia, who have a delay in natural melatonin onset (van der Heijden et al., 2005a, b, c). Among children with ADHD and chronic sleep-onset insomnia, melatonin improves sleep onset, behaviour, and mood (Hoebert, Van Der Heijden, Van Geijlswijk, & Smits, 2009). Both sleep hygiene and melatonin treatment (5 mg taken 20 minutes before bedtime) have been demonstrated to be effective for initial insomnia in children with ADHD who take stimulants, with combination treatment being the most effective (Weiss, Wasdell, Bomben, Rea, & Freeman, 2006).

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