Sleep issues in children with mental health diagnoses

Sleep issues are common among children with mental health diagnoses, and may go undiagnosed due to the co-existing conditions.

Sleep difficulties, particularly problems falling asleep, are common among toddlers and preschoolers with mental health issues, according to a new study.

"Sleep problems in young children frequently co-occur with other behavioral problems, with evidence that inadequate sleep is associated with daytime sleepiness, less optimal preschool adjustment, and problems of irritability, hyperactivity and attention," said the study's leader, John Boekamp, clinical director of the pediatric partial hospital program at Bradley Hospital in Providence, R.I.

However, he said, sleep disorders may be unrecognized and underdiagnosed in young children, particularly when behavioral or emotional problems are present.

The study, published online in Child Psychiatry & Human Development, involved 183 children aged 6 years or younger receiving outpatient treatment for psychiatric problems. The researchers examined the prevalence of sleep disorders among these children and the nature of the sleep problems.

"The most common sleep difficulties reported nationally for toddlers and preschoolers are problems of going to bed, falling asleep and frequent night awakenings. Collectively, these problems are referred to as behavioral insomnias of childhood," said Boekamp in a hospital news release.

Recognized sleep disorders, particularly sleep onset insomnia, were more common than expected, the researchers found. Overall, 41 percent of children in the study met the criteria to diagnose a sleep disorder.

Sleep problems were most common in kids with disruptive behavior, and attention, anxiety and mood problems, the researchers found.

Early sleep problems could not only be the result of behavioral and emotional problems, but could also contribute to them, the researchers noted.

"Essentially, these young children might be caught in a cycle, with sleep disruption affecting their psychiatric symptoms, and psychiatric symptoms affecting their sleep-wake organization," said Boekamp. "It is important for families to be aware of how important sleep is to the behavioral adjustment and well-being of young children."

Sleep problems can complicate treatment for challenging behaviors, such as aggression and attention and mood problems. Daytime sleepiness and fatigue can make these problems even worse, the study's authors noted.

"This study is a great reminder that it's critical for mental health providers working with young children and their families to ask about children's sleep," said Boekamp.

"Simple questions about children's sleep patterns, including how long it takes a child to fall asleep at night and how frequently a child awakens after falling asleep, may yield important information that is relevant to clinical care, even when sleep problems are not the primary focus of treatment," he explained.

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Study: Sleep issues common for children with psychiatric disorders

A study found that sleep issues are more common for children with a psychiatric disorder.

John Boekamp, Ph.D., clinical director of the Pediatric Partial Hospital Program (PPHP) at Bradley Hospital recently led a study that found sleep difficulties - particularly problems with falling asleep - were very common among toddlers and preschool-aged children who were receiving clinical treatment for a wide range of psychiatric disorders. The study, titled "Sleep Onset and Night Waking Insomnias in Preschoolers with Psychiatric Disorders," is now published online in the journal Child Psychiatry & Human Development.

"The most common sleep difficulties reported nationally for toddlers and preschoolers are problems of going to bed, falling asleep and frequent night awakenings – collectively, these problems are referred to as behavioral insomnias of childhood," said Boekamp. "Sleep problems in young children frequently co-occur with other behavioral problems, with evidence that inadequate sleep is associated with daytime sleepiness, less optimal preschooladjustment, and problems of irritability, hyperactivity and attention."

Boekamp's team was interested in learning more about sleep and sleep problems in young children with behavior problems, as early sleep problems may be both a cause and consequence of children's difficulties with behavioral and emotional self-regulation. "Essentially, these young children might be caught in a cycle, with sleep disruption affecting their psychiatric symptoms and psychiatric symptoms affecting their sleep-wake organization," said Boekamp.

The partial program that Boekamp leads at Bradley Hospital is a family-centered, intensive day treatment program for very young children aged from newborn to six who have serious emotional, behavioral or relationship disturbances. This study examined the nature and prevalence of diagnostically defined sleep disorders, including Sleep Onset Insomnia (SOI) and Night Waking Insomnia (NWI), in a group of 183 young children admitted to the program. Diagnosable sleep disorders, particularly SOI, were quite common in the group, exceeding previous estimates obtained in community settings. Overall, 41 percent of children in the study also met diagnostic criteria for a sleep disorder. Sleep problems were especially common in children with disruptive behavior, attention, anxiety and mood problems.

"It is important for families to be aware of how important sleep is to the behavioral adjustment and wellbeing of young children," said Boekamp. "Sleep disorders may be unrecognized and under-diagnosed in young children, particularly when other behavioral or emotional problems are present."

Difficulties with sleep may be particularly important to address when children are also struggling with challenging daytime behaviors, such as problems with compliance, aggression, attention and mood. Sleepiness and fatigue may exacerbate these problem behaviors.

"This study is a great reminder that it's critical for mental health providers working with young children and their families to ask about children's sleep," said Boekamp. "Simple questions about children's sleep patterns, including how long it takes a child to fall asleep at night and how frequently a child awakens after falling asleep, may yield important information that is relevant to clinical care, even when sleep problems are not the primary focus of treatment."

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Autism checklist improved for diagnosis in toddlers

A checklist used as a screening tool for autism has successfully been improved for diagnosis in toddlers.

An updated screening tool that physicians administer to parents to help determine if a very young child has autism has been shown to be much more accurate than earlier versions at identifying children who could benefit from further evaluation, according to researchers supported by the National Institutes of Health.

The Modified Checklist for Autism in Toddlers — Revised, with Follow-Up (M-CHAT–R/F) — is a free, two-step screening tool used to detect children likely to have autism. It is intended for use at regular well-child checkups for children 16 to 30 months old. With the M-CHAT-R/F, health care providers can classify a child’s risk of having autism as low, medium or high, on the basis of parents’ answers to 20 questions.

“This checklist can more accurately identify children likely to have autism so they can get the treatment and support they need,” said Alice Kau, Ph.D., of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the NIH institute that funded the study. “Given that the typical autism diagnosis occurs at age 4, it also offers the possibility of detecting autism much earlier — during regular doctor’s visits when a child is 18 months or 2 years old. And earlier intervention has been shown to improve outcomes for children with autism.”

A score in the high-risk range warrants a referral for further evaluation for possible autism. For a child determined to be at medium risk, M-CHAT R/F includes a follow-up questionnaire used soon after the original evaluation to obtain additional information needed to more definitively classify the child as either high risk or low risk.

Based on the M-CHAT-R/F classifications, the researchers found that a smaller proportion of children received a medium- or high-risk assessment (7 percent) than with earlier versions of the checklist (9 percent). However, more total cases of autism were detected with the revised checklist than with earlier versions (67 cases per 10,000 screened vs 45 cases per 10,000 screened).

Of the more than 16,000 children evaluated with the screening tool, 93 percent of the children screened were considered low-risk, 6 percent were in the medium-risk range and 1 percent were considered high-risk.

Of all the children who determined by the test to be at risk after the M-CHAT-R/F follow-up, 95 percent were eventually found to have some form of developmental delay, including more than 47 percent with autism spectrum disorder.

First author Diana L. Robins, Ph.D., of Georgia State University (GSU), in Atlanta, conducted the research with GSU colleague Karís Casagrande, and Marianne Barton, Ph.D., Chi-Ming Chen, Ph.D., Thyde Dumont-Mathieu, M.D., M.P.H., and Deborah Fein, Ph.D., all of the University of Connecticut in Storrs. Dr. Fein was the study’s senior author.

The findings appear in Pediatrics.

The researchers updated an earlier version of the autism screening tool, adding examples, rephrasing some questions and dropping others that previously did not elicit strong responses. Using the revised tool, the researchers worked with health care providers to screen more than 15,000 toddlers considered at low risk for autism.

“Earlier tools cast a wider net, but these refinements will allow health care providers to focus energy where it is needed most and will reduce the number of families who go through additional testing but which ultimately do not need treatment interventions,” said Dr. Fein.

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