Children with psychiatric disorder

High rates of sleep disturbance have been described in child psychiatric groups compared with other children (2,25. and 26 and in specific psychiatric disorders.

Various sleep problems, including panic attacks, have been described in anxious children in general including those with panic disorders. Similarly, many types of sleep problem (including nightmares and other disturbed nocturnal episodes, excessive daytime sleepiness, and bedwetting) have been reported to be particularly frequent in traumatized children, including those who have suffered burn injury, (28) abuse/29) or road traffic accidents/30 Treatment of the sleep disturbance has appeared to improve their emotional state,(31 but further research is needed to assess the therapeutic contribution of specific treatment for the sleep disorder as part of the overall care of traumatized children.

Difficulty sleeping is the main complaint in children and adolescents with severe depressive disorders but perhaps 25 per cent complain of excessive sleepiness, possibly because of difficulty getting to sleep, and/or poor-quality sleep. (26> The findings are inconsistent concerning the presence in young patients of the sleep-stage (especially REM sleep) abnormalities which have been described as biological markers in some forms of severe adult depressive disorders.

Parental reports of sleep problems in children with ADHD(33) are very common, more than in other child psychiatric groups. Parental impressions can be distorted but preliminary objective evidence also suggests that persistent sleep disturbance is common and sometimes important as the primary cause (or a significant contributory factor) rather than simply a consequence of ADHD. ADHD symptoms have sometimes been attributed to definitive sleep disorders (OSA, periodic limb movements in sleep, circadian sleep rhythm disorders) in which sleep quality is impaired with improvement in ADHD symptoms following treatment of the sleep disorder. Preliminary studies of sleep physiology or other objective aspects of sleep in children have also produced evidence of sleep abnormalities. Even where ADHD is attributable to other factors, sleep disruption is likely to worsen the child's behaviour, meriting treatment in its own right wherever possible.

Other psychiatric disorders in which different types of sleep disturbance is reported to be prominent are autism (including circadian sleep rhythm disorders), Asperger's syndrome (hypersomnia), tic disorders including Tourette's syndrome (sleeplessness and parasomnias), and obsessive-compulsive disorder (poor-quality sleep). Sleep complaints are also prominent in the chronic fatigue syndrome. As mentioned earlier, disruption by frequent awakenings (not obviously attributable to daytime inactivity) has been described in teenagers with this condition (22) suggesting that daytime symptoms might be at least partly attributable to poor sleep quality. Occasionally, Munchausen's syndrome by proxy comes to light in the form of complaints of a sleep disturbance. The sleep of conduct-disordered children has received little attention but preliminary reports are in keeping with the expectation that their sleep is disturbed because of their adverse or disorganized home and social circumstances and general way of life.

Apart from psychiatric disorders themselves, drugs used in their treatment may affect sleep. Stimulant medication for ADHD appears to cause sleeping difficulties is some children but, although some changes in sleep physiology have been demonstrated, some children with ADHD may settle to sleep more readily even if their medication is given later in the day, because it improves their bedtime behaviour.

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