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The etiologies of sleep disturbances in adolescents are varied and include biological, environmental, and sociocultural factors. Health care practitioners need to have a basic understanding of normal sleep development in adolescents and the risk factors for inadequate sleep, as well as an appreciation for the myriad potential consequences of insufficient sleep (ie, mood dysregulation, academic failure, and obesity). This chapter provides a systematic approach to screening and evaluating adolescent sleep complaints in the clinical setting and provides suggestions for anticipatory guidance regarding healthy sleep, which should be part of standard adolescent health care.

The relationship between specific epilepsy syndromes and particular sleep symptoms has not been well delineated. The authors’ aim was to test the hypothesis that children with rolandic epilepsy exhibit more frequent sleep problems and daytime sleepiness compared with children without epilepsy. They compared parent-reported sleep behaviors of 43 children with rolandic epilepsy aged 6 to 16 years recruited from 5 US pediatric neurology centers with a historical reference and sleep clinic sample using the Child Sleep Habits Questionnaire. The authors compared the differences in mean frequency of sleep problems and patterns. Total Children’s Sleep Habits Questionnaire scores were significantly higher (P < .001) in the rolandic epilepsy sample than reference. Parents of children with rolandic epilepsy reported a significantly shorter sleep duration (P < .006), more frequent parasomnias (P < .008), and increased daytime sleepiness (P < .001). Thus, parents of children with rolandic epilepsy reported more problematic sleep and daytime impairment compared with a reference sample of children.

To examine the impact of a 30-minute delay in school start time on adolescents' sleep, mood, and behavior.Participants completed the online retrospective Sleep Habits Survey before and after a change in school start time.An independent high school in Rhode Island.Students (n = 201) in grades 9 through 12. Intervention Institution of a delay in school start time from 8 to 8:30 am.Sleep patterns and behavior, daytime sleepiness, mood, data from the Health Center, and absences/tardies.After the start time delay, mean school night sleep duration increased by 45 minutes, and average bedtime advanced by 18 minutes (95% confidence interval, 7-29 minutes [t(423) = 3.36; P.001]); the percentage of students getting less than 7 hours of sleep decreased by 79.4%, and those reporting at least 8 hours of sleep increased from 16.4% to 54.7%. Students reported significantly more satisfaction with sleep and experienced improved motivation. Daytime sleepiness, fatigue, and depressed mood were all reduced. Most health-related variables, including Health Center visits for fatigue-related complaints, and class attendance also improved.A modest delay in school start time was associated with significant improvements in measures of adolescent alertness, mood, and health. The results of this study support the potential benefits of adjusting school schedules to adolescents' sleep needs, circadian rhythm, and developmental stage.

With the increase in the number of international projects in pediatric sleep medicine, the need to adapt sleep-screening tools for use in cross-cultural settings has rapidly grown. However, accepted procedures for translating and adapting existing measures are not uniformly and consistently incorporated in epidemiologic studies, resulting in potential measurement problems. The aims of this brief report are to (a) give an overview of principles for the translation and cultural adaptation of pediatric sleep-screening instruments and (b) illustrate these procedures in describing the translation and adaptation of two widely used pediatric sleep-screening tools for a German population. Challenges in the development of cross-cultural adaptations of parent-report sleep-screening measures for children are also discussed.

Plasma concentrations of Δ-9-tetrahydrocannabinol, the principal psychoactive cannabinoid in marijuana, decline to values substantially

Sleep disturbances in children with neurodevelopmental disabilities are common and have a profound effect on the quality of life of the child, as well as the entire family. Although interventions for sleep problems in these children often involve a combination of behavioral and pharmacologic strategies, the first line of treatment is the promotion of improved sleep habits or “hygiene.” Despite the importance of sleep-hygiene principles, defined as basic optimal environmental, scheduling, sleep-practice, and physiologic sleep-promoting factors, clinicians often lack appropriate knowledge and skills to implement them. In addition, sleep-hygiene practices may need to be modified and adapted for this population of children and are often more challenging to implement compared with their healthy counterparts. This first comprehensive, multidisciplinary review of sleep hygiene for children with disabilities presents the rationale for incorporating these measures in their treatment, outlines both general and specific sleep-promotion practices, and discusses problem-solving strategies for implementing them in a variety of clinical practice settings.

The relationship between attention-deficit/hyperactivity disorder (ADHD) and sleep is a complex one which poses many challenges in clinical practice.Studies of sleep disturbances in children with academic and behavioral problems have underscored the role that primary sleep disorders play in the clinical presentation of symptoms of inattention and behavioral dysregulation. In addition, recent research has shed further light on the prevalence, type, risk factors for, and impact of sleep disturbances in children with ADHD.The following discussion of the multi-level and bi-directional relationships among sleep, neurobehavioral functioning, and the clinical syndrome of ADHD synthesizes current knowledge about the interaction of sleep and attention/arousal in these children.Guidelines are provided, outlining a clinical approach to evaluation and management of children with ADHD and sleep problems.

Approximately 25% of all children experience some type of sleep problem at some point during childhood. A number of studies have examined the prevalence of parent- and child-reported sleep complaints in large samples of healthy, typically developing children and adolescents; many of these have also further delineated the association between disrupted sleep and behavioral concerns. Sleep problems are even more prevalent in children and adolescents with chronic medical, neurodevelopmental, and psychiatric conditions. It is important to note that definitions of normal sleep patterns, sleep requirements, and sleep disorders in childhood must necessarily incorporate the wide range of normal developmental and physical maturational changes across childhood and adolescence, and cultural, environmental, and social influences.

These practice parameters pertain to the treatment of hypersomnias of central origin. They serve as both an update of previous practice parameters for the therapy of narcolepsy and as the first practice parameters to address treatment of other hypersomnias of central origin. They are based on evidence analyzed in the accompanying review paper. The specific disorders addressed by these parameters are narcolepsy (with cataplexy, without cataplexy, due to medical condition and unspecified), idiopathic hypersomnia (with long sleep time and without long sleep time), recurrent hypersomnia and hypersomnia due to medical condition. Successful treatment of hypersomnia of central origin requires an accurate diagnosis, individual tailoring of therapy to produce the fullest possible return of normal function, and regular follow-up to monitor response to treatment. Modafinil, sodium oxybate, amphetamine, methamphetamine, dextroamphetamine, methylphenidate, and selegiline are effective treatments for excessive sleepiness associated with narcolepsy, while tricyclic antidepressants and fluoxetine are effective treatments for cataplexy, sleep paralysis, and hypnagogic hallucinations; but the quality of published clinical evidence supporting them varies. Scheduled naps can be beneficial to combat sleepiness in narcolepsy patients. Based on available evidence, modafinil is an effective therapy for sleepiness due to idiopathic hypersomnia, Parkinson's disease, myotonic dystrophy, and multiple sclerosis. Based on evidence and/or long history of use in the therapy of narcolepsy committee consensus was that modafinil, amphetamine, methamphetamine, dextroamphetamine, and methylphenidate are reasonable options for the therapy of hypersomnias of central origin.

To achieve consensus among pediatric sleep medicine practitioners on recommendations for the advancement of the field in the areas of research, clinical practice, education, and public policy.Leading pediatric sleep medicine researchers and clinicians, in collaboration with Brown Medical School, convened a conference to discuss the state of the field. Participants engaged in multiple discussion panels and work groups, ultimately creating recommendations to advance basic and clinical research, clinical practice, sleep education, and public policy.Participants reached agreement on the major challenges facing the field. Key points of consensus were the need to conduct long-term epidemiologic studies of sleep patterns and sleep disorders in children, standardize polysomnography and other sleep-measurement methodologies, examine the links between insufficient and disrupted sleep in the pediatric population and physical and mental health outcomes, and develop clinical standards of practice. Attendees also agreed on the need to educate more medical health practitioners and the public on pediatric sleep. The importance of research on sleep in children and adolescents to inform public policy decisions was also endorsed.Pediatric sleep medicine is a related, but unique, discipline within the broader field of sleep medicine. Additional research, both basic and clinical, on all aspects of children's sleep is necessary to elucidate the neurophysiologic basis of normal sleep development; to establish a solid foundation for the evaluation, diagnosis, and treatment of pediatric sleep disorders; and to formulate evidence-based public policy in sleep health.

To formulate a rational approach to the pharmacologic treatment of pediatric insomnia, and to develop clinical guidelines regarding indications, target populations, and parameters for the use of these medications, especially by community-based pediatricians.A multidisciplinary task force developed under the auspices of the American Academy of Sleep Medicine, which included experts in pediatric sleep medicine, psychiatry, pharmacology, neurology, and general pediatrics.Review of existing data regarding current use of over-the-counter and prescription medications for pediatric insomnia in the primary care practice setting, and of empirical data on the pharmacology, safety, efficacy, and tolerability of medications commonly used for the treatment of pediatric insomnia.Group consensus definition of pediatric insomnia and clinical guidelines; working group recommendations regarding special populations and future directions.Use of medications for pediatric insomnia should be diagnostically driven, and should be implemented in conjunction with empirically-based behavioral treatment strategies and adequate sleep hygiene. Specific target populations include children with neurodevelopmental disorders, pervasive developmental disorders, chronic medical conditions, and psychiatric disorders. Additional research, including clinical trials, is critically needed to provide an evidence-based approach to the use of these medications in clinical practice.

OBJECTIVE: To explore the association between sleep and accidental injury among school-aged children in a rural area of China. METHODS: Information was collected regarding parent-reported sleep patterns and problems of 182 children with a history of a medically attended injury in the previous 12 months and of 207 non-injured control children, and data were analyzed to compare differences between the two groups of children. RESULTS: Global sleep disturbance (Children's Sleep Habits Questionnaire [CSHQ] total score) was significantly higher in the injured group (IG) than in the non-injured group (NIG), and a greater percentage of the IG scored above the clinical cut-off score on the CSHQ. Stepwise multivariate logistic regression analysis showed that the CSHQ parasomnias and daytime sleepiness subscale scores were significantly and positively related to injury. Sleep duration was also shorter in the IG, and this group had a greater percentage (23% vs 12%) of "short sleepers" (

Pediatric sleep disorders are common, have significant effects on daytime functioning of children and families, and most are amenable to some combination of behavioral management strategies and pharmacological treatment. It is particularly important for the primary care physician to screen for sleep problems in children, especially in high-risk populations. A detailed history evaluating circumstances related to the sleep problem should be obtained. Addition of pharmacological therapy to non-pharmacological interventions for pediatric sleep disorders for disorders such as insomnia, parasomnias, narcolepsy, RLS or PLMs should be diagnostically driven, and should consider both the best match between the medication type and individual patient, as well as the dosing regimen with the least side effects. Until these medications are systematically studied or newer specific agents are developed for pediatric sleep problems, it is necessary for practitioners looking after children to optimize quality of life and sequalae related to sleep problems, while minimizing potential side effects.

There is continuing speculation about the relationship between attention-deficit/hyperactivity disorder (ADHD) and obstructive sleep apnea (OSA) or periodic limb movement disorder (PLMD)/restless legs syndrome. The objective was to determine if a significant portion of children with ADHD diagnosed using DSM-IV criteria have OSA or PLMD.Sleep disorders centers in a private practice setting and a hospital setting.Children aged 6 to 14 years with ADHD were enrolled. Patients with snoring were not excluded. Although patients with snoring plus either observed apneic episodes in sleep or excessive daytime sleepiness were to be excluded, as were patients with restless legs at night, only 1 subject actually had to be excluded because of these criteria.Forty children were evaluated with a polysomnogram. A respiratory disturbance index cut-off of more than 5 per hour of sleep was used to diagnose OSA, and a periodic limb movement (with arousal) index cut-off of 5 or more per hour of sleep was used to diagnose PLMD. The Attention-Deficit/Hyperactivity Disorder Rating Scale-IV-Parent Version: Investigator Administered and Scored was used to determine severity of inattentive, hyperactive, and total ADHD symptoms. Except for a somewhat longer rapid eye movement sleep latency and decreased percentage of rapid eye movement sleep, polysomnography was essentially normal. No patient had OSA or PLMD on polysomnography.OSA or PLMD is not a common underlying disorder or etiologic factor in patients who meet the criteria for ADHD. In the absence of symptoms suggesting a primary sleep disorder, such as snoring with observed apneic episodes in sleep or daytime sleepiness or restless legs, polysomnographic evaluation does not seem indicated in patients with ADHD.

These practice parameters are an update of the previously-published recommendations regarding the indications for polysomnography and related procedures in the diagnosis of sleep disorders. Diagnostic categories include the following: sleep related breathing disorders, other respiratory disorders, narcolepsy, parasomnias, sleep related seizure disorders, restless legs syndrome, periodic limb movement sleep disorder, depression with insomnia, and circadian rhythm sleep disorders. Polysomnography is routinely indicated for the diagnosis of sleep related breathing disorders; for continuous positive airway pressure (CPAP) titration in patients with sleep related breathing disorders; for the assessment of treatment results in some cases; with a multiple sleep latency test in the evaluation of suspected narcolepsy; in evaluating sleep related behaviors that are violent or otherwise potentially injurious to the patient or others; and in certain atypical or unusual parasomnias. Polysomnography may be indicated in patients with neuromuscular disorders and sleep related symptoms; to assist in the diagnosis of paroxysmal arousals or other sleep disruptions thought to be seizure related; in a presumed parasomnia or sleep related seizure disorder that does not respond to conventional therapy; or when there is a strong clinical suspicion of periodic limb movement sleep disorder. Polysomnography is not routinely indicated to diagnose chronic lung disease; in cases of typical, uncomplicated, and noninjurious parasomnias when the diagnosis is clearly delineated; for patients with seizures who have no specific complaints consistent with a sleep disorder; to diagnose or treat restless legs syndrome; for the diagnosis of circadian rhythm sleep disorders; or to establish a diagnosis of depression.

Study objective There is continuing speculation about the relationship between attention-deficit/hyperactivity disorder (ADHD) and obstructive sleep apnea (OSA) or periodic limb movement disorder (PLMD)/restless legs syndrome. The objective was to determine if a significant portion of children with ADHD diagnosed using DSM-IV criteria have OSA or PLMD. Setting Sleep disorders centers in a private practice setting and a hospital setting. Participants Children aged 6 to 14 years with ADHD were enrolled. Patients with snoring were not excluded. Although patients with snoring plus either observed apneic episodes in sleep or excessive daytime sleepiness were to be excluded, as were patients with restless legs at night, only 1 subject actually had to be excluded because of these criteria. Measurements and results Forty children were evaluated with a polysomnogram. A respiratory disturbance index cut-off of more than 5 per hour of sleep was used to diagnose OSA, and a periodic limb movement (with arousal) index cut-off of 5 or more per hour of sleep was used to diagnose PLMD. The Attention-Deficit/Hyperactivity Disorder Rating Scale-IV-Parent Version: Investigator Administered and Scored was used to determine severity of inattentive, hyperactive, and total ADHD symptoms. Except for a somewhat longer rapid eye movement sleep latency and decreased percentage of rapid eye movement sleep, polysomnography was essentially normal. No patient had OSA or PLMD on polysomnography. Conclusions OSA or PLMD is not a common underlying disorder or etiologic factor in patients who meet the criteria for ADHD. In the absence of symptoms suggesting a primary sleep disorder, such as snoring with observed apneic episodes in sleep or daytime sleepiness or restless legs, polysomnographic evaluation does not seem indicated in patients with ADHD.

The objective of this study was to investigate the relationship between sleep disturbance and both injury rates and injury-prone behaviors in preschool-age and early school-age children, using cross-sectional surveys of sleep disturbance (Children's Sleep Habits Questionnaire) and injury-related behaviors (Injury Behavior Checklist), and chart review of injuries. Participants were 71 patients enrolled in a pediatric clinic in a children's teaching hospital, ages 3 through 7 years, coming either for well-child care in a pediatric primary care clinic or for pediatric emergency room treatment of minor injuries. Results suggest that children with more frequent injuries had significantly more sleep problems overall, particularly anxiety around sleep, than did children with low injury rates. Children with more parent-reported injury-prone behaviors also had significantly more sleep disturbance. Daytime sleepiness-related items did not differ between injury history or injury behavior groups. Results of this study support an increased prevalence of sleep disturbances in young children with higher injury rates and more injury-prone behavior. Sleep disturbance may be a potential risk factor for increased injuries in this age group.

To identify and model the effects of sleep loss and fatigue on resident-physicians' professional lives and personal well-being.In 2001-02, 149 residents at five U.S. academic health centers and from six specialties (obstetrics-gynecology, emergency medicine, family medicine, internal medicine, pediatrics, surgery) were recruited for the study. Residents were all in good standing in their programs. In a mixed-methods design, focus groups consisted of an average of seven (range, three to 14) individuals in the same year of training and residency program, for a total of 60 interns and 89 senior residents. Trained moderators conducted focus groups using a standardized, semistructured discussion guide. Participants also completed a 30-item quantitative questionnaire assessing sleepiness and workplace sleep attitudes that included the Epworth Sleepiness Scale (ESS).Residents described multiple adverse effects of sleep loss and fatigue on learning and cognition; job performance, including professionalism and task performance; and personal life, including personal well-being and relationships with spouse or significant other and family. Only 16% of the sample scored within the "normal" range on the ESS; 84% scored in the range for which clinical intervention is indicated. Sleepiness was consistent across institution, specialty, years of training, age, gender, marital status, and having children.More residents perceived that sleep loss and fatigue had major impact on their personal lives during residency, leaving many personal and social activities and meaningful personal pleasures deferred or postponed. Sleep loss and fatigue also had major impact on residents' abilities to perform their work. This finding further substantiates the growing concern about the potential impact on professional development. These observations should be taken into account in developing new training guidelines and educational interventions for housestaff.

Reduced sleep time is commonplace for many interns and residents. Recent studies, however, suggest that sleep loss and fatigue result in significant neurobehavioral impairments in healthy young adults. We reviewed studies addressing the effects of sleep loss on cognition, performance, and health in surgical and nonsurgical residents. We describe the effectiveness of countermeasures for sleepiness, including recent work-hour restrictions. A more complete understanding of the issues of sleep loss during residency training can inform innovative strategies to minimize the effects of sleepiness and fatigue on patient care and resident safety.

To determine what sleep abnormalities may exist in children with juvenile rheumatoid arthritis (JRA). and their relationship to pain, dysfunction. and disease activity.Twenty-five children with active JRA (11 pauciarticular, 9 polyarticular, 5 systemic) had their sleep assessed by parallel, validated patient and parent questionnaires (Sleep Self-Report, SSR, and Children's Sleep Habits Questionnaire, CSHQ). Disease activity was assessed by parent and physician global assessments (on a 5 point scale: 0 = no disease activity to 4 = very severe disease), erythrocyte sedimentation rate (ESR), and numbers of swollen and limited joints. Functional assessment was based on parental completion of the Juvenile Arthritis Functional Assessment Report (JAFAR). Pain was assessed by the average pain visual analog scale of the Varni Pediatric Pain Questionnaire. Results were compared to those from 45 healthy age and sex matched controls by Mann-Whitney U tests, and correlated with variables of JRA disease activity, function, and pain using Spearman correlations.Patients with JRA had higher total score on the CSHQ (p0.0001), as well as subscales assessing night wakings, parasomnias. sleep anxiety, sleep-disordered breathing, and morning wakening/daytime sleepiness (p0.0001-0.05). There were no correlations between CSHQ scores and JRA disease activity or pain variables, but the total score on the SSR did correlate with pain (r = 0.56, p = 0.005).We conclude that sleep abnormalities are common in children with JRA, and are multi-dimensional.

To the Editor .— We read with great interest the recent revised sudden infant death syndrome (SIDS) policy statement from the American Academy of Pediatrics (AAP).1 The AAP should be commended for its leadership in this important area. The reduction in SIDS death subsequent to the 1992 AAP recommendations regarding sleeping position has been an enormous achievement, and we sincerely hope that this new policy will successfully lead to a further decrease in SIDS. However, from the perspective of the field of pediatric sleep medicine, the policy statement's laudable but narrow focus on SIDS prevention raises a number of important issues that …

The incidence of parent-reported parasomnias in children with obstructive sleep apnea (OSA) is increased in comparison with a normative age-matched sample of children but is not higher than that for a similar clinical sample of children with a diagnosed behavioral sleep disorder.

Giant fibrovascular polyps of the esophagus and hypopharynx are benign tumors of the upper digestive tract Although a rare cause of asphyxiation, laryngeal impaction by a regurgitated polyp of the esophagus may be the initial symptom that brings the patient to request medical attention. Two new cases of giant fibrovascular polyps with dramatic and potentially life-threatening presentations illustrate the unpredictable behavior of these unusual tumors. Both patients presented to the emergency center with a history of coughing and eructation followed by temporary airway obstruction that was relieved by clenching a regurgitated fleshy mass between the teeth. Diagnostic and therapeutic intervention requires aggressive airway management, radiographic and endoscopic evaluation, and definitive surgical treatment. Tracheotomy was required in one patient, and successful endotracheal intubation provided satisfactory airway control in the second. Esophagoscopy revealed the origin of both tumors to be near the cricopharyngeal muscle. Complete surgical excision was curative in both cases.

Despite the recognized ototoxicity of cis-platinum, a clinical outline for the audiologic evaluation of patients receiving this drug has not been clearly defined. In a practical approach to this problem, the audiograms of 48 pediatric patients referred for monitoring during planned cis-platinum therapy were reviewed. Eleven patients tested with auditory brain-stem response (ABR) audiometry demonstrated several limitations of this modality. Fourteen children underwent initial ABR testing followed by at least two pure-tone audiograms. The remaining 23 patients had their hearing evaluated by pure-tone audiometry only. Various factors such as patient age, cis-platinum dosage, and cranial radiation exposure were analyzed for apparent effect. Younger patients tended to be more susceptible to audiologic changes with the administration of cis-platinum. The proportion of patients who demonstrated a hearing loss increased with successive dosing as did the severity of the hearing loss. Prior exposure to cranial radiation was strongly linked to the development of hearing loss following cis-platinum therapy. Guidelines are presented regarding the use of clinical audiometry in the screening of these pediatric oncology patients.

To assess the relative contribution of potential risk factors for adverse neurobehavioral outcomes in children referred for evaluation of sleep-disordered breathing (SDB), including weight, mean sleep duration, and comorbid sleep disorders.Medical record review.Academic pediatric medical center.Clinical sample of 235 children aged 3 to 18 years undergoing overnight polysomnography for symptoms of SDB.History of behavioral, emotional, and academic problems and Child Behavior Checklist (CBCL) scores.More than half (56%) of the sample was overweight or at risk for overweight, more than one-third (36%) was classified as being short sleepers, and almost half (49%) had at least 1 additional sleep diagnosis. Forty-seven percent had a history of behavioral problems and 23% had a reported diagnosis of attention-deficit/hyperactivity disorder. There were no significant differences in CBCL scores based on any measure of SDB disease severity. Increased weight was associated with increased internalizing CBCL scores in a dose-dependent fashion (P = .003), while short sleepers were more likely to have elevated externalizing scores (P.001). Overall, the strongest predictor of adverse behavioral outcomes was the presence of at least 1 additional sleep diagnosis (P.001).The relationship between SDB and parent-reported behavioral outcomes in children is complex. In addition to SDB-related impairments, clinicians should consider the relative contributions of being overweight, insufficient sleep, and comorbid sleep disorders when assessing behavior in these children.