Waiting for the sandman

The Baltimore Sun

People tend to think of sleep problems as adult problems, generally connected to trouble with weight, diet, stress or depression. But more and more children are having trouble sleeping - and more often than not, a new study finds, the treatment they receive comes in the form of a pill.

The trend is concerning, the study authors say, because sleep deprivation can lead to headaches, irritability, impaired concentration and even behavior akin to attention-deficit hyperactivity disorder.

In addition, little is known about the consequences of the prescriptions children are being given to deal with their sleep disturbances. Neither their safety nor effectiveness has been studied in young people.

In the report, published in the Aug. 1 issue of the journal Sleep, researchers at Ohio State University in Columbus analyzed 18.6 million reported cases of sleep disorders in patients age 17 and younger. They found that 81 percent of these cases resulted in the prescribing of a drug to treat the problem. Only 7 percent of patients received dietary counseling, and only 22 percent were given behavioral therapies such as psychotherapy or stress management counseling.

The data, collected from 1993 to 2004 as part of the National Ambulatory Medical Care Survey, consisted of nationwide records of visits to doctors within all areas of medical practice. Included were the reason for the visit, diagnosis, demographic information and treatments prescribed. The data did not, however, include any information about whether medications were prescribed appropriately - nor was there data on what dosages were prescribed or for how long.

The high rates of sleep disorder prescriptions are supported by industry figures. According to a drug trend report published by Medco, a company that processes prescription-drug claims, sedative or hypnotic drug prescriptions grew at a rate of 14.6 percent in 2006, faster than any other class of medications. Medco also reported large increases in sleep aid prescriptions made to children ages 10 to 19, with an 80 percent increase in prescriptions for girls and a 64 percent increase in prescriptions for boys from 2001 to 2006.

In many cases - even more than is seen for adults - the drugs prescribed to the children were not ones specifically designed to aid sleep. For example, alpha-2 agonist drugs (such as Catapres or Tenex) and antihistamines (such as Atarax) have sedative effects that are secondary to their intended use. They were prescribed to 26 percent and 33 percent, respectively, of the children diagnosed with a sleep disorder.

Psychoactive drugs such as nonbenzodiazepines, specifically designed to improve sleep, were prescribed less often. The long-term effects of these drugs on the developing brains of children are unknown, and it's possible, experts say, that doctors prescribe the other medicines because they pose less risk.

Many factors that result in sleep problems in adults are at work in kids, says study senior author Milap Nahata, an Ohio State University professor of medicine - factors such as obesity, which has been on the rise among children as well as adults.

Changed habits may be playing their part as well. The National Sleep Foundation reported in 2006 that only 20 percent of adolescents get the recommended nine hours of sleep, and distractions such as phones, computers, or video games in children's bedrooms - where parents cannot easily monitor use - may lessen sleep quality.

Another problem may be that sleep issues in children aren't always easy to recognize. "Children with sleep disorders don't necessarily look sleepy. That's what happens in an adult," says Dr. Ronald Chervin, director of the University of Michigan Sleep Disorder Center. "In fact, some [sleepy] children look hyperactive - they fidget, they jump up and down. It could be that children are so motivated to stay awake that they create the stimulation themselves."

Chervin speculates that a substantial minority of hyperactive children may have undiagnosed sleep disorders. Children who snore, a behavior that indicates poor sleep quality, are more likely to be hyperactive - and also, he adds, to be in the lowest quartile of their class at school.

He adds that it's very reasonable for doctors to prescribe a sleep aid for a short time, to smooth the transition while behavioral changes are made. Behavioral approaches are almost always worth trying, he says: "It's very easy to develop some disorders, and it can be very easy to get rid of them as well."

However, only 19 percent of cases in the study received medication in concert with behavior therapy. Chervin adds that in some cases, such as when a child is developmentally impaired, behavioral approaches may not be appropriate.

But there are other factors at work, experts say. Pediatricians may be too busy, or influenced by parents not to try behavioral approaches, which can be time-intensive. Oftentimes, says Dr. William Kohler, medical director of the Florida Sleep Institute, "if we don't use [medication], both the family and the child are going to suffer."

The study showed that parents, when struggling with a child's sleep problem, take their kids to a variety of doctors, including pediatricians, family practice doctors, neurologists and other specialists. Many of these doctors lack understanding of sleep disorders, Kohler says.

Medical schools spend only a few hours on sleep problems. A 2001 survey of 626 pediatricians reported that less than half felt confident screening for such disorders, and only 25 percent felt confident about treating them.

Chelsea Martinez writes for the Los Angeles Times.

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