Diagnostic and Treatment Challenges in Pediatric …...© Associated Professional Sleep Societies,...
Transcript of Diagnostic and Treatment Challenges in Pediatric …...© Associated Professional Sleep Societies,...
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Valerie M. Crabtree, Ph.D., CBSMSt. Jude Children’s Research Hospital
Lisa J. Meltzer, Ph.D., CBSMNational Jewish Health
AASM Sleep Medicine TrendsFebruary 20-22, 2015
Talking Stick Resort – Scottsdale, AZ
Diagnostic and Treatment Challenges in Pediatric Behavioral Sleep MedicineValerie McLaughlin Crabtree, Ph.D., CBSM
Department of PsychologySt. Jude Children’s Research Hospital
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1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR
X 2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Type of Potential Conflict Details of Potential Conflict
Grant/Research Support
Consultant
Speakers’ Bureaus
Financial support
Other Co-author: Meltzer and Crabtree, Pediatric Sleep Problems: A Clinican’s Guide to Behavioral Interventions (2015). APA Books.
3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
X 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:1. Lack, L.C., & Wright, H.R. (2007). Clinical management of delayed sleep phase disorder. Behavioral Sleep Medicine, 5, 57-76.2. Simard, V. & Nielsen, T. (2009). Adaptation of imagery rehearsal therapy for nightmares in children: A brief report. Psychotherapy
(Chic.), 46, 492-497.3. Mindell, J. A. & Owens, J. A. (2010). A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. (2nd ed.)
Philadelphia, PA: Lippincott, Willians, & Wilkins.
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Healthy sleep in children Anxiety and bedtime worries Nightmares Nocturnal enuresis Delayed Sleep-Wake Phase Disorder (DSWPD)
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Medical sleep disorders◦ Narcolepsy◦ CPAP adherence
Medically-induced sleep disorders◦ Pain◦ Nighttime caretaking
Parasomnias Infant/toddler sleep disturbance
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After infancy, consistent pattern of sleep/wake at night with afternoon naps in young children
Consistent bedtimes Consistent rise times Ability to self-soothe and return to sleep
after brief awakenings Average sleep efficiency 90-95% in
childhood Average sleep onset latency 10-20 minutes
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Age Ideal Sleep Duration Sleep Patterns0-2 months 12-18 hours Wide variability3-11 months 14-15 hours Multiple daytime naps1-3 years 12-14 hours Naps consolidate to 1
per day3-5 years 11-13 hours Naps stop around 5
years of age6-11 years 10-11 hours Discrepancy between
school and non-school nights
12-18 years 8.5-9.5 hours Later bedtimes
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Iglowstein et al., 2003
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10-year-old male “Worrier”◦ Getting in trouble at school◦ Problems with friends◦ Fears of illness
Fears at bedtime◦ Frequent checks
Curtain calls
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Target bedtime 9:00 pm Frequent checks leading to delayed sleep
onset Rise time 6:45 am Difficult to awaken Daytime irritability, daytime anxiety
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Pervasiveness of the anxiety◦ night-time only vs. throughout the day and night
History of trauma?◦ If yes, treat primary trauma
Reality basis of worries Developmental norms◦ Distinguishing fantasy from reality
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Backbone of anxiety interventions Create hierarchy of anxiety-provoking steps
toward going to bed and sleeping independently
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Lying in bed in dark alone
Lying in bed with lights on alone
Sitting in bedroom in dark with parents
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Backbone of anxiety interventions Create hierarchy of anxiety-provoking steps
toward going to bed and sleeping independently
Flashlight treasure hunts Positive self-talk Positive reinforcement
Pincus et al., 2012
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Set aside 15-30 minutes per day to worry. Should be separated from bedtime (before or
after dinner). May worry alone or with a parent present. Express any and all worries for worry time◦ May problem solve
At any other time of the day or night that the child begins to worry, cue to wait for worry time.
Parent does not provide reassurance outside of worry time
Jellesma et al., 2009
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Think like a detective Child identifies frequent worries and writes
them down. Look for all evidence for and against the
likelihood of the worry being true. A competing, more positive thought should
be developed for those worries that have the most evidence against them.
Replace fearful statements with positive self-statements.
Gordon et al., 2007
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Worry time 2x during the day◦ 15 minutes before school◦ 15 minutes just before dinner
Positive reinforcers for waiting until worry time to seek parental reassurance
During worry time:◦ Identified likelihood of each worry occurring◦ Problem-solved potential responses to each worry
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Progressive muscle relaxation◦ Practiced during the day◦ After effective use, began to use at bedtime
Sleep onset latency to 15 minutes Discontinued worry time Improved general worry
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7-year-old Asian male New onset of nightmares Precipitated by death of friend Nearly nightly basis Moving into parents’ room Sleeping on parents’ floor or in their bed Pre-sleep anxiety
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Occasional nightmares developmentally appropriate
Assess frequency, intensity Fears excessive if last beyond 8 years of age
and/or disrupt family Recurrent nightmares more common in
children with history of trauma◦ Criterion for Post-traumatic Stress Disorder
If PTSD, refer for treatment◦ Can simultaneously treat nightmares
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While awake, choose a recent nightmare “You can be the boss of your dreams.” Change the nightmare to have more positive
content Practice newly scripted dream repeatedly In children, modify instructions to include
drawing rather than simply writing, as with adults
When awaken following nightmare, practice in vivo with new, positive content
Simard & Nielsen, 2009
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Identified primary dream content◦ Being stepped on or shrunk by giant creatures
Able to draw most recent dream in the visit Re-scripted with new endings◦ Would point a shrink ray at the giant and “shrink
it to the size of an ant” Drew the new dream and hung it above his bed Home practice Nightmares ended within 2 weeks
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10-year-old Caucasian male Nephrogenic diabetes insipidus (NDI) ◦ Polydipsia throughout the day and night
ADHD, Primarily Inattentive Type Reading Disorder Methylphenidate Extended Release 18 mg Improved sustained attention in school
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Nightly enuresis 3-4 wetting episodes/night No daytime enuresis but urinates
approximately 1 X/hour No reported daytime fatigue or daytime
sleepiness
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Thorough physical examination ◦ Rule out enuresis secondary to medical condition
Assess if enuresis is primary or secondary◦ If secondary, assess for psychosocial stressors
and psychopathology◦ If related to stressors/psychopathology, treat
primary disturbance If primary, most likely unrelated to
emotional disturbance
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Can improve self-esteem Initiate treatment when child concerned &
motivated Eliminating liquids before bedtime has not
been shown to significantly reduce enuresis
Campbell et al., 2009; Glazener et al., 2005
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Imipramine, DDAVP, anticholinergic medications useful in short-term but see recurrence of enuresis when medication is discontinued◦ Unwanted side effects
Urine alarm (1938) most effective treatment Exact action unknown 40% relapse rate after treatment has ended Most can be corrected with additional course of
alarm intervention Overlearning reduces relapse ratesCampbell et al., 2009; Glazener et al., 2005
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Mowrer (1938) Child places on underwear prior to bedtime If alarm sounds/vibrates, child is to leave bed to
finish urinating in bathroom◦ Many children will require parents to awaken
them Child should change pajamas and sheets as
independently as possible Maintain record of dry vs. wet nights
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Glazener et al., 2005; Hjalmas et al., 2004
**Adding tolterodineslightly improves effect of desmopressin(Kazemi Rashed et al., 2013)
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Urine alarm Cleanliness training Positive reinforcement Retention control training Overlearning
Houts, 1996
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“Stream interruption”◦ constrict and release urinary muscles repeatedly
while urinating Postpone urination◦ Start with 1 minute◦ Gradually increase to up to 45 minutes
May cause learning to occur more quickly
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After 14 dry nights Drink water one hour before bedtime◦ Calculate amount by using 2 ounces per year of age
+ 2 Urinate before going to bed Continue until child achieves 14 additional
dry nights Generally have initial relapse for ~ 1 week Helps decrease relapse rate from ~40% to ~
20% May be difficult to implement
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Up to 85% resolution 7-29% relapse rate Usually improves with additional course of
intervention
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Alarm intervention after pharmacologic intervention failed
Mom placed his nighttime water in the bathroom
Increased volume of daytime water consumption
Reduced nighttime water consumption Improvements within the first few days Learned how to wake on his own after three
days
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After 4 weeks, only one wetting episode per night, with less volume
Consistently occurred just before midnight At all other times, he was waking before the
alarm went off and was successfully going to the bathroom
Hunter is very proud!
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14-year-old African American female Excessive Daytime Sleepiness Difficult to awaken in morning Truant Watches TV in bedroom until sleep onset of
2:00-3:00 am On sertraline and bupropion for several
months but still feels “low”
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Frequent co-occurring conditions◦ Depression◦ Truancy◦ Substance use/abuse
Psychoeducational assessment for those with school avoidance/truancy
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0:00
1:12
2:24
3:36
4:48
6:00
DSWPD Insomnia DSWPD Insomnia
BedtimeSleep Onset Time
Weekday Weekend
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Sunday Friday
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03:00 13:00
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Less focus on intensity and more on wavelength Adequate blue light necessary for phase shift Many now with light-emitting diode (LED) lights No UV exposure Use within 18 inches and 45º of midline of
patient’s visual field Do other activities while in front of the light box 30 minutes in the morning to advance circadian
rhythm
Meesters et al., 2011; Postolache & Oren, 2005
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May use chronotherapy if not in school Advance bedtime and rise time by 2 hours
daily Risk of continuing forward progression of
sleep onset time
Lack & Wright, 2007; Weitzman et al., 1981
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Stimulus Control Bedtime routine Bedtime 1:30 am Rise time 9:30 am Gradual advance of bed and rise time by 15
minutes every other day Goal of 10:30 pm bedtime; 6:30 am rise time Melatonin 0.5 mg 3 hours before bedtime Bright light therapy School consultationIvanenko et al. (2003); Samaranayake et al. (2010)
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Maintaining bedtime of 10:30 pm Rise time of 6:30 am Significant improvement in mood Significant improvement in family
interaction Attending school regularly
Note: At risk for delay of circadian rhythm delay again in the future
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