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When dealing with sleep-onset insomnia caused by anxiety, physicians will ask about daytime complaints, fears, or worries, which may suggest a more pervasive anxiety problem warranting referral to a children's mental health professional. Exposure to frightening media events and a history of stressful events such as a death in the family or the arrival of a new sibling should be explored. More severe stressors, such as enduring sexual abuse or witnessing family violence, are considerations in some cases. A simple but common cause of sleep-onset insomnia in children is rumination on issues of the day at bedtime. This problem can often be settled with a small amount of extra attention and conversation with a parent at bedtime. Anxious children are best treated with a combination of therapies, including a cognitive-behavioral approach that empowers them to generate solutions and gain mastery over their worries. For example, the physician might say to the child, "Adults sometimes feel nervous, too. Let's make a list of the things that could make you feel safe and brave and strong." In persistent and difficult cases, a 1- to 3-month trial of the short-acting benzodiazepine alprazolam (Xanax) may be indicated, along with referral to a mental health professional. Obstructive sleep apnea is seen in as many as 3% of preschool and school-age children. Parents often complain that the child snores nightly in all positions, perhaps worse when lying on their backs. Parents may also observe choking spells or what they refer to as breath holding or a halting pattern in the snoring. Children may assume a position of neck hyperextension during sleep. Sleep fragmentation caused by obstructive sleep apnea may lead to daytime sleepiness, manifested as increased napping or falling asleep at school or while watching TV. Alternatively, children may show changes in daytime behavior, including hyperactivity, distractibility, and mood changes. Common childhood causes of sleep apnea are inflammation of the tonsils or adenoids. These can usually be removed in a simple operation and give your child some relief. Sleep disorders to watch for in adolescents are delayed sleep-phase syndrome - a disorder of circadian rhythm and narcolepsy. Delayed sleep-phase syndrome is common among teenagers, although some delay in sleep phase is considered normal in this age-group. These teens often describe feeling wide awake in the late-evening hours, with a delay in sleep onset until 3 or 4 AM. When they manage to drag themselves to school, their performance is impaired, and they may fall asleep in morning classes. Accordingly, the young person often presents with academic failure, truancy, or tardiness. Their sleep debt accumulates until the weekend, when they may sleep until early afternoon, further disturbing their circadian clock. Changing a delayed sleep cycle is usually a challenge. It consists of setting the morning wake-up time 15 minutes earlier each successive day until the desired target is reached. This procedure is accompanied by exposure to bright natural light or use of a high-intensity (2,500-lux) light box in the morning. Other measures that may be beneficial in resetting the brain clock are minimizing exposure to evening light, a trial of melatonin 4 to 5 hours before desired sleep onset, and a short course of sedative medication in the evening. Strict adherence to the new sleep schedule, even on weekends and holidays, is usually necessary to prevent relapse to previous patterns.
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