Children and adolescents who are experiencing difficulties with their mental health also often struggle with their sleep. Indeed disrupted or altered sleep has been associated with most psychiatric disorders (Gregory & Sadeh, 2016). Although a range of sleep difficulties can co-occur with mental health problems, a common difficulty is insomnia. As such this guidance will primarily focus on difficulties with getting to sleep and staying asleep.

It’s noteworthy that sleep problems can sometimes be an invisible risk (parents are not aware) and can also constitute a red flag for the development of problems in the future. It is important to increase awareness of sleep difficulties and address them should they occur.

It is very common for young people (and adults) to have trouble sleeping (Owens, 2014; Sivertsen et al., 2017). It is normal to struggle with sleep around important events, even positive ones such as parties or holidays. Excitement and anxiety can both keep us awake. One or two nights of poor sleep does not necessarily forecast a problem and most young people can cope with that. However, if someone has been sleeping badly for a few weeks, this may be a good time to try and change things.

Young people who are anxious or depressed often find it particularly hard to get to sleep (Peterman et al., 2014; Blake et al., 2018). There are many reasons for this, but one possibility is that they have worries and thoughts going through their minds that keep them awake. Once they are asleep they may wake up during the night, begin to worry, and find it hard to get back to sleep. Young people who are anxious or depressed may also wake up too early in the morning and not be able to get back to sleep. Once sleep is a problem, it’s quite easy to see how it might keep anxiety or depression going, or even make it worse. Thoughts about the lack of sleep become another thing to worry about.

Problems sleeping is a common symptom of many mental health difficulties in young people, such as anxiety, depression, and behavioural difficulties (DSM-5, American Psychiatric Association, 2013). In some instances, sleep has been found to be amongst the most common symptoms reported in young people with mental health problems (e.g. Goodyer et al., 2017). Poor sleep can exacerbate other symptoms of mental health problems such as difficulties concentrating, thinking, planning and making judgements, or feeling exhausted and hopeless. These difficulties make it hard to take part in normal activities at schools, with friends and at home, and young people may find themselves feeling able to do less and less when they are having problems sleeping.

These problems can create a vicious cycle, with each problem making the others more difficult to manage. For example, a young person may be finding it hard to engage in normal activities if they are tired, this might stop them going out with friends, or they could fall behind at school. Getting out of routine and feeling low or anxious can then contribute to further difficulties with sleep.

Sleep problems can sometimes be triggered by something bad or difficult happening. For example, being bullied or having negative experiences with friends can lead to trouble sleeping (van Geel et al., 2016). Young people may also feel under pressure to perform well in exams or coursework, and may be involved in other hobbies that bring pressure from competitions or exams. However, sometimes sleep problems seem to appear out of the blue. This is not uncommon in young people due to natural changes in sleep cycles that arrive with adolescence.

General information about sleep in children and adolescents

Our sleep and wakefulness are influenced by two processes (Borbely, 1982). The first refers to our sleep drive (the homeostatic process). The general idea is that we feel ready to fall asleep after we have been awake for a long time. It seems that the longer our brain and the rest of our nervous system has been awake, the greater the accumulation of certain molecules that trigger sleepiness. The second process controlling our sleep and wakefulness relates to when we fall asleep and wake up (the circadian process). This works like a powerful biological clock, which means that we are more likely to feel tired at night and awake during the day, regardless of when we last slept. ‘Clock genes’ are important in driving these patterns (Takahashi, 2017) although environmental cues (in particular light) are also helpful in adjusting our internal clocks. There is some individual variation in terms of when we like to do things, and some prefer to stay awake later and sleep longer in the morning (owls) while others prefer an early night and an early start (larks). This is partly influenced by the genetic differences between us (Barclay & Gregory, 2013).

Sleep changes a lot from infancy through to adulthood. This includes the amount of sleep that we need (Hirshkowitz et al., 2015; Paruthi et al., 2016), as well as the way in which we sleep. Sleep is characterised by different stages. One of these is non rapid eye movement (NREM) sleep which can be partitioned into N1 (the lightest stage of sleep), N2 (slightly deeper sleep) and N3 (deep sleep). We also experience Rapid Eye Movement (REM) sleep, during which our bodies are paralysed and our eyes dart about. We cycle through these different stages of sleep during the night, moving from NREM to REM sleep. Each cycle typically takes between 90-110 minutes in adults.

When a baby is first born, it is possible to distinguish what is referred to as ‘active’ and ‘quiet’ sleep. Active sleep is similar to REM, yet babies are twitchy and jerky during this stage. Quiet sleep is similar to NREM – but before four to five months it is not possible to differentiate N1, N2 and N3. What is more the order of the sleep stages within a cycle will differ in young babies, who will enter their REM-like (active) sleep before their NREM-like (quiet sleep) until they reach 3 months of age.

Many parents of young children consider them to have a ‘sleep problem’. For example, in a large study of the parents of babies and toddlers, many reported their child to have a sleep problem (from 11% of those asked in Thailand to 76% of those asked in China, Mindell et al., 2010). However, it’s important to keep in mind that parents perceptions of a ‘sleep problem’ can differ quite dramatically (Wiggs, 2007). For example, some parents expect to cuddle a baby as he or she falls asleep and for their child to wake up during the night. Other parents might expect a child to fall asleep without intervention and to sleep through the night. The idea of what constitutes ‘sleeping through the night’ also differs greatly too. Such different expectations can lead to different perceptions of whether a child has a sleep problem. Sleep always needs to be considered in the family context and (after considering safety) what is right for one family may not be for another.

By adolescence sleep cycles are roughly the same length as those of adults. However, sleep in adolescents can differ from that in adults in other ways. For example, during adolescence the circadian rhythm changes quite dramatically (Crowley et al., 2018). Most teenagers have a shift in the time which they feel sleepy. Their natural rhythm is to go to sleep late and wake up late. This pattern can be reinforced by social pressures, school activities, media use and a reduction in parental involvement in the sleep-wake schedule. However, this delayed sleep timing does not fit with the usual school timetable and as a result, during school and working weeks teenagers often get less then recommended 8-10 hours of sleep. Sometimes a lie-in at the weekend can help an adolescent cope with missing out on sleep during the week. However, a lie in can also delay the body clock, which produces a feeling of jetlag (referred to as ‘social jetlag’, Wittmann et al., 2006). Adolescents then struggle to cope when they have to get up early on Monday morning. It is sometimes recommended that if we need a lie-in we should try to avoid changing our sleep schedule too much (e.g. limit our lie-in to no more than 2 hours). Ideally, we should be getting enough sleep regularly and a consistent schedule.

Sleep disorders are listed in The International Classification of Sleep Disorders, which is currently in its third edition (ICSD-3, American Academy of Sleep Medicine, 2014). The major categories of sleep disorders are insomnia; sleep-related breathing disorders; central disorders of hypersomnolence (involving daytime sleepiness), circadian-rhythm sleep-wake disorders, parasomnias (involving unwanted physical experiences/ events that occur during the transition into/ out of sleep), sleep related movement disorders and other sleep disorders.

We now know that most psychiatric disorders are associated with disrupted or altered sleep. Some associations are well-established, for example, one of the symptoms of depression is experiencing insomnia or hypersomnia (excessive sleepiness) nearly every day. People experiencing other disorders, including anxiety, ADHD, autism spectrum disorders and schizophrenia, amongst others, may also experience disrupted or altered sleep.

The mechanisms underlying these associations are complex. Research has started investigating some of these mechanisms. For example, a recent review exploring factors underlying the association between insomnia, anxiety and depression highlighted a range of biological, social and cognitive mechanisms (Blake et al., 2018). Biological factors include our genes; social mechanisms include family stresses; and psychological processes include cognitive style.

Treatment for insomnia

Sleep disturbances are often short-lasting and do not require intervention. But if problems are persistent or impacting upon day to day life, such as difficulties concentrating at school, or lack of interest in usual hobbies or activities, then children and young people may benefit from treatment for their sleep problems.

Psychological therapies

The treatment recommended will depend on the precise difficulty being experienced and specific circumstances surrounding the sleep disorder. A range of techniques are used in psychological therapies for improving sleep problems. Many of these stem from Cognitive Behavioural Therapy for Insomnia (CBT-I). CBT-I is one of the most effective and commonly used psychological therapies for insomnia (Qaseem et al., 2016; Riemann et al., 2017). It helps to treat adults, adolescents and children (Blake et al., 2017). Below are some of the techniques commonly used:

• Sleep Hygiene: It is important to establish a good routine and habits around bedtime and sleeping. For example, we should avoid caffeine (particularly as the day progresses) and avoid light at night.
• Stimulus Control: A key idea is to make sure that a young person’s bedroom is associated with sleeping, not with being awake and active. This might mean changing some arrangements in the home.
• Relaxation: Relaxing before bedtime can be helpful for those struggling with their sleep. For example, you might want to try progressive muscle relaxation or practice mindfulness.
• Sleep Restriction: Sleep diaries can be used to reschedule sleeping patterns. Using information about the time at which a young person needs to get up for school, a ‘sleep prescription’ is calculated, fitting the average amount of sleep that a young person is getting to the perfect window. For example, Sam is getting just over 7 hours sleep on average – but he wakes up lots of times during the night. He doesn’t need to get up until 6.30am, so based on what sleep Sam is getting currently, he should not go to bed until 11.30pm. This will fit his current habit to the perfect window. This will prevent Sam from going to bed too early, and lying awake, or waking up in the night. Once Sam’s sleep quality has improved, he can gradually start increasing his sleep quantity.

Pharmacological therapies

Research into pharmacological therapies (such as antihistamine agents) prescribed for sleep problems in children is limited. Drugs are not typically prescribed as an initial treatment strategy. Pharmacological therapies to treat insomnia in children have not been approved by the US Food and Drug Administration (FDA) or the European Medicines Agency (Bruni et al., 2018). In cases where pharmacological therapy is used – it should be following very careful consideration by a healthcare provider, who can consider individual circumstances (e.g. comorbidity, age etc). Drugs are typically used in conjunction with psychological treatments – with the latter considered to be the first-line treatment.

There have recently been a number of excellent studies supporting the idea that treating sleep difficulties might have knock-on positive effects for different aspects of mental health (e.g. Freeman et al., 2017; Gee et al., 2019). The extent to which sleep interventions might be sufficient to support recovery from different mental health diagnoses is not yet clear – and further research is needed in this area.

Recently, there has been greater awareness of the importance of sleep throughout the life-course, with a huge number of scientific studies on sleep currently underway. For example, work is under-way to further develop brief and effective treatments for disturbed sleep in adolescents. There are now excellent online CBT-I programmes designed for use with adults (Cowie et al., 2018), and the further development of these programmes might be useful for children and adolescents. While CBT-I is considered the most effective treatment for insomnia, not all people find it useful. Within child psychology and psychiatry, attention is being turned to personalised medicine (Ng & Weisz, 2016). Clinical advice is already tailored to specific families (for example, noting what is considered desirable and tolerable when addressing child sleep). There is also work being designed to understand more about factors predicting response to CBT-I with the ultimate aim of improving treatments for all.

Sources

American Academy of Sleep Medicine (2014). International classification of sleep disorders – third edition. Darien, Illinois: American Academy of Sleep Medicine.

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition. Washington, DC: American Psychiatric Association.

Barclay, N. L. & Gregory, A. M. (2013). Quantitative genetic research on sleep: A review of normal sleep, sleep disturbances and associated emotional, behavioural, and health-related difficulties. Sleep Medicine Reviews, 17, 29-40.

Blake, M. J., Sheeber, L. B., Youssef, G. J., Raniti, M. B., & Allen, N. B. (2017). Systematic review and meta-analysis of adolescent cognitive-behavioral sleep interventions. Clinical Child and Family Psychology Review, 20, 227-249.

Blake, M. J., Trinder, J. A., & Allen, N. B. (2018). Mechanisms underlying the association between insomnia, anxiety, and depression in adolescence: Implications for behavioral sleep interventions. Clinical Psychology Review, 63, 25-40.

Borbely, A. A. (1982). A two process model of sleep regulation. Human Neurobiology, 1, 195-204.

Bruni, O., Angriman, M., Calisti, F., Comandini, A., Esposito, G., Cortese, S. et al. (2018). Practitioner review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities. Journal of Child Psychology and Psychiatry, 59, 489-508.

Cowie, J., Bower, J. L., Gonzalez, R., & Alfano, C. A. (2018). Multimedia field test: Digitalizing better sleep using the Sleepio program. Cognitive and Behavioral Practice, 25, 442-448.

Crowley, S. J., Wolfson, A. R., Tarokh, L., & Carskadon, M. A. (2018). An update on adolescent sleep: New evidence informing the perfect storm model. Journal of Adolescence, 67, 55-65.

Freeman, D., Sheaves, B., Goodwin, G. M., Yu, L. M., Nickless, A., Harrison, P. J. et al. (2017). The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis. Lancet Psychiatry, 4, 749-758.

Gee, B., Orchard, F., Clarke, E., Joy, A., Clarke, T., & Reynolds, S. (2019). The effect of non-pharmacological sleep interventions on depression symptoms: A meta-analysis of randomised controlled trials. Sleep Medicine Reviews, 43, 118-128.

Goodyer, I. M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., Hill, J. et al. (2017). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry, 4, 109-119.

Gregory, A. M. & Sadeh, A. (2016). Annual Research Review: Sleep problems in childhood psychiatric disorders – a review of the latest science. Journal of Child Psychology & Psychiatry, 57, 296-317.

Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, L. et al. (2015). National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health, 1, 40-43.

Mindell, J. A., Sadeh, A., Wiegand, B., How, T. H., & Goh, D. Y. T. (2010). Cross-cultural differences in infant and toddler sleep. Sleep Medicine, 11, 274-280.

Ng, M. Y. & Weisz, J. R. (2016). Annual research review: Building a science of personalized intervention for youth mental health. Journal of Child Psychology and Psychiatry, 57, 216-236.

Owens, J. (2014). Insufficient sleep in adolescents and young adults: An update on causes and consequences. Pediatrics, 134, E921-E932.

Paruthi, S., Brooks, L. J., D’Ambrosio, C., Hall, W. A., Kotagal, S., Lloyd, R. M. et al. (2016). Recommended amount of sleep for pediatric populations: a consensus statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine, 12, 785-786.

Peterman, J. S., Carper, M. M., & Kendall, P. C. (2014). Anxiety disorders and comorbid sleep problems in school-aged youth: Review and future research directions. Child Psychiatry & Human Development, 45, 1-17.

Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165, 125-133.

Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Groselj, L. D., Ellis, J. G. et al. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research, 26, 675-700.

Sivertsen, B., Harvey, A. G., Pallesen, S., & Hysing, M. (2017). Trajectories of sleep problems from childhood to adolescence: a population-based longitudinal study from Norway. Journal of Sleep Research, 26, 55-63.

Takahashi, J. S. (2017). Transcriptional architecture of the mammalian circadian clock. Nature Reviews Genetics, 18, 164-179.

van Geel, M., Goemans, A., & Vedder, P. H. (2016). The relation between peer victimization and sleeping problems: A meta-analysis. Sleep Medicine Reviews, 27, 89-95.

Wiggs, L. (2007). Are children getting enough sleep? Implications for parents. Sociological Research Online, 12, 13.

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Popular science book on sleep: Gregory, A. (2018). Nodding Off: The Science of Sleep from Cradle to Grave. London, UK: Bloomsbury.

Useful books for clinicians dealing with pediatric sleep problems:

• Meltzer, L. J. & McLaughlin, V. (2015). Pediatric sleep problems: A clinician’s guide to behavioral interventions. Washington, DC: American Psychological Association.
• Mindell, J. A. & Owens, J. A. (2015). A clinical guide to pediatric sleep: Diagnosis and management of sleep problems. (Third Edition ed.) Philadelphia, PA: Wolters Kluwer.

A useful book for dealing with pediatric sleep problems – designed for use with children: Huebner, D. (2008). What to do when you dread your bed: A kid’s guide to overcoming problems with sleep. Washington, DC: Magination Press.

Useful websites for parents of young children:

• babysleep.com
• basisonline.org.uk

Freely available course incorporating a week on the topic of sleep hosted by the University of Reading: Understanding Depression and Low Mood in Young People

Useful books designed for parents who have children with sleep problems. These are just a small sample of the many books available on the topic:

• Mindell, J. A. (2009). Sleeping Through the Night: How Infants, Toddlers, and Their Parents. New York, NY: William Morrow Paperbacks.
• Hiller, R. & Gradisar, M. (2018). Helping Your Child with Sleep Problems: A self-help guide for parents. London, UK: Robinson.
• Ferber, R. (2006). Solve Your Child’s Sleep Problems. New York, NY: Touchstone.

Please note: ACAMH does not endorse any individual product.