A recent study published in the journal Sleep Medicine revealed that most child psychiatrists prescribe medication for sleep at least once a month, despite the fact that no sleep medications are approved for use in children. The study was funded by Sanofi-Aventis, makers of Ambien.
Managing sleep is one of the greatest challenges of being a parent. It represents the first major separation and can be fraught with complex ambivalent feelings. As children get older, battles for control often play out around sleep. Most significant behavior problems are associated with major emotional dysregulation. Calming down sufficiently to fall asleep may be very difficult. Sleep deprivation, in turn, exacerbates emotional dysregulation. Children learn to regulate emotions in relationships with the people who care for them. Efforts to help children regulate emotions must focus on supporting these relationships.
The trend towards medicating away these complex sleep problems, rather than getting at the root cause, is, in my opinion, quite disturbing.
Consider the following story. I first saw Charles when he was three. His mother, Anne, described terribly disrupted sleep (details, as always, have been changed to protect privacy.) He would wake multiple times at night and scream for his mother who was, in fact sleeping right next to him. Even as she held him he would continue to thrash and cry out. His behavior was so wild and out of control that his parents feared he was having a seizure. To reassure both them and myself, I sent him to a neurologist, who after an exam and EEG, declared that there was “nothing wrong.” He prescribed a tricyclic anti-depressant.
His mother threw the pamphlet about the drug in the garbage and arrived at my office horrified, yet ready to do the difficult work addressing this problem in a meaningful way entailed.
Charles had been a dysregulated baby since birth. In addition, as we came to understand in or time together, Anne had been abandoned by her own mother, who had severe mental illness. Not only had she been left alone in her crib as an infant, but as she grew up, her mother had not been emotionally available to her, though she had provided physical care. Anne recognized that in order to be emotionally available to Charles in the way he needed, she would have to address her own trauma.
With time and lots of hard work, Anne came to understand that Charles’ neediness at bedtime was so disturbing to her that in a sense she was not there emotionally, though physically she was present. Once she felt supported and understood, she was able to be emotionally present with Charles at bedtime as well as other times that were difficult for him. Gradually the sleep disruption subsided. By the time Charles was in Kindergarten he was sleeping well and thriving in school.
There may well be a role for short term use of sleep medication for children in situations where families are spiraling dangerously out of control. But routine use, without careful thought, as was the case when the neurologist prescribed a tricyclic for Charles, represents a risky oversimplification of often very complex problems.
Claudia M. Gold is a pediatrician who blogs at Child in Mind.
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