Routine use of sleep medication for children

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 and is the author of Keeping Your Child in Mind.

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  • David Behar, MD,EJD

    First, any mention of FDA approval as setting any standard is medical malpractice. Half the prescriptions in the US are off label. Any doctor limiting itself to approved use would not be practicing half the standard of care medicine in the US.

    Second, kids with ADHD sleep very little, feel no fatigue the next morning, and disrupt the house running about at night, if not doing dangerous acts. Parents will have done many on-off experiments validating the use of anti-depressants as sleep medication in the person. It is the fault of the NIH and of academia that they have failed to research and to validate this extensive practice.

    Thirdly, philosophically, the doctor is a bit inconsistent. She should walk everywhere instead of driving and taking airplanes. Medications are tools, just as are cars and planes. All have side effects. The user calculates the risk-advantage ratio at every use. That she finds that personal decision invalid is inappropriate.

  • Kathy Robinson

    Charles has been a dysregulated child from birth, his grandmother had severe mental illness, and his mother Anne’s main problem is that she’s not able to be emotionally present for his nightly “neediness”?! Baloney. Anne’s main problem is chronic, severe sleep deprivation coupled with the stress of parenting her challenging, sleep-deprived, and most likely diagnosable toddler.

    This type of psychodynamic approach advocated by Dr. Gold, applied to brain-based conditions, is malpractice in my opinion and experience. As the mother of a child who experienced abrupt onset of severe OCD and sleep dysregulation at 3 years, 11 months, I wasted a precious two years with psychodynamically-oriented counselors and psychiatrists while my child was miserable, her disorder and comorbid sleep issues worsened, and the whole family suffered. I was initially thrilled to learn that something about my parenting had caused abrupt OCD in my child, because that meant I could change how I parented her and the OCD would go away. It offered hope! But two years on, despite twice-weekly therapy and my complete cooperation, my child’s OCD, associated sleep dysregulation, and general dysfunction was markedly worse.

    Medication–off-label due to her age–was the answer. It was near-miraculous how her OCD lessened and her sleep issues resolved; and coupled with *behavior* therapy *proved* to reduce OCD symptoms, she and the whole family have had our lives back for many years now. My daughter is a junior in high school, earns good grades, is a cheerful and happy girl, a talented actress and artist, and has a satisfying social life.

    The diagnosing psychiatrist had given us a horrifying and dismal prognosis: she would most likely not be able to attend traditional school past the elementary years, and would likely require institutionalization at some point. I can hardly imagine her life today had I not sought out a child psychiatrist unburdened by a psychodynamic approach to brain disorder.

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