Case Study Paper: Pediatric Insomnia

One of the categories of disorders children are likely to suffer from are sleep-wake disorders. One of the most widespread sleep-wake pediatric disorders is insomnia. Pediatric insomnia can be defined as a certain sleep disturbance that causes problems when falling asleep or staying asleep during the nighttime among children (Parritz, 2014). The basic complaint of the patients is waking up too early. Generally, insomnia complaints refer to a feeling of non-restorative sleep and a certain degree of impairment during the daytime (Cleveland Clinic, 2017). Often parents notice that there is something wrong with their child’s sleep; however, older children can complain of some sleep disturbances on their own. Therefore, parents should be attentive to their child’s health and monitor even small alternations. The objective of this paper is to provide basic information about the peculiarities of pediatric insomnia and immediately apply the acquired knowledge by creating a conceivable case study referring to theoretical material covered; the case study can help come up with a framework of the course of the disorder and give possible recommendations suitable for the case.

Etiology of the Disorder

A number of causes can lead to insomnia in children. Stress is one of the basic reasons. Children are thought not to suffer from stress; however, in reality, the situation is quite opposite. Children tend to worry about things that occur at school or about certain situations with parents or friends. While not typical among underaged persons, alcohol or energy drink abuse can result in insomnia. Additionally the disorder may be appear as a side effect of certain kinds of medication (Crosta, 2017). Moreover, there are some medical and psychiatric disorders which might prevent a child from sleeping well. These include thyroid disease, growing pains, heartburn, muscle cramps, etc. (Cortese, 2014). There are some illnesses and diseases which can cause temporal insomnia,such as a stuffy nose or itchy skin due to eczema. In that case, one should start the treatment of this illness and the insomnia symptoms will be mitigated as well. Additionally, environmental factors can affect sleeping well-being. Noise, cold, excessive heat, bright lights may serve as basic things that distract a child from proper sleep. Careful attention to the environment in which a child sleeps and the restrictions on possible distractions can help solve the problem (Cortese, 2014). Thus, the range of reasons for childhood insomnia is varied. 

Prevalence of Insomnia

The rate of insomnia prevalence can vary depending on the age and gender, according to the research performed by Calhoun, Fernandez-Mendoza, Vgontzas, Liao, and Bixler (2014). According to their findings, the prevalence of insomnia among children reaches approximately 19.3 %. The scientists revealed the interaction between gender and age showed that girls at the age of 11-12 had the highest prevalence of insomnia symptoms (about 30.6% from the tested group) (Calhoun et al., 2014). According to the general investigation of the prevalence of insomnia among children and the parent’s participation in the process of symptoms identification mentioned by Kovachy, O’Hara and others in their research, around 25 -30 % of parents reported that their child sometimes has difficulties sleeping, while only around 6 % of parents claim that their child faces constant problems with initiating sleep (Kovachy, 2013). The rating is higher among children. Around 40 % of children admit that they sometimes have problems sleeping, and only 10 % claim than their sleep initiating problems occur really often (Kovachy, 2013). In terms of sleep maintenance problems, the situation is almost the same, but there are small differences. The research shows that parents are more aware of sleep initiation problems than sleep maintenance ones. Approximately 11 % of parents claim that their children sometimes have sleep maintenance problems, but only 2 % of parents state that their children have constant sleep difficulties (Kovachy, 2013). At the same time, 23 % of children report to sometimes have some problems maintaining sleep, while 5% admit that they have serious problems with it (Kovachy, 2013). The research leads to two important conclusions. The first is that insomnia in children manifests itself more during the sleep initiating stage, and the second is that parents cannot always understand that something wrong is going on with their child. That is why the child should be taught to tell their parents about any problems from a very early age.

Characteristics of Insomnia

Pediatric insomnia has several characteristics which help identify the children suffering from this disorder. The information mentioned in the section can be fairly useful to parents who can notice the disorder during its initial stages and consult with the doctor if necessary. Insomnia in children is characterized by negative daytime outcomes, such as irritability, behavioral problems (especially with attention and concentration), bad mood, frustration, increased stress, etc. Furthermore, children with insomnia symptoms are reported to be less successful in cognitive tasks of different kind (Brown & Malow, 2016). Thus, it becomes evident that insomnia mostly affects cognitive processes with possible mood swings.

Insomnia in children is divided into three types. The first one is the association type that starts occurring typically from the age of 6 months. This type is characterized by the absence of certain kind of stimuli (watching TV, rocking, sleeping in parents’ bed etc.) that leads to the inability to fall asleep and can cause severe sleeping disturbances (Cortese, 2014). Another type of insomnia is called limit setting type and is characterized by the difficulties which a child encounters when it comes to establishing sleeping limits, namely, bed time routines and sleep onset (Cortese, 2014). The third type of insomnia is called mixed and comprises the characteristics of both of the above mentioned types. All these types of insomnia have their own ways of treatment which arise from their characteristic features.

Insomnia Prognosis

The prognosis of insomnia for infants and children is fraught with consequences. The basic prognosis is connected to the appearance of primary consequences, such as problems with mood, behavior, cognition, and relationships between family members. Moreover, insomnia can result in prefrontal cortical dysfunction, and cause problems with executive functioning, such as working memory, emotional regulations, and behavioral inhibition (Calhoun et al., 2014). Sleep deprivation has a negative impact on learning ability. When sleeping problems are connected to longer sleep duration, the sleeping problems can result in daytime hyperactivity (Calhoun et al., 2014). Thus, these cases of insomnia can cause problems at kindergarten, school, university, and have a negative influence on information acquisition, processing, and memorization.

Child Background

Child and Family Characteristics

The case of a young boy called Mathew is under consideration. He is only two years old. He cannot speak well; however, he understands speech properly. Parents never had any problems with their child because Mathew is a fairly calm and obedient child. Mathew’s parents are called Dominik and Peter. Mathew is their first child. They take good care of him, which includes planning his day and sleep regularly. The family lives together. Mother is on maternity leave to be able to take care of Mathew every day. Because of this excessive love to their child, they allow Mathew to sleep with them in their bed before the night sleep. They allow him to watch cartoons and different films before going to bed because Mathew likes them. After some time, Mathew started to go to bed earlier or later regardless of his timetable. He began to be capricious and parents could not please their little son. Later, parents noticed that Mathew’s timetable became unbalanced and it was difficult to make Matthew fall asleep.

Risks and Protective Factors

The main risk in the situation is the wrong parenting style and strategy. The parents allowed their son to behave frivolously because of their lenient attitude towards his wishes. At the very beginning, they set rules, created a timetable, but then got rid of that style of managing Mathew’s life. The child felt the leniency and took advantage of it. Thus, his biological clock went wrong, and the whole system suffered from the change, which led to a sleep-wake disorder. Furthermore, this permissiveness changed the conditions in which the child got used to falling asleep. Parents allowed sleeping with them, which resulted in adaptation. Thus, Mathew could not fall asleep in his bedroom. In such a situation, the age of the child is a risk factor because his level of maturity does not allow him to control his behavior and adjusts to habitual actions quickly. That is why parents should take responsibility for proper time organization. The Bible supports this idea by claiming that insomnia can be caused by overabundance of things a person focuses on mentally (The Lockman Foundation, 1995). Thus, Mathew was allowed to watch movies, cartoons, and play with his toys without any time restrictions, which led to the issue at hand. 

Primary Concerns

Mathew was brought to a hospital by his parents with a suspicion of temporal difficulties with sleep initiating. Mathew could not fall asleep at all. He cried, his eyes were red, he obviously wanted to sleep, but he could not do that. If Mathew did fall asleep, he would awaken several times during the night and start to cry. Parents noticed that and made many attempts to calm him down. During daytime naps, Mathew slept properly because he slept near his mother in his parents’ bed, except for the cases when Dominik left Mathew in his room during the nap. In that case, he refused to sleep, started to cry, and endured some kind of panic attack. Other factors of Mathew’s development, health, and growth were completely normal. Because of constant lack of sleep during the nighttime, during the day Mathew behaved in a quite negative way. He was easy to irritate, very emotional or very passive, and did not want to play or eat. He behaved in a very naughty manner and confused his parents. They did not know what to do since Mathew has never behaved that way. He was constantly in a bad mood, so it was really easy to upset him. Furthermore, Mathew had a deficit of attention and could not focus neither on playing nor on watching his favorite cartoons. Finally, Mathew’s parents started to be wary of nighttime, because it was necessary to get their son to sleep and they could not. That is why they decided to take him to the hospital.

Intervention Approach

Before starting the treatment, a doctor should examine the young patient very carefully since insomnia is not a diagnosis. Insomnia is a part of a bigger problem; it is merely a symptom that can point at more complicated issue, such as illness (Sharma & Andrade, 2012). Thus, the task of the pediatrician is to analyze the general situation, instead of simply treating insomnia. In Mathew’s case, taking into consideration his background, the way his parents treat him, and his sleep hygiene, one can draw a conclusion that the child suffers from behavioral insomnia, mixed type. Basically, the problem is that parents allowed their son to sleep near her in her and her husband’s bed. That led to an adaptation that caused a disorder of the association type. Furthermore, parents allowed Mathew to watch TV (cartoons and films) before sleeping time by delaying the time he had to go to bed. That caused the problem of a limit-setting type. The interaction of this type resulted in the mixed type of insomnia disorder. 

The basic approach to the intervention into this kind of insomnia is behavioral therapy. Effective treatment of insomnia addresses the cognitive and behavioral mechanisms that maintain insomnia. That starts with desensitization, relaxation, hypnosis, biofeedback, and paradoxical intention which targets hyperarousal associated with insomnia. In Mathew’s case, there is no need to resort to complicated treatment approaches.

Future Recommendations

Mathew’s insomnia disorder can be treated provided the parents are ready to become less lenient and resort to several effective methods of disciplining their son. First, it is necessary to set a clear bedtime (the time of initiating the sleep and the time of waking up) taking into consideration the age of the child. For instance, at the age of two children need more than 12 hours of night sleep. Maintaining this regular sleeping schedule is essential; otherwise, the treatment will be in vain. The establishment of appropriate sleeping hygiene is a similarly helpful and relevant idea. In this case, it means restricting time spent in bed without sleeping and excluding some stimulating activities before going to the bed (watching TV, playing active games, etc.) (Cleveland Clinic, 2017). If there is a need, the parents can use behavioral techniques and methods which are sure to help deal with Mathew’s sleeping problems.

Conclusion

One should admit that pediatric insomnia is a complex disorder that is spread among young children. The disorder can happen to people of different ages because of stress, medication, problems with time-managing, environmental factors, etc. Pediatric insomnia is fraught with symptoms that include cognitive and mental difficulties, mood swings, hyperactivity, and aggression among others. Children often cannot identify that they suffer from a sleep-wake problem; therefore, the information provided in the paper is essential for parents who want to be able to assist their child, prevent the disease, identify the symptoms, and provide them with necessary treatment.

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