Frequently Asked Questions

Q: What is "normal" sleep?

A: Getting enough sleep is essential for normal functioning in children and adolescents. Young people require more sleep than adults. For instance, elementary-age children generally need between 9 and 11 hours of sleep per night, whereas adults typically need 7 to 9 hours of sleep per night. Infants and preschoolers need even more sleep than older children. Infants and preschoolers benefit from sleep during the day, but by the time children start attending school typically naps are no longer necessary. View the Sleep chart for more information about how much sleep is needed for children of different ages.

It is important to keep in mind that all children are different, so just because your child sleeps a little more or less than average does not mean that he or she is "abnormal." Almost all children and adolescents have an occasional sleepless night. Kids also occasionally have difficulty with bedtime routines (e.g., not wanting to go to bed, stay in bed or becoming upset when bedtime routines change or when parents set limits). More

Q: What kinds of sleep problems do children experience?

A: Children experience a number of sleep-related difficulties, including:

• Insomnia: problems falling or staying asleep, or failure to get restorative sleep
• Refusing to go to bed or stay in bed
• Nightmares
• Sleepwalking
• Shouting or talking during sleep
• Overly tired during the day
• Enuresis: bedwetting

Q: If my child or adolescent gets out of bed during the night or does not want to go to sleep, is that a problem?

A: It depends. Children will sometimes get out of bed and seek your comfort if they are frightened, sick, or have soiled themselves. It is normal if this happens every once in awhile. However, if your child is having difficulty going to bed or staying asleep on a consistent basis it may be time to take action.

Q: How common are sleep disturbances in children?

A: Sleep disturbances among children and adolescents are the second most frequently encountered behavioral problem encountered by primary care providers. It is estimated that 42% of children of various ages experience sleep-related difficulties.¹ Between 35 and 45% of children age 2-18 suffer from a Sleep Disorder at some point in their lives. ²

• 27% of parents of school aged children report bedtime resistance¹
• 11% of parents of school aged children report sleep-onset delays¹
• 25% of adolescents do not get as much sleep as needed ¹
• 3% of young children have sleep terrors at some point ³
• Although between 10 and 50% children (especially preschool-age children) have nightmares, the actual prevalence of Nightmare Disorder is unknown
• Enuresis (bedwetting) is one of the most common sleep disturbances experienced by children⁴, affecting 8 to 10 percent of the school age population⁵

Q: Are sleep problems considered mental disorders?

A: It depends. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Primary Sleep Disorders are diagnosed when sleep problems cannot be attributed to another mental disorder, a general medical condition, or use of a substance. Secondary Sleep Disorders are sleep problems that are associated with medical, neurological,or substance use disorders. There are two categories of Primary Sleep Disorders listed in the DSM-IV: Dyssomnias and Parasomnias. More

Q: What causes sleep disturbances in children and adolescents?

A: The International Classification of Sleep Disorders lists more than 80 different Sleep Disorders, some of which are classified in the DSM-IV as mental disorders and some are not. Not all Sleep Disorders are attributed to psychiatric or behavior causes. Medical and biological factors can also cause Sleep Disorders. Possible causes or contributing factors include:⁶

• Stress or anxiety
• Depression
• Parenting
• Poor sleep hygiene
• Obstructed airways
• Pain
• Medication side-effects (e.g., stimulant medications)
• Poor sleeping environment (e.g., excessive light or noise)
• Sleep deprivation
• Allergies/asthma
• Gastrointestinal esophageal reflux

Q: Do children outgrow sleep problems?

A: Although sleep problems tend to decrease with age, once sleep disturbances have taken hold and become significant problems children or adolescents are not likely to simply "outgrow" them.⁶ This is particularly true if young people and their parents have adopted poor sleep habits that cause or contribute to the difficulties. Like many habits, once they are well formed they can be difficult, but not impossible, to break. Symptoms are likely to improve over time as young people and their families receive treatment or develop tools to cope with sleep disturbances.

Q: What treatments are helpful for sleep disturbances?

A: Treatments vary depending upon the type of sleep disturbance. Most people benefit from basic education about normal sleep (may reduce patient's anxiety about sleep) and sleep hygiene (activities that interfere with sleep).⁷ Research has shown that children's sleep difficulties are often related to behavioral problems and how their parents interact with them at bedtime.¹ Therefore, behavior therapy can be helpful for a variety of sleep difficulties.

Q: How do I locate professional to treat sleep disturbances?

A: You can contact any of the following organizations, which have referral capabilities:

• Association for the Advancement of Behavior Therapy or call 1-212-647-1890.
• American Psychological Association or call 1-800-964-2000.
• National Association of Social Workers—Search Clinical Register
• American Academy of Child and Adolescent Psychiatry

Q: Do I have to see a specialist in order to get help?

A: No. Caregivers can learn a number of tools on their own for coping with sleep disturbances. You can try to administer some behavioral techniques on your own. Check out the self-help tools offered on this site. Your doctor will be able to assist you with specialty care, if needed. Sometimes family, friends, or clergy can be excellent sources of support when facing a challenging behavioral change.

Q: Are sleep disturbances a covered TRICARE benefit?

A: TRICARE policy for reimbursement requires that services must be medically necessary for a diagnosed psychological disorder. The disorder must be one referenced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and must be of a severity not only to cause the patient distress but also to interfere with the patient's usual activities. More

References:

¹Moore, B. (in press).Pediatric insomnia.In J. E. Fisher & W. O'Donohue (Eds.). Practitioner's guidelines for evidence based psychotherapy. New York: Kluwer.

²Connelly, K. P. (2006). Sleep disorder: Nightmares. Accessed 4/24/06.

³Durand, V. M. (in press). Sleep Terrors. In J. E. Fisher & W. O'Donohue (Eds.). Practitioner's guidelines for evidence based psychotherapy. New York: Kluwer.

⁴Friman, P. C., & Jones, K. M. (1998). Elimination disorders in children. In. T. S. Watson & F. M. Gresham (Eds.). Handbook of child behavior therapy (pp. 239-260). New York: Plenum Press.

⁵Mellon, M. W., & Houts, A. C. (in press). Nocturnal enuresis: Evidence based perspectives in etiology, assessment, and treatment. In J. E. Fisher & W. O'Donohue (Eds.). Practitioner's guidelines for evidence based psychotherapy. New York: Kluwer.

⁶Durand, V. M., Mindell, J., Mapstone, E., & Gernert-Dott, P. (1998). Sleep problems. In. T. S. Watson & F. M. Gresham (Eds.). Handbook of child behavior therapy (pp. 203-219). New York: Plenum Press.

⁷McCrae, C. s., Sidney, D. N., Taylor, D. J., & Lichstein, K. L. (in press). Insomnia. In J. Fisher and W. O'Donohue (Eds.), Practice guidelines for evidence based psychotherapy.  New York: Kluwer Academic Publications.

⁸Owens, J. (2005).Insomnia in Children and Adolescents. Journal of Clinical Sleep Medicine, 1, 4, e454-e458. Accessed 4/27/06.

⁹McCrae, C. s., Sidney, D. N., Taylor, D. J., & Lichstein, K. L. (in press). Insomnia. In J. Fisher and W. O'Donohue (Eds.), Practice guidelines for evidence based psychotherapy. New York: Kluwer Academic Publications.

¹⁰National Institutes of Health, National Institutes of Neurological Disorders and Stroke. NIDS Hypersomnia Information Page. Updated 1/14/06. Accessed 2/26/06.

¹¹American Academy of Child and Adolescent Psychiatry (2002).Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. Journal of the American Academy of Child Adolescent Psychiatry, 41, 2 Suppl, 26S-49S.

¹²Littner, M., Johnson, S. F., McCall, W. V., McDowell Anderson, W., Davila, D., K. Hartse, Kushida, C. A., et al. (2001).  Practice Parameters for the Treatment of Narcolepsy: An Update for 2000. Sleep, 24, 4, 451-466.

¹³Chan, J., Edman, J. C., & Koltai, P. J. (2004). Obstructive sleep apnea in children. American Family Physician, 69, 5.

¹⁴American Academy of Pediatrics (2002). Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics, 109, 4, 704-712.

¹⁵Cataletto, M. E., & Hertz, G. (2005). Sleeplessness and Circadian Rhythm Disorder. Updated 9/27/05. Accessed 2/26/06.

¹⁶Heussler, H. (2005).Common causes of sleep disruption and daytime sleepiness: childhood sleep disorders II. Medical Journal of Australia, 182, 9, 484-489.

¹⁷Krakow, B.,Johnston, L., Melendrez, D., Hollifield, M., Warner, T. D., Chavez-Kennedy, D., & Herlan, M. J. (2001). An Open-Label Trial of Evidence-Based Cognitive Behavior Therapy for Nightmares and Insomnia in Crime Victims With PTSD. American Journal of Psychiatry, 158, 2043-2047.

¹⁸Pagel, J. F. (2000).Nightmares and Disorders of Dreaming. American Family Physician, 61, 7, 2037-2050. 

¹⁹Sharp, S. J., & D'Cruz, O. F. (2006). Somnambulism (Sleep Walking). Updated 1/3/06. Accessed 2/26/06.

²⁰Houts, A.C. (1996). Behavioral treatment of enuresis. The Clinical Psychologist, 49, 1, 5-6.

 ²¹American Academy of Child and Adolescent Psychiatry (2004). Psychiatric medication for children and adolescents part II: Types of medications. Fact Sheets for Families, 29. Accessed 4/26/06.