November 1st, 2010

Study: Are insomnia medications effective for children?

Despite uncertainty about the safety and efficacy of insomnia medication for children, a new survey finds that child psychiatrists endorse using medication in at least one-quarter of their patients. The study’s authors are recommending the clinical trials be used to learn how effective sleep medications are for children, what the optimal doses are and how the drugs affect mood and daytime functioning.

The findings, reported in the August issue of Sleep Medicine, are based on responses from nearly 1,300 members of the American Academy of Child and Adolescent Psychiatry. Insomnia is a significant clinical issue among many school-aged child and adolescent patients, the psychiatrists noted, and seems to become more prevalent as children age: More than 20 percent of preschoolers receiving psychiatric care are affected by insomnia, while almost one-third of school-aged children and adolescents receiving care are affected.

The psychiatrists reported recommending both prescription and non-prescription medications, often varying according to diagnosis. Clonidine was found to be widely prescribed for those with ADHD, while trazodone (a sedative antidepressant) is often prescribed for children with mood and anxiety disorders. Determining dosages, though, is a decidedly inexact science, says Judith Owens, M.D., a sleep expert at Hasbro Children’s Hospital in Providence, R.I., and leader of the research team.

“Because there’s such little data out there, psychiatrists are left to their own devices in guesstimating what the appropriate dosage might be,” she says. Although psychiatrists might be inclined to prescribe children lesser amounts of drugs than they would prescribe to adults, one study of Zolpidem, the generic form of Ambien, found children needed a higher dose than adults do, since children metabolize it more quickly.

“We need to have data on which to base dosage and understand tolerance, and just to be able to make more informed recommendations,” Owens says.

The over-the-counter drug melatonin was recommended by more than one-third of respondents, which Owens attributes to its acceptability – the pill is perhaps more familiar than other drugs and is based on a substance the body naturally produces.

The psychiatrists surveyed said they prescribed medication primarily to lessen the effects of sleep disruption on daytime functioning. Excessive sleepiness and fatigue may exacerbate psychiatric symptoms.

“There’s obviously very widespread use of these medications, and that’s testimony to the clinical need for them,” Owens says. “Quality of life for children and their parents is impacted by insomnia.”

Still, she adds, certain behavioral techniques that past studies have found effective, such as relaxation and cognitive behavioral therapy, are probably not being adequately explored.

“There’s a substantial literature documenting the benefits of behavioral treatment,” she says. “I think these approaches are inadequately taught. There’s a lack of knowledge of them on the part of psychiatrists, and they’re time-consuming… Sometimes, parents are resistant as well, and want a quick fix.”

Some psychiatrists surveyed noted concerns about the side effects of medications and the lack of empirical support of their efficacy. “I didn’t get the impression that [psychiatrists] were saying ‘let’s just throw a pill at it and make it better,’” Owens says. “I think the reality is clinicians don’t have the skills and the knowledge.”

By Ami Albernaz

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