Insomnia is defined as difficulty in falling asleep, prolonged nighttime awakenings, or insufficient amount or quality of sleep, which affects daytime functioning, despite adequate opportunity for sleep [1, 2]. Daytime somnolence associated with insomnia in childhood and adolescence may cause impairment in attention, cognition and memory, which can adversely impact academic performance . In children, insomnia typically is not a primary condition , but rather associated with psychological or medical conditions, such as anxiety , depression , pain , asthma and cystic fibrosis .
Insomnia affects a large proportion of school-age children. In a survey published in 1997, parents of 987 New York State elementary school children, ages 5–12 years, reported that 11% of their children had difficulty falling asleep, 7% had nighttime awakenings, 17% had difficulty awakening in the morning, and 17% were tired in the daytime . In a 1994–1995 survey of 2,339 US adolescents, 12–16 years of age, 23% reported difficulty with falling asleep or nighttime awakenings once a week or more, and 39% reported frequently waking tired .
Insomnia in elementary-school children often involves complaints about nighttime fears and anxiety-provoking dreams [3, 9, 10]. Sleep disturbances during adolescence can occur as a result of differing bedtimes on school nights as opposed to non-school nights, inadequate parental supervision, environmental factors including use of television and the internet, and consumption of alcohol or caffeine . Adolescents also experience an apparent biologically based delay in the timing of sleep onset and awakening, associated with their pubertal status, which can cause a conflict with the social demands for early morning schooling [11–13].
Treatments for insomnia include cognitive behavioral therapies and pharmacologic therapies [1, 2]. However, there is a lack of data regarding the efficacy of pharmacologic agents in the management of children with insomnia . The following types of cognitive behavioral therapies are appropriate for school-age children:
(1) Stimulus-control therapy is intended to teach the child to associate the bed with sleep. With this modality, the child goes to bed only when sleepy, uses the bedroom only for sleep, has a regular wake time regardless of the duration of sleep, and avoids daytime napping .
(2) Sleep restriction therapy initially reduces the amount of time in the bed to the estimated time spent asleep, and then the time is increased in increments every week until optimal sleep duration is achieved [1, 2, 15].
(3) Relaxation therapies, including imagery training, meditation, hypnosis, progressive muscle relaxation, and biofeedback [1, 2].
(4) Education regarding sleep needs and consequences of poor sleep can help decrease anxiety regarding the inability to fall asleep [1, 15].
(5) Sleep-hygiene education emphasizes correction of extrinsic factors that may affect sleep, such as pets, television, room temperature, or exercise [1, 15].
Most published reports regarding the use of hypnosis as a cognitive therapy for insomnia have involved adults. Instruction of self-hypnosis for relaxation in two sessions to 18 subjects between 29 and 60 years of age was shown to be more effective in improving insomnia than use of nitrazepam or placebo . Among 45 subjects between 23 and 67 years of age, the use of four 30-minute sessions to instruct hypnosis for relaxation and sleep hygiene education was shown to be more effective with insomnia than stimulus-control or placebo therapy . The insomnia of 3 of 6 subjects between 26 and 61 years of age improved following 6 sessions of hypnosis instruction and reinforcement, including two initial sessions that had a total duration of 210 minutes . Single case reports of improvement of insomnia with the aid of hypnosis in children have been published [10, 19, 20]. Because children are adept at using hypnosis , a non-pharmaceutical intervention without side-effects, we chose to study its effect on insomnia in a larger pediatric population.
The purposes of this study are to document psychosocial stressors and medical conditions associated with development of insomnia in a large series of school-age children and to report use of hypnosis for this condition.