Clinical Context

Symptoms of insomnia are transdiagnostic to physical and mental health disorders. There is a lack of population-based cohorts with objective sleep measures and long-term follow-ups. As a result, little is known about the chronicity of childhood insomnia symptoms.

As objective short sleep duration (OSSD) has been linked to persistence of insomnia symptoms into adult insomnia, it may be a useful biomarker of insomnia chronicity; however, it is undetermined whether the impact of OSSD in the trajectories of insomnia symptoms depends on the developmental stage in which youths are evaluated and whether it affects development of insomnia in the transition to adulthood.

Study Synopsis and Perspective

Childhood-onset insomnia is a chronic problem in 43% of children, according to 15-year follow-up data from approximately 500 individuals.

Difficulty initiating or maintaining sleep (DIMS) is the most frequently reported insomnia symptom in children and teens, but longitudinal data on the trajectory of insomnia symptoms from childhood into adulthood are limited, Julio Fernandez-Mendoza, PhD, of Penn State College of Medicine, Hershey, Pennsylvania, and colleagues wrote.

Previous studies have shown varying results, notably on the effect of OSSD, they said. The extent to which OSSD affects insomnia trajectories and whether OSSD affects the development of insomnia in the transition to adulthood remains uncertain.

In a study published in Pediatrics, the researchers reviewed data from 502 children who enrolled at age 5 to 12 years between 2000 and 2005. The participants underwent laboratory polysomnography (PSG) visits at baseline; 421 had a second laboratory visit between 2010 and 2013 (median age, 16 years), and 502 completed a structured self-reported survey between 2018 and 2021 at a median age of 24 years. At the first visit, 118 children met criteria for insomnia, defined as parent reports of often/moderate or very often/severe DIMS and/or use of over-the-counter or prescription sleep medications for DIMS. At the second visit, 120 children met the definition for insomnia.

Among children with insomnia symptoms at baseline, 53.7% had persistence of insomnia symptoms in adolescence and 61.9% had symptoms in young adulthood; 46.3% and 38.1% remitted at these times.

Among children with insomnia symptoms at adolescence, 57.5% and 42.5% had persistence and remittance, respectively, in young adulthood.

In children with insomnia at baseline, therefore, the most frequent developmental trajectory was persistence (43.3%) followed by remission (26.9% since childhood and 11.2% since adolescence) and a waxing and waning pattern (18.6%), the researchers said.

Among children with normal sleep at baseline, 69.7% retained normal sleep patterns in adolescence, and 63.3% retained normal sleep in young adulthood; 30.3% and 36.7% developed insomnia in adolescence and young adulthood, respectively.

Overall, adult insomnia was reported by 22% and 20.8% of individuals with childhood and adolescent insomnia, respectively. In a multivariate analysis, the odds for adult insomnia were 2.6 times and 5.5 times higher among persons with histories of short sleeping in childhood and adolescence, respectively.

"The most common developmental trajectory for insomnia symptoms was that of persistence from childhood through young adulthood," the researchers wrote in their discussion of the study.

"These 15-year longitudinal findings across three developmental stages indicate that insomnia symptoms should not be expected to developmentally remit in at least 40% of children and that adolescence is a critical developmental period for the adverse prognosis of the insomnia with short sleep duration phenotype," they emphasized.

The study findings were limited by several factors, including the collection of OSSD and other sleep data via a 1-night, 9-hour PSG, which might not be representative of habitual sleep at home, the researchers noted. Other limitations include the lack of PSG data to accompany the young adult survey and the inability to validate insomnia in young adults via strict diagnostic criteria.

The results reveal, however, that the persistence of childhood insomnia is higher than suggested in previous studies, and that these children and adolescents, especially short sleepers, are at significantly increased risk for adult insomnia, the researchers concluded.

"Early sleep interventions are a priority, as clinicians should not expect insomnia symptoms to developmentally remit in a high proportion of children, although objective sleep measures may be indicated in adolescence to identify those with poorer long-term prognosis," they said.

Pandemic Prompts Interest in Sleep Issues

The current study is important at this time because sleep disruptions in children and adolescents have increased over the course of the COVID-19 pandemic, Karalyn Kinsella, MD, a pediatrician in private practice in Cheshire, Connecticut, said in an interview.

Kinsella said she was especially surprised to see that adolescent insomnia will most likely not remit in young adulthood, as she had considered it a disorder of adolescence.

The study highlights the need for early intervention to manage insomnia in children; however, there are several barriers to such intervention.

"Parents [of young children] are overwhelmed and just need sleep themselves, so they don't always have the energy to work on good sleep habits in their children," she said.

Improving sleep habits in adolescents requires overcoming the barrier of the young patients' attitudes.

"For adolescents, they need to buy into the change," Kinsella explained.

Still, the take-home message for clinicians is that it is important to work to overcome these barriers and improve sleep in children and teens, because the longitudinal data suggest that the problem is "likely to persist and unlikely to remit," for many, she said.

As for additional studies, "I would like to see more research done on neurologic and psychological causes of insomnia," Kinsella said.

The study was supported in part by grants from the National Heart, Lung, and Blood Institute; National Institute of Mental Health; and the National Center for Advancing Translational Sciences of the National Institutes of Health. The researchers had no financial conflicts to disclose. Kinsella had no financial conflicts to disclose and serves on the editorial advisory board of Pediatric News.

Pediatrics.2022;149:e2021053616.^[1]

Clinical Implications

• Nearly half (43%) of children have persistent insomnia symptoms and 20% worsen into adult insomnia, with greatest risk in short-sleeping adolescents, suggests a 15-year prospective cohort study by Fernandez-Mendoza and colleagues.
• As pediatricians should not expect insomnia symptoms to developmentally remit in ≥ 40% of children, early sleep interventions are essential, despite several barriers.
• Implications for the Healthcare Team: Objective sleep measures may be clinically useful in adolescence, a critical period for adverse prognosis of insomnia with short-sleep duration.

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