The nature of and behavioral treatment of sleep problems in youth with bipolar disorder.

Abstract

Abstract Bipolar spectrum disorders (BP) occur in up to 1% of youth and are associated with significant impairment. Individuals with BP are often characterized by a decreased need for sleep or dysregulated sleep-wake schedules. For children, such sleep problems often relate to impairment in school and social functioning. Thus, sleep is an especially important target of intervention for youth with BP because of children's sensitivity to lack of sleep and dysregulated sleep routines. The present paper describes sleeprelated issues in individuals with BP while also discussing potential behavioral interventions to improve sleep in youth with BP. Two case examples are presented to illustrate potential interventions. Keywords: Bipolar spectrum disorders (BP), sleep-wake cycle. ********** Bipolar spectrum disorders (BP) affect about 1-4% of the population and are chronic mood disorders characterized by fluctuating states of depression and mania often resulting in significant impairment (Kessler, Chiu, Demler, & Walters, 2005). BP may also be present in childhood or adolescence and subsequently affect social and school functioning. Prevalence estimates range from 0% (Costello, Angold, Burns, Stangl et al., 1996) to 1.2% (Shaffer, Fisher, Greenwald, & Greenberg, 2002) for bipolar I in youths, .1% to .6% for bipolar II (Costello, Angold, Burns, Erkanli et al., 1996; Kessler, Avenevoli, & Merikangas, 2001; Lewinsohn, Klein, & Seeley, 1995; Shaffer et al., 2002; Wittchen, Nelson, & Lachner, 1998), and .3% for bipolar NOS (Lewinsohn et al., 1995). The nature of symptoms in youth with BP disorder may differ somewhat from those seen in adults. For example, youth with BP are more likely to exhibit rapid cycling and mixed states of mania and depression (National Institute of Mental Health, 2001). Symptoms may be similar to the hyperactivity that is characteristic of attention deficit and hyperactivity disorder, oppositionality seen with other behavior problems such as oppositional defiant disorder, or irritability characteristic of childhood depression. However, one symptom that is characteristic of BP that distinguishes it from these other disorders of childhood is a decreased need for sleep (Kowatch, Youngstrom, Danielyan, & Findling, 2005) and dysregulated sleep-wake schedules (Faedda, Baldessarini, Glovinsky, & Austin, 2004). In fact, sleep and related characteristics have long been known to play an important role in mood disorders, especially BP (Rao, 2003). Thus, the purpose of this paper is to describe the importance of sleep for youth in general, and youth with BP, in particular. The paper also describes potential behavioral interventions to improve sleep in youth with BP, and concludes with two case examples that illustrate these techniques. Relevance of Sleep for Child and Adolescent Functioning and Mood Sleep is important for regulating children's mood and behaviors and for maximizing attention and learning (Dahl, 1996; Mindell & Owens, 2003). In non-clinical samples, studies have shown that sleep problems are associated with behavioral and functional impairments. Indeed, one study with healthy children ages 7 to 12 found that quantity of sleep, especially low sleep time, was associated with teacher report of problem behaviors including attention and externalizing problems (Aronen, Paavonen, Fjallberg, Soininen, & Torronen, 2000). Irregularity in children's sleep-wake schedules are also related to poor teacher ratings of school functioning in fifth graders (Acebo & Carskadon, 1993). A large epidemiological study found that parent reports of their children's sleep problems were associated with their reports of internalizing and total problems, and with teacher reports of emotional, social, somatic, attention, and delinquent problems (Paavonen, Solantaus, Almqvist, & Aronen, 2003). Youth with sleep problems were almost three times more likely to have clinically significant emotional problems. …