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Children \200\231s expression of negative aff ect: reasons and methods. Dev Psychol, 32 , 842 \200\223849 . CHAPTER 15 Sleep and pain in children and adolescents Bruce D. Dick , Penny Corkum, Manisha Witmans , and Christine T. Chambers Summary Ongoing pain is a problem that aff ects a large number of chil- dren and adolescent s. It has been well documented that recurrent and chronic pain are associated with many dif fi culties related to both physical and psychological function. A major diffi culty that ma ny young people with chronic or recurrent pain experience is disrupted sleep. Sleep problem s have been reported to exist in as many as 50% or more of children with chronic illnesses (Owens, 2007). In many cases, pain is reported by the suff erers to cause sleep fragmentati on as well as signifi cant diffi culties with delayed sleep onset. As well, there is increa sing evidence that disrupted sleep is associated with increased pain. Both pain and sleep d is- ruption further complicate the patient \200\231s overall clinical picture by making it more diffi cult for children and teens to cope with health problems and associated diffi cu lties. Further, there is evidence that childhood sleep problems can have important negative eff ects on adult sleep patterns and, thereby, infl uence health status later in life (Fri cke-Oerkermann et al., 2007; Sivertsen et al., 2009). Th is chapter will address the preval ence, importance, and consequences of sleep problems in children and adolescents with pain. First, the prevalence and possible relationship between pain and sleep will be discussed. Next, we will highlight the assessment of sleep with a specifi c focus on assessment of sle ep in pediatric pain populations. We will then review established and emerging medical and psycho- logical treatment strategies used to eff ectively treat these important diffi culti es. Practical suggestions will also be provided as a general and basic guide for treatment of children and teens with pain and sleep problems. relatively short-term basis. Recurrent or persistent pain can have a useful function but of t en results in prolonged and more signifi cant impairment. Chronic pain can become highly disruptive of func- tion but generally tends not to have a useful or adaptive function, som etimes resulting in a complex web of negative outcomes that can have widespread eff ects on a young person \200\231s life. Clinically, when pain becomes disruptive of function, it is fre- quently reported by child and adolescent suff erers to result in a range of negative outcomes. Th ese negative eff ec ts include impairment of physical function and activity levels, decreased school attendance and academic performance, cognitive interruption, mood prob- lems, particularly anxiety an d depression, decreased social activity including negative eff ects on friendships, and poo rer quality of life (Dick and Pillai Riddell, 2010; Forgeron et al. 2011). Th e nature and severity of the eff ects of these problems can interact with each other and can be associat ed with several negative vicious cycles. Amidst all of these diffi culties, sleep is a primary factor reported to be negatively aff ected by pain. In clinical settings, sleep is com- monly reported to be one of the major co mplications caused by pain and a primary source of diffi culty associated with mood problem s, school attendance and performance, cognitive function, and qual- ity of life (Owens, 200 5). It is not uncommon for one or more of the major negative clinical features associated w ith pain to improve markedly when treatment results in improved sleep. Sleep and pain Sleep is of critical importance to the developing child. It has been found t o be associated with physical health, growth, and function, development, learning, and cogn itive function, several aspects of behavior, mood, emotional regulation, and psychological health, coping, and family function (Durmer and Dinges, 2005; Forest and Godbout, 2000; Mel tzer and Mindell, 2009 Mindell and Owens, 2003; Owens, 2005). Sleep problems are also assoc iated with other health problems including cardiovascular disease, diabetes, obesity both i n children and in adults (Cappuccio et al., 2008; Foley et al. 2004), and stress and other negative eff ects on parents of these chil- dren (Martin et al., 2007). Pain in children For most children and adolescents, pain is a noxious experience that inter rupts and negatively aff ects many aspects of function. As pain exists across a spectrum fr om acute and episodic to persistent and chronic, the disruptive eff ects of pain also range across a con- tinuum from mild to disabling. Acute pain oft en plays an important protecti ve role in alerting the suff erer to injury or illness and can therefore have a very disrup tive eff ect on function, generally on a SECTION 3 social and psychological basis of pediatric pain 136 Table 15.1 Sleep-related symptoms in the context of pain in children (but not pain speci \201 c) Daytime symptoms Irritability, hyperactivity, daytime sleepiness, fatigue, increased pain, behavioral proble ms, anxiety, lower frustration tolerance Bedtime symptoms Delayed sleep onset, irritability, bedtime battles, anxiety, hyperactivity, increased pain Sleep symptoms Wakefulness after sleep onset, lower sleep e \203 ciency, fragmented sleep (microarousals) , nightmares, worse parasomnias resulting from sleep fragmentation, night-time arousals, ir ritability, sudden awakenings, inconsolability. While sleep problems in children and teens in the general pop- ulation are common, it has b een recognized that children and adolescents with pain may be at particular risk for sleep prob- lems (Owens, 2011). For example, adolescents with infl ammatory bowel disease reporte d poorer quality sleep with increased disease severity. Th e parents of those adolescents a lso reported that their children experienced more nightmares and other sleep diffi cul- tie s and that disease severity was associated with higher levels of daytime fatigue and an inc rease in the amount of time that their children spent sleeping during the day (Pirinen et a l. 2010). In another study, Lewandowski and colleagues (2010) found that pain ratings were predicted by longer sleep duration and longer sleep onset delay. Given that pain can have s uch a dramatic eff ect on sleep quality, duration, and fragmentation, understanding the int eraction between pain and sleep and how to eff ectively co-assess and treat these diffi cul ties can have broader positive implications on child health and well-being in a variety of ways. It is remark- able how many common negative outcomes are uniquely associ- ated with p ain and/or sleep. Each problem can have a dramatic impact on function, mood, and cognition (Palermo, 2009; Sadeh, 2007). When pain and sleep problems coexist, the nature and extent o f problems arising from the association can appear to be more complex and dynamic rather th an simply additive. Chronic pain may also aff ect the child \200\231s sleep patterns over t ime and result in behavioral manifestations such as daytime irritability, moodi- ness, hype ractivity, and sleepiness. Unresolved sleep issues may make pain more diffi cult to manage. Table 15.1 provides common examples of behavioral manifestations in children struggling wi th sleep problems and pain. 2007). Some conditions can be associated such as sleep disordered breathing has been report ed to have a higher prevalence in children with sickle cell disease (Brooks et al., 1996; F uggle et al., 1996). Not only are sleep problems more common in children with chronic pain, but the severity of sleep disturbances is generally related to pain intensity; children wi th more severe pain are likely to report a greater degree of sleep problems (Bloom et al., 2002; Miller et al., 2003). Data evaluating the association between pain and sleep in chil- dren are emerging, most usi ng self-report and subjective assess- ment tools. A small group of adolescent females with chronic musculoskeletal pain were found to have similar total sleep time compared to norms but signifi cantly longer sleep onset latency, more night wakings, a later morning wake tim e, and more symp- toms of daytime sleepiness using validated questionnaires (Meltzer et al. , 2005). Some of these teens reported improvement in pain aft er a sleep period. Conversely , a study of children with polyarticu- lar arthritis tracked pain severity and sleep qualit y over a period of 2 months and found that poorer sleep quality was associated with higher next-day ratings of pain (Butbul Aviel et al., 2011). Th ese fi ndings associating disturbe d sleep and fatigue, with increased pain have been also found in other rheumatological cond itions (Butbul Aviel et al., 2011) and result in lower quality of life (Gold et al., 2009; Long et al., 2008). Th ere is currently adequate evidence to suggest that any program invol ving treatment of pain should also address sleep parameters of the aff ected individuals. A series of papers (Long et al., 2008; Tsai et al., 2008; Palermo and Owens, 2008; Valrie e t al., 2008; Ward et al., 2008) published in a special issue of the Journal of Pediatric Ps ychology (2008, Volume 33, Issue 3) dedicated to sleep in children with medical conditions, have extended our current understanding of the importance of sleep in pediatric chronic pa in. Th e results of these studies have confi rmed that sleep problems are common in childre n with chronic pain, and highlight the importance of factors such as mood, stress, and dayt ime napping in helping to understand the relationship between pain and sleep in children wi th chronic pain. For example, Valrie and colleagues (2008) showed that, among children with sickle cell disease, a day with high pain was related to poor sleep quality that night, wh ich was then related to higher pain the following day. Th e relationship between pain and s leep has been shown to be further exacerbated by high levels of stress (Valrie et al., 2007 ). Tsai and colleagues (2008) examined the important role of naps in children with chronic pain, fi nding that children with chronic pain were likely to engage in daytime naps to com pensate for lost night time sleep, which may have a negative eff ect on night-time sleep. Prevalence and impact of sleep problems In recent years there has been tremendous advances in the study of the relationship between pain and sleep problems in children. Two prior rev iews (Gagliese and Chambers, 2007; Lewin and Dahl, 1999) have highlighted the importance of sleep in the assessment and management of pediatric pain, and have summarized the prevalen ce of sleep problems among children with various painful conditions, such as headache, recu rrent abdominal pain, sickle cell disease, musculoskeletal pain, and arthritis. Th ere is a clear con- sensus that children with chronic pain are more likely to experi- ence a variet y of sleep diffi culties than their healthy peers (Gagliese and Chambers, 2007). Estimates indicate that approximately 50% of children with chronic pain experience a signifi cant sle ep distur- bance (Long et al., 2008; Palermo et al., 2007, 2011), in contrast to 10% to 20% in healthy peers. Sleep diffi culties are also commonly experienced as a result of pain am ong children with intellectual and developmental disabilities (Breau and Camfi eld, 2011). Across studies and pain types, diffi culties falling asleep (i.e. insomnia), night wakings, and daytime fatigue are the most common sleep dis- turbances in children with chronic pain (Gagliese and Chambers, Of concern, sleep problems in children and teens with chronic pain are associated with lowe r quality of life and a greater degree of functional disability (Chambers et al., 2008; Lon g et al., 2008; Palermo et al., 2007, 2008). Recent work examining behavioral and psychosoc ial factors associated with insomnia in adolescents with chronic pain has highlighted that, while sleep disruption may CHAPTER 15 sleep and pain in children and adolescents 137 initially be a result of pain, sleep diffi culties may evolve into a pri- mary sleep disord er. forms of sleep diaries which require recall of information about sleep quantity and timing (<http://www.sleepfoundation.org/; http://www.sleepforkids.org/pdf/SleepDiary.pdf>). An exc ellent detailed review of the strengths and limitations of subjective paedi- atric sleep me asures is available (Lewandowski et al., 2011a). Relationships between sleep and pain Th e interaction between pain, sleep, physical functio n, and emo- tional regulation is complex. Although the mechanisms of the inter- actions and pathogenesis of pain and sleep are poorly understood, it is probable that pain, sleep and emotion share common neuro- biological pathways and neuronal mechanisms. Th e neurobiology of the specifi c pain condition based on its associated symptoms may have widespread eff ec ts that may be linked to sleep related cel- lular activity and neurotransmitter processing areas of the hypotha- lamus, amygdala, limbic region, and frontal cortical areas. Information on objective parameters of sleep and sleep quality in children with chronic pai n are sparse and limited. An overnight polysomnogram, which involves monitoring multiple ph ysiologi- cal signals related to sleep and breathing, is the gold standard of sleep assessm ent. Polysomnography has been widely used to docu- ment the presence or absence of sleep di sordered breathing. Th e role of this test in populations with chronic pain is limited part ially due to limited access to such testing in many geographic locations, a paucity of rese arch related to its role in the care of these chil- dren, and the fact that, in many cases, monitoring only takes place over one night. Alternatively, actigraphy, a wrist-watch like device that uses accelerometers to monitor activity patterns, can provide ecologically vali d objective information related to sleep. Actigraphs are extensively validated and widely u sed devices in sleep research with reasonable sensitivity and specifi city. Moreover, in pa ediat- ric populations generally, actigraphs provide accurate estimates of total sleep time and sleep effi ciency, but are generally poor at dis- cerning wakefulness aft er sleep ons et (Meltzer and Westin, 2011). Actigraphs have also been used in pain research in children to measure physical activity (Kashikar-Zuck et al., 2010; Long et al., 2008; Palermo et al. , 2008). Recent studies involving neuroimaging and neurophysiology are shedding light on the altered functional and structural changes in chronic pain. For example, in fi bromyalgia, the pain is thought to be neurogenic in origin and results from neurochemical imbal- ances that lea d to amplifi cation of pain perception and abnormal signal processing (Henry et al., 2011). Th is may be associated with changes in cellular activation or cortical sensory integratio n. It has been suggested that other chronic pain syndromes also have similar dysfunction in pa in processing within the brain, although the exact mechanisms have not been elucidated. Sle ep deprivation or sleep fragmentation may further exacerbate the disruption in processing. It is then conceivable that the aberrant signal processing may not be related to pain alone , but potentially to other homeostatic mechanisms within the central nervous system, includ ing the proc- esses that govern sleep physiology and circadian rhythms. Whether poor sleep is the manifestation of underlying biological dysfunction or a result of such dysfunction r emains to be determined. Of note, the same neurotransmitters that infl uence pain sensitivi ty such as dopamine, serotonin, and noradrenaline, are the same ones involved in sleep and emotional regulation (Saper et al., 2005). As more ambulatory monitoring systems are developed, we can expect that such monitoring in the home environment will become more popular. What has been learned thus far is that polys om- nography in children with juvenile fi bromyalgia showed increased periodic limb movemen ts in a subset of children but little is known about which children would benefi t from hav ing polysomnography testing (Tayag-Kier et al., 2000) without comorbid sleep complaints (Br omberg et al., 2011). Another study evaluating polysomnog- raphy in children with headache showed an association between migraine and sleep disordered breathing, and tension headache and bruxism (Vendrame et al., 2008) and less rapid eye movement sleep and slow wave sleep. Practically speaking, persistent sleep complaints or lack of improvement in symptoms with behavioral interventions would be reasonable indications for pursuing further detailed slee p evaluation, including polysomnography. Assessment of sleep in children with chronic pain Th e assessment and evaluation of childre n with chronic pain and sleep issues is both challenging and complex because of the poten- tial bidirectional relationship and mitigating factors that aff ect both sleep and pain. Th e assessment of a child with chronic pain condi- tion should include a thorough history of sleep practices, routines, cultural beliefs and values related to sleep, sleep preferences , and screening for possible associated sleep disorders (such as sleep disor- dered breathi ng, restless legs syndrome, periodic limb movements, or disorders of excessive sleepiness). Th e evaluation should also include a typical comprehensive medical history, including det ails about psychiatric, developmental, social history and medication use. Further specifi c inquiry such as previous medication trials or complementary alternative therapy trials sho uld also be included. Another test to objectively measure sleepiness in children is the multiple sleep latency te st. A patient is given nap opportunities at 2-hour intervals through the day, and the degre e of sleepiness is documented objectively by determining how quickly the individual falls a sleep using standardized testing parameters. However, the role of such testing in children with chronic pain is not known, especially in the context of medications that may be partia lly responsible for the daytime fatigue or sleepiness. Optimizing sleep in children with chronic pain Treatment of children with chronic pain who also have comorbid sleep problems requires a multidisciplinary, and oft en a multimodal app roach. Th e multidisciplinary clinics oft en include an anaesthe- siologist specialized in pain management, nurses, physiotherapists, occupational therapists, and child psychologists with interest and expertise in pain but oft en not the sleep medicine specialist. Either Th ere are validated tools developed for children with chronic pain (Kashikar-Zuck et al., 2010, 2011; Palermo 2009). Validated ques- tionnaires such as such as the Children \200\231 s Sleep Habits Questionnaire (Owens et al., 2000), or the Pediatric Sleep Questionnaire (Ch ervin et al., 2007) have been used to identify sleep problems in various clinical and resea rch populations but are not specifi cally designed for use with children or teens with chro nic pain. Subjective, self-re- port measures for documenting sleep are available such as va rious SECTION 3 social and psychological basis of pediatric pain 138 the addition of a sleep medicine specialist or involvement via con- sultation could help im prove outcomes of both sleep and chronic pain. Despite the fact that pharmacological interv entions are fre- quently used to treat insomnia in children and adults, the empirical evide nce shows that psychological interventions are more eff ective in both children and adults, especially in the longer-term (Mindell et al., 2006a; Stiefel and Stagno, 2004). muscle relaxation, guided imagery, deep breathing), and sleep hygiene (i.e. a range of stra tegies that lead to healthy sleep habits). Th ese strategies, along with cognitive restruct uring (i.e. identifying and challenging illogical and maladaptive thoughts related to sleep ) have been combined into a multi-component treatment approach, labeled cognitive-behaviora l therapy for insomnia (CBT-I). In adult populations, CBT-I has received strong research su pport, based on meta-analyzes and systematic reviews, for the treatment of primary insomnia (i.e. insomnia without any other medical or psychological conditions; Morin 2010). Less is known about the use of this technique in children. Given that CBT requires cognitive skill s that emerge as development progresses, using CBT-I methods would require matching the tre atment task requirements to each child \200\231s individual needs. Th ere are emerging data about the use of behavioral and psy- chological treatments for chi ldren with chronic pain with positive results in improved pain intensity, functional impair ment, and emo- tional functioning (Palermo, 2009). Cognitive-behavioral therapy (CBT) incor porates both cognitive strategies and behavioral tech- niques to improve sleep that have a well-established empiric basis in management of insomnia in adults. One randomized control trial provided CBT using Internet delivery of sleep-related advice dur- ing one session wit h promising results (Palermo et al., 2009). CBT does appear to be eff ective for functional disability in children with juvenile fi bromyalgia but the role of sleep has not been spec ifi cally addressed (Kashikar-Zuck et al., 2010, 2012; Lewandowski et al., 2011b). Neverthe less, it is commonly accepted that sleep health counseling including healthy sleep habits ( sleep hygiene) should be addressed as part of the treatment for chronic pain (Box 16.1). Th e added value of such interventions to an integrated pain pro- gramme warrants further eva luation (see Logan et al., Chapter 50, this volume). Sleep interventions for children Research examining the eff ectiveness of psychological tre atments for insomnia in children has focused on testing the various treat- ment components in isolation or in combination, but has not spe- cifi cally evaluated CBT-I. Th e vast majo rity of research has been conducted with infants and preschoolers and very little intervent ion research has been conducted with school-aged children and adoles- cents. Also, there ha ve been very few randomized controlled trials (RCTs) conducted to document the effi cacy of sleep interventions for children of any age. Mindell et al. (2006b) conducted a review of treatment randomized trials in young children and found that in the vast majority, children demonstrated improved sleep with the use of behavioral interventions. Not only did the chi ldren \200\231s sleep improve (80% of whom demonstrated clinically signifi cant improvement ), but also improvements in children \200\231s daytime func- tioning and parent well-being were noted (Mindell, et al., 2006b). Psychological treatments Treatment studies can be used to tease apart the bi-directional re la- tionship between sleep and pain, as well as provide clinicians with needed empirical su pport for selecting and implementing appro- priate interventions. Of particular interest to the current review are studies that have treated sleep disturbances in individuals with ch ronic pain using psychological strategies. Th ese studies examine how sleep problems in ind ividuals with chronic pain respond to treatment. Th ey also highlight the impact of improvi ng sleep on pain and associated symptoms such as mood. In order to better understand the re lationship between sleep and pain, and to high- light what we know about evidence-based psy chological treatment of sleep problems in children with chronic pain, we will fi rst review the empirical evidence for psychological treatment of sleep prob- lems in otherwise health y children. Due to the small amount of research on children in this area, adult studies are included. Th e primary goal of sleep interventions in children is to create positive associations wit h sleep, establish bedtime routines, and learn relaxation or self-soothing skills. Th e int erventions that are considered well established by research are: extinction (i.e. parent no t responding to child \200\231s attempt to re-engage parent to provide external soothing), graduated extinction (i.e. parent ignoring their child \200\231s attempt to re-engage for p redetermined length of time), and parent education (i.e. teaching parents about children \200\231s sleep and appropriate sleep hygiene). Strategies considered to be prob- ably effi cacious include: scheduled awakenings (i.e. pre-emptive waking schedule for which parents wake their child 15 to 30 min prior to the time of typical night awakenings) and bedtime fa ding (i.e. putting the child to bed at a time that he/she is likely to fall asleep quickly and once successful backing up bedtime in 15-min increments). Insomnia and sleep interventions Th e most common sleep problem in both adults and children is insomnia. Approximately 30% of children and adults display some symptoms of insomnia an d about 10% reach full diagnos- tic criteria for insomnia (Meltzer et al., 2010; Morin, 201 0). Th is rate is even higher for individuals with chronic pain; up to 50% of children and 50% to 70% of adults with chronic pain report insomnia (Lewandowski et al., 2011b; Menefee et al., 2000). Th ere are a number of treatment strategies that are eff ective in treating insomnia in adults. Th ese strategies include sleep restriction (i.e. limiting total sleep time to number of hours currently sleeping and slowly increasing sleep time), stimulus cont rol therapy (i.e. chang- ing conditioned associations with bed and sleep, e.g., using the b ed as a place for sleep only), relaxation exercises (such as progressive Sleep interventions for children with chronic pain Although there is strong support for som e intervention techniques in certain age ranges, there is very little research testing the eff ec- tiveness of these interventions for children with physical or mental health diagnos es (Lewandowski et al., 2011b; Vriend and Corkum, 2011). Th ere is even less research on ch ildren with chronic pain. Four studies have provided sleep intervention as part of a multic om- ponent treatment for pain (Bruni et al., 1999; Degotardi et al., 2006, Maynard et al., 2010, Palermo et al., 2009). Each of these studies is CHAPTER 15 sleep and pain in children and adolescents 139 Table 15.2 Intervention studies which included a sleep component for treating children with chronic pain Author Participants Design Treatment Outcome Child intervention studies Degotardi et al., 2006 N = 67 (59 females, 8 males); \201 bromyalgia; mean age: 13.9 years (SD = 2.8, range = 8 \200\22320) Pre-post design; outcome was measured by questionnaires on physical (e.g. pain, sleep quali ty, fatigue) and psychological (e.g. anxiety, internalization, quality of life) symptoms co mpleted by parents and children 8 weekly sessions which focused on psycho-education about pain and sleep, sleep improvement , pain management, and activities of daily living. Sleep treatment strategies included slee p hygiene, relaxation, self-reward, stimulus control, sleep restriction, and cognitive rest ructuring. Treatment was based on a CBT treatment manual developed by the authors Improvements reported across all measures, including decreased pain, somatic symptoms, anxi ety and fatigue as well as improved sleep quality. 24% of the children were reported to be pain free at the end of the intervention. Both self-reports and clinical observations showe d dramatic improvements. Results were based on participants who completed the intervention (34% attrition rate) Maynard et al., 2010 N = 41 (30 females, 11 males); pain-associated disability syndrome; mean age: 13.8 years (S D = 2.8, range = 8 \200\22321) Retrospective chart review; outcome was measured by information in chart on school attendan ce, medication usage, sleep, functional disability, coping skills, and mobility Treatment through an interdisciplinary inpatient rehabilitation program including several c omponents. Psychological treatment focused on CBT for pain and anxiety and the use of shapi ng to improve functional ability. Sleep intervention included relaxation strategies at bedt ime Improvement in functional ability, physical mobility, as well as school status, sleep, and medication use Palermo et al., 2009 N = 48 (35 females, 13 males); chronic headache, abdominal, or musculoskeletal pain; mean a ge: 14.8 years (SD = 2.0, range = 11 \200\22317) RCT; Internet-treatment group (n = 26), waitlist control group (n = 22); outcomes (e.g. rec ording pain and activity levels) were measured by daily diaries and questionnaires pre- and post-treatment Internet-delivered CBT intervention which included 8 weeks of modules focused on treating p ain through relaxation training, cognitive strategies, parent operant techniques, communica tion strategies, and sleep and activity interventions. Sleep intervention included informat ion on sleep and good sleep hygiene practices Improvements in pain intensity and activity levels at end of treatment and 3-month follow-u p. No improvement in parental protectiveness or child mood symptoms Bruni et al., 1999 N = 70 (32 females, 38 males); migraine su \200 erers with poor sleep hygiene; mean age: 9 .7 years (SD = 1.5, range = 5 \200\22315 years) RCT, assigned to treatment (n = 35), no treatment (n = 35); outcomes were assessed by track ing duration, frequency and severity of migraines Treatment included application of sleep hygiene guidelines, but these were not speci \201 ed in the paper Improvement in frequency and duration of migraines for treatment group, but no change in se verity described in detail in Table 15.2 . Results across these studies were generally positive, w ith improvements in both pain and sleep, as well as other associated areas (e.g. functional disability, fatigue). A series of randomized trials conducted among adults with chronic pa in conditions (Currie et al., 2000; Edinger et al., 2005; Jungquist et al., 2010; Rybarczyk et al., 2005) has yielded similar positive results. More intervention research in this are a is needed, with a focus on demonstrating that improvements in sleep does indeed result in improved pain outcomes. of childhood insomnia. Of note, many pain medications that are prescribed oft en have sleep -related eff ects. For example, tricyclic antidepressants and anticonvulsants oft en have s leepiness as a side eff ect which may help promote sleep. Th ese same medications may also cause daytime sleepiness or fatigue which may further worsen functional adaptation in deali ng with pain. In some instances, such as with the use of gabapentin for neuropathic pain, t he medication may help reduce pain and possibly improve a comorbid sleep dis- order such as restless legs syndrome. Selective serotonin reuptake inhibitors (e.g. paroxetine) may be u sed for treatment of comorbid psychological disorders rather than pain itself and the impac t of these medications on sleep such as rapid eye movement suppres- sion, or increased peri odic limb movements (Vendrame et al., 2011) should not be overlooked. Similarly, opioid med ications for chronic pain may worsen underlying sleep disordered breathing, or result in co nstipation and associated discomfort that impairs sleep. Controlled trials using medication s for treating chronic pain in children and teens are lacking. Future research studies shou ld add in components that address sleep specifi cally. (For more infor- mation on clinical use of opioids see Strassels, Chapter 45, and for Pharmacological treatments Pharmacological therapy for chronic pain should take into con- s ideration potential interactions with sleep. Th ere are no approved medications for the tre atment of insomnia in children or medica- tions for chronic pain in children. Reviews about insomnia and treatment options in children are available (Owens and Moturi, 2009; Owens et al., 2005). Chronic pain in children is oft en managed with similar medications as in adul ts off label, but integration of behavioral strategies are oft en paramount, much like mana gement SECTION 3 social and psychological basis of pediatric pain 140 drugs for neuropathic pain, see Rastogi and Campbell, Chapter 48, this volume.) Box 15.1 Healthy sleep habits for children and adolescents \227\206 Ensure morning bright-light exposure Key recommendations Given the evidence to date, we recommend that children with pain and sl eep problems be provided with a developmentally appropri- ate, evidence-based intervention for their sleep problems as one component of their pain management plan. A detailed descrip tion of these intervention strategies is beyond the scope of this review; however, Box 15.1 lists some healthy sleep habits for children and adolescents and Table 15.3 contains a lis t of resources. Some modi- fi cations or special considerations might be useful to consider when implementing sleep intervention for children with chronic pain (Smith et al., 2005). Th e clinician may have to explain to parents why treating sleep problems is important, as a study by Claar and Scharff (2007) found that parents did not see sleep interventions as l ikely to help with the treatment of pain in their children. It will also be important to de velop sleep interventions that parents of children with chronic pain can readily access. Fo r example, novel delivery methods, such as internet (Corkum and Davidson, 2011) or tel- ehe alth (Witmans et al., 2008) may help to reduce access barriers. Clinicians working with chi ldren with chronic pain may also want to consider the following when implementing sleep int erventions: \227\206 Schedule daily physical activity (ideally earlier in the day) \227\206 Avoid caff eine in the aft ernoon and evening \227\206 Reduce (and avoid where possible) bright light in the evening and in the night \227\206 Reduce stimulating activities before and at bedtime \227\206 Set an age-appropriate bedtime \227\206 Establish a regular, consistent bedtime routine \227\206 Maintain a consistent schedule for weekdays and weekends \227\206 Create an environment conducive to sleep: cool, dark, quiet, comfortable \227\206 Remove electronics from the bedroom \227\206 Use the bed only for sleep \227\206 Monitor for side eff ects of medications that may aff ect sleep. Table 15.3 Resources for sleep intervention in children \227\206 Managing pain will help the child be able to fall asleep and stay asleep. Also, m aking sure that medications taken by the child are not interfering with sleep. Journal articles