Objectives 11/11/14. Identifying and Treating Pediatric Sleep Disorders. Normal Sleep in Children. When baby ain t sleepin, ain t nobody sleepin!

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1 When baby ain t sleepin, ain t nobody sleepin! Identifying and Treating Pediatric Sleep Disorders Theodore Wagener, PhD OU Children s Physicians, Pediatric Behavioral Sleep Medicine Clinic Objectives Attendees will be able to identify what is considered normal versus abnormal sleep in children. Attendees will be able to identify the defining features of Behavioral Insomnias of Childhood and describe evidence based protocols to treat these disorders. Attendees will be able to identify the defining features of various Parasomnias (Sleepwalking, Sleep Terrors, Nightmares) and describe their causes and steps to manage them. Normal Sleep in Children 1

2 How many hours of sleep should a 4 year old get each night? a) 8.5 hours b) 9.5 hours c) 10.5 hours d) 11.5 hours How many hours of sleep should a 4 year old get each night? a) 8.5 hours b) 9.5 hours c) 10.5 hours d) 11.5 hours How many hours of sleep should a 10 year old get each night? a) 8 hours b) 9 hours c) 10 hours d) 11 hours 2

3 How many hours of sleep should a 10 year old get each night? a) 8 hours b) 9 hours c) 10 hours d) 11 hours What age do children stop taking naps? a) 1 years old b) 2 years old c) 3 years old d) 4 years old What age do children stop taking naps? a) 1 years old b) 2 years old c) 3 years old d) 4 years old 3

4 Total Sleep Time Requirements by Age 18 Nighttime sleep Daytime sleep wk 1 mo 3 mo 6 mo 9 mo 12 mo 18 mo 2 yr 3 yr 4 yr 5 yr 6 yr 7 yr 8 yr 9 yr 10 yr 11 yr 12 yr 13 yr 14 yr 15 yr 16 yr 17 yr 18yr Sleep Requirement Guidelines Newborn 2 yrs 10 yrs Yng Teens Adult Newborn 2 yrs 10 yrs Yng Teens Adult Two processes drive sleep 4

5 Is it normal for kids to wake 4-5 times during the middle of the night. a) True b) False Normal Sleep Architecture Bedtime Problems & Night Waking 5

6 What do bedtime problems look like? Epidemiology Bedtime Problems Common 10-30% of toddlers and preschoolers 15% of 4 to 10 year olds Chronic when untreated 84% of 1½ to 4 year olds continued to have problems three years later What s the problem with kids getting poor sleep? 6

7 Pediatric Diagnoses Behavioral Insomnia of Childhood Limit- Setting Type Inadequate enforcement of bedtime by caretakers Child effectively stalls Delayed sleep onset Sleep Onset Association Type Needs something to re- establish familiar bedtime conditions: bottle, parent, rocking, patting Mixed Type Did/do you co- sleep with your child? a) Yes b) No c) No children Did/Does your child have sleep problems? a) Yes b) No c) No Children d) I can neither confirm nor deny I ve repressed these memories 7

8 How to create bedtime/sleep problems Inconsistent bedtime- waketime How to create bedtime/sleep problems Inconsistent bedtime- waketime Inconsistent bedtime routine/inadequate routine How to create bedtime/sleep problems Inconsistent bedtime- waketime Inconsistent bedtime routine/inadequate routine Let the child run the show 8

9 How to create bedtime/sleep problems Inconsistent bedtime- waketime Inconsistent bedtime routine/inadequate routine Let the child run the show Stay in the bedroom until they fall asleep Attend/reinforce: Curtain calls, crying out, calling out During nightwakings allow child to sleep in parents bed Have child fall asleep in parent s bed or couch and then move them to their own bed. Does the Cry- it- out method cause long- term parent- child attachment issues? a) Yes b) No c) I don t care, I need to sleep! How to fix bedtime problems Sleep hygiene Consistent bedtime- waketime 7 days a week Soothing bedtime routine (30 min) No screen time 1 hour before bed No vigorous activity1-3 hours before bed Soothing bedroom environment (quiet, dark, comfortable, non- stimulating) 9

10 How to fix bedtime problems 3 Strategies Extinction (aka Cry- it- out ) Gradual Extinction Ferber method (crib) Floating chair technique ( toddler bed) Excuse- Me Drill How to fix bedtime problems Excuse- Me Drill (Brett Kuhn, PhD, CBSM) 1) Teach child to fall asleep in desired bedroom Experience initiating sleep in their own bed/bedroom 2) Select a start night Friday night is a good night 3) Temporarily delay bedtime (bedtime fading) Increase homeostatic sleep drive Bedtime = Avg child s typical sleep onset Advance by 15 min every 2-3 nights when SOL appropriate 4) Begin EMD EMD Excuse me, I need to go but I will be right back to check on you. Do this at increasingly longer intervals (5 sec to 15 min) Reinforces sleep compatible behaviors with attention, calm touch, labeled verbal praise Quiet while awake Lying down Calm Ignores inappropriate behaviors Calling out Demanding 10

11 When things go wrong When things go wrong, as they sometimes will, When the road you're trudging seems all uphill When the funds are low and the debts are high, And you want to smile, but you have to sigh, When care is pressing you down a bit, Rest, if you must, but don't you quit Leaving bed return in matter- of- fact fashion its time for bed Warning if you get out again I will have to close your door Few seconds of quiet (3 seconds) Adjuvants Bedtime Pass Morning rewards Parasomnias Sleepwalking Night/Sleep Terrors Nightmares Kids are actually asleep when they have night terrors? a) True b) False 11

12 Parasomnias: Sleep Walking and Sleep Terrors Usually occurs within the first few hours of sleep Agitation and confusion due to partial arousal Inconsolable during sleep terrors No memory of event the following morning Typically runs in families (80-90% likelihood of first degree relative with parasomnia history) Treatment of Parasomnias Injury prevention for sleepwalking Primary etiology is sleep deprivation Assess for other sleep disorders (sleep apnea, RLS/ PLMD, delayed sleep onset, seizures) Improve sleep hygiene Avoid known triggers Avoid waking during event, guide child back to bed, no need to discuss event the next day Scheduled awakenings Nightmares & their Treatment Symptoms 75% have had 10-50% require parent Common 6-10 yo Treatment/Prevention Avoid frightening movies or situations Nightmares that child recalls Cognitive behavioral Difficulty returning to sleep strategies to reduce Delaying sleep onset stress (e.g., relaxation) Bedtime resistance Image Rehearsal Therapy Need parental reassurance 12

13 Other pediatric sleep problems: not discussed here Delayed Sleep Phase Disorder night owls Rhythmic Movement Disorder Head banging/body rocking Nighttime Fears Nocturnal Enuresis bed wetting (+ snoring = Sleep Apnea) Restless Leg Syndrome pain/creepy crawlies in legs at bedtime. Sleep Apnea snoring is usually not normal in children. Periodic Limb Movement Disorder twitching legs Psychophysiological Insomnia - adolescents Good Resources for Providers My little sleepers sometimes 13