Better Nights, Better Days What, Why & How

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1 Better Nights, Better Days What, Why & How Penny Corkum, PhD (Psychologist) Professor, Department of Psychology & Neuroscience, & Psychiatry, Dalhousie University Scientific Staff, IWK Health Centre Director, Colchester East Hants ADHD Clinic 92 nd Annual Dalhousie Fall Refresher December 6-8, 2019 Halifax, NS

I have no actual or potential conflict of interest

from Canadian Institutes of Health Research, Kids

Excellence), Nova Scotia Health Research

2 I have no actual or potential conflict of interest in relation to this presentation Research funding from Canadian Institutes of Health Research, Kids Brain Health Network (a National Center of Excellence), Nova Scotia Health Research Foundation, IWK Health Centre, & Dalhousie s Psychiatry Research Foundation

3 Educational Objectives At the end of this session, participants will be able to: Have increased knowledge about the prevalence and impact of sleep problems, particularly pediatric insomnia Understand best practice to treatment of pediatric insomnia and barriers to the provision of this care Become familiar with the Better Nights, Better Days programs and future plans for sustainability of these program Session Overview Refresher re: sleep structure Sleep disorders Insomnia contributing factors and consequences Assessment Treatment Questions & Answers

4 10-year-old boy Only child Parents divorced; Alex lives mostly with mom but stays at his dad s house every second weekend Bedtime 9:30pm; Wake time: 6:30am Trouble falling asleep (60-120min) Once asleep stays asleep (used to have night awakenings) Trouble waking up in morning, results in lots of stress Parents and teachers think that at times Alex seems tired and other times he seems revved up Has ongoing academic problems, attention problems and at times he s irritable

5 REM (20-25% of total sleep; 4-6 episodes) High levels of cortical activity Paralysis Episodic bursts of eye movements Occurs min after sleep onset Function Learning, memory consolidation NREM (75-80% of total sleep) 3 stages (previously considered 4 stages) Low brain activity Body movements are preserved Function Restoration of body functions

NREM/REM alternate through the night in cycles Cycles of about 90-100 minutes Brief arousal

6 NREM/REM alternate through the night in cycles Cycles of about minutes Brief arousal and return to sleep every cycle (4-6 times) Early sleep mostly NREM, later sleep mostly REM

months: 12-16 hours 1-2 years: 11-14 hours

9 0-3 months: hours 4-11 months: hours 1-2 years: hours 3-4 years: hours 5-13 years: 9-11 hours years: 8-10 hours 9

10 Children s sleep duration has decreased between 30 minutes to one hour in recent decades 31% of school-aged children and 26% of adolescents in Canada are sleep-deprived 36% of Canadian year olds find it difficult to stay awake during the day 43% of Canadian year olds are not getting enough sleep on weekdays 33% of 5-13 year olds and 45% of year-olds in Canada have trouble going to sleep or staying asleep at least some of the time Sleep is an essential component of healthy cognitive and physical development because many kids are too tired to get enough physical activity during the day, and not active enough to be tired at night it s a vicious cycle. 10

11 DSM-5 (2013) / ICSD-3 (2013) 10 different sleep disorders/sleep disorder groupings 1) Insomnia Disorder 2) Hypersomnolence Disorder 3) Narcolepsy 4) Breathing-related sleep disorders 5) Circadian rhythm sleep-wake disorders 6) Non rapid eye movement (NREM) sleep arousal disorders 7) Nightmare disorder 8) Rapid eye movement (REM) sleep behavior disorder 9) Restless legs syndrome 10) Substance/medication-induced sleep disorder Maski, K., & Owens, J. (2018). Pediatric sleep disorders. CONTINUUM: Lifelong Learning in Neurology, 24(1), Kotagal, S. (2017). Sleep-wake disorders of childhood. CONTINUUM: Lifelong Learning in Neurology, 23(4),

12 Disorder Prevalence Narcolepsy.05% Restless Leg Syndrome/PLMD 2-6% Sleep Disordered Breathing 2-3% Circadian rhythm disorders 7% Parasomnias NREM REM 13% 5% Insomnia 20-30%* * 70%+ for children with NDDs American Academy of Sleep Medicine. International classification of sleep disorders (ICSD). 3rd ed; Available in:

13 Criteria (ICSD-3 & DSM-5) Difficulties falling asleep/difficulty initiating sleep without parent/caregiver intervention, staying asleep, and early waking (resistance to going to bed; ICSD-3 only) Impairment/Daytime consequences of sleep problem (e.g., daytime sleepiness, attention problems, mood disturbance/ irritability, behaviour problems, low motivation/energy/initiative) Sleep problem cannot be explained by inadequate opportunity for sleeping Frequent ( 3x/wk) and chronic ( 3 mos) Not explained by or occur exclusively during another sleep-wake disorder, medical condition, or mental health disorder

14 Children sleep-onset association limit-setting Adolescents sleep hygiene problems delayed sleep phase Young Adult psychophysiological insomnia Developmental Stage Prevalence Infants/Toddlers ~30% Preschoolers/School-aged ~15% Adolescents (peak at puberty) ~30% Adult ~15%

15 3 P s: Predisposing Precipitating Perpetuating Sleep Practices Genetics Sleep Environment Social Cultural Sleep Family/ Parents Social Emotional Health Development Slide courtesy of Jodi Mindell 15

16 Cognition/ Learning Mental Health Quality of Life Physical Health

17 Consequences of Sleep Problems/Disorders Community School Family Child

18 SCREENING Interviews & Questionnaires Subjective Sleep Diary Actigraphy PSG Objective

19 Ask about sleep! Owens, JA. & Dalzell, V. (2005). Use of the BEARS sleep screening tool in a pediatric resident s continuity clinic: A pilot study. Sleep Medicine, 6 (1),

21 Lewandowski et al., 2011 Review of Pediatric Questionnaires (n=21) Multidimensional sleep measures received the highest ratings 6 Well Established Brief Infant Sleep Questionnaire (Sadeh, 2004) (0-29 months) Infant Sleep Questionnaire (Morell, 1999) (12-18 months) Child Sleep Habits Questionnaire (Owens et al., 2005) ( years) Preschool Sleep Questionnaire (Chervin, 1997) (2-18 years) Sleep Disturbances Scale for Children (Bruni, 1996) (5-15 years) Pediatric Daytime Sleepiness Scale (Drake et al., 2003) (11-15 yrs) Ji & Liu, 2016 Review of Adolescent Questionnaires (n=13) Most validated questionnaires Cleveland Adolescent Sleepiness Questionnaire (Spilsbury et al., 2007) (11-17yrs) Chronic Sleep Reduction Questionnaire (Dewald et al. 2012; Meijer, 2008) ( yrs) Lewandowski, A. S., Toliver-Sokol, M., & Palermo, T. M. (2011). Evidence-based review of subjective pediatric sleep measures. Journal Of Pediatric Psychology, 36(7), doi: /jpepsy/jsq119 Ji, X. & Liu, J. (2016). Subjective sleep measures for adolescents: a systematic review. Child: care, health and development, 42, 6,

Sleepiness Owens, JA., Spirito, A., & McGuinn, M. (2000).

22 Sleep Duration Sleep Anxiety Night Wakings Parasomnias 45 Items Sleep Onset Delay Sleep Disordered Breathing Bedtime Resistance Total Sleep Disturbances (Cutoff=41) Daytime Sleepiness Owens, JA., Spirito, A., & McGuinn, M. (2000). The Children s Sleep Habits Questionnaire (CSHQ): Psychometric properties of a survey instrument for school-aged children. Sleep, 23(8), 1-9.

23 Record of sleep and wake times and related information Completed by parent and/or child Commonly used in clinical practice Examines for patterns across days/weeks

25 Corkum, et al. (unpublished)

An actigraph is a wrist-watch like device

accelerometer-based findings as measures

26 An actigraph is a wrist-watch like device with an accelerometer used to measure movement. Computer algorithms are used to interpret accelerometer-based findings as measures of sleep and waking. Actigraphy has become an increasingly popular method for estimating sleep parameters in both research and clinical studies over the past 30 years.

27 Considered the gold standard for measuring sleep Measures: Brain waves/activity Oxygen level Breathing Heart rate Eye and leg movements

28 10-year-old boy Only child Parents divorced; Alex lives mostly with mom but stays at his dad s house every second weekend Bedtime 9:30pm; Wake time: 6:30am Trouble falling asleep (60-120min) Once asleep stays asleep (used to have night awakenings) Trouble waking up in morning, results in lots of stress Parents and teachers think that at times Alex seems tired and other times he seems revved up Has ongoing academic problems, attention problems and at times he s irritable What diagnosis do you think is most likely? What assessment approach would you take to determine his diagnosis? What additional information would you want?

30 Best Practice Treatment Less than 15% of children with insomnia receive evidence-based treatment Medication Behavioural Strategies Healthy Sleep Practices Psycho-education 30

Sometimes sleep problems are a result of lack of knowledge and due to faulty beliefs, for example Expect the child to sleep too long/too little Lack of understanding of circadian rhythms and sleep

31 Sometimes sleep problems are a result of lack of knowledge and due to faulty beliefs, for example Expect the child to sleep too long/too little Lack of understanding of circadian rhythms and sleep pressure Expect child to have same chronotype as parents (e.g., owl/lark) Think that keeping child up later will result in the child sleeping in later in the morning Think that arousals at night are not typical (rather than seeing this as self-soothing problem) Not understanding the biological shift in sleep time during adolescents

32 Handouts for parents Mindell, J. A., & Owens, J. A. (2010). A clinical guide to pediatric sleep: Diagnosis and management of sleep problems (1st ed.). Baltimore, MD: Lippincott Williams & Wilkins Resource List Corkum LABS Websites Canadian Sleep Society Brochure and ebook - Insomnia Rounds - Pediatric Sleep Council Sleep for Kids Participaction National Sleep Foundation Better Nights, Better Days

Age-appropriate Bedtimes, wake-times and naps, with Consistency Schedule and routines Location no Electronics in the bedroom or before bed Exercise

Coulombe, A. & Corkum, P. (2013). Sleep Hygiene in Children with ADHD: Research Findings and Clinical Recommendations. ADHD Report, 21 (3). Allen, S.

33 Age-appropriate Bedtimes, wake-times and naps, with Consistency Schedule and routines Location no Electronics in the bedroom or before bed Exercise and diet Positivity and relaxation Independence when falling asleep Needs met during the day.all of the above equals Great sleep! Bessey, J. Coulombe, A. & Corkum, P. (2013). Sleep Hygiene in Children with ADHD: Research Findings and Clinical Recommendations. ADHD Report, 21 (3). Allen, S., Howlett, M., Coulombe, A., & Corkum, P. (2015). ABCs of Sleeping: A Review of the Evidence Behind Pediatric Sleep Practice Recommendations. Sleep Medicine Reviews.

35 35 Step 1: Online Questionnaire Step 3: Handouts Step 2: Report Card If you are interested in participating, please contact us at

s14057 Corkum, P., Davidson, F., Tan-MacNeill, K., & Weiss, S. (2014).

36 Vriend, J. & Corkum, P. (2011). Clinical management of behavioral insomnia of childhood. Psychology Research and Behavior Management. 4, Doi: Corkum, P., Davidson, F., Tan-MacNeill, K., & Weiss, S. (2014). Sleep in Children with Neurodevelopmental Disorders: A focus on insomnia in children with AD/HD and ASD. Sleep Medicine Clinics. 9(2), Doi: /j.jsmc

37 Goal typically involves some combination of developing positive sleep-related associations, establishing routines, and implementing relaxation/self-soothing skills Strong evidence for sleep intervention programs- with TD 94% of studies found behavioural interventions to be effective 80% of children had clinically significant improvements Improvements in sleep onset latency, frequency and duration of night wakings and sleep efficiency (not sleep duration) Improvements lasted 3 to 6 months Few studies on children with special needs

38 Specific Sleep Strategies Reward Programs Unmodified Extinction Extinction with parent presence Relaxation Training Graduated Extinction Learning Principles Cognitive Strategies Bedtime Fading Sleep restriction Stimulus control Sleep Scheduling

39 Intervention Description Unmodified Extinction Extinction with parent presence Graduate Extinction Bedtime Fading Stimulus Control Sleep Scheduling Sleep Restriction Cognitive Strategies Relaxation Training Reward Programs Infant is placed in bed while awake, left alone until asleep, and night-wakings are ignored. Infant learns to self-soothe once realizing that nighttime crying does not result in parental attention. Parent remains in room during extinction, acting as a reassurance for the child but providing little interaction. This involves ignoring negative behaviors (i.e., crying) for a given amount of time before checking on the child. The parent gradually increases the amount of time between crying and parental response. Parents provide reassurance through their presence for short durations and with minimal interaction. Operates by delaying bedtime closer to the child s target bedtime. The goal of this treatment is for the child to develop a positive association between being in bed and falling asleep rapidly. Bedtimes can be gradually moved earlier. Making the bedroom/bed a discriminant stimulus for sleep by only using the bedroom/bed for sleep (not play, time-outs, etc.) Scheduling regular, appropriate sleep and wake times that allow for an adequate sleep opportunity. Restrict time in bed to build sleep pressure and gradually lengthen time in bed as sleep efficiency improves. Contraindicated in youth with parasomnias, seizure disorders, OSA, mania These strategies are used to address non-productive beliefs about sleep, including the belief that the child cannot change their sleep difficulty. Coping strategies are also included (e.g., relaxation skills such as abdominal breathing). Teach diaphragmatic (belly) breathing and progressive muscle relation to reduce arousal. Need to practice regularly before introducing at bedtime. Reinforce healthy sleep practices, appropriate time in bed, etc. 39

GREAT SLEEP CHART 0 19 No reward 20 39 $5 gift

40 GREAT SLEEP CHART 0 19 No reward $5 gift certificate from Blockbuster or Empire Theatres $10 gift certificate from Blockbuster or Empire Theatres $20 gift certificate from Blockbuster or Empire Theatres 40

41 Community Mental Health Private Practice Psychologist Canadian Sleep Society Service Providers Map

42 Better Nights, Better Days

44 Better Nights, Better Days

46 Adolescents: years Young Adults: years

48 48

49 Children presenting with insomnia are being prescribed medication at high rates, especially when child has a NDD (Stojanovski et al., 2007; Owens et al., 2010) e.g., antidepressants, atypical antipsychotics, anticonvulsants, beta-blockers No FDA approved medications for treatment of insomnia in children and there are concerns about the safety and side effects of these medications (Owens et al., 2010) Pharmacological treatments may have rapid short-term effects on sleep problems, but typically do not have long-term positive effects on sleep

Nunes, N.L. & Bruni, O. (2015). Insomnia in childhood and adolescence: clinical aspects, diagnosis, and therapeutic approach. J Pediatr (Rio J). 2015;91(6 Suppl 1):S26---S35 Pelayo, R.

50 Nunes, N.L. & Bruni, O. (2015). Insomnia in childhood and adolescence: clinical aspects, diagnosis, and therapeutic approach. J Pediatr (Rio J). 2015;91(6 Suppl 1):S26---S35 Pelayo, R., & Yuen, K. (2012). Pediatric Sleep Pharmacology. Child Adolesc Psychiatric Clin N Am 21, Troester,M.M. & Pelayo, R. (2015). Pediatric Sleep Pharmacology: A Primer. Semin Pediatr Neurol, 22,

Melatonin Melatonin is secreted by the pineal gland in response to darkness and is involved in maintaining the circadian rhythm of the sleep-wake cycle Melatonin supplements provide much larger

52 Melatonin Melatonin is secreted by the pineal gland in response to darkness and is involved in maintaining the circadian rhythm of the sleep-wake cycle Melatonin supplements provide much larger amount than what is typically secreted Studies that exist find benefit and few side-effects Short-acting forms used to treat sleep onset problems and long acting forms to treat sleep maintained problems However, studies include small sample sizes and do not assess long-term use Canadian Pediatric Society Position Paper re: Melatonin

First step in management of all sleep disorders is establishing good sleep hygiene All studies have involved small numbers of subjects and address only short-term use No good data concerning

53 First step in management of all sleep disorders is establishing good sleep hygiene All studies have involved small numbers of subjects and address only short-term use No good data concerning the safety and efficacy of longterm melatnoin use Further studies are needed to confirm the usefulness and safety of melatonin for sleep disorders in children and adolescents 2012, Reaffirmed 2015

54 10-year-old boy Only child Parents divorced; Alex lives mostly with mom but stays at his dad s house every second weekend Bedtime 9:30pm; Wake time: 6:30am Trouble falling asleep (60-120min) Once asleep stays asleep (used to have night awakenings) Trouble waking up in morning, results in lots of stress Parents and teachers think that at times Alex seems tired and other times he seems revved up Has ongoing academic problems, attention problems and at times he s irritable What treatment plan would you suggest for Alex? How would you change your treatment approach in these situations? Alex has ADHD and is on stimulant medication? Alex has ASD and an anxiety disorder?

penny.corkum@dal.ca http://myweb.dal.ca/pvcorkum/ Resources Durand VM.

New York: Oxford University Press; 2008. Mindell JA, Owens JA.

Philadelphia, PA: Lippincott Williams & Wilkins; 2009. Sheldon SS, Ferber R, Kryger MH. Principles and Practice of Pediatric Sleep Medicine.

55 Resources Durand VM. When Children Don t Sleep Well: Therapist Guide: Interventions for Pediatric Sleep Disorders (Treatments that work). New York: Oxford University Press; Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; Sheldon SS, Ferber R, Kryger MH. Principles and Practice of Pediatric Sleep Medicine. 1st ed. Philadelphia, PA: W.B. Saunders; Stores G, Wiggs L. Sleep Disturbance in Children and Adolescents with Disorders of Development: Its Significance and Management. London, UK: MacKeith Press; Autism Speaks Sleep Tool Kit ources-programs/autism-treatmentnetwork/tools-you-can-use/sleep-tool-kit 55

ADHD and Sleep. Dr. Jessica Agnew-Blais MRC Postdoctoral Fellow SDGP Centre Institute of Psychiatry, Psychology & Neuroscience

ADHD and Sleep. Dr. Jessica Agnew-Blais MRC Postdoctoral Fellow SDGP Centre Institute of Psychiatry, Psychology & Neuroscience ADHD and Sleep Dr. Jessica Agnew-Blais MRC Postdoctoral Fellow SDGP Centre Institute of Psychiatry, Psychology & Neuroscience Who am I? Who I am: ADHD researcher Parent Who I am not: Clinician Sleep expert