Sleep: What s the big deal?

Rise & Shine: The Importance of Sleep Sleep: What s the big deal? Sleep affects every aspect of a child s physical, emotional, cognitive, and social development. 1

Sleep is the Primary Activity of the Developing Brain J. Mindell By age 2 the average child has spent about 9,500 hours (13 months) sleeping, in contrast to 8,000 hours for all waking activities combined. Between ages 2 & 5 children spend equal amounts of time awake and asleep. Throughout childhood and adolescence sleep continues to account for about 40% of a child s average day. Circadian rhythms shift developmentally (D. Beebe, 2011) In teenagers, research has shown that melatonin levels in the blood naturally rise later at night than in most children and adults. Since teens may have difficulty going to bed early to get enough sleep, it can help to keep the lights dim at night as bedtime approaches. It can also help to get into bright light as soon as possible in the morning. 2

2018 Sleep Poll A new Sleep in America poll by the National Sleep Foundation finds that individuals with the healthiest sleep habits are far more likely than poor sleepers to rate themselves as effective. 65% of American adults report that sleep contributes to next day effectiveness. Only 10% of people prioritize it over other aspects of daily living. How neuron electrical activity control the biological clock 3

Sleep Problems Prevalence Estimates: Approximately 25% of children overall experience some type of sleep problem. More than one third of elementary school aged children have significant sleep complaints. Approximately 40% of adolescents have significant sleep complaints. J.. Mindell Major Impact on Families Significant Caregiver Stress Fatigue Mood Disorders Decreased Level of Effective Parenting 4

Sleep in Cultural Context Important to consider the cultural and family context within which the sleep problem occurs. How we sleep, where we sleep, with whom and for how long we sleep is shaped by culture and customs. Sleep issues in mental health clinical settings are commonly inadequately addressed. 5

Sleep Disorders are Highly Treatable and Preventable Educate parents about normal sleep. Primary Prevention: teach strategies to prevent sleep problems. Normal Sleep Patterns Newborns (0 2 months) 10 19 hours per 24 hour period. Sleep periods separated by 1 2 hours awake. Most sleep issues at this age represent a discrepancy between parents expectations and developmentally appropriate sleep behaviors. Sleep wake cycles are dependent on hunger and satiety. Immaturity of the circadian system and melatonin production results in limited rhythmicity and predictabiltiy of sleep. Infants that are extremely fussy and difficult to console are more likely to have underlying medical issues, such as gastroesophageal reflux and formula intolerance. Mindel: Pediatric Sleep 6

Normal Sleep Patterns Infants (2 12 months) Average 9 10 hours nighttime sleep. Average naps of 3 4 hours. Total average of 12 13 daily. Sleep during infancy must be understood in the context of the relationship and interactions between the child and caregiver. Attachment and social interaction play a big part in shaping sleep behaviors. Normal Sleep Patterns Toddlers (12 3 years) Average 9.5 10.5 hours nightime sleep. Naps average 2 3 hours. Total Average of 11 13 hours. The toddlers drive for independence may lead to bedtime resistance. Development of imagination and fantasy may result in increased nighttime fears. Separation anxiety is often associated with bedtime difficulty and nightwaking. 7

Normal Sleep Patterns Preschool (3 5 years) Average 9 10 hours nighttime sleep. Naps decrease from 1 nap to none. May engage in more limit testing at bedtime. May have heightened nighttime fears. A number of studies suggest that sleep problems in this age group may become chronic. Appropriate stage to introduce positive behavior reinforcement strategies, such as sticker charts, etc. Establish bedtime routine of reading stories aloud. Normal Sleep Patterns School Age (6 12 years) Average is 9 10 hours night Data suggests that children may begin to develop a relatively lifelong circadian sleep phase preference at this stage. Parents should be encouraged to be sensitive to circadian preferences and adapt sleep schedules for these children. 8

Normal Sleep Patterns Adolescents (12 18 years) Recommended 9 9.5 hours daily. The vast majority of teens are sleep deprived and on average obtain only 7 7.5. Results in an approximate sleep debt of about 2 hours nightly which accumulates over the school week. One poll found that 70% of parents think their teen is getting adequate amount of sleep. Hormonal changes during puberty impact the sleep wake cycles. Sleep Disorders Excerpted from Beebe, D.W. (2012), Child Neuropsychology and Mindell, J. (2010) Pediatric Sleep: Diagnosis and Management of Sleep Problems Condition Behavioral Insomnia, Limit Setting Type Features/Sympto ms Noncompliant behavior at bedtime or refusal to return to bed after nightwaking. Evaluation Interventions Parent education and guidance using behavior management principles. Behavioral Insomnia, Onset Association Type Sleep onset at bedtime or after nightwaking requires highly specific environmental conditions Parent education and guidance using behavior management principles. 9

Sleep Disorders Condition Features/Symptom s Evaluation Interventions Adjustment Insomnia Problems with sleep onset or maintenance associated with a stressor Reduce Stress, build coping and treat underlying anxiety Nighttime fears Fearful behavior such as crying & clinging. Bedtime resistance. Curtain calls (extra drinks, kisses). Coach parents to help child develop coping mechanisms including distraction (thinking of other things) social support (talking about their fears) Refer with persistent or severe bedtime fears. Sleep Disorders Partial Arousal Parasomnias Condition Features/Symptoms Evaluation Interventions Sleepwalking Walking or engaging in nonsensical behaviors while asleep or altered consciousness., Sleep dairy. Provide reassurance, encourage parents to insure safety, avoid waking the child and redirect to bed. Avoid next day discussions. Sleep Terrors Confusional Arousals Sudden autonomic symptoms of terror while asleep Partial arousal characterized by confusion, difficulty waking, agitation. Child does not recall the event., sleep dairy, in some cases referral to MD. same same 10

Nightmares Child awakes with recall of frightening dream. May be crying or screaming. Needs time to calm down. Reduce frightening or stressful events. Provide reassurance Sleep Enuresis Involuntary voiding during sleep at least twice per week in children 5 or under. Refer for medical screening. Provide reassurance and use of pull ups. Enuresis alarms and behavior management. Restless Leg Syndrome Periodic Limb Movement Disorder Parasthesias in legs (tingling or prickling) Repetitive sterotyped limb movements Medical referral Medical Referral diagnosis requires overnight polysomnography Massage, distraction techniques, Iron supplements May occur secondary to a number of medical conditions. Iron deficiency Sleep Interview Question: BOWS Excerpted from Beebe, D.W. (2012), Child Neuropsychology Domain Parent Screening Questions Follow Up Questions Bedtime Does child have problems getting to sleep? What time does child go to sleep on school night? Weekends? Overnight Once asleep does child wake up or get out of bed before morning? Does child sleep soundly, or is there snoring, crying out, sleepwalking or restlessness? What happens when you try to get child to bed? What do you think is causing the problem? Is there an evening family routine? Is there screen time in the evening, like tv, video games, internet? What exactly happens? How many nights per week? What do you do when it happens? Does child seem awake? How long does it take child to go back to sleep? 11

Waking What time does your child wake in the mornings on school days? Weekends? How hard it is for child to wake up? Are the bedsheets tangled like he/she was very restless? What does it take to get child out of bed in the morning? How late does your child sleep if allowed to? What does he/she do in the morning once awake? Sleepiness Does child seem sleepy, tired or spaced out during the day? Does child nap or do other things to cope with sleepiness, such as caffeinated drinks? How often does this happen? Does it get in the way of learning or enjoying life? Does it seem to change depending on how much sleep? When and how long are naps? When and how much caffeine? Books: Parents Resources Sleeping Through The Night: Mindell, 2005 Sleep Training for Your Child: Burnham & Lawler, 2006 Your Adolescent: Pruitt, 2000 Solve Your Child s Sleep Problems: Ferber, 2006 12

Resources Books: Professionals Clinical Guide to Pediatric Sleep: Diagnosis & Management of Sleep Problems (2 nd Ed.) Mindell, JA and Owens, JA (2010) Basics of Sleep Guide (2 nd Ed.) Sleep Research Society. Darien, IL Author. (2009) http://www.sleepresearchsociety.org/ When Children Don t Sleep Well: Interventions for Pediatric Sleep Disorders Therapist Guide. Durand, V.M. (2008) Websites National Sleep Foundation. http://www.sleepfoundation.org/ American Board of Sleep Medical & Behavioral Specialties. http://www.absm.org/listing.aspx http://absm.org/smspecialists.aspx 13