Part I: Waking Up to All that Sleep Does
Every day for most people, something mysterious begins to take shape that still defies scientists in these times. Although the primary reasons for most basic bodily functions, such as eating and moving, have been known for centuries, sleep, or also known as slumbering or snoozing or napping or crashing, still remains an enigma in many ways. Yet, there is no single activity that we do more in our life. It is largely controlled by two bodily systems and one earthly one. One, the circadian rhythms and sleep/wake homeostasis of our body, tells us that the longer it has been since we slept, the more it is time to close our eyes. And two, the less light that we perceive, the more our brain (largely through the use of melatonin) tells us it is time for bed. The average person will sleep for 25 years in their lifetime. Infants typically sleep average between 14-15 hours a night. Toddlers spend half of their day horizontal. Even by the time our kids reach school age, we hope that their daily hours of sleep reaches double digits.
Although researchers acknowledge that there is much to learn, what we do know increasingly sends one clear message. Sleep is vastly more than simply rest and quietness. It makes sense. Why would the human body spend a 1/3 of its time doing something unnecessary? In 2013, an article was published in the journal of Scientific American entitled, Sleeps Role in Obesity, Schizophrenia, Diabetes…Everything In it, the authors provide an overview of the growing mountain of studies that point to the amazing potential, and significant risks, associated with different sleep patterns. Studies (e.g., Chase & Pincus, 2011) have long shown that roughly 90% of people diagnosed with anxiety disorders report sleep-reported problems, the latter potentially causing or worsening the former. We know that ADHD rates are higher in kids with poor sleep. We know that psychologically healthy kids look a lot like those diagnosed with ADHD when they are chronically sleep deprived (Paavonen et al., 2009). If you take kids with obstructive sleep apnea and ADHD symptoms and remove their tonsils and adenoids, the improvement in attention is typically much better than using medication. Shortened sleep duration in young kids is associated with a lifelong risk for obesity (Bell & Zimmerman, 2010). Long-term sleep deprivation mimics psychosis in healthy individuals. If you have sleep apnea, your risk for depression is fivefold; if you have depression, the risk of apnea is fourfold.
But sleep is not just about warding off disease and disability. Good sleep is associated with learning better and remembering more. It appears that our memory is better if we “sleep on it.” Taking naps after learning tasks results in greater recollection and retrieval than staying awake. Dreams, long the source of so many conjectures and theories, appear to not necessarily recreate what actually has happened, but create scenarios about events and tasks that likely serve many purposes. All of us, including athletes, (especially those in intense, ongoing training) often depend on sleep, including recovery naps, to repair the body. Exercise often improves sleep. Sleep often improves exercise. Roughly two-thirds of our growth hormone, which is involved with muscle development, is secreted during sleep. Sleep helps control when we feel full, and when it is time to eat in order to prepare for the day. Sleep appears to regulate our blood sugar. Studies suggest that going to bed earlier can help make a diet more successful. Even the types of foods and drinks we consume can significantly affect our sleep.
As we get deeper into the mystery, we know that not all sleep is created alike. There are stages of sleep, and patterns of sleep. Very simplistically, there are five primary stages of sleep—stages 1-4 and the Rapid Eye Movement (REM) phase. Stages 3 and 4 are considered deep, slow-wave sleep. The average child gets most of his deep sleep in the first three hours of the night (which diminishes as we get older). That is when issues, such as sleepwalking and sleep terrors, usually occur. Kids really aren’t awake when this happens and therefore, can’t remember a thing next morning. On the contrary, REM sleep, usually occurs for children after the 3rd hour and increases as the night goes on. This is when nightmares typically arise, which may wake the child up and leave memories in the morning. And somewhere in the night, we all have a “point of singularity”, which nearly coincides with where our body temperature reaches its lowest point. At this juncture, our core temperature begins to rise, cortisol secretion increases, and the proportion of REM sleep grows. Unbeknown to us, it is as if our body begins to prepare for another day.
For many, the science of sleep might be liable to, well, put them to sleep. But the further into the spindles we get, the more astounding and captivating it becomes. As Dr. Ruben Naimen noted in her book, Hush: A Book of Bedtime Contemplations, sleep becomes less about something we do, and more about who we are and the rhythms that we feel. It seems there is a psychophysiological, meta-physical, even spiritual nature to it all. Yet unfortunately, sleep appears to have become one more marketed commodity. In past two decades, artificial sleep aids have sharply risen (NCHS, 2013). Market research between 1998-2006 indicated sleep aid prescriptions for young adults (ages 18-24) had tripled (Russo, et. al, 2008). They come by many names, on and off label, prescription and over-the-counter, medication and supplement. But all concoctions used are intended to onset or enhance sleep, or completely sedate the people who use them. Meanwhile, many researchers suggest that 80-90% of sleep difficulties could be address through cognitive, behavioral, and lifestyle changes. Recently, the American Academy of Sleep Medicine (AASM) weighed in on this discussion through a document entitled Five Things Physicians and Patients Should Question. Advice #2: Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive-behavioral therapy, and reserve medication for adjunctive treatment when necessary. Advice #3: Don’t prescribe medication to treat childhood insomnia, which usually arises from parent-child interactions and responds to behavioral intervention.
The great irony is that despite all our attempts to augment sleep, we are slumbering less than we did just a century before. Twenty percent less. There are many arguments why. Maybe our biological systems are evolving. Maybe our 24/7 culture and the lure of incessant media and bright lights, whether of a mobile screen or the conventional tube, are just too alluring. Maybe we think we can “beat the system” and get by just fine without adhering to time-honored needs. Years ago, I got to know a father who swore he didn’t need any more than 4-5 hours of sleep a night. He was forty pounds overweight, anxious, irritable, divorced, and felt his only child was slowly parting from him. I challenged his assumptions about his need for sleep, and mused with him what just a couple of more hours a night could do for his quality of life. I am not sure if he ever saw how more darkness could lead to more light.
And maybe, just maybe, we simply don’t value sleep like we do so many other things. I cringed a few years ago when I read a blog written by someone about how to truly be a successful professional. One of the messages was simple: get used to living with less sleep. It seemed like a falsity laden with strong undertones that went well beyond the zzz’s. It echoed of a message we hear elsewhere, which proclaims that whatever we could find outside of ourselves—money, status, power—is well worth sacrificing what we can find within. Of course, what he forgot to mention was that even if the false promise was true (which it is not), it is only plausible for the few that could make it as he aspired. Sleep, on the other hand, is given to everyone, even though for some it seems like a nightmare, not a remedy. As a father, I never knew just how much I loved my sleep until my first kids were born. There are times when sleep might just be the most important and productive part of my day.
It is time to reclaim the value of the Betty White party, or counting our sheep, and just getting some old- fashioned shut eye. It is time to stare down the screen and let it know that the bed is calling. I think we would all be happier, and really not miss a thing. And better yet, I (and many others) think that when the demands of the day do come calling, striving for optimal sleep will only allow us to be more productive, healthier, more patient, and more loving than before. And it could all be free.
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Bell, J.F. & Zimmerman, F. J (2010). Shortened nighttime sleep duration in early life and subsequent childhood obesity. Archives of Pediatric & Adolescent Medicine, 164, 840-845.
Chase, R. M., & Pincus, D. B. (2011). Sleep-related problems in children and adolescents with anxiety disorders. Behavioral Sleep Medicine, 9, 224-236. doi: 10.1080/15402002.2011606768
Russo A, Miller K, Marder W. Prescription sleep aid use in young adults. Thomson Reuters Research Brief. 2008.
Part II: The ABC’s of ZZZ’s
Despite the importance of sleep, including for our kids, evidence suggests that many of our youth do not get the recommended sleep each night. A recent article through NBC News indicates that 90% of high schoolers fall short of the optimum amount of sleep. When this occurs, significant risks emerged in many domains. One study indicated that teens who sleep the least are 21% more likely to be involved in a motor vehicle accident.
Issues of chronic sleep deprivation also persist for younger kids in this country. Polls taken between 2004 and 2007 by the National Sleep Foundation indicated that the average school age child was getting 9.5 hours per day (instead of 10-11) and preschoolers were averaging 10.4 hours (instead of 11-13). Two factors were most associated with poor sleep outcomes: later bedtime (after 9 PM) and parental presence upon sleep onset (Mindell et al., 2009). Children who come to depend on their parents from an early age to soothe and reassure them to sleep (and back to sleep) often continue to have difficulties into their adolescent years and beyond. Parents can be just one source of “sleep-onset associations”, which are characterized as any factor, beyond darkness and fatigue, which are needed to consistently aid someone in falling asleep. Other associations can include rocking, nursing, eating, television/ music, or white noise just to name a few. Not all associative factors are bad, but the more that these involve other people and direct engagement (e.g., watching television), the more disruptive they will likely be.
This all speaks to why developing good, early sleep habits are critical, both for children and their parents. Sleep issues not only can result in physical and psychological ramifications for all involved. They also cause further strain in the parental bond. This can occur for multiple reasons. One, parents may disagree on how to handle sleep issues that occur, and may accuse the other caregiver of being too lenient or harsh. Two, later bedtimes for youth (especially those that require parental intervention) inadvertently reduce the time that parents have to “unwind” from their day, and engage with each other and/or in other activities of interest. Ultimately, when parents find themselves going to bed at nearly the same time as their kids, it removes a layer of separation that is usually necessary for the vitality and rhythm of the household as a whole.
Therefore, the goal of all sleep habits and interventions is to provide for a few main things. One is a consistent, reliable routine that allows and promotes optimal sleep, even when a child is just a few months of age. Studies have indicated that good sleep routines not only improve sleep onset, but also decrease night awakenings (e.g., Mindell, Telofski, and Wiegand, 2009). Two, it is critical that parents determine whether daytime factors, such as diet and activity level, are negatively contributing to sleep. Three, parents should utilize various strategies to make sure that sleep is not seen as something to fear and avoid, but instead an essential part of our day that provides for, and enhances, our health and well-being.
Given this, here are primary considerations for youth to encourage optimal sleep (a pdf copy of these recommendations is available at the following link entitled General Pediatric Sleep Recommendations: http://www.stmarys.org/related-links
When sleep problems occur, always consider possible medical issues (e.g., diabetes, enlarged tonsils and adenoids, asthma, allergies, etc…) that may be impacting sleep. Regular, noticeable snoring and irregular breathing may be a few signs that suggest medical concerns and should prompt further discussion with your child’s doctor.
The bedroom should be conducive to sleep. Television, video games, and extensive amounts of toys send a message that it is an “entertainment zone”, not a place to sleep. These should be removed whenever possible, with only some toys, books, and few stuffed animals in the room. It also may be helpful to have a different place to do homework, in order to provide a clear “sleep zone”.
It is important that the bedroom be as calming and secure as possible. Fans, humidifiers, or other simple noisemakers can be helpful in reducing outside distractions. A nightlight and favorite stuffed animal can be helpful to reduce fears of the dark. If a child has difficulty falling asleep, the use of a dim light for reading (not overhead light) is generally acceptable. The room should be as dark and cool as possible; warm temperatures generally make it more difficult to sleep. In the morning, exposure to bright light, especially outdoor light, is helpful for making children more alert and regulating the sleep cycle.
Regular routines during the day (e.g., mealtime, homework, play time) and nighttime routines are very important. Parents should create a regular routine at night that incorporates a “gradual slowdown” towards bedtime, which can include basic hygiene needs and a nighttime story, brief “talk time”, etc… Screen time and intense physical activity should be avoided 45-60 minutes before bedtime. If child becomes upset after being laid down, parents should refrain from holding, rocking, etc…, but can provide brief reassurance that is gradually reduced over time for younger children. Avoid turning on bright lights.
Parents should work to provide a consistent bedtime/wake time within a 1 hour “window”. Regularly going to bed or waking up at very different times affects a child’s sleep cycle, and often results in more bedtime struggles or morning irritability. Consistent nap times are also important.
Avoid excessive fluids around bedtime, although a small drink of milk or water is appropriate. Refrain (or severely limit) from all caffeinated or very sugary drinks during the day, especially soft drinks and tea.
Children should be encouraged to be active during the day, with a preference towards at least an hour of physical and/or outdoor activity. Increasing evidence suggests that excessive media time (e.g., television, internet, and video games) has been associated with poorer sleep. Parents should work to limit this to an hour per school day. Naps are generally discouraged for school-aged children as they disrupt the sleep cycle.
Parents should work to make sleep time a positive experience, not something to be feared. This may include talking briefly at night about positive experiences during the previous day, reinforcing good things that a child may have done, and generally reassuring that they will see the child in the morning.
Awareness of total sleep targets (including naps) for different age groups is important. The following are general guidelines: 3-5 years (11-13 hours), 6-11 (10-11 hours), and 12-18 (8 ½ – 9 ½ hours).
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Mindell, J.A., Meltzer, L.J., Carskadon, M.A., and Chervin, R.D. (2009). Developmental aspects of sleep hygiene: Findings from the 2004 National Sleep Foundation Sleep in America Poll. Sleep Medicine, 10, 771-779
Mindell, J.A, Telofski L.S, Wiegand B, Kurtz, E.S. (2009) A nightly bedtime routine: impact on sleep in young children and maternal mood. Sleep, 32:599–606.
Part III: Putting to Bed Specific Sleep Problems
Even when parents utilize good routine and emphasize healthy living, sleep difficulties can arise. Issues occur for many reasons. Some are related to developmental milestones, such as increased mobility or verbal abilities in young kids. Other challenges emerge during changes in the home environment, such as a move or a parent starting a new job. And then, as with all families, sometimes unexpected illnesses emerge or other personal issues that may result in a shift in nightly patterns. A good book that addresses a variety of pediatric sleep issues is Take Charge of Your Child’s Sleep by Judy Owens and Jodi Mindell.
Whatever the cause, it is critical to recognize that people are never too old to improve sleep patterns. Although change typically is more difficult with age, commitment to research-based strategies for a decent period of time can make a noticeable improvement for almost all sleep problems. However, it is important to recognize factors that can impede otherwise reasonable treatments. One factor is simply parental tolerance and acceptance (or lack thereof) of discomfort that may result in using a specific protocol. For example, multiple parents have informed me that although they know it may be necessary for a child to cry for a certain amount of time in order to adjust sleep patterns, their level of discomfort with crying is too intense, and thereby they simply can’t see themselves following through with a recommended treatment.
This being said, the treatment called unmodified extinction, or “cry it out”, has been shown to be quick and effective in dealing with bedtime problems in young kids. Children are monitored for safety and illness, but ignored otherwise. Nineteen separate studies have shown rapid, positive results (typically issues resolve within 3 days with brief, periodic episodes of crying that may return) without any clear psychosocial side effects. However, it has very limited parental acceptance, as most acknowledge significant unease with hearing their children cry. Other more gradual methods, including the Ferber or Mindell method or “no cry approaches”, are more accepted by parents, but take longer and require more parental effort and consistency.
When parents find themselves at odds with a particular mode of treatment (such as those mentioned above), there are a few logical courses of action. One, each of us must assess whether our reaction is reasonable given the situation, or whether it results from significant psychological issues of our own left unresolved (e.g., anxiety, depression). If this is the case, it behooves parents to consider whether further treatment in these areas would not only be beneficial for their child’s progress, but also their own. Two, parents must consider if other factors, such as marital issues, work schedules, and/or childhood activities, are obstructing needed sleep changes. Again, if this is the issue, it is important to consider all options that would potentially allow for better sleep. Unlike most daily habits or practices, sleep should not be considered negotiable as it is one of the three pillars of health.
If parents have considered both of these issues, and do not feel that these are contributing factors to their decisions, then different alternatives for sleep concerns should be considered. However, it should be noted that while the less direct approaches may involve less initial discomfort and change, they will also likely require a longer commitment to effect change.
Given these considerations, I will now move into addressing specific sleep issues that commonly occur. All the documents listed below are available at the following link under the specific heading listed below Pediatric Sleep Recommendations: http://www.stmarys.org/related-links. The first is what we call “sleep association difficulties.” It is when a young child, who no longer needs to feed during the night, has difficulty getting to sleep or staying asleep without a specific “association.” This could include rocking, nursing, television, having a “bed partner” (e.g., parent), or any other set of rituals or needs. For parents, this can become a significant struggle as the child associates sleep with this person, object, or routine, and does not learn to fall back asleep on their own. It is important to note that all people wake up multiple times a night, but most of the time we unconsciously settle back into a sleep pattern. The following is a gradual method that has shown to be effective:
Limit-setting issues also commonly emerge in preschool or school-age children. To reduce these issues, the focus must be on setting clear contingencies and expectations, and working to reduce the level of emotion that exists between a parent and child at bedtime. This is one of the biggest issues that derails good sleep onset and turns putting children to bed as a self-professed nightmare. For children who have difficulty getting to bed, there are multiple options, including the two linked here. The first is called the Bedtime Pass Program, which specifically addresses issues with kids who leave the bedroom frequently after being put down to sleep. The second is Bedtime Fading, which is for kids who complain they are not tired when put to bed and/or resist going to sleep.
As kids transition into preschool, issues with partial arousal parasomnias often become a big concern. These are conditions that commonly occur during deep sleep, which largely happens in the first third of the night. They can include night terrors, sleepwalking, talking during sleep, and even in rarer cases, eating and engaging in other complex activities while not actually awake. It is critical for parents to understand that children do not remember what happens during these activities, even if the experience is very unnerving for mom or dad. The following guidelines are given for sleepwalking and night terrors, but can be adjusted for most parasomnias.
Sleep Terrors and Sleepwalking
Unlike parasomnias, nighttime fears and nightmares can lead to other difficulties because the child is often aware of what is happening, and then may increasingly resist going or staying in their bed. Fears of monsters and the dark are common in preschool and elementary-aged children, but again, it is critical that parents cultivate an environment of security, calmness, and good routine in addressing these concerns. The following are guidelines to address nightmares and nighttime fears that may occur.
Nighttime Fears and Nightmares
Finally, as children grow up, many continue to experience issues with nighttime enuresis, or what is more commonly referred to as bedwetting. This can result in embarrassing and tedious situations, especially if it occurs multiple times a week. It is very important that parents do not create an attitude of shame in the child, but do make it clear that there are ways in which the child can both decrease the likelihood of this occurring and also help out if it does. Further considerations for addressing this issue are as follows:
Ultimately, any intervention is only as good as the person doing it, and the consistency and resolve with which it is done. Although not all pediatric sleep problems can be addressed through behavioral and environmental strategies, most can. However, we as parents have to be both aware and honest with ourselves about factors which may be impeding progress. We also have to recognize that sometimes the best effort doesn’t go rewarded, at least not as quickly as we would like. As with every parental endeavor, there is much to gain from the pursuit of a better night’s sleep. Let’s all consider it a value worth reclaiming, and say good night to distractions and demands that tell us otherwise.
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Special thanks to Dr. Sarah Honaker, whose expertise made this series possible, and to Ms. Kristyn Jeffries, whose time and attention to detail in preparing the handouts was greatly appreciated.