Children’s sleepChallenges and opportunities

Dr Andrew Mayers, PhD, MBPsS

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Children’s sleep

Overview

How common are sleep problems in children?

What are the problems?

Who is it a problem for?

The child

The family

Causes?

Solutions and suggestions

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Children’s sleep problems: prevalence

Sleep problems in children common

About 25–40%

Sleep problems in children can persist

Don’t underestimate impact

But do be aware that there are solutions

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Children’s sleep problems

Typical problems

Difficulty settling

Refusing to go to bed

Coming downstairs repeatedly after bedtime

Others settle easily but wake several times

Parents disturbed by crying or calling for attention

Creeping into their parents’ bed

More unusual problems:

Nightmares, sleep terrors, sleep talking, sleep walking, bedwetting, tooth grinding

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Sleepwalking

May appear distressing – but it is quite normal (in children) 15% of children aged 4-12 sleepwalk

Generally occurs in deep sleep in 1st/2nd ‘cycle’ of sleep Children tend to spend more time in deep sleep than adults

Which may explain increased incidence in children In adults, sleepwalking my be caused by several

factors In children, it is just part of normal development

Mostly ‘quiet’ walking about – but can be ‘agitated’ Also see ‘sleep terrors’ later

Typical behaviours Clumsiness, ‘glazed’ look, poor ‘nonsense’ speech,

repetitive behaviour, some bedwetting

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Sleepwalking

Event usually forgotten – especially if not woken And it’s best not to wake child (may get embarrassed)

NOT associated with room sharing, being alone, being afraid of dark

May be associated with lack of sleep and/or emotional problems

Rarely needs any treatment But seek help if very frequent or very disturbing

Child could get hurt Avoid bunk beds, lock outer doors, keep floor clear… Possibly fit ‘alarm’ to doors Consider ‘sleep improvement’ – see later

Usually disappears by puberty

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Night terrors

More extreme form of sleepwalking – and rarer (1-6%) Quite different to nightmares

Nightmares occur in lighter sleep and may ‘recalled’ Sleep terrors tend to occur in deep sleep Sleeper usually unaware of night terrors

Sudden ‘agitated’ arousal – child appears violent and terrified

More likely in toddlers – through to 5-7 But can go through to adolescence More frequent in younger children

If younger than 4 – may be at least once a week May be related to stress and some medications

If frequent and disturbing – talk to GP

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Sleep problems: consequences

Tired children At school

Hyperactivity and inattention Poor concentration Poor impulse control Disruptive behaviour Emotional problems Performance

At home Temper tantrums, quarrel with siblings… Accidents

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Sleep problems: consequences

Chronic problems disrupt family life Affects parental sleep

Especially if child enters parental bed Increased relationship strife Arguments with/about siblings

Blame, unfairness, disruption Increased punishments Poorer mood and mental health in family

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Sleep problems: possible causes

Irregular sleep-wake schedule

Bedtime and rising

Lack of bedtime routine/supervision

Poor daytime exercise

Caffeine

Inappropriate food

Room/bed sharing

Use of technology in bedroom

TV, computers/internet, game consoles, mobile phones…

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Modern technology and sleep

Recent study (2008): more than 500 schoolchildren researched

Aged 6-12 (average 9 years)

Watching TV before bedtime had little effect on amount of sleep

But bedtime and wake-time later

Especially on weekdays

Playing video games OR using Internet just before sleep-time Poorer sleep outcomes than children who did not do this

At least 1 hour shift in bedtime/wake-time

Worse effect on weekdays than weekends

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How much sleep?

Recommended:

Infants (pre-school): 14 hours

School children (4-12): 9-11 hours

Adolescents (13+): 8 hours

But there are cultural an societal variations

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Good sleep – some tips for children

Bedtime/wake-up time should be consistent every day Should not be > 1 hour difference in bed/wake time

School nights vs. non-school nights Have nightly bedtime routine

Prepare child for bed

Young children – about 30 minutes before ‘sleep time’

Older children – about 30–60 minutes ‘Best’ to keep TV/Games consoles out of bedroom

Or carefully restrict use Employ good ‘sleep hygiene’

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Sleep hygiene

Warm bath It worked for your baby Adults report better sleep after having bedtime bath So why not school children?

Reading Can help solve problems of night-time fears Help child with improving reading Good bonding between parent and child Relaxing Reduce night-time fears Recommended routine for children of all ages

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Sleep hygiene

Physical environment Child’s bedroom should be a quiet, darkened, warm

place Noise and light increases risk of problem sleep A room too hot (or cold) may disrupt sleep

No hotter than 75°F or 24°C Lighting

Lights out – encourage sleep onset Lights on – associate with getting up

Reinforces sleep and wake times Many children will not sleep with the light off

Use ‘glow’ lights

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Sleep hygiene

Spend time in daylight every day

Daytime exercise

Adult research physical exercise good for sleep

But not within 3 hours of bed time

So, probably good for children too!

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Sleep hygiene

Daytime food/drink Avoid caffeine drinks 4 hours before bedtime

Caffeine also in some foods – so watch that Large quantities of food too near to bedtime should be

avoided Main meal not less than 2 hours before bedtime

Light snack just before bed OK, but use ‘snooze foods’ Contain sleep-promoting chemicals:

Dairy products, meat, poultry, beans, rice Food high in carbohydrate and calcium also useful:

e.g. peanut butter sandwich, oatmeal biscuit, milk

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Behavioural methods

Reinforcement and extinction:

Reinforcing and rewarding good bedtime behaviour

Cuddles, praise etc

Some therapists encourage star charts

Great evidence of helping maintain desired behaviour

Ignoring ‘bad behaviour’ helps it go away!

We call this ‘extinction’

Behaviours tend not to repeated if not reinforced

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Behavioural methods

Unmodified extinction Child left to cry self to sleep

Can be very stressful (for child and parent) Graduated extinction (‘controlled crying’)

Rather more acceptable than unmodified extinction Parent progressively increases time taken to respond Brief intervention – say 15 seconds with minimal

interaction Extinction with parental presence

Parent remains in room during extinction procedure Can incorporate ‘fading out’

Parent gradually removes themselves from bedroom Presence more reassuring to child

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Summary

Sleep problems common in children More so if child has ‘other’ problems

Problems relate to two factors Sleep timing Sleep arousal

problems for child and the family Causes…

Irregular/unsupervised routines, poor exercise, poor diet, inappropriate bedroom technology, room sharing

Solutions… Consistency, sleep hygiene, behavioural programmes

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Further reading?

All materials (including these slides) now on my website http://www.andrewmayers.info/Workshops.html

Several published papers also on that website Helping children sleep Poor sleep hygiene Video games and sleep Violent video games Neurocognitive effects of sleep disruption Sleep disorders prevalence Sleep problems in primary school children