UNDERSTANDING AND MANAGING CHILDREN’S SLEEP

1. UNDERSTANDING AND MANAGING CHILDREN’S SLEEP

2. Aims of this session • To raise awareness of the sleep processes • To look at why good sleep is essential and the effects of disturbed sleep • To think about the modern barriers to good sleep • To be familiar with what Cerebra sleep service offers, along with the charity as a whole

3. What is sleep? A state of rest characterised by unconsciousness. Def: Collins English Dictionary A reversible state of reduced awareness of, and responsiveness to the environment, usually occurring when lying down, quietly with little movement. Def: Oxford Specialist handbook of Paediatric Neurology

4. Why is sleep essential? • Sleep is still a biological enigma, it is still not fully understood, but we do know it is essential to life • Growth hormones are released, usually during deep sleep • Consolidation of memory and learning • Essential to emotional well being • Good concentration and behaviour

5. How the sleep-wake cycle usually works • Circadian rhythms are biological cycles that repeat about every 24 hours • They include patterns of sleeping, waking, activity, rest and eating • A person’s ability to fall asleep and stay asleep is very much linked to the timing of their biological clock, which is reset each day by the use of cues i.e. Meal times, bed and waking time.

6. Melatonin and the sleep-wake cycle • The timing of sleep (not its amount) is regulated by our circadian clock in the suprachiasmatic nucleus (SCN) of the hypothalamus in the brain. This clock also controls other biological rhythms such as body temperature and cortisol production, with which sleep-wake rhythm is normally synchronized. • Melatonin is a hormone that is produced and released as darkness falls. It is produced in the pineal gland during darkness. It is suppressed by bright, natural or artificial light. Sleep Disturbance in Children and Adolescents with Disorders of Development: its Significance and Management. Pages 12 &13. Gregory stores and LuciWiggs

7. The two different states of sleep NREM Non rapid eye movement • Stages 1 - light sleep, easily woken • Stage 2 – deeper but still quite easily woken • Stage 3 & 4 - deep slow wave sleep, blood pressure, heart rate and breathing slow, very difficult to wake • REM Rapid eye movement • Skeletal muscle virtually paralysed • Variable heart rate, blood pressure and respiration • Body temperature regulation impaired

8. Nightly sleep cycles

9. Indicators of regular sleep disturbance Affect on a child: • Grogginess, confusion on morning waking • Grumpy/unhappy • Excessive daytime sleepiness • Accident prone • Can’t concentrate well • Prone to sickness/coughs and colds • Displays of negative behaviour • Easily provoked to tears • Can’t easily retain information learned form the day before • Often hungry for sugary snacks Affect on the family: Tiredness/ stress Accidents Poor emotional and physical health Sibling rivalry Breakdown in relationships within family unit Financial difficulty

10. The modern day culprits that can be barriers to good sleep • TV, DVD, Computer and x-box, especially those in a child or young persons bedroom • Mobile phones • Inappropriate expectations of tired parents • Separation and loss • De-motivation of parents(maybe depressed, stressed or ill) • Chaotic households/family breakdown • A lack of wind down activities and lack of daily bedtime routine • Unhealthy diet and drinks • Lights being left on in bedroom • Cluttered bedrooms full of toys etc – busy decor and wall posters • Medication

11. Sleep management – things to consider • Timing of physical activity • A healthy diet/drinks • Timing of medications • Relaxing activity at least an hour before routine starts • Bedroom environment • Wake the child at a regular time in the morning • Ensure the child falls asleep alone • Use communication the child understands • Celebrate small steps • Consistent messages – parents saying the same things to their child • Timings – is this the appropriate time to start a sleep programme • What is appropriate for the child

13. Difficulty settling Night waking Difficulty sleeping alone Early rising Unsuitable room Reinforced waking Sleep onset association disorder Lack of understanding Unsuitable bedtime Ineffective routine Terrors/Night-mares/Pain/Bed wetting. See: Sheets (IS 3,4,5,6) See: Advisable bedroom environment See: Realistic expectations and reduction of bedtime See: Consistent structured routine and info sheet (IS1) See: Scheduled waking See: Gradual withdrawal technique and info sheet (IS7) See: Robotic parenting technique and behaviour See: Tools See:Rewards IS1. Good sleep hygiene IS2. Difficulty with night waking IS3. Night terrors IS4. Nightmares IS5. Anxiety IS6. Night time enuresis IS7. Encouraging children to sleep alone FLOW CHART

14. DIFFICULTY SETTLING Unsuitable bedroom Unsuitable bedtime Ineffective routine

15. Unsuitable bedroom An advisable bedroom environment: • Plain neutral walls, carpet and duvet cover, minimal furniture • No toys or other stimulating objects in the room, or for toys to be out away in cupboards, boxed up or at least covered over at bedtime • Black out blinds to ensure that the room is dark

16. Unsuitable bedtime • Have realistic expectations • Putting a child to bed when they are physically tired is going to be the right time for that child • Signs of being tired are the rubbing of eyes, yawning and ‘grumpy’ behaviour • If a child is in bed for a longer period than 15 minutes, they are going to sleep, and are probably not tired.

17. Ineffective routine A structured routine is very important. A routine should include a set waking up time every morning and a set going to bed time. An ideal bedtime routine would include: • Quiet time (TV off) • Have a light snack/drink (avoiding caffeine) • Take a bath ensuring that it is relaxing rather than stimulating • Put on bedclothes • Brush teeth • Read a short story • Make sure the room is quiet and a comfortable temperature • Put the child to bed • Say goodnight and leave the room

18. NIGHT WAKING Ineffective routine Terrors/ nightmares/ pain/ bedwetting Reinforced waking

19. Terrors/nightmares/pain/bedwetting Scheduled waking technique: • This involves waking your child sometime prior to a sleep waking episode, generally when the child is waking up at the same time each night • Determine the time or times when the child tends to wake during the night(use a sleep diary if required) • Wake the child approximately 15 minutes before typical waking time. Do not fully wake the child, just gently touch them or speak to them until they become awake and then let them fall straight back to sleep. • If the child fully wakes up, alter the timing the next night to approximately 25 minutes before their normal wake time. Continue with this until the child is no longer fully waking, and then gradually remove the scheduled waking.

20. Reinforced waking • Robotic Parenting Technique: After you have said goodnight, become ‘robotic’ by keeping conversation, eye contact and cuddles to an absolute minimum or even better to zero! • Behaviour Including the ABC model: A parent’s response to a child once they have said goodnight to a child is crucial, as without even realising it, a parent can create and maintain as unwanted behaviour in their child.

21. Difficulty sleeping alone Reinforced waking Sleep onset association disorder

22. Sleep onset association disorder Needing something or someone in order to get to sleep: • Gradual withdrawal technique. • Gradual withdrawal of an object (e.g. bottle or person) • Removing parent - start off next to your child and gradually move away from your child over a period of time, remaining in each position for 3-4 days at a time. • Removing a bottle - either dilute the milk gradually or you can reduce the amount of milk gradually.

23. Early rising Lack of understanding your child may not realise that they should stay in bed, or what you expect of them when they wake up. If it is light outside the child may believe it is morning, if they wake up and feel alert they may also assume it is morning and time to get up.

24. Lack of understanding Tools Rewards There are many bed time tools on the market that can aid in helping your child to understand that it is still bedtime, including alarm clocks, such as the bunny alarm clock and the Gro light clock. These can include praise, stickers, toys, money or food, to name a few. Or you could implement a reward chart. Try to remember that what a child finds rewarding can change regularly, so make sure your child is motivated for their reward.

25. Remember.......... • If you put your child into their PJ’s just after tea and then they watch TV and play before going to bed, they will not recognise getting ready for bed as a trigger or cue to bedtime. • A lot of children need help in recognising these cues, i.e. A child with visual impairment may not see darkness fall. • A consistent bedtime routine helps the child to understand what is expected of them, it can make them feel safe and secure.

26. The role of the sleep practitioner • To help parents of children aged 0-16 yrs, who have a neurological condition, learning difference or developmental delay. • To offer information and guidance to families, by post, telephone, email or face to face. • To set up and run sleep clinics across the country, offering one to one appointments. • To offer sleep workshops and talks to groups of parents/carers or professionals, to raise awareness about sleep related issues. • Most services offered by Cerebra are FREE to parents.

27. What we don’t do • Move in • Provide medical advice • We do not provide equipment at this time • Offer 24 hour support

28. Who to contact: What next? If you would like further information please do not hesitate to contact us: • Sleep team contact (general) – sleep@cerebra.org.uk • Moira Draper (North)moirad@cerebra.org.uk01942 719887 – 07818 829299 • Patricia Everitt (Central) patriciae@cerebra.org.uk 07920106217 • Marion Miller (South) marionm@cerebra.org.uk 01935 824764 – 07827 829300 • Sarah Gait (South West) sarahg@cerebra.org.uk 07780983122

29. A mother’s feedback “ Thank you for helping livia and our family. Our little girl’s condition made it difficult for her to sleep through the night. Cerebra’s sleep practitioners came to visit us at home and listened to our problems and are existing routine. We put a new routine in place and although I had my doubts it would work at first, within just a few nights we were all getting a full nights sleep! Everyone is now much happier thanks to the advice and support from Cerebra’s sleep team. “

30. Cerebra - what the charity can do to help

31. Contact Cerebra: FREEPHONE 0800 3281159 Cerebra, FREEPOST SWC3360, Carmarthen SA31 1ZY www.cerebra.org.uk