Effective Behavioral Strategies for Pediatric Sleep Challenges

1. Behavioral Sleep Strategies After Pediatric Brain Injury Dean W. Beebe, PhD 4/26/2019

2. Overview • Common truly medical conditions (OSA, PLMD) • Poor sleep hygiene/opportunity • Insomnia • Circadian Rhythm Disorders • Parasomnias

3. Common Truly Medical Dx: OSA, RLS, PLMD

4. Common Truly Medical Dx: Obstructive Sleep Apnea (OSA) • Repeated obstruction of airway during sleep • Visible Symptom: Snoring • Diagnosed via: Polysomonogram (PSG) • Risk factors: • Obesity • ↓ upper airway tone • Craniofacial anomaly • In young kids, large tonsils / adenoids • In adults, male sex

5. Common Truly Medical Dx: Obstructive Sleep Apnea (OSA) • Treatment Options: • Positive Airway Pressure (CPAP/BiPAP) • Tonsillectomy and Adenoidectomy • Nasal Steroids (e.g., Flonase, Nasonex) • Dental appliances • Weight loss

6. Common Truly Medical Dx: Sleep-Related Movement D.O. • Restless Leg Syndrome (awake) • Dysesthesias (“pins and needles”) increased at rest; relieved by movement • “Fidgetiness” at bedtime, hard to fall asleep • Periodic Limb Movement Disorder (asleep) • Restless sleep, rhythmic jerking movements legs • Frequent arousals from sleep • Requires PSG to diagnose

7. Common Truly Medical Dx: Sleep-Related Movement D.O. Risk Factors: • Genetics • Low iron stores • Medications, especially those affecting dopamine • Neuropathies, spinal cord disease Treatments: • Iron supplements if serum ferritin is low. • Distraction, massage may help RLS • In some cases, medications used

8. Poor Sleep Hygeine/Opportunity Not a disorder, Super common

9. Poor Sleep Hygeine/Opportunity Healthy sleep-wake determined by 2 processes, …except when human behavior messes it up. (Borbely et al., 2016)

10. Poor Sleep Hygeine/Opportunity Habits that limit / disrupt sleep time or patterns. • Increase pm arousal • Excessive/late caffeine • Smoking • Stimulating play near bedtime • Excessive noise • Late-day napping • Evening “screen time” • Disrupt sleep organization • variable sleep-wake cycle • activities in bed that are incompatible with sleep • Bright light in the p.m., dark in the a.m.

11. Poor Sleep Hygeine/Opportunity

12. Poor Sleep Hygeine/Opportunity % Year/Grade in School (NSF 2006 Sleep in America Poll)

13. Poor Sleep Hygeine/Opportunity (Beebe et al., 2018) %

14. Poor Sleep Hygeine/Opportunity • Sleep hygiene & opportunity essential. • Simply telling people is only a start, but failing to emphasize is a mistake. • We’re piloting 1-hour trial for teens slow to recover from mTBI who sleep too little Wknt Duration (hr) Intervention Control

15. Insomnia

16. Insomnia: Definition Global sleep symptom complex marked by • Difficulty initiating or maintaining sleep • Daytime impairment • Even with good sleep opportunity, timing • Diagnosed largely by symptom report, sometimes confirmed by actigraphy.

17. Insomnia: Etiology (Perlis et al., 2011) • The 3-P Model • Predisposing Factors (e.g., genetics), • Precipitating (triggers): illness/health problems, stressors, changes in routine • Perpetuating: factors that maintain problem (e.g., behaviors, mood, beliefs)

18. Insomnia: Etiology • Potential Perpetuating Factors • “Compensatory” napping or caffeine • Light/activity exposure

19. Insomnia: Etiology (Perlis et al., 2011) • Potential Perpetuating Factors • “Compensatory” napping or caffeine • Light/activity exposure • Operant conditioning (rewarded behavior) • Classical conditioning (stimulus–behavior, stimulus–mood) • Unhelpful beliefs

20. Insomnia: Treatment • Sleep Hygiene is foundational • Eliminate behaviors (e.g., naps) that undermine healthy homeostatic sleep drive or distort circadian rhythm. • Consistent bedtime routine – verbal and activity cues, with behavioral momentum toward bedroom • Address perpetuating factors

21. Insomnia: Treatment • Extinguish & Replace Bedtime Stalling • Consistent routines and response to behaviors • Ignore complaints or protests • Calmly, firmly return to bed, minimizing interactions • Reinforce desired bedtime behaviors • Visual bedtime chart with reward system • Bedtime pass/bucks –set limits for repeatedly getting out of bed or introduce reward system • Brief, non-stimulating parent check-ins can include incentive component for child laying quietly in bed

22. Insomnia: Treatment • Change unhealthy sleep onset associations: If child can’t fall asleep without a certain stimulus, but is fine when it’s there (but it can’t always be that way). • Extinction: withdrawal of reinforcement that maintains a given response (e.g., crying). • Traditional “cry it out” • Graduated (Checking method) • Watch out for extinction burst or random reinforcement

23. Insomnia: Treatment • Address nighttime fears or worries • Introduce a security object • Coping thoughts, positive self-talk • Relaxation strategies • Exposure with response prevention • Practice facing fears and replacing previous responses (leaving) with coping response • Engaging in games or fun activities resulting in increased positive time spent in the dark

24. Insomnia: Treatment • Stimulus Control Therapy: Use classical conditioning for good, not harm • Bed for sleep only • Go to bed when sleepy • If awake >20 min: get out of bed, non-stimulating activity, return to bed once drowsy • Get out of bed at scheduled time regardless of last night’s sleep

25. Insomnia: Treatment • Sleep Restriction: limit time in bed to the amount of time sleeping, then shift (capitalize on conditioning + homeostatic sleep drive) • No napping during treatment • Decrease TIB to total sleep time most nights • Maintain bed/wake times for several days • When sleep efficiency ≥85%, increase 15 min • Continue until getting desired duration at good sleep quality

26. Insomnia: Treatment • Relaxation Training • Diaphragmatic Breathing: open lungs fully using diaphragm (not chest) in slow breathing • Progressive muscle relaxation: tense and release techniques individual muscle groups • Visual imagery: focus thoughts on calming multisensory “images”

27. Insomnia: Treatment • Cognitive Therapy: • Address cognitive arousal (racing thoughts, worries) and negative beliefs/attitudes about sleep that can interfere with sleep • Address ruminative thoughts: specific time set aside (not near bedtime) when worries are expressed and problem-solved.

28. Circadian Rhythm Disorders Especially Delayed Sleep Phase

29. Circadian Rhythm Disorders: Most Common Types • Sleep period mis-timed with external world • Sleep is fine during desired sleep period • Functional deficits typically due to sleep deprivation and mismatch with demands

30. Delayed Sleep Phase Syndrome vis-à-vis Development (Hagenauer & Lee, 2012)

31. Delayed Sleep Phase Syndrome Symptoms • Sleep period delayed relative to demands, despite good sleep hygiene • Symptoms of sleep onset insomnia or difficulty waking at the desired time. • Once asleep, sleep is OK • Would sleep enough if allowed to sleep in • Functional deficits typically due to sleep deprivation and problems waking on time.

32. Delayed Sleep Phase Syndrome Treatment Requires motivation! • Behavioral • Phase advancement (best if phase off < 2 hrs) • Phase delay (chronotherapy) BedtimeWake time Baseline night 4:30 am 12:30 pm Tx night 1 7:30 3:30 Tx night 2 10:30 6:30 Tx night 3 1:30 9:30 Tx night 4 4:30 12:30 Tx night 5 7:30 3:30 Goal night 10:30 pm 6:30 am

33. Delayed Sleep Phase Syndrome Treatment • Bright light shifts sleep earlier if given after circadian nadir (brighter = stronger). Limit p.m. light. • Melatonin can shift sleep phase forward if given prior to DLMO. Response more about timing than dose. (Mundey et al., 2005, SLEEP)

34. Parasomnias

35. Parasomnias: Non-REM Partial Arousal Disorders • Confusional Arousals • Sleep Terrors • Sleep Walking

36. Parasomnias: Non-REM Partial Arousal Disorders • Confusional Arousals • Sleep Terrors • Sleep Walking • Confusion • Difficulty waking • Sometimes agitation

37. Parasomnias: Non-REM Partial Arousal Disorders • Confusional Arousals • Sleep Terrors • Sleep Walking (Owens & Mindell, 2011)

38. Parasomnias: Non-REM Partial Arousal Disorders • Confusional Arousals • Sleep Terrors • Sleep Walking • Usually quiet • Can be agitated • Can include complex behaviors

39. Parasomnias: Non-REM Treatment • Rule out epilepsy and treatable causes • Sleep apnea, PLMD • Insufficient sleep • Parental reassurance, education on redirecting child to bed • Safety precautions • Stress reduction • Scheduled awakenings • Pharmacotherapy rarely needed

40. Parasomnias: REM Nightmares (most common) • Awakens from sleep with recall of frightening dream • Reasonably coherent and oriented • May take time to calm enough to return to sleep • Can usually later recall having been awake

41. Parasomnias: REM Nightmare Treatment • Reduce frightening/stressful events, esp. close to bedtime • Ensure adequate sleep time • Provide reassurance • Build self-soothing skills • In rare cases, medication

42. Never forget… Every child is unique. This can affect sleep. • Involvement of sleep-relevant neuro circuits • Diminished light input • Medications & regimen • Pain • Craniofacial anomalies • Hypotonia • Sensory pursuits • Sensory sensitivities • Emotion dysregulation • Poor understanding of social cues • Can’t communicate comfort needs • Problems executing calming routines • Family and cultural factors

43. Thank You! Co-Investigators & Co-Conspirators: • Stephen Becker, Ph.D. • Stephanie Crowley, Ph.D. • Mark DiFrancesco, Ph.D. • Sean Drummond, Ph.D. • Jeff Epstein, Ph.D. • Kendra Krietsch, Ph.D. • Lisa Meltzer, Ph.D. • Michelle Perfect, Ph.D. • Stacey Simon, Ph.D. • Tori Van Dyk, Ph.D. Funding: • US National Institutes of Health • Ohio Emergency Medical Services • Cincinnati Children’s Research Foundation • American Sleep Medicine Foundation • Canadian Institutes of Health Research • Institute of Educational Sciences • American Diabetes Association

44. (Extra slides for reference as needed)

45. Sleep Assessment Tools: Polysomnography (PSG) • Overnight study with limited montage EEG, EOG, respiratory and movement monitors

46. Sleep Assessment Tools: Polysomnography (PSG) • Overnight study with limited montage EEG, EOG, respiratory and movement monitors Good for… • Sleep Stages • Sleep-disordered breathing • Periodic limb movements • EEG-based arousals • Some seizures with expanded EEG montage and special review Bad for… • Typical sleep latency, onset, offset, behaviors around sleep • Sleep in kids sensitive to monitoring • Infrequent events • Seizure if using traditional PSG montage & scoring

47. Sleep Assessment Tools: Multiple Sleep Latency Test (MSLT) • Several standardized nap opportunities across the day, while wearing EEG leads. If you see kids, you see kids with sleep problems (30 min MSLT; group effect across trials p < .005) Controls ADHD (Golan et al., 2004)

48. Sleep Assessment Tools: Multiple Sleep Latency Test (MSLT) • Several standardized nap opportunities across the day, while wearing EEG leads. Good for… • Excessive Daytime Sleepiness • Sleep-onset REM, which is helpful in narcolepsy Dx Bad for… • Children whose sleep is highly sensitive to artificial setting and monitors

49. Sleep Assessment Tools: Actigraphy • Wristwatch-like accelerometer, with movements used to infer sleep-wake states. (Pedersen & Baumann, 2011)

50. Sleep Assessment Tools: Actigraphy • Wristwatch-like accelerometer, with movements used to infer sleep-wake states. Good for… • General sleep-wake patterns and movement-related arousals • Recordings lasting multiple nights, even > 1 month • “Natural” sleep-wake patterns Bad for… • Respiration, EEG during sleep • Sleep while moving (e.g., in car, parasomnias, seizures) • Anything at all if the person doesn’t wear the unit!