Children’s sleep Typical problems

Children’s sleepTypical problems Dr Andrew Mayers amayers@bournemouth.ac.uk

Children’s sleep • Overview • Types of problems • Insomnia • Sleep arousal • Nightmares • Night terrors • Sleep walking

Sleep problems in children? • Sleep problems common in children • Problems relate to two factors • Sleep timing • Sleep arousal •  problems for child and the family

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 specific problems: • Nightmares, sleep terrors, obstructive sleep apnoea, narcolepsy, sleepwalking, bedwetting, tooth grinding… • We should look at some child-specific DSM-5 sleep diagnoses…

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

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

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

Sleep problems: consequences • Tired children • At school • Hyperactivity and inattention • Poor concentration • Poor impulse control • Disruptive behaviour • Emotional problems • Performance • At home • Inter-sibling fights • Family stress, physical and mental health • Parents relationship with each other

Sleep problems: consequences • Effects of poor child/adolescent sleep (O’Brien, 2009) • For child, multiple behavioural and cognitive impairments • Learning, daytime function, conduct • For family, significant source of stress • Parental sleep, greater tension, reduced parenting effectiveness • More sleep education needed and better sleep hygiene

Sleep problems: consequences • Meta analysis - 86 studies and ~36000 children (Astill, et al 2012) • Examined children aged 5-12 • Shorter sleep related to poorer cognitive performance, more specifically… • Executive functioning, multi-tasking, and school performance • But not with intelligence • Shorter sleep duration associated with more behavioural problems • Internalising and externalising • Drew on studies published across last 100 years! • So what’s new about children’s sleep problems? • I feel there’s plenty – as we will see

Sleep problems: possible causes • Irregular sleep-wake schedule • Bedtime and rising • Problems rooted in toddler-child transition? • Lack of bedtime routine • But some children are night owls! • Poor daytime exercise • Caffeine • Inappropriate food • Room/bed sharing • Use of technology in bedroom • TV, computers/internet, game consoles, mobile phones…

Possible causes • Behavioural • Negative association, family schedules, non-reinforced routines, anxiety, poor sleep hygiene • Circadian problems • e.g. delayed sleep-phase syndrome • Breathing problems • e.g. snoring, sleep apnoea • Parasomnias • Night terrors, nightmares, sleepwalking • Medical/developmental • Asthma, eczema, epilepsy, autism… etc • Environmental • Noise, light, ventilation, distractions, family trauma

Modern technology and sleep • Recent study explored impact of gadgets in bedroom (Oka et al 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

Are violent video games worse? • A Swedish study (Ivarsson et al. 2008) suggested not • But did find large differences in heart rate • Violent games associated with greater heart activity • Especially those played nearer to bedtime • They found no difference between games on sleep timing/waking • But greater physical activity during sleep cannot be good • May indicate continued emotional and physical processing of game • More ‘restless’ sleep? • Could be reflected in dreams? • More research is need

Key facts • Most children stop ‘napping’ 3-5 years • Nocturnal sleep tends to increase at that point • Night waking in toddler/pre-school common • 20% wake up at least once a night • 50% at least once a week • After that, going back to sleep may be a ‘behavioural’ problem • Ability to do so without parental intervention • Self-soothing • Good time to establish routines

When self-soothing becomes problem • Toddlers are more mobile! • Make way to parental bed on waking • Cognitive development • Establish own beliefs and night-time fears • Establish ‘transition’ objects (dolls, teddies, pacifiers) • Attachment issues may develop • Separation anxiety • Increased ‘independence’ and ‘autonomy’ • Bedtime resistance may develop • How do parents overcome this? • Is it too late to change behaviour later? • We will address these (and other issues) later

Children’s sleep Typical problems