1. Childrens sleep Challenges and opportunities Dr Andrew Mayers, PhD, MBPsS

2. 2 Childrens 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

3. 3 Childrens sleep problems: prevalence Sleep problems in children common About 25–40% Sleep problems in children can persist Dont underestimate impact But do be aware that there are solutions

4. 4 Childrens 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

5. 5 Sleepwalking May appear distressing – but it is quite normal (in children) 15% of children aged 4-12 sleepwalk Generally occurs in deep sleep in 1 st /2 nd 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

6. 6 Sleepwalking Event usually forgotten – especially if not woken And its 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

7. 7 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

8. 8 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

9. 9 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

10. 10 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…

11. 11 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

12. 12 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

13. 13 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

14. 14 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

15. 15 Sleep hygiene Physical environment Childs 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

16. 16 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!

17. 17 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

18. 18 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

19. 19 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

20. 20 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

21. 21 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