Pediatric Sleep Disorders/Sleep in Children with Chronic Illness.
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behavioraltreatmentsofpediatricsleepdisorders-21.pptxBehavioral Treatment of Pediatric Sleep Disorders
Kevin C. Smith, PhD
Pediatric Psychologist
Children’s Mercy Kansas City
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Objectives
Identify the most prominent pediatric behavioral sleep disturbances
Discuss prevalence rates and diagnostic criteria of each disorder
Highlight the psychological theory behind the treatment of pediatric sleep disturbances
Provide behavioral recommendations for clinical management
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Insomnia:
Persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and result in some form of daytime impairment.
Sleep disturbance and associated daytime impairment occurs at least 3x per week for at least presents for 3 months
International Classification of Sleep Disorders, 3rd Edition
Common pediatric insomnia presentations
Bedtime resistance
Frequent nighttime awakenings
Inability to achieve/resume sleep independently
Nighttime fears, nightmares
Psychophysiologic insomnia (generally with older children/adolescents)
This is not an exhaustive list
So here are some of the more prominent behaviorally focused sleep problems that one would see him in clinic setting. For this talk, I am going to be highlighting the ones in bold.
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Start with Sleep Habits:
Behaviors that affect sound sleep
Diet
Avoid Caffeine, Nicotine, Alcohol, Chocolate
Avoid eating right before bedtime, but don’t go to bed hungry
Instead, small snack earlier in evening – protein and fiber
Sleep environment
Comfortable, quiet, dark
Exercise (lack of or poorly timed)
Stress
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But a great place to start is sleep hygiene. Sleep hygiene refers to a variety of different practices that are necessary to have normal, quality nighttime sleep and full daytime alertness.
Some sleep hygiene areas seem straightforward like avoiding caffeine before bedtime, but often parents will underestimate the affect caffeine can have on a child even earlier in the day. Diet is also important. Eating right before bed time is not recommended (possible gastrointestinal issues and also because the body then has to focus on digestion instead of focusing on sleep). That said, going to bed hungry is not a good idea as well. Having a snack before bedtime consisting of healthy options such as low-fat proteins and foods high in fiber will help keep the child satiated throughout the night.
The bedroom should be quiet, dark, with a comfortable bed and comfortable room temperature. Electronics should be shut off. This is one of the more challenging issues especially with teens although an increasing number of young children also have televisions in the room as well as portable electronics. Light emitted from the electronics can delay the production of melatonin, a hormone secreted by our pineal gland that helps to control our sleep wake cycles. Studies also show that children who have a TV in the room tend to sleep less.
Exercise also is key. Children who exercise regularly tend to sleep better, as long as it is not right before bed. The thought is that this may inhibit sleep because during exercise, our core body temperature increases. During sleep, our core body temperature actually decreases throughout the night so exercise right before could cause our body to have to work harder to achieve this.
Sleep Habits, cont.:
Bedtime routine
Consistent sleep/wake times
Jet Lag Effect
Consistent bedtime routine (weekday and weekends)
Activities before sleep
Relaxing (e.g. some types of reading) vs. non-relaxing (e.g. playing Call of Duty, Halo)
Activities in bed
Bed is for sleep only…
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Having a consistent bedtime especially between weekday and weekend days is important. Children who stay up later and get up later on the weekends can develop a “mini jetlag “ Sunday night and have difficulty falling asleep for the next few nights.
Educating families that achieving sleep is a gradual process and that the hour before bedtime should be protected and be thought of as a transition time from wakefulness to sleep. Therefore, encouraging relaxing activities before bed is recommended.
Finally, encourage that the bed be used for sleep only so that there is a strong association between the child’s bed and sleep.
How are children actually sleeping?
69% experience one or more sleep problems at least a few nights a week
30% wake at least once a night needing attention
National Sleep Foundation’s Sleep in America Poll: 2004
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That said, the reality is that sleep hygiene and sleep habits in general are challenging for our children and families.
Sleep hygiene reality…
Three-quarters of adolescents report drinking at least one caffeinated beverage daily, and nearly one-third (31%) consume two or more such drinks each day.
Not surprisingly, teens who drink caffeinated beverages get less sleep than those who don’t.
National Sleep Foundation 2006 Sleep in America Poll.
One of the challenges of caffeine is that this is now available and so many different products such as mints, calm, water (meaning bottled water was caffeine added), and energy drinks. So your patients may be getting more caffeine then you think.
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Sleep hygiene reality…
Watching television is the most popular activity (76%) for adolescents in the hour before bedtime
surfing the internet/instant-messaging (44%)
talking on the phone (40%)
Nearly all adolescents (97%) have at least one electronic item in their bedroom.
6th graders=2 items, 12th graders=4
Adolescents with four or more items are 2x likely to fall asleep in school and while doing homework.
National Sleep Foundation 2006, 2011 Sleep in America Poll.
I had mentioned television earlier, as you can see from the statistics electronics in the bedroom is a significant problem for many children.
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How much sleep are children getting?
Parent report: National Sleep Foundation’s 2014 Sleep in America Poll
This is a great slide that shows how much sleep our children need compared to what parents report they are actually getting. This is data from the national sleep Foundation. As you see on the left, sleep needs decrease with age. If you compare these needs, though, with the amount parents said their children were getting (which is on the right hand side of the slide), you see that all age groups are getting less than what we would want and especially adolescents, which may be getting 1-2 hours less than what we would hope for based on their age.
So in summary: just talking with parents about developmentally appropriate sleep needs plus the basics of sleep hygiene is a good place to start. Now lets talk about specific behavioral sleep disorders.
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Sleep onset associations
Falling asleep is extended process requiring special conditions
Associations are problematic
If conditions are not met, onset is significantly delayed
Behavioral insomnia childhood is one of the more common sleep issues. Children may have difficulty falling asleep, staying asleep, or both . There are 2 types. The first type of sleep onset association. It is characterized by the child dependency on specific stimulation, objects, or settings for initiating sleep or returning to sleep following awakening. The main issue is that in the absence of these conditions, sleep onset is significantly delayed. There are many sleep associations that are good – meaning, associations that do not disrupt sleep and are sustainable. We all have them. You may have a certain pillow that you like or a white noise machine that you use. Some adults find that they sleep better with their partner next to them. For Children, good sleep associations include a transitional object like a stuffed animal, a blanket that they like, or soft music. Usually, sleep associations that provide challenges for the parents are generally one that involve the parents themselves. Most kids that present in clinic for this issue are unable to fall asleep or fall back to sleep without parental contact.
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Bedtime resistance
Difficulty initiating/maintaining sleep
Stalling/bedtime refusals
Inappropriate/insufficient parental limit-setting skills to establish appropriate sleep behavior
Them there is a limit setting type. It is basically what sounds like. Is characterized by bedtime stalling and/or bedtime refusal that is the result of inadequate limit setting by a caregiver. Bedtime stalling behaviors include attempts to delay bedtime with a bedtime routine or following lights out. The requests are based on what the child has learned will elicit a parental response. caregivers also may institute limits inconsistently or in an unpredictable manner. This inconsistent caregiver response provides intermittent reinforcement and maintains the awakenings. Limit setting may not become a problem until a child can climb out of a crib or has been moved into the bed.
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Sleep onset associations/limit setting
Etiology
Delay in emergence of (or regression of) sleep consolidation and sleep regulation skills
Intrinsic (e.g. temperament) and extrinsic (e.g. sleep hygiene, parenting practices) involved
The etiology of behavioral insomnia childhood is multifaceted. These problems are strongly related to caregivers behaviors, bedtime interactions, and culture. Therefore the interpretation of nighttime awakenings and demands for parental contact should be considered in the context of the family and culture. There are cultures in which cosleeping is a common, and therefore it is important not to pathologize this (except for infants, where it is recommended by the American Academy of pediatrics that for safety reasons infants do not sleep in her parents’ bed.) Therefore, if the family does not have a problem with co-sleeping, I recommend that they encourage the patient to fall asleep independently (meaning putting the patient to bed before they go to bed) so these self soothing skills can be fostered.
Sleep onset association problems are often associated with difficult temperament or other challenges related to calming the child. Environmental factors such as the child having to share a room with a parent or with other siblings, the presence of others in the home such as grandparents, or cramped living accommodations may contribute to negative sleep onset associations or poor limit setting.
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Sleep onset associations/limit setting
Prevalence
20-30% during infancy/childhood1
Diagnosis usually not considered for infants under the age of 6 months
Important to treat early
Can be persistent if untreated
Child sleep problems correlated with poor cognitive/emotional functioning, family and parent stress
1. Tikotzky and Sadeh, 2010.
1. Tikotzky and Sadeh, 2010.
This is one of the most common presentations in a behavioral sleep clinic and actually one of the more common problems presented to pediatricians as well. Because children are not expected to sleep through the night with regularity until they are 3-6 months of age, 6 months is a reasonable age to first consider a diagnosis of behavioral insomnia of childhood.
Research has also shown that frequently these problems persist if untreated. As with most pediatric sleep problems, this becomes a family problem and most parents report that with this disorder, the family’s sleep also suffers significantly.
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Treatment options
Behavioral interventions (standard)
Unmodified extinction (standard)
Extinction with parental presence (standard)
Graduated extinction (guideline)
Parent education/prevention (guideline)
American Academy of Sleep Medicine, 2005.
I will be discussing Practice parameters throughout this talk. These are parameters from the American Academy of sleep medicine. A “standard” is an accepted patient care strategy – with a high degree clinical certainty (empirical support). A “Guideline” is a recommendation with a moderate degree of clinical certainly. I will go over each other these recommendations…. (NEXT SLIDE_)
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Treatment of sleep onset associations/bedtime resistance
Assess for common obstacles
Readiness to change
Current parenting strategies
Parental disagreement of strategies
Other children in the home
Lack of time/energy
Child temperament
The first thing I would do, though, is assess for any common obstacles that family might face when attempting to implement a treatment plan. I really looking to meet the family where they are at to determine what first steps I would recommend.
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Treatment options: Sleep-Onset Association Disorder
Extinction techniques
Variety of starting points for parents based on parental readiness for change and potential barriers
Standard/Unmodified Extinction (cry it out method)
Removal of rewarding consequence (parent contact/interaction)
Effective (see changes in one-two weeks), but often hard for parents to implement
Gets worse before it gets better
Prepare parents for worst case scenario
No long term psychological harm – instead providing self-soothing skills for long term benefits
So here are some treatment options.
An extinction protocol has been shown to be one of the more effective treatments, but easily it is the most challenging for the parent. The standard/unmodified (cry it out) method is one of these options. Often, parents will come to a sleep behavior psychologist’s office worried that this will be the only option. Again, it is often very effective, but there are several additional options which are available to parents which I now will discuss.
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Treatment options: Sleep-Onset Association Disorder
Extinction with parental presence
Parent is present in the child or parents’ room
Less stressful for child
Many different starting points
Easier to customize
First address child’s need to touch the parent to fall asleep, then to be near the parent, then to see the parent
Slowly fade parental involvement/presence
Another option that many parents find more palatable is extinction with parental presence. With This protocol, the parent is in the bedroom, and the starting point is determined based on where the parent is currently sleeping. Usually, the first step is to have the parent out of the bed so that child does not have to physically touch the parent to fall asleep. (for example, having a parent sit next to the child’s bed as a starting point.)
Then as a child makes progress, the parent is moved farther and farther away from the bed. Often, for children who old enough, we will add a reward component to increase compliance and decrease stress and anxiety about sleep.
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Treatment options: Sleep-Onset Association Disorder
Graduated Extinction
Removal of rewarding consequence (parental presence) for increasing amounts of time
Easier to implement, but takes longer to work
Some parents find this activates the child
Can be harder for parents to provide consistent responses
Another option is graduated extinction. The parent would tuck the child into bed and then leave for a designated amount of time, promising to come back to the room at that time. Then the time interval is slowly increased until the child is actually falling asleep in between parental visits. For children that will stay in the bed and not follow their parents out of the room, this can be an effective strategy. A reward program can be used for this protocol as well to increase compliance. With Young children, It helps when indicating a time interval to provide an actual activity, since time is a abstract concept. For example, the parent can say “I am going to empty the dishwasher and will be back when I am done.”
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Night wakings
Treatment options
Apply selected treatment of sleep onset association disorder, OR
Delay behavior modification to see if night wakings spontaneously resolve because of improvement in sleep onset problems
Often, resolution can occur in as little as 2 weeks
In the meantime, respond immediately and consistently to night waking
Assess readiness for change and child temperament to help family choose appropriate option
Waking in the middle of the night can often be addressed the same way as one would address sleep onset problems. That said, frequently I do not recommend that the family work on both of these together. This tends to be frustrating for families, children and parents, they get minimal sleep, and then families are at a higher risk of quitting the protocol.
Therefore, I recommend helping the child get good sleep onset skills first. If they do not have the skills to fall asleep at the beginning of the night, they will not have these skills to rely on when they try to fall back to sleep in the middle of the night.
Therefore, while the family is working on sleep onset, I recommended they just be consistent in the middle of the night (whether that be going into the child’s room or having them sleep in a palate on the floor in the parents room). Just do the same thing until we start working on middle of the night awakenings.
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Early morning wakings
Determine if waking is sleep termination or final night awakening
If child put in bed with parent, he falls back to sleep quickly?
Does he need a nap after a few hours of being awake?
If yes, treat as night waking
A light with a timer can help a child understand when he can get out of bed
Many parents also Struggle with early morning awakenings. First step is to determine if the awakening is the termination of sleep or if the child will go back to sleep. If it is a termination of sleep and you want to have the child sleep later, one may need to look have a later bedtime. If the child actually easily falls back to sleep with parental contact, treat it like a middle-of-the-night awakening.
Also, there are tools that can help parents help children know when they can leave the room in the morning. (SEE NEXT SLIDE)
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This is an inexpensive clock that can be found online or at major department stores that can be set like an alarm to change color based on when the child is permitted to leave the room in the morning. A cheaper version of this would be to use a nightlight with a timer (like you would use to turn on your lights if you are on vacation). When the nightlight goes off, the child can get out of his room.
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Rewards
Components of a good rewards program
Method to track progress (sticker chart, calendar)
Predetermine prizes or privileges
Must determine child’s “currency” (what they like)
Predetermine distribution of prizes (e.g. one prize after two successful nights)
Small prizes with frequent and early distribution work best
Provides parent with opportunity to give positive attention
When first discussing rewards, talk with parents without child in the room
I talked about rewards before. Lets briefly review the components of a good reward program.
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Pediatric Nighttime Fears
OK lets move on to nighttime fears
Pediatric Nighttime Fears
Almost all children experience them
Peak between 3-6 years
Some common themes
Infants: (Loud noises, sudden moves)
Toddlers: (strangers, separation)
Preschoolers: (the dark, imaginary creatures, thunder, being alone/separation)
Pediatric nighttime fears are common and respond well to treatment. As you can see from the slide, there are common themes to these fears based on the child’s age. An easy way to look at this: young children tend to be afraid of imaginary characters and/or fear of the dark, and older children tend to be afraid of external variables/variable based in reality such as someone breaking into the home.
Nighttime fears in older children
Content
8-12 13-16
Personal security 22% 13%
Environmental threats 19% 18%
Frightening dreams 15% 2%
Imaginary creatures 8% 2%
Family/friends security 4% 2%
Insects/animals 4% 1%
Worry about day’s events 2% 3%
No fears reported 21% 52%
Gordon, King, Gullone, Muris, Ollendick, 2007
This was a great study done in 2007 in Australia that highlights the change in content and nighttime fears and older children.
As you can see the main theme is that nighttime fears decrease over time (even though almost half of adolescent survey between age 3-16 still reports some nighttime fears).
Cognitive Behavioral Therapy (CBT)
Thoughts
Feelings
Behaviors
One of the ways to treat nighttime fears is through cognitive behavioral therapy. CBT is based on learning theories – that is, we learn maladaptive ways to cope with situations in our lives, thus, the goal of CBT is to teach the patient new ways to think and act that are adaptive – how we think, feel, and act are all related to one another
Cognitive behavior therapy, generally has two main components: working on cognitions and behaviors:
Principle 1: Our thoughts influence the way that we feel about things.
People with sleep issues may have a clouded/filtered way of thinking. They have a misperception about an item or situation that tells them that it is either dangerous or exaggerates the danger present in the situation. Maladaptive thoughts are not always 100% wrong.
Cognitive work in CBT involves teaching the person to identify and evaluate negative thought patterns
Behavioral work involves teaching the person to face new situations, to set specific goals and participate in new/feared activities. Examples include self-monitoring (dietary intake/physical activities), stimulus control (manipulating
Therapeutic alliance is something we talk about in reference to how well a patient and his/her therapist works together. Typically it is considered to be an important aspect of treatment and a predictor of good outcome, while it is less important in CBT, therapists should make an effort to work with their patients in a caring manner.
CBT is considered an empirically supported treatment, this means that it has undergone rigorous testing in the academic world to show its effectiveness for several types of disorders. It is most commonly used for anxiety and depressive disorders with great success. It can be used with children as well as adults, although activities should be modified to meet the developmental level of the individual.
CBT and nighttime fears
Desensitization, positive reinforcement, positive imagery and self talk
Challenges: Identifying the essential components of the intervention, and specific child characteristics that predict success
This slide highlights how one would use CBT to address nighttime fears.
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Treatment of Nighttime Fears: Preschool
Graduated exposure to feared situations
In vivo or using imagination
Counter conditioning
Participant modeling
Reinforcement of non-fearful and approach behaviors
For older children: Cognitive restructuring
must be age/developmentally appropriate
Gordon et al., 2006
Preschool/school age nighttime fears: parent tips:
Reassure, but don’t reinforce, fears
Use dim light sources
Nightlights
Avoid scary TV, movies, newscasts
Positive reinforcement
Sticker charts, small prizes/privileges
Teach coping skills
Superheroes/cartoon characters as role models
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Pediatric Nightmares
OK lets move on to pediatric nightmares….
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Sleep Terror Disorder/Sleepwalking Disorder vs. Nightmares
Nightmares
Latter part of night
REM stage
Distress after event
Recall of event
Onset during early school age
STD/SW
First 3 hours of sleep
NREM stage
Distress during event
No recall of event
Onset during early school age – often resolve by age 10-12 years
Generally benign
So Dr. Beckerman are talked about parasomnias such as sleepwalking and sleep terrors. When dealing with nightmares, the first step with parents is to confirm that they are actually nightmares, and not sleepwalking or sleep terrors. This slide highlights the differences. Again, nightmares generally occur in the later part of the night. children are generally distressed after the event and can recall the event. With sleep terrors, the child generally does not recall the event in the morning, and often does not respond to attempts by parents to comfort the child.
Once you can establish with parents that the child is having nightmares, then there are protocols you can follow.
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Pediatric Nightmares
Occur frequently in normal childhood
10-50% of young children have nightmares that need parental contact
Chronic nightmares (longer than 3 months)
24% (ages 2-5)
41% (ages 6-10)
Final prevalence: 7% at age 16 years
Most resolve without significant intervention
Krakow et al., 2001; Mindell & Owens, 2003
Nightmares are common in children and studies cite occurrences anywhere from 10-50% of children needing parental contact affect a nightmare. Nightmares can be chronic
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Nightmares (cont.)
Content varies across developmental stages
Around age 2
Monsters/frightening imaginary creatures
Young children
May involve recent traumatic event
Older children
Frightening/upsetting movies
Disturbing daytime experiences
Stressors
You will see from the slide that the content of the nightmares varies based on age of child.
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Nightmare Treatment (preschool)
Reassurance by parent
Calm, supportive, postpone discussion of nightmare until next day
Encourage use of transitional object
Dim light in room
Decrease chance of nightmare
Encourage adequate sleep (sleep deprivation can increase frequency of nightmares)
Stability in environment
Avoid frightening images
What to do? The main strategy is to not rehash the nightmares at night. No one is at her best in the middle of the night. Instead, be supportive in the middle of the night, return the child to their bed, and support discussion the next day if the child initiates it. Encourage to use a transitional object and a nightlight.
There also are a few factors that can contribute to nightmares and so controlling for these can help. Adequate sleep and a good sleep schedule, basic stability in the home, and the easiest one which is often overlooked is to avoid content that seems to generate nightmares, such as scary movies. This can be difficult given that many of these movies are advertised on commercials, and it is harder to control other media outlets such as Internet access.
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Nightmare Treatment (school-age/adolescents)
Imagery Rehearsal Therapy (IRT)
Evidence-based
Doesn’t focus on entire content of dream or events that precipitated it
“Rewrite” dream, practice rehearsing it during daytime
Improvement can be seen in 3-4 sessions (sometimes more or less depending on patient/family and severity of nightmare disorder)
Can generalize to improvement in mood, daytime functioning, decrease of PTS symptoms
Reduction of nightmare frequency, maintained over 9-month follow-up
There is also a treatment for school-age an adolescent children (as well as adults) called imagery reversal therapy or I. R. T. It is evidence-based.
The patient is encouraged to write a very brief synopsis of the nightmare, then rewrite the ending to the nightmare (which usually includes a happy ending her something funny – some child may need parental help with this). They then “rehearse” this new ending in their head during the day. (Meaning, close their eyes and play the dream back in their head like a “movie” only with the new ending.
Improvement (decrease of intensity and frequency of nightmares) can be rapid and significant. The theory behind IRT is that it can decrease the anticipation/anxiety associated with the possibility of having a nightmare at night and also provide the patient with more control (which also then decreases anxiety about sleep in general).
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Psychophysiologic Insomnia
Diagnostic Criteria
A disorder of learned sleep-preventing associations. People with this insomnia learn to associate sleep with anxiety. A vicious cycle of worrying about Insomnia then not sleeping because of it pursues until the individual changes their perception of sleep and their sleep habits.
Sleep better when away from home
Heightened physical arousal in bed/unable to relax
Mental arousal in bed
Intrusive thoughts, “busy mind”
Here are some other symptoms of psychophysiologic insomnia. Again the main issue is that they are these negative thoughts and feelings surrounding sleep that can make anything associated with sleep feel negative such as the bedroom or even the bed.
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Diagnostic criteria
Symptoms meet criteria for insomnia and must be present for at least one month
One or more of the following:
Learned negative sleep associations
Heightened physiologic arousal
Excessive worry/focus about sleep
Cannot fall sleep during planned times but no problems during monotonous activities
I find that this specific sleep problem is one that surprises families when you talk about it, but actually ends up making sense to them. In a nutshell, the more we think about sleep, the more we are stressed about it and focus on it, the more difficult it is to achieve. Think about when you are anxious. You are in a heightened state of physiologic arousal. Your heart may beat faster, your breath may be shallow. For some children and adolescents, they have been so unsuccessful with sleep that even the thought about sleep brings up these arousals which then of course makes it harder to sleep. It is a vicious cycle that if untreated tends to get worse and worse.
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Diagnostic criteria
Other factors may have precipitated insomnia
Depression, pain, disturbed sleep environment
Psychophysiologic insomnia persists after factors have been removed
Sometimes people with psychophysiologic insomnia cannot identify when it started. Often it starts rather innocently. There are other factors that effect sleep. Frequently at our clinic, the start of the insomnia related to a medical condition. An example: a child may come to the hospital for an extended stay. Their sleep schedules are altered. They go home and have difficulty falling asleep and then the anxiety surrounding sleep begins. Even if the medical issue is resolved, the sleep issue remains.
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Prevalence
11% 13-16 year-old adolescents1
35% adolescents experience insomnia several times a month2
Differential diagnoses
Other medical disorders
Other sleep disorders
Psychiatric disorders
Side effects of medications
Alcohol/drug use
Negative sleep habits
1. Johnson, Roth, Schultz et al., 2006
2. Owens & Mindell, 2011
Psychophysiological insomnia is more common than you think. That said, it is important to also review other possible contributors, such as the more medically-focused sleep issues at Dr. Beckerman discussed.
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Behavioral treatment
Stimulus control
Sleep restriction
Relaxation therapy
Addressing negative/inaccurate sleep cognitions
Improve sleep hygiene
Address comorbid mental health issues
Other (medication)
Cognitive behavioral therapy for insomnia, or CBT-I is empirically supported treatment to address psychophysiologic insomnia. Basically it breaks down to 2 areas: Addressing the environmental cues that perpetuate insomnia, and addressing the negative or inaccurate sleep cognitions that also perpetuate insomnia.
For example: with sleep restriction: we want to minimize the amount of time the patient is awake in bed because their bedtime does not come close to the time they actually fall asleep. Therefore, we may actually recommend that the patient goes to bed later. Families may meet this with some initial resistance, so we have to talk through this. Once they understand that the later bedtime is not permanent, they tend to be on board.
As we previously discussed, sleep hygiene is important, and I like to start there just make sure that there are not some obvious reasons why insomnia is continuing, such as caffeine intake or possibly a functional component to the insomnia (like wanting to stay up late and watch television/surf the web unmonitored).
The cognitions/cognitive component also is very important. Insomniacs often catastrophize their insomnia. For children, they will make statements like” if I cannot sleep tonight I am going to fail all my tests and have to repeat 7th grade.” In reality, most children with psychophysiologic insomnia actually function better than you would think during the day. It is not ideal and it is not to say that we do not want to treat the insomnia. But helping patient to realistically assess the daytime functioning issues surrounding the insomnia can decrease anxiety. Fro example: for many children, the worst thing that can happen if he does not sleep well at night is that he is tired during the day and it is harder to do things. Most patients who have insomnia are not failing tests are not failing school. There are always exceptions of course. Where it becomes a challenges is if parents let children miss school, go to school late, or start to home school only because they cannot get them out of bed. Then, some of the negative sleep cognitions that the child may have actually about their insomnia actually do come through. (Meaning, they do start to do worse in school because they are missing school, coming in late, etc). Therefore, we recommended that children who are suffering from insomnia still get up in the morning and still go to school. This has not always easy to implement so we work with the family to do this.
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Summary
Pediatric behavioral sleep challenges are common
There may be an associated physical or psychological condition that also needs to be addressed
Most behavioral sleep challenges respond well to empirically-supported behavioral treatments
Resources for Parents
Guide to Your Child’s Sleep. George J. Cohen, M.D., F.A.A.P.
Take Charge of Your Child’s Sleep. Judy Owens, M.D., and Jodi Mindell, Ph.D.
Sleeping Through the Night. Jodi Mindell, Ph.D.
Here are some resources for parents. All these books her great and readily available.
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References
American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd Edition, ed., 2014.
Meltzer, 2010. Clinical management of behavioral insomnia childhood: Treatment at bedtime problems and night wakings in young children. Behavioral Sleep Medicine.
Owens and Mindell, 2011. Pediatric Insomnia. Pediatric Clinics of North America.
Tikotzky and Sadeh, 2010. The role of cognitive-behavioral therapy in behavioral childhood insomnia. Sleep Medicine.
And here a few of the main references used in this talk that are great resources for providers.
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Thank you
