+ Sleepy, Dopey, & Grumpy: Behavioral Sleep Disorders of Childhood Courtney Du Mond, PhD, CBSM Clinical Psychologist & Behavioral Sleep Medicine Specialist
+ Outline n Background & Conceptual Model n Sleep 101: Normal Sleep n Behavioral Sleep Disorders n Treatment & When to Refer
+ Why Sleep? n Sleep problems are common in early childhood n When left untreated, sleep problems may persist and become chronic n Poor sleep can have negative consequences across multiple domains of child, parent, and family functioning
+ A Conceptual Model Fragmented Primary Sleep (Sleep Disorders of Disruption) EDS Insufficient Circadian Sleep (Sleep Rhythm Deprivation) Disorders Excessive Daytime Sleepiness
A Conceptual Model Daytime Sleepiness/Insufficient Sleep Problems Cognitive Behavioral Mood Consequences School Performance Social/Family Functioning
+ Impact of sleep problems: Physical n Growth: disruption of normal growth hormone release during sleep n Immune function: sleep deprivation impairs host defenses; infection induces somnogenic cytokines n Endocrine system regulation: cortisol, prolactin thyroid n Metabolic regulation: obesity/metabolic syndrome linked to sleep deprivation n Injuries more common in sleepy children
+ Sleep in the Modern Family 2014 Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.
+ Factors Affecting Sleep in Children Family/Parents (SES, family stress, parental Sleep competence) Environment Health (illness, (temperature, medications, light, sleep reflux) surface) Sleep Practices Development (schedules, (sleep, cognitive, feeding, separation napping, anxiety) cosleeping) Social/Emotional Sociocultural Sleep (attachment, (values, temperament, parenting maternal mental practices) health/stress)
+ What’s Normal?
From: Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics. 2003 Feb;111(2):302-7.
+ What’s Normal
+ Infants n 0-2 Months n 10-19 hours per 24 hours n Bottle-fed sleep longer periods than breastfed n 2-12 Months n 9-10 hours at night n 3-4 hours napping
+ Toddlers n 12 months – 3 years n 9.5 to 10.5 hours sleep at night n 2-3 hours napping n Decreases with age
+ Preschoolers n 3 to 5 years n 9 to 10 hours of sleep per night n Naps decrease from 1 to none
+ School Age n 6 to 12 years n 9 to 10 hours per night Adolescents n 12 to 18 years n Normal is not enough! n Sleep decreases with increasing age n Biologic and environmental shift to later sleep onset n Circadian rhythm disorders are very common and often present as EDS or insomnia complaints n Electronics, electronics, electronics!
+ What parents think... 2014 Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.
+ What kids actually get... 2014 Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.
+ Behavioral Sleep Problems in Early Childhood
+ Common Sleep Complaints n My child refuses to go to sleep n “Curtain calls” n He won’t sleep in his own room n My child has ALWAYS been a terrible sleeper n She wakes up 5 times every night n We moved him to a bed and he won’t stay there at bedtime n I have to lie down with her every night until she falls asleep
+ Case Example n 3 ½ year-old with frequent night wakings n Bedtime n Routine: bath, snack, books, song, TV , lotion, prayers, more books, patted to sleep n Negotiating n Time-outs n Typically falls asleep with mom in his bed n Woke about every 60-90 minutes n Getting out of bed about 35 times per night n Running around n Irritable, arguing with mom n “I’m scared”
+ Epidemiology n Bedtime Stalling n 52% of preschoolers n 42% of school-aged children n Bedtime Resistance n 10-30% of toddlers and preschoolers n 84% of children (15-48mo) continued to have sleep disturbance at 3-year follow up!
+ Etiology & Risk Factors n Permissive parenting style n Conflicting parental discipline styles n Age n Temperament n Oppositional behavior n Environmental settings n Circadian timing
+ Behavioral Insomnia of Childhood § International Classification of Sleep Disorders – Second Ed. (ICSD-II) § Sleep Onset Association Type § Limit Setting Type § Combined Type
+ Sleep Onset Association Type n Complaint = nightwakings n Nighttime arousals are normal (for all of us) n What you need to fall asleep is what you need to return to sleep
+ Sleep Onset Association Type (cont’d) n 6 months to 3 years n Involvement of sleep associations prevents returning to sleep independently n Problematic sleep associations interfere with learning to self-soothe n Requires parental intervention to sleep
+ Limit Setting and Combined Type Limit Setting Type Bedtime struggles/bedtime refusal n Prolonged sleep onset latency n 2-6 year olds n Combined Type Bedtime struggle that ends with negative sleep n association
+ Key Features Sleep Onset Association Type Involvement of sleep associations prevents S returning to sleep Limit Setting Type Bedtime struggles/bedtime refusal S Combined Type Bedtime struggle that ends with negative sleep S association
+ Assessment of Behavioral Sleep Problems
+ Screening for Sleep Problems: BEARS n B = Bedtime problems n E = Excessive daytime sleepiness n A = Awakenings during the night n R = Regularity and duration of sleep n S = Snoring
+ Sleep History – Sleep Habits § Sleep schedule/ patterns § Diaries § Weekday § Weekend § Naps § Consistency § Co-sleeping
+ What’s wrong with this picture?
+ Sleep History - Bedtime § Evening activities § Bedtime routine § Latency to sleep onset § What happens during that time § How do parents respond to stalling? § Sleep onset associations § Sleep location § Where child falls asleep & wakes § Who is present, where are they, what are they doing?
+ Sleep History – Nocturnal Behaviors n Night wakings n Night terrors/Sleepwalking n Sleep-disordered breathing n Leg movements
+ Differential Diagnosis n Delayed sleep phase n Nighttime fears n Transient insomnia n Restless legs syndrome n Obstructive Sleep Apnea n Illness or other health issue n Medication effects
+ Empirically Supported Treatments
+ Standards of Practice: American Academy of Sleep Medicine n Reviewed 52 treatment studies n “Behavioral therapies produce reliable and durable changes” n 80% of children treated demonstrated clinically significant improvement that was maintained for 3 to 6 months n 94% of behavioral interventions were efficacious Mindell et al. Review paper for AASM: Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006: 29: 1263-1276 Morgenthaler et al. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006: 29: 1277-1281
+ Behavioral Treatments -- Basics n Working with caregivers to change their sleep-related interactions with their child n 2 main components n Modifying parental/child cognitions n Modifying parental behaviors and responses to the child
+ Behavioral Treatment Cont’d n Common treatment components n Bedtime Routine n Extinction n Standard/Unmodified or graduated n Shaping n Reinforcement
+ Bedtime Routine n Bedtime routine alone shown to improve problematic sleep behaviors in young children n Also improves maternal mood n Same every night n “Short, sweet and heading in the same direction” n Appropriate baby bedtime between 7:30-8:30 n Daytime schedule n Wake time n Naps Mindell et al., 2006. A nightly bedtime routine: Impact on sleep in young children and maternal mood. Sleep 2009; 32: 599-606
+ Unmodified Extinction or “Cry it out!” § Putting the child to bed at designated bedtime and then ignoring child until morning § monitor for safety and illness § No attention for negative behaviors § Extinction Burst § Standard recommendation § Limited parental acceptance § Crying is tough!
+ Graduated Extinction n Parents ignoring bedtime crying and tantrums for pre-determined periods before briefly checking on child. n A progressive or fixed checking schedule may be used (as long as the parent can tolerate) n Minimize attention n Goal is for child to self-soothe to sleep n Bedtime only n Generalization to night wakings n More acceptable to parents
+ Shaping n Small steps towards big goals n Get rid of bottle and just rock to sleep n Put in crib and sit next to crib n Sit farther and farther away from crib n Consistency, consistency, consistency
+ Reinforcement n Reinforce any and all positive sleep behaviors!
+ When to refer n Behavioral sleep problems that do not respond to typical behavioral strategies n Children with developmental conditions or medical complications n Families who need more support n Breathing problems with sleep n Excessive daytime sleepiness that is not explained by insufficient sleep
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