Sleepy, Dopey, & Grumpy: Behavioral Sleep Disorders of Childhood

Transcription

1 + Sleepy, Dopey, & Grumpy: Behavioral Sleep Disorders of Childhood Courtney Du Mond, PhD, CBSM Clinical Psychologist & Behavioral Sleep Medicine Specialist

2 + Outline n Background & Conceptual Model n Sleep 101: Normal Sleep n Behavioral Sleep Disorders n Treatment & When to Refer

3 + 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

4 + A Conceptual Model Fragmented Sleep (Sleep Disruption) Primary Disorders of EDS Insufficient Sleep (Sleep Deprivation) Excessive Daytime Sleepiness Circadian Rhythm Disorders

5 A Conceptual Model Daytime Sleepiness/Insufficient Sleep Problems Cognitive Behavioral Mood Consequences School Performance Social/Family Functioning

6 +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

7 + Sleep in the Modern Family 2014 Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.

8 + Factors Affecting Sleep in Children Sleep Environment (temperature, light, sleep surface) Family/Parents (SES, family stress, parental competence) Health (illness, medications, reflux) Sleep Practices (schedules, feeding, napping, cosleeping) Development (sleep, cognitive, separation anxiety) Sociocultural (values, parenting practices) Sleep Social/Emotional (attachment, temperament, maternal mental health/stress)

9 + What s Normal?

10 From: Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics Feb;111(2):302-7.

11 +What s Normal

12 + Infants n 0-2 Months n 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

13 + 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

14 + Preschoolers n 3 to 5 years n 9 to 10 hours of sleep per night n Naps decrease from 1 to none

15 +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!

16 + What parents think Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.

17 + What kids actually get Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.

18 + Behavioral Sleep Problems in Early Childhood

19 + 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

20 + 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 minutes n Getting out of bed about 35 times per night n Running around n Irritable, arguing with mom n I m scared

21 + 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!

22 + 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

23 + Behavioral Insomnia of Childhood International Classification of Sleep Disorders Second Ed. (ICSD-II) Sleep Onset Association Type Limit Setting Type Combined Type

24 +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

25 + 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

26 +Limit Setting and Combined Type Limit Setting Type n n n Bedtime struggles/bedtime refusal Prolonged sleep onset latency 2-6 year olds Combined Type n Bedtime struggle that ends with negative sleep association

27 + Key Features Sleep Onset Association Type S Involvement of sleep associations prevents returning to sleep Limit Setting Type S Bedtime struggles/bedtime refusal Combined Type S Bedtime struggle that ends with negative sleep association

28 + Assessment of Behavioral Sleep Problems

29 + 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

30 + Sleep History Sleep Habits Sleep schedule/ patterns Diaries Weekday Weekend Naps Consistency Co-sleeping

31 + What s wrong with this picture?

32 + 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?

33 + Sleep History Nocturnal Behaviors n Night wakings n Night terrors/sleepwalking n Sleep-disordered breathing n Leg movements

34 + 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

35 + Empirically Supported Treatments

36 + 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: Morgenthaler et al. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006: 29:

37 + 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

38 + Behavioral Treatment Cont d n Common treatment components n Bedtime Routine n Extinction n Standard/Unmodified or graduated n Shaping n Reinforcement

39 + 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., A nightly bedtime routine: Impact on sleep in young children and maternal mood. Sleep 2009; 32:

40 + 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!

41 + 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

42 + 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

43 + Reinforcement n Reinforce any and all positive sleep behaviors!

44 + 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

45 + Resources Mindell JA. Empirically supported treatments in pediatric psychology: Bedtime refusal and night wakings in young children. J Pediatr Psychol 1999;24: Kuhn BR, Elliott AJ. Treatment efficacy in behavioral pediatric sleep medicine. J Psychosomatic Res 2003;54: Mindell JA, Kuhn BR, Lewin DS, Meltzer LJ, Sadeh A. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006;10: Morgenthaler TI, Owens JA, et al. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006; 10:

46 + Questions?

47 + THANK YOU! n Please feel free to contact me with any further questions or referrals n n dumondpsych@gmail.com