Sleep problems in children and adolescents |
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Many parents worry about the quantity and quality of their child’s sleep. In fact, sleep problems are one of the most common concerns that parents report to their child’s pediatrician. Good sleep is important for several reasons, and affects every aspect of child development. For instance, sleep problems can attribute to poor mood, behavior problems, academic concerns, health problems, anxiety, and attention problems. If left untreated, early sleep problems can lead to behavioral or emotional problems in the future. The good news is that pediatric sleep problems are highly treatable using behavioral and medical interventions, and preventable with good sleep hygiene and regular medical care!
Typical Sleep Patterns
In order to understand sleep problems for children and adolescents, it is important to understand what typical sleep looks like. Newborn babies typically sleep between 16-20 hours during a 24-hour period, and may not have a specific sleep/wake pattern during the first few weeks of life. For newborns (0-2 months of age), the sleep-wake cycle depends mostly on hunger, and circadian rhythms and environmental cues, such as light and darkness, are less important. Between the ages of 2 and 12 months, infants begin to sleep between 9-12 hours at night. In addition, they take long naps (2-4.5 hours) 1-4 times per day. Sleep problems for infants are often related to the association of sleep with specific events or items that become cues for sleep, such as rocking or feeding, and difficulty sleeping without those cues.
As infants grow into toddlers (12 months – 3 years of age), they begin to take fewer naps, and by 18 months of age children typically take only one nap a day. Toddlers usually need between 12 and 13 hours of sleep, with more sleep occurring at night and less during daily naps. During this age, the transition from a crib to a bed is often a source of sleep problems. In addition, toddlers often experience normal separation anxiety, which may result in increased fears about going to bed or desires to have parents nearby when going to bed.
As children enter preschool, between the ages of 3-5, total sleep time decreases to 11-12 hours per 24-hour period, and it is common for naps to begin to disappear around age 4. School-age (6-12 years old) children need about 10-11 hours of sleep per night, and nap very infrequently. Adolescents continue to need more sleep than adults, usually between 9 and 9.5 hours per night. However, adolescents frequently do not get enough sleep due to their busy schedules.
Common Sleep Problems
Nightmares/Nighttime Fears
Nightmares are defined as frightening dreams that usually awaken children, leaving them feeling upset, while nighttime fears are fears that cause children to experience anxiety at bedtime, such as fear of the dark. Both are quite common for children, and most children experience nightmares and nighttime fears at some point. However, nightmares and nighttime fears become a concern when they are persistent over time and begin to interfere with a child’s other activities. For example, if your child cannot sleep because of nighttime fears and then begins to do poorly in school because of lack of sleep, this would become a significant concern.
Children who have nightmares or nighttime fears are often tearful at bedtime, and cling to their parents when asked to go to bed. They may frequently leave their bedroom to seek out the comfort of their parents, may resist going to bed, and may have frequent “curtain calls,” such as repeatedly asking for a hug, a drink of water, etc. In addition, these children often report feeling much less fearful if a sibling, parent, or other family member is present at bedtime.
Nightmares and nighttime fears are more likely to occur if your child has experienced a traumatic event, such as a loss of a family member, or a significant change, such as move to a new school. In addition, children who experience significant anxiety are more likely to have frequent nightmares and nighttime fears. However, nightmares/nighttime fears may be present even if none of these events have occurred.
Bedtime Resistance
Bedtime resistance involves various activities that delay bedtime or the bedtime routine, including refusing to get ready for bed, frequently getting out of bed, or “stalling” to delay bedtime. Bedtime stalling often involves activities such as asking to watch additional television or play on the computer a little while longer, asking a parent to read another story, or repeated requests for drinks or hugs. Bedtime resistance is common after the age of two, when children learn to climb out of their crib or are moved to a bed.
Bedtime resistance is often the result of inconsistent limit-setting by parents at bedtime. Allowing children to fall asleep while watching television, allowing children to play video games in bed, and inconsistently enforcing bedtime are all examples of poor limit setting that can lead to sleep problems for children. Children who frequently do not follow adult instructions during the day are at risk for exhibiting bedtime resistance. In addition, a child’s temperament, family stress, and a parent’s discipline style can also influence the development of bedtime resistance in children.
Nightwakings
Nightwakings occur when children frequently wake up during the night and cannot fall back asleep independently. Often, children who experience nightwakings need a parent or caregiver to be present in order to fall asleep. Nightwakings are typically related to sleep-onset associations, which are cues or triggers that children learn to need to fall asleep. For example, if your child usually falls asleep with the television on, they may develop a sleep-onset association with television. When they wake up during the night, they may not be able to fall asleep again if the television is not on. Other common sleep-onset associations include rocking, parental presence, and feeding. It is common for children to have 4-6 brief wakings during the night, and those wakings are not a problem. However, if your child has developed a sleep-onset association, they may have a hard time getting back to sleep. Children who frequently sleep with their parents are at risk for nightwakings, especially if the parent leaves the child’s bed after, rather than before, they have fallen asleep.
Sleep Terrors and Sleepwalking
Sleep terrors and sleep walking are also called partial arousal parasomnias, because people who experience them are stuck between wakefulness and sleep. When children have sleep terrors, they may sit up in bed, cry or scream, and appear agitated or confused. Some children may have their eyes open during a sleep terror, but will look as thought they are “looking right through” caregivers. Sleep terrors and sleep walking can last for a few minutes to an hour, are most likely to occur 1-2 hours after your child has fallen asleep, and are usually not remembered by the child the next day. While 15-20% of children have a sleep terror or sleep walk at least once, 3-4% of children have more persistent sleep terrors or sleepwalking that are of concern.
Risk factors for developing sleep terrors or sleep walking include having a parent or other family member who experienced them at a young age, having an irregular sleep schedule, fever or illness, stress, sleeping in a different environment that usual, sleeping in a noisy environment, sleeping with a full bladder, taking certain medications, obstructive sleep apnea or disordered breathing, and sleep deprivation.
Most children will avoid being comforted or soothed when sleepwalking or having a sleep terror. While this can be distressful for parents, the best thing to do is to ensure your child’s safety (e.g., if they are sleep walking, gently guide them to a safe area) and allow them to get back to sleep on their own. Trying to wake up a child who is having a sleep terror or is sleepwalking can increase their agitation and confusion.
Obstructive Sleep Apnea and Disordered Breathing
Many sleep problems are related to the quality of breathing during sleep. Children who have disordered breathing may experience occasional snoring or gasping for air during sleep, especially if they have a cold or suffer from allergies. Obstructive Sleep Apnea (OSA) is a more severe form of disordered breathing that involves either complete or partial stopping of airflow for a brief period of time. Children with OSA tend to snore loudly, and often have a pause in breathing followed by gasping for air. Breathing problems can lead to other sleep concerns, such as frequent wakings during sleep, restless sleep, and daytime sleepiness due to poor quality sleep.
Snoring is a major indication of disordered breathing. If you notice that your child snores loudly enough that you can hear him or her outside of the bedroom, of if they snore for several nights in a row, it’s a good idea to mention the snoring to your child’s pediatrician so he or she can screen for breathing issues. Other risk factors for disordered breathing and OSA include a family history of sleep apnea, low muscle tone, obesity, and some medical conditions. In addition, children who tend to be “mouth breathers,” have frequent ear infections, and/or chronic congestion are also at risk for disordered breathing during sleep.
Delayed Sleep Phase Syndrome
Delayed sleep phase syndrome (DSPS) is a circadian rhythm disorder that is common for adolescents, and involves a shift in the sleep-wake schedule that interferes with other activities. If a child is experiencing DSPS, we are concerned about the quantity, rather than the quality, of their sleep. Teenagers who exhibit DSPS are often called “night owls,” are difficult to awaken in the morning, and often complain that it is hard for them to fall asleep.
Children with DSPS often do not fall asleep until sometime after midnight, and would sleep until 10:00 am or later if allowed. Because they typically cannot “sleep in” due to school and other activities, teens with DSPS may take long afternoon naps or sleep very late on the weekends to make up sleep. They may also demonstrate behavioral and academic problems because they are not getting enough sleep. In addition, these students may refuse to go to school, and complain of feeling too tired for school. Interestingly, they may also complain of “insomnia,” and report that they cannot fall asleep at night. However, once children with DSPS fall asleep, they tend to sleep well through the night and be very difficult to awaken in the morning.
Addressing Sleep Problems at Home – Sleep Hygiene
Many sleep problems can be addressed at home with changes in sleep hygiene. “Sleep hygiene” is a term used to describe appropriate bedtime routines, sleep schedules, and a good sleeping environment.
Bedtime Routine
For children and adolescents, the bedtime routine should be structured and predictable, and should be followed in the same order each night. Sometimes it is helpful to create a “bedtime routine schedule” using pictures to help your child remember the steps in the routine. The routine should always end with a quiet activity in the child’s bed, such as reading a story or saying prayers. In addition, it is important that your child fall asleep independently, so they do not learn to need someone else to be present to fall asleep. So, part of the bedtime routine should include making sure that your child is still awake when you leave the room. Also, if your child gets out of bed after bedtime, return him or her to their bed with very little interaction. If you give your child a lot of attention when they get out of bed, they may learn that getting out of bed is something they enjoy doing!
Sleep Schedule
Your child’s bedtime and wake time should be the same every day. If you let your children stay up late or sleep in on the weekends, try to keep the difference in bedtime and wake time as small as possible. When setting up your child’s sleep schedule, remember to consider naps. As mentioned above, children age 4 and younger often take naps during the day. Naps should also occur around the same time each day. If your child does not have a consistent sleep schedule but you would like to help them develop one, make very gradual changes in your child’s sleep patterns. For example, if your child does not fall asleep until 10:00 p.m., but you would like for her to fall asleep by 9:00 p.m., you could start by having your child go to bed at 9:55 p.m. for a few days, then 9:50 p.m., then 9:45 p.m., and so on until your child is able to fall asleep at the earlier bedtime.
Sleep Environment
A final component of sleep hygiene is the sleep environment. There are several aspects of the sleep environment that should be considered. For instance, the amount of light in your child’s room should be as minimal as possible. If your child needs a night light to sleep, make sure that it is not so bright that you could read by it. In addition, avoid allowing your child to watch television or play video games while in bed. Cues such as light and television tell the brain that it is not time for sleep, and can make falling asleep difficult. In addition, your child’s room should be as quiet as possible. Consider whether your child can hear others watching television in another room, or perhaps noises from the street outside. If so, you may want to place a fan in the room to help disguise some of those noises. Finally, if your child plays with toys rather than going to sleep, or wakes up in the middle of the night to play with toys, you may need to remove the toys from the sleep environment.
A very important issue to consider in relation to the sleep environment is sleep-onset associations. Sleep-onset associations are specific items, behavior, or persons that children need to be present in order to fall asleep. Some sleep-associations involve caregivers, such as when a child needs to be rocked or fed to fall asleep. Others involve activities, such as watching television or playing handheld video games, and still others involve certain tangible items, such as a pacifier or a favorite stuffed animal. Because all of us have several short awakenings during the night, sleep-onset associations can be problematic if they are not available for the awakenings. For example, if your child becomes accustomed to falling asleep when you are in their room, they may need to crawl into bed with you in order to fall back asleep if they wake up in the middle of the night. Or, if your child often falls asleep while playing a video game, they may need to play the game to return to sleep after a night waking, which can lead to prolonged periods of wakefulness during the night.
Addressing Sleep Problems at Home – Specific Techniques
If you address your child’s sleep hygiene and your child still experiences sleep problems, there are some other tools you can use at home. These include the Bedtime Pass and the Excuse Me Drill.
Bedtime Pass
The goal of the Bedtime Pass is to decrease “curtain calls” after bedtime. You may want to use the bedtime pass if your child frequently gets out of bed after bedtime, if he is resistant to going to bedtime, or if she has frequent requests after bedtime. To use the Bedtime Pass, sit down with your child and decorate a note card with the words “bedtime pass” written on it. Tell your child that he/she is allowed to use the pass for one trip out of the bedroom after bedtime each night. Also, inform your child that the pass must be used for a specific request, such as an extra hug, a drink of water, a trip to the bathroom, etc., and not just to get out of bed. If your child uses the pass appropriately, they should earn some type of reward the next morning or at then end of the week. The bedtime pass is effective in reducing the number of times a child gets out of bed after bedtime, and usually increases a child’s total sleep time because they are in bed longer.
Excuse Me Drill
The Excuse Me Drill is used to help children learn to fall asleep independently, and is a good alternative to the “cry it out” method. You may want to use the Excuse Me Drill if your child has a difficult time calming down at bedtime, or if your child cannot fall asleep without you or another caregiver present. To implement the Excuse Me Drill, begin by engaging in a quiet activity, such as reading a book, while your child is appropriately in bed. Before your child falls asleep, say, “Excuse me, I need to check on the laundry,” or “Excuse me, I need to see what your brother is doing,” or some other statement that indicates that you need to leave the room. If your child remains quiet and stays in bed, go right back into the room, and praise him or her for appropriate bedtime behavior. Continue to say the excuse me statements, gradually increasing the amount of time that you are gone from the room. Remember to only go back in the room when your child is quiet and calm in bed. The Excuse Me Drill teaches children that they can earn your attention for appropriate bedtime behavior, and also helps them to gradually become more comfortable with going to bed independently.
Seeking Additional Help for Your Child’s Sleep Problems
Sometimes you may not be able to address sleep problems at home, and may need to seek outside support. Certain sleep concerns should always be brought to the attention of your child’s pediatrician, including breathing problems or sleep apnea, Restless Leg Syndrome, and persistent sleepwalking/sleep terrors. In addition, if your child has sleep problems related to noncompliance with adult instructions, you may want to seek support in addressing the behavioral issues before addressing sleep concerns. Highly irregular sleep schedules are also sometimes difficult to adjust and may require the support of a professional. Finally, nightmares or nighttime fears that persist over time may be indicators of anxiety or other emotional concerns that warrant treatment.
Sleep problems are also common for children with special needs. For example, children with Autism Spectrum Disorders (ASD) often sleep less than other children and have irregular sleep schedules. In addition, parents of children with Attention Deficit Hyperactivity Disorder (ADHD) often report that their children have a difficult time “winding down” before bed. Children who experience significant anxiety may also have a difficult time falling asleep, and often report fears or worry before bedtime. If your child has sleep problems in combination with other needs, you may want to seek professional support to address concerns about your child’s sleep.
Finally, it is important to consider the impact of cultural variables on family sleep practices when considering whether or not your child has a sleep problem. Sleep practices, such as co-sleeping, sleeping arrangements, and sleep schedules, vary widely across cultures. The key issue to consider is how your child’s daily functioning in areas such as school, peer relationships, and behavior, is impacted by sleep.
For more information on children’s sleep problems, contact Melissa Hunter, PhD at (814) 867-0670. There are also several helpful websites that address sleep concerns for children, including the Center for Pediatric Sleep Problems at Children’s Hospital of Boston (http://www.childrenshospital.org/clinicalservices/Site1547/mainpageS1547P0.html) and the American Academy of Child and Adolescent Psychiatry (http://www.aacap.org/cs/root/facts_for_families/childrens_sleep_problems).
References:
Mindell, J.A. & Owens, J.A. (2003). A Clinical Guide to Pediatric Sleep: Diagnosis and
Management of Sleep Problems. Philadelphia, PA: Lippincott, Williams, & Wilkins.
