Signs of sleep problems in children and young people Dr Sarah Blunden University of South Australia

What we will do Experience in the room? Normal sleep – quantity and quality Sleep problems in children Effects Co-morbidities Chicken or egg? Intervention strategies

How? Divided into Non – Rapid Eye Movement (NREM) Four stages – 1,2, 3 and 4 Stages 3 and 4 are the deepest (slow wave – deep sleep) and the first 3 hours of sleep are NREM 1- 4 Rapid Eye Movement (REM ) Happens after NREM stages These cycle through the night – more REM in the early morning Sleep Architecture ( the patterns of sleep) Pages 6-9 in the TT manual.

How - Sleep Stages This slide shows the cycle of sleep through the stages of NREM (1,2,3,4) and then REM. It demonstrates that : We only go into stage 4 twice both during the early part of the night. This is why we rarely wake up in the first three hours of sleep. It is VERY deep sleep. After the first two sleep cycles, we do not get to stage 4, but only get to stage 2 sleep. That after REM periods, because REM sleep is light sleep, we are close to waking up and indeed often wake after REM periods. REM periods increase in length and frequency towards the early morning Therefore : We wake more often from sleep in the early morning because REM sleep is light sleep. If we get up before our sleep period is finished we will miss out on much of our REM sleep (consequences are …???) REM periods are more frequent during the early morning This slide is presented on page 8 of TT manual 4

How Much Table taken from SOLVE YOUR CHILD’S SLEEP PROBLEMS by Richard Ferber, MD. Copyright © Dr Richard Ferber 1986 and presented on page 9 of the TT manual and page 5 of the student’s workbook (SD) Need to note that recent studies have suggested that in fact adolescents need more like 9 ¼ hours per night and not 8 ½ as suggested on the table. Also interesting to note the small change in sleep needs from about year 8 to where they are. 91/4 91/4 91/4 91/4 91/4 5

Total time in bed has significantly decreased from 1985 to 2004 (30min; 5% change; p<.0001) (Dollman and Olds 2008)

When children don’t sleep enough…. Clear evidence of reduced: Neuropsychological function Memory, attention, intelligence Emotional stability Depression, anxiety, self esteem Psychosocial function Aggression, hyperactivity, peer relations, families, drug and alcohol misuse Performance school performance, sport Physiological health immune, cardio vascular and endocrine systems (weight status)

Daytime effects of sleep disturbance on children

Education Australia (Blunden & Chervin 2007) America 5 times more likely to have sleep disturbance Sleep disorders = poor learning = lower IQ Falling behind – loss of self esteem America Children on Ritalin for ADHD ceased medication 8/8 children in special schools able to return to mainstream schooling (Guilleminault et al 1981) Children moved from lowest percentile to middle range of school grades with treatment of sleep disorders (Gozal 1998)

Students who don’t sleep are more likely to repeat grades.. Students in behavioural units compared to mainstream controls. Students in behavioural units: Had worse sleep (quantity or quality). They were 5 times more likely to have sleep disturbance Had more ‘Ds’ and ‘Es’ than those who did sleep well (teacher report) A = top of the class B = above average C = average D = below average, almost failing E = failing F = bottom of the class Had worse parentally reported school performance (Blunden & Chervin 2009) They are NOT less intelligent – just sleepy One of the studies undertaken by SB in South Australia evaluated the sleeping habits of children and how well they did in school. The results showed that students (the ages ranged from 7 years – 15 years) who did not sleep well (that is, had reduced total sleep time AND/OR had poor quality sleep) had more Ds and Es than children and adolescents who did sleep well. They were failing more often. In other words poor sleep = worse academic performance and worse school grades. Do you think the students who are failing are likely to go on to year 12? What if better sleep can help them do better in school and maybe stay at school. Page 18 – item number 1.4.1 - TT manual

What we can see that may be misinterpreted Non completion of assignments, giving up. Poorer learning outcomes Remedial teaching Increased failure rate ADHD like behaviour, hyperactivity Acting out – aggression Mood disorders Decreased participation in sport

Chicken or egg? ↓ sleep = ↑ anxiety = ↓ sleep High achievers, competition, performance ↓ sleep = ↑ depression = ↓ sleep Mood, manifestations of depression in kids ↓ sleep = ↓ coping = ↑ frustration = ↑ stress ↓ self esteem, learned helplessness ↓ trying = ↓ failure ↓ sleep = ↑

What can we do? What can a parent do? What can a professional do? Teach children how to ‘self-soothe’ Regulate bed and wake times Ensure adequate amounts of sleep What can a professional do? Be aware of the signs of fatigue in children during the day Be aware of the relationship between sleep and mood, emotion Sleep diaries? Promote good sleep hygiene

What is sleep hygiene? Sleep hygiene is what needs to be done to promote the best environment for good sleep… No TV/computer games 1 hour before bed. No TV s in bedrooms. Monitor mobile phone use in bed No coke/caffeine 3-4 hours before bed Ensure relaxing and regular bed time routine – special time, worry time, relaxation techniques No vigorous exercise 1 hour before bed Finish eating 2-3 hours before bed - hot milk is OK Make sure the bedroom is comfortable (temperature, light, noise) Set bedtimes and wake times (delayed phase, sleep onset insomnia, sleep propensity) Use a sleep diary to check sleep habits.

Australian Centre for Education in Sleep (ACES)© Junior school Session 1

Websites www.unisa.edu.au/sleep www.sleepeducation.net.au