1. Behavioural Sleep Difficulties in children Presented by Denise Gillespie RANP Child Health & Parenting, ICHN Annual Conference 18 th May 2016, Aisling Hotel, Dublin.

2. Why Sleep? Disorders of initiating and maintaining sleep (DIMS) are relatively common in young children. Studies have been undertaken in many countries and the prevalence rate is 20-40% amongst children 1-5 years (Mindell & Owens 2010). Sleep disturbance can impact significantly on family life but if identified early, interventions to address sleep difficulties have been shown to have consistently positive outcomes. Public Health Nurses visit all families with young children and are ideally placed to support parents dealing with sleep difficulties in their children.

3. Perception!

4. Functions of sleep: Cognition Sleep is needed to: Remember what we learned Organise our thoughts, predict outcomes and avoid consequences React quickly Work accurately and efficiently Think abstractly Be creative

5. Normal Sleep Sleep is an essential part of existence Sleep is a biologically complicated state and there are complex brain processes involved in going to sleep and in moving from one type of sleep to another. There are two types of sleep, REM & NREM sleep.

6. NREM Sleep (non rapid-eye-movement) In adults NREM sleep accounts for 75% of sleep There are three stages to NREM sleep: stages 1 & 2 are relatively light sleep with stage 3 involving deep sleep which it is more difficult to waken from. In NREM sleep your muscles are more relaxed, you lie still because the brain is not sending movement signals to most of the muscles. Sleep disorders such as sleepwalking occur in the NREM phase of sleep.

7. REM Sleep (rapid-eye-movement) This can be called dreaming sleep because it is when most dreams occur. REM sleep develops in the fetus from 6 or 7 months gestation, a full term baby spends half her sleep time in REM From age two REM accounts for 33% of sleep, reducing to 25% in later childhood and adolescents

8. Sleep Cycles During a period of sleep children move between NREM & REM sleep. In children the first 3-4 hours of the night are spent mainly in deep sleep. The next 4 hours are spent transitioning between REM & NREM and this is lighter sleep and it is during this time that wakenings are most common. Towards morning children return to deep sleep for 1-2 hours Children who waken from deep sleep can appear crankier than those who waken from lighter sleep.

10. Disturbed Sleep 25-30% of children from early years to adolescence in general are considered to have a sleep disturbance which is significant (Stores 2009) There are 80 different types of sleep disorder identified by the American Academy of Sleep Disorders (ICSD 2005) For practical purposes we are going to focus on disorders of initiating and maintaining sleep (DIMS).

11. Strange Behaviour Experienced at night (Parasomnias) There are many different manifestations of sleep disturbances at night Although they may appear dramatic they are not indicative of an underlying medical or psychological difficulty They often resolve of their own accord Occasionally this type of sleep disorder can be part of a psychological or medical condition which needs treatment. Parasomnias can be identified with when they occur in the sleep cycle

12. Sleep Hygiene Sleeping environment conducive to sleep Consistent bedtime routine Avoid sleep associations Avoid going to bed too early Avoid late naps Have a wind down routine

14. Bedtime Routines Should last 30-45 mins Ideally should be at same time each night Relaxing activities (bath, story ) Repeating routine reinforces the activity Baby put to bed when sleepy not asleep

15. Assessment of sleep problems The first part of the sleep assessment process is to identify if a sleep problem is present. The Tayside Children’s Sleep Questionnaire is a suitable screening tool for behavioural sleep difficulties. (McGreavey et al 2005)

16. Please complete the questionnaire about your child’s sleep pattern over the last 3 months PLEASE PUT AN “x” IN THE APPROPRIATE BOX 1 How long after going to bed does your child usually fall asleep?15 mins 15-30 mins30-45 mins45-60 mins More than 60 mins NeverOccasionally Once or twice a month Sometimes Once or twice per week Often 3 or 5 times per week Always Daily 2 The child goes to bed reluctantly 3 The child has difficulty getting to sleep at night (and may require a parent to be present) 4 The child does not fall asleep in his or her own bed 5 The child wakes up two or more times in the night 6 After waking up in the night the child has difficulty falling asleep again by him/her self 7 The child sleeps in the parent’s bed at some time during the night 8 If the child wakes, he or she uses a comforter (e.g dummy) and requires a parent to replace it 9 The child wants a drink during the night (including breast or bottle- feed) 1010 Do you think your child has sleep difficulties

17. NAPS

18. SLEEP RECORD NAME: ____________________________________________ DATE____________________ MONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAYSUNDAY Time wakened in the morning Mood on wakening Time going to bed Time asleep Time wakened in night What happened Time Naps

20. Put baby in their bed drowsy but not asleep Establish a regular bedtime routine Set limits at bedtime and during night wakenings Encourage your child to drink milk before bedtime Keep the bedroom temperature at 18 c Keep ambient noise to a minimum Reduce light in the bedroom Phase out daytime naps as child reaches 3rd birthday Ensure child has plenty exercise in the day. Establishing Good Sleep Practices

21. Avoid Creating a bedtime routine that requires parental presence or props which could become inappropriate sleep associations. Confuse the child by bringing them back to the living area once their bedtime routine is completed Sooth the baby to sleep with a feed after weaning is established. Send the child to bed as a punishment, the bedroom should be a calm and happy place Allow the child to nap after 3.30pm from 9 months old. Give the child caffeine containing food or drink in the evening. Encourage the child to do any stimulating activity or exercise in the hour before bedtime.