© Springer International Publishing AG 2017
Christina A. Di Bartolo and Maureen K. BraunPediatrician’s Guide to Discussing Research with Patients10.1007/978-3-319-49547-7_1111. Sleep
(1)
The Child Study Center, NYU Langone Medical Center, New York, New York, USA
(2)
Department of Pediatrics, The Mount Sinai Hospital, New York, New York, USA
Keywords
Co-sleepingDisruptive bedtime routinesDelayed sleep onsetAntihistaminesSleep trainingCry-it-outOverview
The occurrence of childhood sleep problems is one of the most common challenges parents present to their physicians [1]. Parents report sleep difficulties throughout childhood at rates between 20 and 30% [2–6]. Problems span from typical but frustrating challenges to clinical sleep disorders. Among the numerous types of sleeping difficulties, some are psychological, others behavioral, and still others physical [7]. Prevalent sleep problems that do not typically warrant diagnosis but suggest that intervention is appropriate include disruptive bedtime routines, difficulty falling asleep, nighttime awakenings, and subsequent interactions in which children attempt to get out of bed after it is expected that they stay in bed [1, 8]. Disruptive bedtime routines refer to situations in which children actively resist their parents’ attempts to get them to bed and then to sleep [9]. Diagnosable sleep problems cover a range of medical and biological abnormalities: insomnia, hypersomnolence, narcolepsy, breathing sleep disorders (including sleep apneas), circadian rhythm disorders, and parasomnias (including nightmare disorders and Restless Leg Syndrome) [10].
Sleep problems present a special challenge for pediatricians. Physicians must first recognize which behaviors are normal amidst the wide variability of healthy sleep. They also encounter parents who perceive a normal problem as pathologic. Finally, they must assess the numerous factors affecting children’s sleep patterns: biological, psychological, cultural, social, and familial [6]. For example, a child may show bedtime resistance, which appears behavioral in nature. However, the child may suffer from a medical condition such as sleep apnea or nighttime enuresis (bedwetting) that makes sleep an unpleasant experience. The medical challenge leads the child to reject the bedtime routine because it signals the uncomfortable situation about to occur. A physician must identify the complex interplay of factors before deciding on appropriate referrals or initiation for treatment.
On average, children with intellectual or developmental disabilities (IDD) experience a higher prevalence of sleep disorders and poor sleep habits than the general population [9]. Impaired sleep occurs widely in children with Down syndrome, Autism Spectrum Disorder, Angelman’s syndrome, and Prader–Willi syndrome, who encounter higher than average rates of sleep problems [9]. Children with IDD display disruptive bedtime routines, vocally and/or physically resisting caretaker attempts to guide the children through their bedtime routine, into bed, and finally to sleep [9]. These children may also experience delayed sleep onset, a difficulty falling asleep according to typical circadian rhythms [9]. Children who exhibit disruptive bedtime routines frequently experience delayed sleep onset as a consequence of the difficult interactions preparing for bed [9]. A sleep–wake cycle disturbance is characterized by short episodes of sleep that occur in the evening or early morning hours as a result of premature awakening [9]. Disruptive bedtime routines, delayed sleep onset, and sleep–wake cycle disturbance contribute to difficulties in attaining sufficient and regular sleep in children with IDD [9].
Cultural and social influences of sleep are by no means new. However, of recent interest among Western parents and physicians alike is the practice of co-sleeping. Fairly common in Asian countries, co-sleeping is the practice of children sleeping in the same bed as their parents [6]. Infants and young childhood in Asian countries frequently co-sleep with their parents, but prevalence decreases as children age [6]. Social factors such as acceptability influence the prevalence of this practice [11]. For example, a survey of Korean mothers found a nearly 75% approval rate for co-sleeping with young children (ages 3–6 years) [11]. Co-sleeping is not the norm in Western countries, and is particularly rare among non-Hispanic parents [6]. Western parents are more likely to use solo sleeping, in which children sleep in their own bassinet, crib, and/or room. Researchers presume Western acceptability for co-sleeping is lower due to cultural taboos, drives to foster independence even in young children, and medical recommendations as to the safety hazards of co-sleeping [6].
This socially influenced practice affects sleep problems, as co-sleeping is related to changes in children’s sleep patterns, disturbances, and sleepiness the following day [12, 13]. One study of Chinese children and American children compared a number of sleep variables to determine if co-sleeping in Chinese children (where it occurs more as the cultural norm) prompted later bed times, earlier wake times, higher report of sleep problems, and increased daytime sleepiness with lower total sleep times [6]. Researchers found that Chinese children went to bed an average of 30 minutes later and woke 30 minutes earlier than their American counterparts [6]. This resulted in a loss of 1 hour of sleep per night [6]. Daytime sleepiness in Chinese children was associated with shorter sleep times, whereas American children were more likely to show daytime sleepiness if their parents reported restless sleep and snoring [6]. While these results provide further evidence as to the detrimental effects of co-sleeping, study authors noted other cultural factors that may have influenced differences [6]. Chinese children have more homework than American children and take a 2 hour nap in the middle of the day [6]. Both of these factors could affect sleep quantity and quality, just as co-sleeping might.
Until a randomized controlled trial is conducted, wherein some parents are randomly assigned to co-sleeping and others assigned to solo sleeping, causality between co-sleeping and these detrimental effects cannot be established. The lack of evidence has prompted some Western parents to question advice to avoid co-sleeping with their young children. Specialists in sleep disorders do not specifically reject co-sleeping [14]. If parents choose to co-sleep with their children, physicians concern themselves with how parents can do so without risking their children’s physical safety [14].
Despite the significant concerns regarding children’s sleep and sleep problems, few pediatricians receive sufficient training in this area [1, 7]. This training deficit is at least partially due to the emerging nature of sleep research and sleep medicine [15]. Complicating matters, sleep disorders manifest differently in children than in adults [7]. A fair conclusion to this deficiency in training is that general practitioners likely struggle with appropriate assessment, diagnosis, treatment, and specialist referral for improving children’s sleep [7]. One study of pediatricians found they commonly informed parents that children outgrow sleeping problems, and consequently did not recommend treatment [16]. In fact, there is little evidence to suggest that sleep problems remit without treatment [17]. When treatments are recommended, physicians frequently prescribe medication (prescription or nonprescription) despite both inadequate evidence such medications for sleep problems in children and a plethora of research promoting the efficacy of behavioral interventions [1, 14, 18]. When sleep problems are not properly assessed, they can be treated ineffectively or inappropriately [7].
Figures bear out these concerns. Despite sleep as a common parental concern, one study reviewed 50,000 patient-physician contacts and found sleep mentioned in less than 200 [19]. Without proactive screening from physicians, parents bear the responsibility of identifying whether their children may have sleep problems and bringing up their concerns for clinical consultation [20]. Parents identify sleep problems according to a number of factors: parental expectations for childhood sleep (realistic or not), parental knowledge of developmentally appropriate sleep, and cultural norms influencing parental perception of normative versus problematic sleep [20]. For example, regular awakenings during the night are an unremarkable aspect of healthy sleep patterns, yet parents may think these awakenings indicate a sleep problem [21]. In turn, parental cognitions and perceptions about children’s sleep are influenced by culture, parental childhood experience of sleep, and experiences with their children’s sleep [20]. Parents require assistance from a trained medical professional to help them assess their children’s sleep and obtain evidence-based help when needed.
Common Parental Concerns
Physically and Emotionally Draining Nighttime Battles
Children’s sleep problems are inherently intertwined with their parents’ sleep [22]. Anecdotal reports from clinicians highlight an emerging pattern of stressed and tired parents of children with sleep difficulties [22]. In one author’s experience, children who display bedtime resistance and nighttime awakenings prevent their parents from attaining maximum sleep. When children display disruptive bedtime routines, parents spend more time getting their children into bed than they would otherwise. This causes parents to do their other tasks later in the evening. This shift creates later bedtimes for already tired parents. Parents also find their opportunities to relax and unwind are diminished because of the extra time putting their children to sleep.
Once children are asleep, those who wake during the night cause specific challenges for their parents. Children may cry, call out, or climb into their parents’ beds. These actions disrupt parents’ sleep at various points in their sleep cycle, affecting their ability to achieve restful sleep. Additionally, abrupt awakenings can cause parents to be emotionally dysregulated or behaviorally uninhibited. This causes challenges in the parent–child interaction when “half-awake,” possibly short-tempered parents must guide their children back to bed. Rather than engaging in the process of getting children back to bed, some parents elect to let their child sleep for the remainder of the night in their own bed. While some parents choose to co-sleep with their children, there is anecdotal evidence that parents who find themselves in a “reactive co-sleeping situation” experience stress, marital tension, and frustration [23]. Parents who take this path of less resistance may still end up tired and stressed.
Using these common anecdotes as an entry point, one research team studied whether children’s sleep problems disrupt their parents’ sleep and cause deleterious effects [22]. Researchers examined 47 parents, some of whom had children with sleep problems and others did not [22]. Tellingly, the researchers found no significant difference between children with and without sleep problems with regard to bedtimes, wake times, and total sleep time of the children [22]. What did differ was that parents of children with sleep problems got out of bed to respond to their children’s awakenings more than the other parents [22]. These results indicate that the more parents get up in the middle of the night, the worse their perception of their children’s sleep. More child sleep disruptions significantly predicted maternal sleep quality [22]. In turn, poor maternal sleep quality significantly predicted maternal depression, parental distress, fatigue, and sleepiness [22]. Confirming the common sense hypothesis that a tired parent is not an optimal parent, sleep disruptions of children significantly predicted parental functioning [22]. Mothers of children with sleep difficulties reported higher feelings of stress and overload, due in a meaningful part to their own poor sleep quality [22].
Study authors concluded that children’s sleep is important for the functioning of the whole family [22]. In a sense, parents have to “put on their own oxygen first” to best care for their children. Parents who manage their children’s awakenings in the night fight an uphill battle to be the best parents they can be in the daytime. Taking an example from the child abuse literature, preliminary evidence shows that one risk factor for child abuse is a parent with insufficient sleep [24]. On the other hand, when children’s bedtime resistance and nighttime awakenings improve, so do rates of maternal depression, parenting ability, parental stress, and marital satisfaction [3, 25–27].
Children Need a Certain Number of Hours of Sleep Per Night
Assessing adequacy of sleep by number of hours is extremely challenging, given that children’s needs vary according to age and other individual factors [7]. The ability to provide evidence-based sleep requirements would require very large controlled studies conducted cross-culturally, which are nearly impossible to undertake for practical reasons [28]. Most sleep duration recommendations come in the form of charts that display recommended number of hours of sleep for various age brackets. The recommendations tend to be based on studies of Western populations [29, 30]. This is despite clear cultural differences in the perceived need for sleep among children [30]. These cultural differences emerge in other considerations for sleep sufficiency, such as napping practices [30]. Numerous factors affect an individual’s need for sleep, and while not all are currently known, growth rates, stress, and illness are all likely implicated [31]. As a result, there is no optimal level of sleep based on age that parents should aim for [31].
Parents concerned with whether their children are getting sufficient sleep are served by examining their children’s daytime functioning rather than timing their sleep [31]. In children, insufficient sleep can manifest as, for example, becoming frustrated more easily than that child normally would for their temperament, or an increase in impulsiveness relative to that child’s baseline level of impulsivity [32]. Children who remain sleepy after waking in the morning are likely not attaining sufficient sleep [31]. Tired children also tend to have trouble focusing and may fall asleep quickly when given the opportunity (such as during a car ride) [31].
Common Misconceptions
The only effect of lack of sleep is feeling tired the next day
When children beg to stay up “just ten more minutes,” or point out that they are not finished with their homework, parent may be tempted to relent. Extensive research from a variety of methods shows that deficits in sleep quality and quantity cause numerous negative outcomes, with strong potential for adverse long-term outcomes [33]. The research-established outcomes of disrupted sleep indicate wide-ranging negative effects on mood, affect, energy, weight, behavior, learning, memory, and executive functioning (an aspect of cognitive functioning associated with higher order thinking) [7, 22, 33–35]. Based on psychometric tasks, disturbances in sleep have variable effects on functioning based on the task’s demands and duration, as well as children’s level of motivation, personality, and personal sleep requirements [36]. In some children, it seems possible that activity levels may actually increase in response to sleep deprivation, rather than display the sluggishness more typically associated with fatigue [7]. This paradoxical response has led some to hypothesize that a subset of children diagnosed with Attention-Deficit/Hyperactivity Disorder may actually be suffering from impaired sleep [32].
One study experimentally reduced children’s sleep to capture subsequent teacher ratings [34]. Verifying common impressions, even children with no sleep disorders experienced a decline in academic performance as rated by their teachers when they received less sleep [34]. Interestingly, the teachers in this study were aware that their students were participating in a study where their sleep would be restricted, but teachers were blind as to when the students were sleep deprived versus when they slept as usual [34]. This allows for a more objective rating than reports of parents who are fully aware of when their children receive more or less sleep. Most parents are aware that sleep is a biological imperative. That it commonly takes a lower priority than schoolwork is counterproductive, the given loss of sleep’s effect on behavioral, emotional, and cognitive functioning is needed for school success.
Giving children antihistamines or other medications is a good way to get them to sleep
Only a limited number of studies provide any evidence of efficacy for using medications to help children sleep [37, 38]. A very small number of studies specifically examined medications to assist sleep onset in children [8]. These studies either found no effect, effects when used in conjunction with behavioral interventions, or have not examined sleep aides in children younger than 3 years [39–41]. As such, the Food and Drug Administration does not recommend the use of any sleep medications for children [8].
Despite the lack of evidence, pharmacologic treatments are commonly used both in clinical practice and in homes without physician recommendation [8]. For example, about half of the respondents in one survey of 670 pediatricians reported that they recommended a nonprescription antihistamine to be used off-label for the purposes of promoting sleep in children younger than 2 years [42]. Until further evidence in favor of medications presents itself, physicians should not prescribe medications or suggest over-the-counter interventions to parents [8]. Parents should be specifically advised not to give their children over-the-counter medications for the reduction of sleep problems [8]. Physicians who recommend medication should do so only in conjunction with a behavioral intervention, for the purposes of mirroring how medications in research were examined [8].
Using behavioral interventions to improve children’s sleep cause attachment problems and possibly trauma
Behavioral Interventions Overview
Given parents’ struggles with sleep, clinicians developed and tested behavioral interventions to fill this need. Many parents turn to these established behavioral interventions to address their concerns [8]. These interventions vary in application, but different versions have been shown to be effective in helping parents assist their young children to sleep [43]. Some parents use these interventions with a clinician’s help and support, and others read books or articles to implement the intervention independently [43].
Behavioral sleep interventions utilize basic behavioral approaches to increase desired sleep-related behaviors (e.g., staying in bed, self-soothing). Behaviorists work from a theory that examines the antecedents and consequences that occur before and after (respectively) a behavior occurs [44]. By adjusting antecedents before the behavior occurs and the consequences after a behavior occurs, the learning of new behaviors can be achieved [44].
A Note About Implicit Learning
Behaviorists speak in terms of “learning.” Most people are familiar with explicit learning, whereby children learn how to tie their shoes or recite times tables. The kind of learning behaviorists refer to is implicit learning. Implicit learning is what allows children to realize gradually over time that certain actions are connected with certain outcomes. This process is often unconscious. When behaviorists explain concepts such as children learning that their cries will gain them parental attention, they do not propose that infants are consciously thinking, “If I keep crying, I’ll keep getting cuddles from Mom.” Instead, they are referring to the learning that occurs beneath conscious awareness, over time, with regard to repeating patterns of interactions.
Whenever possible, behaviorists prefer providing reinforcement after a desired behavior has occurred, whether it be providing something positive (e.g., praise, pat on the back) or removing something negative (e.g., nagging stops once child has displayed the desired behavior). Either of these reinforcement mechanisms increase the likelihood that the child will display the desired behavior again.
Some behaviors, however, are undesired and should not be reinforced. Many parents believe that if they yell, frown, lecture, or scold such behaviors, that they will occur less frequently. In many cases, this is a misguided principle. Children are highly influenced by interactions with their parents, whether those exchanges are positive or negative in nature. In the case of sleep, infants who cry when they should be sleeping often receive cuddles and rocking, teaching the child that to receive such attention, they should continue to cry. Older children who get out of bed and/or negotiate with their parents for more time awake often receive extensive responses from parents (in the form of answering questions, reading books, getting water, etc.). If parental attention reinforces crying or out-of-bed behavior, removing parental attention should result in a diminishment of these behaviors. Any time behaviors do not receive reinforcement over a prolonged period of time, the behavior is very likely to decrease and then stop completely. Behaviorists refer to this as “extinction,” because the behavior stops [8].
Regardless of the differences among behavioral interventions for sleep, they all rest on two key principles: parental attention maintains a behavior; children older than 3 months old can soothe themselves to sleep if given the chance [8]. Applying a behavioral approach to sleep is fairly straightforward in theory, though challenging to implement in practice. When infants cry prior to falling asleep, many parents seek to comfort and soothe them. To maintain that parental attention, infants may continue to fuss. Crying is not consistent with sleeping. Older children may get out of bed or negotiate or argue with parents around bedtime. Parents who engage in these discussions inadvertently help their children in accomplishing their goal—staying awake. Talking is not consistent with sleep. When parents withdraw their attention, infants, and children will (eventually) naturally fall asleep on their own.
A Vocal Minority
There is extensive research showing that behavioral approaches improve children’s sleep [43]. Despite the clear evidence in favor of using behavioral interventions for children (at least 3 months of age) with sleep problems, debate continues in the academic and public sphere as to the advisability of using this approach [8]. In part, some of the behavioral terms sound jarring, such as “extinction” [8]. The colloquial terms often sound just as negative, such as “cry-it-out” [8]. A vocal minority of researchers and, in many cases, non-researchers argue that behavioral approaches should not be used with children [45]. Instead, these critics of behavioral sleep interventions believe parents should be unilaterally responsive to their children’s every need [45]. These critics uphold the theory that children should control every parent–child interaction. They refer to this theory in various ways. Some misapply attachment psychology literature [46]. Others lift terms from sociocultural fields, such as anthropology [45]. Critics of behavioral interventions recommend extensive interactions between parent and child, such as proximal care, which employs extensive holding, frequent breastfeeding, near-immediate responses to children’s crying or fussing, and co-sleeping [45]. Others use terms such as “external womb,” in which mothers are expected to provide the same level of support, holding, and responsiveness as supposedly occurs in the womb [47].
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
