Solving Sleep Problems – PediaCast 469

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Show Notes

Description

• Dr Jack Stevens visits the studio as we explore the importance of sleep and offer practical solutions for common sleep problems… in babies, toddlers, children, teenagers and adults. We hope you can join us!

Topic

• Solving Sleep Problems (All Ages)

Guest

• Dr Jack Stevens
  Pediatric Psychologist
  Nationwide Children’s Hospital

Links

• Childhood Sleep Guidelines (AAP)
• Solve Your Child’s Sleep Problems by Dr Richard Ferber
• The SleepEasy Solution – DVD
• Clocky: The Alarm Clock on Wheels
• Healthy Sleep Habits for Infants and Toddlers
• Healthy Sleep Habits for Older Children and Teens
• Baby Sleep Resources from HealthyChildren (AAP)
• Child and Teen Sleep Resources from HealthyChildren (AAP)

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio. 

It's Episode 469 for August 20th, 2020. We're calling this one "Solving Sleep Problems". I want to welcome all of you to the program.

So as the title suggests, we are covering sleep this week, including the importance of sleep. And we'll answer the ever popular question, how much sleep do children and adults need? We'll also offer practical solutions to common sleep problems for children of all ages, from babies through teenagers and grownup-children.

0:01:18

Meaning all of us, which as it turns out is an easy thing to do because the big principles of getting more and better sleep are really the same regardless of your child's age. It's how you apply those principles that will change depending on your child's age and development.

So we'll cover all of these big principles for all ages, so stick around because we'll have lots of useful information for everyone today, whether you have an infant at home, toddler, preschooler, school-aged kiddo, or teenager, or even if we're talking about as adults. We'll have great information about sleep that everyone will be able to use.

And it's a terrific time to talk about sleep as we head into a new school year during a time of uncertainty and in ongoing global pandemic, which changes what school looks like from one school district to another, sometimes, from one day to another, from one house to another.

0:02:17

In other words, it's a stressful time. And we deal with stress best, regardless of our age, when we and our children get the right amount and the right quality of sleep.

So that's what we'll talk about today. And in our usual PediaCast fashion, we have a terrific guest to help us cover the topic. Dr. Jack Stevens is a pediatric psychologist and sleep expert at Nationwide Children's Hospital. He'll be joining us soon. 

But before he stops by, let's cover a few brief housekeeping items. I do want to remind you that you can find PediaCast on all sorts of places, really wherever podcast are found. So there may be an easier way for you to subscribe and get regular updates as new episodes are released.

0:03:04

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We also have a handy contact page over at pediacast.org. If you'd like to leave a comment or suggestion for an upcoming show topic, feel free to do that. Again, that's the contact link over at pediacast.org.

And then, I know we also have lot of pediatric providers, pediatricians, family practice doctors, nurse practitioners, physician assistants. I know there's a lot of you out there in the audience. I do want to remind you, we have a podcast for you as well called PediaCast CME, which stands for Continuing Medical Education. It's similar to this program. We turn up the science a couple notches and offer free Continuing Medical Education Credit for those who listen.

0:04:18

And since Nationwide Children's is jointly accredited by many professional organizations, it's likely we offer the exact credits that you need to fulfill your state's Continuing Medical Education requirements.

Shows and details are available at the landing site for that program, pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.

Also, I want to remind you, the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

0:05:05

So, let's take a quick break. We'll get Dr. Jack Stevens connected to the studio and then, we will be back to talk more about sleep and solving sleep problems. It's coming up right after this.

[Music]

Dr. Mike Patrick: Dr. Jack Stevens is a pediatric psychologist at Nationwide Children's Hospital and an associate professor of Pediatrics at the Ohio State University College of Medicine. One of his clinical interest is helping children and families get more sleep. That's what he's here to talk about, the importance of sleep and solving sleep problems.

0:06:04

So, let's give a warm PediaCast welcome to Dr. Jack Stevens. Thanks so much for visiting us today.

Dr. Jack Stevens: Thanks for having me on your program, Dr. Mike.

Dr. Mike Patrick: I really appreciate you taking time to visit with us. Let's start with sort of a foundation. And why is that that sleep is so important for us, as human beings?

Dr. Jack Stevens: Well, I think sleep has widespread implications for a wide range of health and behavioral concerns. So poor sleep has been linked to hyperactivity, inattention, oppositional behavior, and low grades at school. Sleep problems have been linked to unsafe driving, and problematic sleep has been linked to a wide range of chronic health concerns including unhealthy weight. 

So the hope is that good sleep can help address but certainly not eliminate many of these concerns.  In addition, good sleep is certainly relevant for quality of life and just having good relationships with one another. 

0:07:00

So my hope today is that we're going to discuss one set of strategies, but certainly not the only ways to promote sleep for kids and their families.

Dr. Mike Patrick: I think to some degree, maybe the pandemic has helped us to a degree, is it seems like we have so many things to do. And families tend to be really busy and can be overscheduled, at least pre-pandemic, that a lot of times, our sleep was sacrificed so that we can do more, do more, do more. 

But the quality of what we're doing is going to be so much better when we get enough sleep that it's worth the sacrifice of not as much to-do time to have better but less to-do time, if that make sense.

Dr. Jack Stevens: Absolutely.

Dr. Mike Patrick: But maybe the pandemic has helped us slow our lives down a little bit and hopefully make it easier for people to get more sleep.

One resource that I did want to include for everyone because this question always comes up is what are the recommendations at different age groups, or how much sleep that you should get.

And it's one of those things I think that's difficult to memorize and remember. So I wanted to include a link in the show notes to the American Academy of Pediatrics, their Childhood Sleep Guidelines. 

0:08:08

And the quick of it is infants, we're talking 12 to 16 hours of sleep during a 24-hour period. And that would include naps, so it's not 12 to 16 hours necessarily in one stretch.

For toddlers, that goes down to 11 to 14 hours, preschool, 10 to 13 hours, grade school, 9 to 12 hours, and then teenagers, 8 to 10 hours, which would probably be similar for adults as well. 

And again, not that you need to memorize those numbers, but they always come up, how much sleep am I supposed to get? And I will include a link in the show notes. And that's just the consensus based on the evidence that's known by a lot of professionals that the American Academy of Pediatrics came out with.

Another important question I think that parents have is in babies, at what age can we begin to modify their sleep? So when they come home from the hospital as a brand newborn, you're really on the baby schedule in terms of sleep, wake cycles, and feeding when the baby is hungry. But at what point can we say, "Hey, enough is enough. We need to start getting longer stretches of sleep, especially at night." What do you tell parents about that?

0:09:15

Dr. Jack Stevens: Sleep strategies are generally appropriate for children starting at six months of age. Some of the strategies we discuss really are not appropriate during the first half or the first year of life because children require middle-of-the-night feedings. But once children reached six months of age, they typically don't require middle-of-the-night feedings or parental attention.

That being said, one of the strategies we'll discuss involving putting the child to bed when the child is drowsy but still awake still might be relevant for children under six months of age.

Dr. Mike Patrick: That make sense. So in that case, you're encouraging them to go to sleep but not necessarily trying to change their ability to soothe themselves and get to sleep until they're about six months old, right?

Dr. Jack Stevens: Correct.

0:10:03

Dr. Mike Patrick: I also know, having seen lectures that you'd given in the past, that you believe there are three global principles for promoting healthy sleep that really can be applied in different ways at all the age ranges. What are those three global principles?

Dr. Jack Stevens: Absolutely. I encourage parents, as well as kids to consider these three basic ideas. First of all, it's really important to put the child to bed when the child is drowsy but still awake. Second, the ability to self-soothe is one of the greatest gifts a parent can help a child obtain. And third and perhaps most importantly, make the child's world boring, both in terms of caregivers and the environment to promote sleep.

Of course, it's really important to children to be engaged, to have interest in activities during the day. But come bedtime, it's really important for the surroundings to be boring in order to encourage sleep. I'll suggest that boring is the single most important word when it comes to pediatric sleep, not fun, not reassuring but boring.

[Laughter]

0:11:08

Dr. Mike Patrick: So you're really trying to calm the brain down, right? And the more that we are stimulated, the more that there's exciting things to look and interesting thing to do, the harder it's going to be to sort of slow the brain down and get yourself into sleep, right?

Dr. Jack Stevens: Absolutely.

Dr. Mike Patrick: So I just want to point those out again because these are three really big principles that we're going to apply to different age groups. You want to go to bed when you're drowsy but still awake, the ability to self-soothe, so I don't always need mom and dad to help me soothe. And then, to make that bed time boring.

Let's start with going to bed when drowsy but awake. What are some strategies at various age groups for being able to accomplish that?

Dr. Jack Stevens: Sure. Well, I think it's really important to avoid the extremes. If children are put to bed when they're full of energy, they're physiologically not ready for sleep.

0:12:04

And furthermore, their minds and their bodies may start to associate the bed with being awake as opposed to the bed being a place for sleep. So often, what's recommended for these children is actually to delay bedtime.

Parents can certainly wake their child up a little bit earlier in the morning that maybe the child would naturally prefer. But if a child is a little bit tired during the day, that might make it actually easier for the child to fall asleep at their desired time the next night.

It's also really important to avoid the opposite extreme. So if children fall asleep in their parent's arms and then are put to bed, that can be problematic for a different reason. It's completely normal for children, as well as adults to periodically waken briefly during the course of the night.

This probably goes back to our ancestors from many generations ago where we would briefly wake up in the middle of the night to scan the environment, to make sure things were safe. The problem is that if children initially are put to bed when they've fallen asleep in their parent's arms, when they undoubtedly will wake up during the course of the night, they may think they need their parent's help in order to fall back asleep.

0:13:11

So really, what we want to do is want to hit that middle zone when the child is drowsy but awake. So it's really important to look for signs that the child is in the state, child's rubbing eyes, child is yawning, child is starting to slow down.

If children take the final steps to initially fall asleep by themselves, then hopefully they're going to start to develop some of those self-soothing skills, then so they aren't seeking assistance from mom and dad in the middle of the night.

Dr. Mike Patrick: I imagine there's a degree of sort of anxiety with that too because if you fall asleep in mom's arms and then you wake up and she's gone, it's like, "Where did mom go?" So you are going to be more likely to sort of be upset and cry and want mom to come back because the last thing you remembered is you were right there in her arms.

Dr. Jack Stevens: There's a change in your surroundings, so that can absolutely be disruptive in the middle of the night.

0:14:00

Dr. Mike Patrick: And then, routines, especially when you're starting to feel sleepy, if the things that you do as a family sort of lead up to that drowsiness, then you want to sort of be doing those things day in and day out, right? That means routines and schedules are going to be important for young kids.

Dr. Jack Stevens: Absolutely. So if you can kind of set list of activities that are done that again serve as a signal to the child's mind and the body that it's almost ready for sleep, that absolutely is really important. 

And one of the things in particular that I often recommend to families is why I think reading is a great thing to do right before bedtime. Often, that activity is best achieve with the child outside of bed because you really want to reserve the bed for sleep and sleep only.

Reading from a number of different reasons has so many positive benefits. But particularly for children who's struggling with sleeping, that might be something best to do on the floor in the room or in a chair in the room, and then when it comes time for the child to actually sleep, to have the bed be the place just for that.

0:15:04

Dr. Mike Patrick: That make sense. And maybe not become too animated with your reading?

Dr. Jack Stevens: Absolutely.

Dr. Mike Patrick: Because you want it to be boring, right? 

[Laughter]

Dr. Jack Stevens: Absolutely. It can't be too interesting.

Dr. Mike Patrick: Yeah, a boring book, but a book all the same. 

And then, you mentioned self-soothing. What exactly is that and why is it important?

Dr. Jack Stevens: Self-soothing involves learning strategies for somebody to be able to cope without getting assistance from others. So regarding sleep, some children may suck their thumb. They may switch positions in bed. They may rock themselves. They may engage in another type of common activity.

Parents realize that they can't be with their child for the rest of his or her life and parents also realize that they need their own quality sleep themselves. So if children are put to bed in a drowsy but awake state, that helps children learn some of these self-soothing skills. So again, when they wake up in the middle of the night, they're not trying to seek assistance from mom and dad.

0:16:01

One of the things I often I recommend the parents is they consider a transition object. So just remember, during the first year of life, it's not recommended that a child sleep with anything in the crib or bassinet. But once a child turns one year of age, a transition object like a blanket can be really helpful, if it's given at the beginning of a sleep period and then taken away at the end of the sleep period.

I really like blankets because they're relatively boring. They're not as engaging as stuff animals or dolls. And certainly, I think it's great for kids to be playing with stuff animals and dolls during the day. But again, we want to keep things as boring as possible at night and a blanket is one way to achieve that.

Dr. Mike Patrick: I really love that you point this out as a skill because a lot of times, this creates anxiety within families. And as a parent, you want to protect your kids, you want them to be comfortable. You don't like when they're upset, you're there for them, and you want to be a protector of them. 

So it can be difficult when run into difficulties with sleep time and we have to do things that's going to, at least in the short term, seems to make the child more uncomfortable. They're crying longer. You're telling them, "You have to go back to bed. You have to go back to bed." 

0:17:16

One of the things as a parent is you want them to be happy. But if you look at it is you're really teaching them something that is going to be an important part of their life for the rest of their life. I mean, when you spin it that way, which is the true thing, I think that does help families look at this as a skill, an important skill that you're teaching them. And it's going to make life better for everybody.

Dr. Jack Stevens: And I certainly agree with you. Basically, what's been found is that for a few nights to a few weeks, the types of strategies we'll talk about will actually lead to an increase in child's level of distress. But over the long run, they certainly lead to a decrease and better sleep for everybody in the family.

Dr. Mike Patrick: Yeah, which is going to makes us better parents when we get more sleep, right?

Dr. Jack Stevens: Agreed.

0:18:00

Dr. Mike Patrick: Now you talk about making bedtime boring. Do you have particular strategies for accomplishing that goal?

Dr. Jack Stevens: Absolutely. So, we can never force a child to sleep but we can make it as boring as possible to be awake. Children will often fight sleep because their worlds, toys, technology, caregivers are really interesting. So, we really want to restrict access to those things at night so that children don't fight against their internal sleep drive.

Certainly, when children sleep well, they can interact with all those things in just such a better fashion during the day. So one concrete example I have is in regards to technology. We know that TV and other electronic devices can interfere with the child's sleep for number of reasons.

First of all, they give off blue light. That's that bad light, it's a signal through the eyes to the brain that it's time to be awake as opposed time to be asleep. Second, they're naturally engaging. 

And third, they have variation with them, both in terms of sound and light. And whenever something is varying in our background in terms of sound or light, that's much more likely to wake us up or keep us up in the middle of the night. 

0:19:10

So really, what I encourage parents to do is to restrict access to those forms of technology at night. I've had some families locked up those items in trunks of cars. I've had some families use parental controls. But really think about the best ways to restrict access to those items at night. Because, again, if you can do that, the child is going to be just sleeping better. 

In fact, it's even best if you can restrict access to those items 30 to 60 minutes before bedtime. And some parents will say, "Well, my kid needs to fall asleep with some sound." But rather than using the sound of a TV, often I'll recommend something like white noise, the sound that you have for a fan or an air filter, a constant boring noise.

And some parents will say, "My kid needs light in order to fall asleep." Rather than TV light, I often recommend light on a dimmer switch, on a lamp, or a night light. This constant boring small amount of light that may actually help children get over the fear of the dark.

0:20:08

Dr. Mike Patrick: Yeah, very very important. So, again, we're wanting to avoid stimulation and certainly screens provide stimulation in lots of different ways, from the light to the sound, which actually happening on the screen.

And then, in terms of just making the environment boring, even before bed time, when we talk about routines, if you can make the routine have some boring elements like starting to dim the lights, if you do have dimmer switches around the time you're wanting them to become drowsy, can also help.

And then, maybe soft music in that routine stage, not right before you go to bed. But then for some folks that may be relaxing bath, again, a boring book. Just really trying to slowly decrease stimulation as we get closer and closer to bedtime, right?

Dr. Jack Stevens: Absolutely. The one caveat I'll give has to do with the bath because for some kids, a bath is very calming. For other kids, it's very activating. 

0:21:03

So you really have to observe what happens to your child after the bath. And if the bath tends to be really activating, then that might be something you want to move up until earlier in the day.

Dr. Mike Patrick: Totally make sense. You don't want the splashing and playing, more of a soothing bath. And that really is child dependent for sure.

Dr. Jack Stevens: That's right.

Dr. Mike Patrick: What about bed sharing? Now, we know that's not safe for little babies. We talk about the ABCs of safe sleep, alone, placed on their back, in the crib. Nothing else, no pillows, blankets, stuff animals, toys, nothing that they can suffocate in. 

But as kids get older and I find even, whether you have a spouse or partner, bed sharing with the kids or if you're single parent, bedsharing with the kids, sometimes kids will fall asleep easier when they're in bed with their parent. What do you think about that?

Dr. Jack Stevens: I think bedsharing is problematic for many families because it's completely normal for us as well as kids to move periodically during the course of the night. 

0:22:04

All parents need to do is look at their hair, their bedding, their clothing in the morning to figure out that they moved a lot during the course of the night, even if they felt like they got a really good night sleep.

So what that means is if that a parent is sharing a sleeping space of bed with the kid, the parent is probably unintentionally waking up the kid periodically during the course of the night and neither person may actually realize it. Actually, some past research has actually suggested that bed sharing can actually lead to future sleep problems.

So bottom line is when I think about bedsharing, I usually don't recommend it for two reasons. First of all, because it's linked to unsafe sleep and because it also may be linked to poor quality sleep. So having your own separate bed is both safe and is a way to promote good sleep.

Dr. Mike Patrick: That make sense. And so even though your child may fall asleep faster if they're in bed with you, you have to look at the quality of the sleep overnight.

0:23:04

And by moving around and bumping into one another and waking up, "Oh, mom is here. I'm going to wake her up because now I want to engage." All of these things can play into not getting as good of quality of sleep which then reduces the number of hours of sleep that you're getting and not getting those benefits from sleep that we talked about. 

So, ABCs of safe sleep for babies, alone, on your back, in a crib. For older kids, we still can have ABCs and I came up with still alone, make it boring, that's the B.

Dr. Jack Stevens: I like it.

Dr. Mike Patrick: And check that nighttime routine.

Dr. Jack Stevens: Very good.

Dr. Mike Patrick: These are your ABCs. All right, one of the topics that's often controversial is this idea in infants when we're getting to the point of, okay, they don't really need a nighttime feed anymore. We're six months of age or older. 

They're crying often. They're getting us up in the middle of the night. We really want to change their routine of sleep to sleep more overnight or at least to soothe themselves to get to sleep.

0:24:11

There's a method out there that we all have heard about, cry it out, also sometimes called the Ferber method because of a popular book by Dr. Richard Ferber. Tell us about the cry-it-out method, the Ferber method. And is this something that you endorse or is this harmful for young babies?

Dr. Jack Stevens: So for the vast majority of children, we absolutely endorse the Ferber method. In fact, the Ferber method can be used for children as young as six months of age. They can be used for toddlers, preschoolers, and even throughout the elementary school years in order to promote better sleep.

And there are couple of different ways that this method can be utilized. I really encourage our listeners to think about following these steps in a fair amount of detail because how you do the steps will really determine the likelihood of success.

So, the first approach is where the child is put down to sleep in a drowsy but awake state and the parent does not interact with the child for the rest of the night. So that means no talking, no eye-to-eye contact, not facing towards the child, not giving the child any food or beverage or toys. 

0:25:19

The only thing that parent would be allowed to do is to physically take the child back to bed if the child leaves the bed. But even during that time, parents can avoid talking and maintaining eye contact with the child.

Usually, after few nights of doing this, parents will observe that their child is learning some self-soothing and some independent skills and is actually sleeping much better at night. But the challenge with this is that this is very difficult for parents because in the short run, children can be distressed for long periods of time and that can be really difficult for a parent to ignore.

So often, what's recommended instead is a second approach. And the second approach features brief check-ins. So basically this is how these approach would work, the parent ignores the child once the child is put down in bed for say five minutes. 

0:26:06

So again, no talking, no eye to eye contact, not facing towards the child. If the child is still upset after those five minutes, the parent is allowed to use a brief check-in to say something like "It's time to fall sleep. I'll see you in the morning."

Then, the child is ignored for ten minutes by the parent. Again, following the no talking, no eye to eye contact, not facing towards the child approach. The child still upset, the parent can use another brief check-in, "It's time to fall asleep. I'll see you in the morning." Then the child is ignored for 15 minutes, with 15 minutes being the longest time between check-ins.

And this approach actually takes a bit longer to work because there are some brief check-ins that are used, but a lot of families find this to be more acceptable. And this is something that they're actually more likely to be able to carry out.

Dr. Mike Patrick: And maybe with the second night start with a little longer. So if you started five minutes, the first night, maybe the second night start at ten minutes?

0:27:02

Dr. Jack Stevens: You can do that. Sometimes just for simplicity, I recommend the 5, 10, 15-minute schedule. But again, the basic idea is to just go a little bit longer each time. And they just might be aware that this is something that you can use both at the beginning of the night, as well as for middle of the night awakenings.

Dr. Mike Patrick: And how long, in your experience, does it usually take of doing this before you're not thinking about it anymore? Like it seems to have worked?

Dr. Jack Stevens: This is a really important question. Previous work is suggested that it takes a few nights to a few weeks to see result. So this isn't something that you can just take care of in one or two nights. But generally, it's not something that takes several months to work.

The real challenge is parents have to be able to dig in their heels if they're going to use this approach. Unfortunately, there is no partial credit for a halfway response. 

So if a parent tries this for say 30 or 40 minutes and the child is really distressed. And then, the parents give in to the child's demand for attention. The parent has inadvertently taught the child that persistence pays off, that eventually mom and dad are going to give the attention that the child really wants.

0:28:10

So I really encourage parents, when they think about this approach, to be prepared to ignore children, particularly those first couple of night, for hours sometimes if needed. And because of that, some parents will think about the best night that this strategy would work for them.

So some families will start this on a Friday night or they'll start this in the beginning of a vacation period because they know in the short runs, sleep is going to be disruptive for everybody in the family.

Dr. Mike Patrick: Great points. There are times when perhaps your child is fuzzy at night for a different reason. For instance, let's say they have an ear infection and they're in pain. When you come to this episode, they interfere with this plan. 

I guess life comes along and you just have to understand there are going to be times when it's okay to soothe your child in the middle of the night, because they may be uncomfortable or something else is going on. And then you just have to start this over again, right, when they're feeling better?

0:29:04

Dr. Jack Stevens: That's right. Absolutely. If there's a short-term illness, of course, it's understandable that you may need to check on or implement some type of medical intervention in the middle of the night. But I really encourage parents to think about, even if there's a short term illness or another type of change, the child's moved to a new bed or has a new bedroom or new home, that still you may have to restart some of these general strategies, but they can be successful again.

Dr. Mike Patrick: The book that this is sort of based on by Dr. Richard Ferber, Solve Your Child's Sleep Problems, I'm going to put a link to that in the show notes for this episode over at pediacast.org, from Good Reads. And then, it has links to various retailers that you might want to use. And you can also check your local library to get a copy of that, if you'd like to hear more about it.

Can this method be harmful for some children? And in what situation might it be inappropriate?

Dr. Jack Stevens: Some parents are definitely worried that this will cause long-term psychological harm. And previous scientific studies suggest that generally is not the case. It can cause short-term distress but not long-term psychological difficulties.

0:30:09

In fact, I think some of these strategies can actually be helpful in the long run. They can actually improve the overall quality of the parent-child relationship because both the children and the parents are sleeping better.

That being said, there are few exceptions where maybe these strategies are not appropriate. For example, if you have a child who has really serious daytime separation anxiety, so they refuse to go to preschool or daycare because they are away from mom or dad. That maybe a family that requires more ongoing behavioral health services.

If you have a child who have such a severe temper tantrum at night because of these ignoring strategies. And by severe, I mean the child become really seriously violent or will seriously destroy physical property in the home, again, that family may require ongoing behavioral health services.

And certainly, if you have a child who's experienced a major traumatic event and having daytime trauma symptoms, so intrusive thoughts, feeling like they're on edge, severe avoidance of certain places, they may require more ongoing trauma services.

0:31:14

But that being said, probably the vast majority of children with sleep problems can still benefit from the type of strategies we talked about thus for.

Dr. Mike Patrick: Can you describe for older kids, so now we're talking more like toddlers kind of age. So they're not really trapped in a crib anymore. They're able to get out of bed, come downstairs, talk to parents, so it becomes a little difficult to ignore them. Are there some positive behavioral strategies that you can do to encourage toddlers to stay in bed?

Dr. Jack Stevens: So I think there are a couple. One is I would suggest that you can at least partially ignore them. Even if you have to physically take that child back to bed, you can make sure when you're taking your child to bed, that you're not talking with the child and that you're avoiding eye contact, that you're making yourself as boring as possible even though, obviously, you have to physically interact with the child.

0:32:09

The second approach is something called a bedtime pass reward system. So let me briefly explain how that works. So if you make some type of prediction about how many times the child would require your assistance or attention in the beginning of the night. So where you have to do a check-in or where you have to physically take the child back to bed, you make some type of prediction. And for some parents, they may say that will happen 20 times the first night.

So what would happen is the child would get 20 bedtime passes. So this is where the child would have these passes and the pair would actually hold on to the passes and take one pass away for each time the parent needs to interact with the child.

If the child has just one pass left over by morning, the child can trade it in for special small treat they don't normally get, something like in the 25 to 75-cent range.

So what that would mean is that if the child had starts off the night with 20 passes and they disrupt the parents 19 times, we want them rewarded the next day, because that's certainly not perfection, but it is progress.

0:33:09

And as you can imagine, over time, you can gradually start to reduce the number of passes and eventually, you want to get down to a one-pass system. So under that situation, the parent can't interact with the child at all if the child is going to get a small reward the next day.

So that type of reward system, I think, can be generally be appropriate for toddlers, as well as children during the preschool and elementary school age period.

Dr. Mike Patrick: And just to be transparent, when my kids were young, we use the Ferber method. We used these reward systems when they were toddlers. And they are young adults now and they don't seem to have any issues associated using these techniques. 

So from my own personal experience, they seem to work. I don't have any grandchildren yet, but I suspect that they will require some sort of similar interventions as well.

0:34:00 

There is another system called the Sleepeasy Solution DVD. Tell us a little bit about this one.

Dr. Jack Stevens: The Sleepeasy Solution DVD is a 60 to 90-minute DVD developed by two outside sleep experts. So, my colleagues here at Nationwide Children's Hospital and I recently conducted a study on this product. 

And just to be clear, we have no financial, no scientific relationship with the developers. And what we found in the study is that this particular product could help parents learn about some of the strategies we've discussed and can actually learn about some of the strategies in greater detail than we've actually described today.

What we've found is that this strategy was very useful for children between six months of age and 36 months of age, so three years of age. That's the age group that we studied. And again, I have to caution that this was just a single study that we conducted but nevertheless, this might be one resource that parents want to consider and this can be something that can be purchased online.

0:35:02

Dr. Mike Patrick: And I'll put a link in the show notes so folks can find it easy, the Sleepeasy Solution DVD. 

And just some highlights of the program, and again, no kickback here. We don't have any financial interest in this, just something that there's evidence that it can help families. It has six sleep stealers that cause most problems. So identifies barriers and pitfalls to helping kids sleep well. Step-by-step guide to solving nap and bedtime problems, sample schedules according to age, gentle weaning of nighttime feeds. 

It includes interviews with real families who have used these techniques, they answer frequently asked questions and then provide some great music along with it, too. So, it can be helpful for some families. And again, we'll put a link in the show notes to that. 

But again, we don't have any financial interest in this, or with the Dr. Richard Ferber's book either.

There's another concept that you talked about called sleep restriction. What is sleep restriction and how does this facilitate help the sleep pattern?

0:36:06

Dr. Jack Stevens: So now we're getting in the strategies that I think are very relevant for teenagers, as well as adults. Sleep restriction is the idea that maximizing the percentage of time that somebody's asleep in bed is more important than maximizing the total time spent in bed. It's really the idea of trying to have sleep in one prolong period, as opposed to many different segments.

We certainly don't expect people to be asleep for 100% of the time they're in bed, but ideally, we would like people to sleep for say 85 to 90% of the time that they actually spent in bed. Furthermore, I think it's really important to note that when it comes to children who are at least six to seven years of age, naps are generally not recommended anymore. 

Naps for children that age and older often will interfere with nighttime sleep. Children by that age often do best if they have sleep in one big chunk as opposed to a daytime nap and nighttime sleep.

0:37:04

Dr. Mike Patrick: So, really important. When we talk about how many hours you need, it's actual sleep time, not in bedtime, right?

Dr. Jack Stevens: Correct.

Dr. Mike Patrick: And also, I find it interesting, and this I think during the pandemic and with remote learning, you really want your brain to associate bed with sleep. And so, what about doing schoolwork on your bed?

Dr. Jack Stevens: So I think this is one of the unique aspects of what's been happening over the last several months is that I'm sure a lot of children, because of reasons of comfort, as well as privacy or doing their school work on their beds. And if it all possible, I've really encourage families not to follow that practice to really think about the bed being reserved for sleep and sleep only, and to find other places for the child to do the schoolwork besides bed.

Dr. Mike Patrick: And there's something to be said about getting up, brushing your teeth, putting clothes on, the sort of prepares you for that school day. I know that's not really talking about sleep but just as a psychologist, would you say that's an important thing, even though you're doing remote learning? To still make the environment different and distinguish a school activity versus other activities?

0:38:18

Dr. Jack Stevens: Absolutely. You're trying to establish that positive routine and those positive four steps to the ultimate behavior you want the child to demonstrate.

Dr. Mike Patrick: Now, what about when you wake up in the middle of the night and you're lying there and you're trying to self-soothe, and I know there are a lot of adults who experience this, is there certain amount of time that you should still lay there trying to get back to sleep? Or is it a good idea at some point just to get out of bed and do something?

Dr. Jack Stevens: Good question. Remember, the core concept we're thinking about here is that the bed is for sleep and sleep only. What that means is no homework, no texting, no using electronic devices and often not even reading in bed. 

0:39:01

So we've really want the bed to be a place that's reserve for sleep and part of that actually involves avoiding long periods of time being awake in bed. So generally, what's recommended is that if somebody can't fall asleep or fall back asleep after 20 minutes, you're actually encouraged to physically get out of bed and do something boring in their room.

So fold laundry, read boring material, play some type of game with cards, for example, like Solitaire, not an electronic device but with the actual cards, put together a boring puzzle, something that is boring for their perspective. And then, once they've actually start to feel drowsy, again, that's when they should get back into bed. It's just really important to avoid long periods of time being awake in bed. 

Dr. Mike Patrick: If you use that strategy for a few nights, maybe you are able to start self-soothing and so you don't necessarily have to get up in the middle of the night and play game and solitaire every single night. I mean, does that help in terms of long-term sleeping better?

0:40:07

Dr. Jack Stevens: Absolutely, because your body is, again, more strongly associating the bed with being asleep. And you also realize that it's not the end of the world if you can't fall asleep really quickly and you start to relax more, you calm yourself down more and it just makes it easier for you fall back to sleep.

And often, what will happen with this is that we really encourage for people of all ages to still wake up at a fixed time in the morning, even if they haven't gotten the best night sleep. Because if they actually feel a bit tired during the day, that will actually make it easier to get a good night sleep and to fall asleep at the desired bedtime the next night.

Dr. Mike Patrick: Yeah, I can see that, really, the anxiety of laying there and not being able to fall asleep when you really want to fall asleep. But that's actually a stimulus then, right, that anxiety? I mean, you're get catecholamines, the EPIs going and that can stimulates the brain. And so, that's really counterproductive, the way you're trying to do.

0:41:05

Dr. Jack Stevens: Absolutely. Sleep is one of those behaviors that you can't try too hard. If you try too hard to sleep, it's actually going to interfere with sleep.

Dr. Mike Patrick: And then, you also recommend for some folks a mobile alarm clock. Tell us more about what this is and why you recommend it?

Dr. Jack Stevens: A mobile alarm clock is an alarm clock on wheels that families can actually purchase online. So the problem with the stationary alarm clock is that it's really easy to turn off in the morning. 
In contrast, a mobile alarm clock requires somebody to physically get up out of bed, chase this alarm clock as it moves around the floor, catch it and turn it off. And often by that point, the individual is actually fully awake. They're not going to actually try to fall right back to sleep. 

And sometimes, mobile alarm clocks can be really useful because it will actually help people reduce parent-child conflict about actually getting up in the morning.

0:42:02

I think it's also really important to keep in mind that cell phones are not really great when it comes to being used as alarms. The problem with cell phones and smartphones is they have all these other interesting aspects to them, apps and games and programs that might actually interfere with sleep. 

So that even if you want to use a stationary alarm clock, it's probably worth the purchase of something per se $10 or $20 that can be used just as an alarm clock, as opposed to having all the other features that a smartphone might have.

Dr. Mike Patrick: And then, also, when you do wake up, you turn your alarm off. And then, the next thing you know, you're checking your email, you're checking your social media feeds and then you've been in bed another hour. And then, you sort of regret that a little bit because you had things to do and you're not as productive during the day. 

So this will also help, not using your smartphone as an alarm clock and using something like a mobile one can get you out of bed and get you moving, which is important for adults, too.

0:43:00

Dr. Jack Stevens: Exactly.

Dr. Mike Patrick: And I'll put a link in the show notes to Clocky. It's one example of an alarm clock on wheels. Again, no kickbacks or anything, just one that folks have found useful in the past. And so, we'll share that with you over at pediacast.org.

We've not talked about chemical stimulants like caffeine. What role do those play in our sleep pattern? And at what point in the evening should you stop drinking things with caffeine in them?

Dr. Jack Stevens: So people vary considerably in terms of their response to caffeine. I'm sure your listeners can think of people who can have two cups of coffee right before bed and they fall asleep quickly. And in contrast, other people say that if they have caffeine in the morning, that can interfere with your nighttime sleep.

What the study seemed to suggest is that caffeine taken even six to eight hours before bedtime can often interfere with nighttime sleep. So really think about having that caffeine as early in the day as possible and preferably no later than 1 PM.  Stopping caffeine by that point, hopefully, will mean that the caffeine is out of somebody's system, and it won't interfere with somebody's ability to fall asleep.

0:44:06

Dr. Mike Patrick: And I think that information will come as a surprise to a lot of people that caffeine can last that long in the body. And so, dinner time really is too late for a caffeine especially if you're having sleep problems.

Dr. Jack Stevens: It is.

Dr. Mike Patrick: And then, a technique that you recommend is diaphragmatic breathing. What is that and when can it help?

Dr. Jack Stevens: So there are different relaxation strategies that can be used to promote sleep. My favorite is something called diaphragmatic breathing. And it really involves very slow and deliberate breathing. People can locate their diaphragms by putting their hand below their ribcage, but above their belly buttons.

And here's the approach I often will recommend in order to get really good diaphragmatic breathing. I encourage people to recline on their backs and with their face headed towards the ceiling, looking up at the ceiling. And I encourage people to actually put something on their diaphragm that doesn't weigh very much, say a pad or paper and practice having the diaphragm move that up and then actually have that fall down again.

0:45:07

Once people practices a couple minutes a day, twice a day, and they get really good at this, this is something they can actually use it nighttime to facilitate sleep. This type of diaphragmatic breathing is very similar to the type of breathing we want people to utilize as they fall asleep at the beginning of the night.

Dr. Mike Patrick: Very important technique for a lot of people. And just like anything it's a learned behavior, right? The first time that you're trying to do this should not be when you're having trouble falling asleep in bed, really practice it during the day so you get good at it.

Dr. Jack Stevens: You want to master this another time. You don't want to try to learn a completely new skill as you're already struggling to fall asleep.

Dr. Mike Patrick: Absolutely, because it becomes a stimulant. Like, "Am I doing it right? Why isn't this working?" is sort of going through your mind and possibly keeping you awake.

What about the sleep environment itself? You talked about white noise and dim light. Is that going to be true for everyone? I mean, what are the different parameters of an the optimal sleep environment?

0:46:08

Dr. Jack Stevens: Well, again, I think this just varies a lot from person to person. Again, I always kind of think to myself that these are just one set of strategies, as opposed to the only ways to promote sleep. So, if you have somebody who sleeps well with the TV on and other noises going on, and they're functioning well during the day, so be it.

Other individuals will sleep much better without the white noise and a small amount of boring light like the nightlight. And still, other people will sleep better if there's no light and no sound. So this is where you often have to do a little bit of experimentation to figure what works best for you and your particular child.

The other aspect of the sleep environment that I encourage the listeners to think about is the temperature of the room. So generally, what's been found is a room on the colder side. So a room, for example, that's in the 60s in terms of degrees Fahrenheit often will facilitate sleep more than a room that's a bit on the warmer side, say in the 70s degrees Fahrenheit.

0:47:03

Dr. Mike Patrick: What about folks who would say, "I'm a night owl" or "I'm a morning person."? Do those categories really exist?

Dr. Jack Stevens: Absolutely. We know that particular for teenagers that their biological clock tends to be much different than other age groups. So clearly some of them will struggle simply because they have to get up so early in the morning for school and that's not really compatible with their just naturally preferred sleep pattern. So certainly, those patterns were absolutely exist. But one of the things that can be done to try to reset those patterns is to think about, again, using light and sound.

So just like we want light and sound to be boring at nighttime, when somebody really needs to be up for the day, all of a sudden we want light and sound to be used in a different way. If the child really needs to get up in school, it's really important to turn on the music, to turn on other types of things to make sure that there's lots of natural light or even artificial light in the room, to try to reset the biological clock so people can function according to what they need to do for work and school.

0:48:08

Dr. Mike Patrick: And what about when kids share a room?

Dr. Jack Stevens: This is really tough to deal with from a sleep perspective. A lot of strategies we've talked about really work best if a child has their own room. And this is really a difficult situation.

That being said, I think you can still apply a lot of the strategies we talked about today. And sometimes parents will be surprised because maybe they have one child who's a really good sleeper and another child that struggles with sleep. And they get really concerned if, for example, they use this ignoring approach, what impact that's going to have on the good sleeper. 

And often with that good sleeper, they sleep so soundly at night. They may actually sleep through a lot of disruptions that parents would think will actually wake up a lot of other individuals.

So even though that may not be the ideal circumstances for sleep for some families, you can still use a lot of the same strategies even if people are actually sharing a room.

0:49:02

I think the other part of that as well is to really think about what are ways to make that room still as boring as possible. So if you've taken out the TV, if you've taken out electronic devices, things that would be naturally distracting to both kids in the sleep environment.

Dr. Mike Patrick: Well, it's really terrific information today. A couple of things that we have not covered unintentionally, one is going to be sleep aids in terms of medicine for sleep. And of course, we want to do that as sort of a last resort when these techniques are not helping, and when not getting enough sleep is really interfering with the quality of a child's life and with their learning and their behavior, and interfering with family life, and none of these things seem to be working. 

In terms of medications, we would just direct you to your child's healthcare provider if that's happening because there are medications that can help. But really, we don't want to do that unless we absolutely have to. And so that really is going to be tailored to each individual child and something that you'd want to talk to your healthcare provider about.

0:50:04

There's also medical things that can interfere with sleep. So obstructive sleep apnea, for example, kids who, for instance, maybe their tonsils are really large and obstruct the airway. And as they relax into sleep, muscles relax and the tonsils and adenoids kind of obstruct things. And so, you would diagnose that with a sleep study.

Again, if you have a child who is not responding to these techniques, talk to your child's healthcare provider because there may be more studies and tests. And there may be medications that they could use.

But for the majority of kids, these strategies are really going to work well and for adults too, right?

Dr. Jack Stevens: Absolutely. Really these behavioral strategies are really regarded as kind of first line treatment for these types of sleep problems we discussed today.

Dr. Mike Patrick: And then, one more time, those three global principles that we can apply at the various age groups, remind us what those are.

Dr. Jack Stevens: Absolutely. Put the child to bed when they're drowsy but awake is the first one. The second one is the ability to self-sooth is one of the greatest gifts parents can help children obtain. And third, make the child's world as boring as possible both in terms of the environment, as well as caregivers.

0:51:17

And if I were going to sneak a fourth one in there, if I can, use the bed for sleep and sleep only. And again, I think that's really relevant these days as a lot of kids are going to be using virtual learning as part of their school curriculum.

Dr. Mike Patrick: Great. Great information. We're going to have lots of links in the show notes for you over at pediacast.org for this episode, 469, the Child Sleep Guidelines from the American Academy of Pediatrics will be there, Solve Your Child's Sleep Problems by Dr. Richard Ferber, the Sleepeasy Solution DVD, Clocky: The Alarm Clock on Wheels. 

And then, we have a couple of what we call Helping Hands, which are parent and family educational information from Nationwide Children's Hospital. We have one on Healthy Sleep Habits for Infants and Toddlers. Another, Healthy Sleep Habits for Older Children and Teenagers.

0:52:06

And then, some more resources from the American Academy of Pediatrics, Baby Sleep Resources from healthychildren.org, and Child and Teen Sleep Resources also from healtychildren.org, which is a resource of the American Academy of Pediatrics. We'll put links to all of those things in the show notes so you can find them easily over at pediacast.org.

So, Dr. Jack Stevens, pediatric psychologist at Nationwide Children's Hospital, we really appreciate you stopping by today.

Dr. Jack Stevens: Thanks so much for having me and to all your listeners, I hope they sleep well.

[Music]

0:53:05

Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.

Also, thanks to our guest this week, Dr. Jack Stevens, pediatric psychologist at Nationwide Children's Hospital.

Don't forget, you can find us wherever podcast are found in the Apple and Google Podcast apps, iHeartRadio, Spotify, SoundCloud, Castbox, Himalaya and most other podcast apps for iOS and Android. There may be an easier way for you to listen, subscribe, and get regular updates when we release new programs.

Also, don't forget about our landing site over at pediacast.org. You'll find our entire archive of past programs there. Also, show notes for each episode, our Terms of Use Agreement, and that handy Contact page if you would like to ask a question or suggest a topic for an upcoming episode.

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0:54:07

One more time, I do want to remind all of the pediatric providers in the crowd. And in the intro, I mentioned doctors, nurse practitioners, physician assistants, also, floor nurses, clinic nurses, pharmacist, psychologist, social worker, even dentists, we do have Continuing Medical Education Credit for all of you. 

Since Nationwide Children's is jointly accredited by many professional organizations, it is likely we offer the exact credits you need to fulfill your state's Continuing Medical Education requirements.

Shows and details for our CME programs are available over at the landing site for that program pediacastcme.org. You can also listen wherever podcasts are found. Simply search for PediaCast CME.

Thanks again for stopping by and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

0:55:01

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.