Psychological Sleep Counseling


BEDTIME PROBLEMS
After a long day at work, caring for your children, household duties, and the demands of managing a family most parents look forward to the evening where they can put their children to bed and have a little “me” time. However, if you find yourself arguing with your child about getting ready for bed, getting into bed, dealing with requests for one more hug or one more trip to the bathroom, or feeling frustrated with bedtime temper tantrums you are likely dealing with something called Limit-Setting Sleep Disorder.  This sleep disorder is common beginning around 2-3 years of age when children typically transition from a crib to a bed.  Children engage in bedtime stalling techniques which include any behavior that attempts to delay bedtime.  This is typically followed by a response from parents characterized by inadequate enforcement of bedtime limits, sporadic enforcement of limits, or very few or no limits set for a child.  An additional good hint that this may be the problem for you and your child is if the child goes to bed and falls asleep quickly for other family members.  Bedtime resistance is found in 10% to 30% of toddlers and preschoolers and approximately 15 % of children ages 4 to 10 years.
 
What to expect when you arrive at the sleep clinic
Fortunately, even the most extreme cases of bedtime resistance can be addressed with behavioral techniques that can lead to improvement in a few weeks with consistent follow through.  When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history.  A detailed history of your child’s sleep behaviors will also be discussed.  Your child will also likely have a brief physical examination.

Treatment
Treatment for limit-setting sleep disorders includes the development of good sleep habits including establishing a set bedtime, a consistent sleep/wake schedule, and a consistent bedtime routine.  Daytime habits including napping, types of physical activities, and foods consumed will be reviewed to ensure your child is developing good sleep hygiene practices.  Our sleep psychologist will work with your family one-on-one to develop a personally tailored sleep behavior medicine program to fit your family’s needs.  This intervention may include multiple behavioral strategies including the use of positive reinforcement, consistent parental response, clear limit-setting, the development of independent sleep skills, graduated extinction, bedtime fading, the door closing procedure, and the bedtime-passcard.  Following the initial consultation and treatment session, your family will be asked to complete a 2-week sleep log so that our providers will have detailed information about how the changes you are making are working.  The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 weeks following your initial visit.          

NIGHTWAKINGS
Nightwakings can occur for many different reasons, but are most often related to negative sleep onset associations.  Positive sleep associations are what you want your child to have in order for her to fall asleep quickly and easily on her own.  They are the conditions that are present at the time your child falls asleep.  They are usually required again following normal nocturnal arousals.  Positive sleep associations may include a favorite stuffed animal, sleeping in a certain position, sucking a pacifier, having a night light etc.  The sleep onset associations should be consistent at bedtime and throughout the night.  Parents often fall into the habit of placing their infants to bed after they have fallen asleep such as following nursing or drinking from the bottle, rocking, singing, or cuddling.  Negative sleep onset associations require a parent’s presence or are things that are no longer present when your child wakes in the middle of the night.  Negative associations interfere with your child’s ability to learn the important skill of self-soothing and inhibit her ability to fall asleep on her own.  It is important to note that we all wake through the night.  This is normal.  The problem occurs when your child cannot soothe herself back to sleep following a nightwaking.    Studies suggest that 25% - 50% of 6- to 12- month-olds and 30% of 1- year-olds have problems with nightwakings.  Approximately 15% - 20% of toddlers ages 1- to 3-years old continue to experience nightwakings.

What to expect when you arrive at the sleep clinic
When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history.  A detailed history of your child’s sleep behaviors and nightwakings will also be discussed.  Your child will also likely have a brief physical examination.  If any medical causes are suspected of contributing to your child’s nightwakings (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended. 

Treatment
Treatment for nightwakings related to negative sleep onset associations may include establishing good sleep habits including a consistent sleep/wake schedule, a consistent bedtime routine, the maintenance of a daytime nap (at least through age 3), the encouragement of a transitional object, graduated extinction, fading of adult intervention, weaning/discontinuation of nighttime feedings (when developmentally appropriate), reinforcement strategies, and scheduled awakenings.  Our sleep psychologist will work with your family one-on-one to develop a personally tailored sleep behavior medicine program to fit your family’s needs.  Following the initial consultation and treatment session, your family will be asked to complete a 2-week sleep log so that our providers will have detailed information about how the changes you are making are working.  The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 weeks following your initial visit.  
       
INSOMNIA
Insomnia is defined as having difficulty falling asleep, staying asleep, or waking early.  In many cases, insomnia is a secondary symptom of another sleep or medical disorder.  However when insomnia is not related to a sleep, psychiatric, or medical disorder, it is refered to as primary insomnia or psychophysiologic insomnia and is accompanied by learned sleep-preventing associations, physiological arousal, complaints of sleeplessness and decreased daytime functioning.  Children and adolescents with insomnia may also complain about racing thoughts, difficulty turning off their brain, negative beliefs about sleep, and worries about difficulties falling asleep.  Insomnia theories suggest that this sleep disorder results form a combination of the three Ps – predisposing factors (genetic vulnerability to underlying medical or psychiatric conditions), precipitating factors (stress), and perpetuating factors (poor sleep habits, negative thoughts about sleep, inconsistent sleep schedule).  Children and adolescents who struggle with insomnia may experience a change in mood, irritability, excessive fatigue and sleepiness during the day, and declining school performance.  Adolescents are especially at risk for excessive use of caffeine to remain awake during the day.   

What to expect when you arrive at the sleep clinic
When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical and psychological history), and your child’s behavioral history.  A detailed history of your child’s bedtime routine, sleep behaviors, nightwakings, and daytime behavior and activities will also be discussed.  Your child will have a brief physical examination.  If any medical causes are suspected of contributing to your child’s insomnia (e.g., gastroesophageal reflux, periodic limb movement, restless leg syndrome, sleep apnea, delayed sleep phase, psychiatric disorders, asthma, allergies, etc.), further medical evaluation may be recommended.    

Treatment
Identifying all of the factors contributing to your child’s insomnia is a critical inititail step in developing an appropriate treatment plan.  Our sleep team will work with your family one-on-one to develop a personally tailored sleep medicine program to fit your family’s needs. Initially, treatment will focus on improving sleep hygiene and the consistency of the sleep/wake schedule.  Cognitive behavioral strategies will then be used to disrupt the negative learned associations with sleep and may include: cognitive restructuring, relaxation, sleep restriction, and stimulus control.  Our goal as a sleep team is to avoid the use of hypnotic medication when possible, especially for use with children and adolescents.  When necessary, we use hypnotics on a short-term basis in conjunction with behavioral interventions to break the cycle of insomnia and improve sleep.   The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 weeks following your initial visit.  
       
ANXIETY, NIGHTTIME FEARS, AND SLEEP
Children with anxiety symptoms often complain about sleep disturbances.  However, the relationship between sleep and anxiety is complicated.  Sleep disturbances are a symptom of anxiety disorders, but sleep disruptions and inadequate sleep can lead to anxiety symptoms. It may be a challenge to determine which is the primary disorder. Therefore, the most effective strategy to address these disorders is an integrated approach that evaluates and treats both concerns at the same time.

Anxiety is healthy because it helps protect and enhance our performance in stressful or dangerous situations.  However, experiencing too much anxiety or experiencing anxiety that is overwhelming at inappropriate times can lead to extreme distress and interfere with our ability to complete our daily activities.  Given all of the developmental tasks that children need to accomplish, it is important that they learn skills to cope with anxious feelings.
Fears and anxiety are a part of normal development.  Nighttime fears and nightmares are especially common in preschoolers, but can occur in older children. As children’s cognitive skills develop, they begin to gain a more complete understand that there are things that exist in the world that may hurt them (or a loved one). The following is a list of common fears:

  • INFANTS/TODDLERS (ages 0-2 years) loud noises, strangers, separation from parents, large objects

  • PRESCHOOLERS (ages 3-6 years) ghosts, monsters, supernatural beings, the dark, noises, sleeping alone, animals, blood, needles, thunder, floods

  • SCHOOL AGED CHILDREN (ages 7-12 years) realistic fears such as physical injury, illness, blood, needles, school performance, social situations, death, thunderstorms, supernatural phenomenon (ghosts, witches, aliens) and natural disasters

  • ADOLESCENTS (> 13 years) future events, the unknown, performance failure

It is important for parents to differentiate normal fears from more severe and persistent anxiety across the entire day. Also, some normal bedtime anxieties can become a larger problem if they are accidentally reinforced by parental reactions and attention. Anxiety disorders that may be associated with sleep disturbances include:

  • Stress reactions (e.g., natural disasters, trauma)
  • Adjustment disorders (e.g., reactions to major life changes such as moving, change of school, separation/divorce, death of a family member)
  • Separation anxiety (typically seen in younger children who are extremely unwilling to separate from their major attachment figures such as parents, grandparents or from home. The suggestion of having to separate typically results in crying, trembling, sweating, and physiological complaints)
  • Generalized anxiety disorder (excessive worry about a variety of events that is difficult to control and interferes with daily life)
  • Obsessive-compulsive disorder (recurrent obsessions, or intrusive thoughts, and compulsions/repeated behaviors that are time consuming and cause significant impairment in daily functioning)
  • Posttraumatic stress disorder (PTSD) (the experience or witness of a severely traumatic event that involved actual or threatened death or serious injury including physical, emotional, and sexual abuse)

If your child is exhibiting significant nighttime fears that are not developmentally appropriate, negatively impacting their ability to fall asleep and get an adequate amount of sleep, and/or affecting daytime functioning our sleep psychologist can help to address these issues.

What to expect when you arrive at the sleep clinic
When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history.  A detailed history of your child’s sleep behaviors and fears will also be discussed.  Your child will also likely have a brief physical examination.  If any medical causes are suspected of contributing to your child’s sleep problems (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended. 

Treatment
The most effective treatment for sleep problems related to anxiety is to treat both the sleep issues and the anxiety at the same time.  Our sleep psychologist will work with your family one-on-one to develop strategies to optimize your child’s sleep while helping him or her to develop appropriate coping skills to “boss back” their worries.  Treatments for developmentally appropriate fears may include reassurance of the child’s safety, developmentally appropriate coping skills such as positive self-statements, fostering a sense of mastery and control, encouragement of a security object, use of a nightlight, avoidance of frightening or age inappropriate media, relaxation strategies, appropriate and consistent limit-setting, graduated checking, and rewards for appropriate bedtime behavior.  Treatment for significant anxiety symptoms and pervasive worry may include cognitive behavioral therapy techniques that 1) increase awareness of physiological arousal and negative self-talk during anxiety events; 2) develop coping skills including relaxation skills, restructuring negative thoughts into positive, coping thoughts, and problem-solving strategies; and 3) utilize gradual desensitization, bedtime checks, and weaning of parents presence to increase independent sleeping skills.  In cases of severe anxiety or where anxiety symptoms are affecting daytime functioning, a referral to a psychiatrist for a medical consultation may be needed.  The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 1 - 2 weeks following your initial visit.       
  
ADHD AND SLEEP
Attention-Deficit/Hyperactivity Disorder is a neurobiological disorder characterized by developmentally inappropriate problems with sustaining attention to tasks, persistence of effort, vigilance, inhibiting behavior, impulsiveness, poor self-regulation, and increased activity and restlessness.  Hyperactivity symptoms have been shown to decline significantly across the elementary school years, while problems with attention tend to remain stable across time.  Although excessive activity levels decrease over time, problems with inhibition are typically exhibited in symptoms of poor self-regulation across development. About 70% of males and females that meet criteria for ADHD in childhood continue to experience significant ADHD impairments through adulthood.  The prevalence of ADHD in school-age children is 2% - 7%. There are three primary subtypes of ADHD including: predominately inattentive type, predominately hyperactive-impulsive type, and combined type.

Many parents of children and adolescents with ADHD complain of sleep problems including bedtime struggles, delayed sleep onset, increased nightwakings, restless sleep, and shortened sleep duration.  The relationship between sleep and ADHD is complicated by the fact that most of the common behavioral symptoms of ADHD can also result from inadequate and disrupted sleep including mood, attention and behavioral symptoms. Research suggests that some children with ADHD are misdiagnosed and actually have a primary sleep disorder including obstructive sleep apnea, restless leg syndrome, and periodic leg movement. In addition, sleep disorders can worsen symptoms of ADHD when they coexist.
Sleep problems in children with ADHD can have multiple causes:

  • A primary sleep disorder that “mimics” ADHD symptoms.  These symptoms may improve or be eliminated with treatment of the sleep disorder.
  • Inadequate sleep related to the environment or lifestyle factors (e.g., inconsistent schedules, noisy environment etc.).
  • Coexisting sleep disorder that may make the cognitive, mood, and behavioral disturbances associated with ADHD worse.
  • Coexisting psychiatric disorders such as oppositional defiant disorder, anxiety and mood disorders, Tourette syndrome, and sensory integration disorder and associated impairments in self-soothing skills may contribute to sleep disturbances.
  • Pharmacologic agents used to treat ADHD and/or comorbid psychiatric conditions may be associated with sleep onset and maintenance problems and restless sleep. Sleep problems may be a result of dosage or dosing schedule of medication.
  • Poor Central Nervous System regulation of arousal/activity associated with ADHD may result in sleep disturbances. Parents may report that their child has difficulty “winding down” at bedtime and may be a result of problems with delayed sleep onset.

The accurate identification of children with ADHD requires careful screening followed by a comprehensive evaluation and diagnosis.  Screening for sleep disorders should be part of the evaluation for every child with suspected ADHD in order to rule out or appropriately treat a primary sleep disorder prior to the diagnosis of ADHD.  In addition, periodic rescreenings for sleep disorders should be a part of the ongoing management of every child with ADHD. 

What to expect when you arrive at the sleep clinic
When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history.  A detailed history of your child’s sleep behaviors will also be discussed.  Your child will have a brief physical examination.  If any medical causes are suspected of contributing to your child’s sleep problems (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended including an overnight sleep study. Our sleep psychologist may also request that you and your child’s teachers complete brief questionnaires to better understand what behavioral and neurocognitive symptoms your child is exhibiting in the home and school setting.  

Treatment
If your child has been diagnosed with ADHD, his or her treatment plan likely already includes a behavior management plan, classroom accommodations, individual and family counseling, and medication.  Treatment for children who have comorbid ADHD and sleep problems should include the treatment of the primary sleep disorder.  Our sleep psychologist will work with your family one-on-one to develop a personally tailored sleep behavior medicine program to fit your family’s needs.  Interventions may include the completion of a sleep log to gather further information, extended bedtime routine to help your child learn to decrease his arousal level, the development of good sleep hygiene, a consistent sleep/wake schedule, bedtime fading, and the development of a reward system for appropriate bedtime skills.  Our sleep psychologist and medical providers along with your primary care doctor or psychiatrist will review your child’s current medication regimen and consider if any of the sleep symptoms your child is exhibiting are related to ADHD medication effects or rebound effects as the medication is wearing off.  Changing the dose, timing, or type of medication can decrease ADHD behaviors and make bedtime easier.  On some occasions a child may present with other behavioral and mental health problems that are negatively impacting both daytime and nighttime functioning.  When this is the case, it is recommended that your child participate in a comprehensive psychological evaluation to ensure the appropriate identification and treatment of your child.   The frequency and duration of follow-up depends on each families needs, but you can expect to return in approximately 2 - 4 weeks following your initial visit.   
      
NIGHTMARES
Most parents can remember a time when they were young and were awaken by a scary dream.  You may have needed comfort, reassurance, or just the presence of your mom or dad to return back to sleep.  When you consider that 75% of children report experiencing at least one nightmare and 10% to 50% of young children require some type of adult assistance during the night following a nightmare, parents are spending a significant amount of time addressing these issues.  Nightmares occur during REM sleep and typically result in awakening from sleep.  The content of nightmares varies across the developmental spectrum with younger children exhibiting themes of monsters or separation from caregiver, and older children experiencing themes related to frightening movies or media viewed and disturbing daytime experiences.  Life changes, stressors, or traumatic events (e.g., move to a new home, starting school, parental divorce etc.) can also be associated with nightmares. 

Nightmares should be differentiated from sleep terrors.  Nightmares have the following characteristics:

  • typically occur in the latter half of the night when our sleep cycle is predominated by REM sleep
  • your child remembers partial or whole descriptions of the nightmare
  • they will remember waking up and interacting with you
  • they will not be confused or disoriented during the awakening
  • they may have difficulty returning back to sleep

Frequent and chronic nightmares can be associated with psychiatric disorders such as anxiety disorders, bipolar disorders, and schizophrenia.  However, it is important to remember that most nightmares are common and are part of the normal developmental process.

What to expect when you arrive at the sleep clinic
When you arrive for your initial consultation with the sleep team, the team will spend time evaluating your child’s medical history, developmental history, family history (including medical history, psychological history, parenting skills, and limit-setting abilities), and your child’s behavioral history.  A detailed history of your child’s sleep behaviors and the frequency and severity of nightmares will also be discussed.  Your child will have a brief physical examination.  If any medical causes are suspected of contributing to your child’s sleep problems (e.g., gastroesophageal reflux, periodic limb movement, restless sleep, sleep apnea etc), further medical evaluation may be recommended including an overnight sleep study. 

Treatment
Treatment for nightmares includes reducing the likelihood of experiencing a nightmare by avoiding exposure to frightening or age inappropriate images and media, reducing stress, and ensuring adequate sleep.  Our sleep psychologist will work one-on-one with your family to help parents provide appropriate reassurance without providing excessive attention to the nightmares.  Your child will be encouraged to develop individual coping skills including use of their imagination to facilitate a sense of master and control, relaxation strategies, and systematic desensitization.  Use of a nightlight and security object may also be recommended.  If nightmares are persistent and unresponsive to behavioral interventions, a referral for a psychiatric consultation may be needed.
 
SLEEP HABITS/SLEEP HYGIENE/INSUFFICIENT SLEEP
Every child needs a certain amount of sleep and this depends on many factors including developmental stages.  When the amount of sleep a child is getting falls short of the amount of sleep she needs to function during the day, this results in chronic sleep deprivation.  Children may go from a well-mannered, well-behaved and attentive to sleepy and/or overactive, irritable, and defiant.  Insufficient sleep is the leading cause of excessive daytime sleepiness.  The table below provides a guideline for the estimated average sleep time by a child’s age.  Keep in mind that these are averages and some children need more or less sleep to functioning well during the day.


Hours of Sleep by Age

Age

Average Sleep Duration

Newborns

16 – 20 hrs (1- to 4-hr sleep periods)

Infants ( 0 to 1 yr. old)
~ 4 months old
~ 6 months old

 

14 – 15 hrs
13 – 14 hrs

Toddlers (1 to 3 yrs. old)

12 hrs

Preschoolers (3 to 6 yrs. old)

11 – 12 hrs (napping declines/stops by age 5)

School Age (6 to 12 yrs. old)

10 – 11 hrs

Adolescence (> 12 yrs. old)

9 hrs

In addition, the most common cause of problems getting to sleep and staying asleep in children is poor sleep habits.  These habits or behaviors affect how we sleep and can include what we eat and drink, the temperature in our bedroom, our exercise routine, noises in the environment, the activities we choice to participate in before sleep, and the light we are exposed to before bedtime. 

    • Develop a 30-minute bedtime routine with the same calming activities completed in the same order each night.  The last step in the bedtime routine should happen in your child’s bedroom. Stick to a consistent limit and do not extend the bedtime routine (e.g., “one more book, please?!?!)
    • Avoid activities that tend to increase arousal such as running, jumping, wrestling, or video games.  Establish quiet time for about one hour prior to bed (e.g., reading stories, listening to music, working on a simple art project, etc.)
    • Your child’s bedtime and wake-time should be the same time each night.  This should be consistent across weekdays and weekends.  Some flexibility is fine on the weekends, but the difference in the schedule should not be more than about one hour.
    • Your child will sleep better in a cool, quiet, and dark environment.  A night light can help those children that are scared of the dark.  Avoid bright overhead lights.  The temperature in the bedroom should be cool (< 75 degrees F).
    • Reduce any noise from other family members moving around the house, watching television, and other noisy activities.
    • Provide your child with a light, healthy snack prior to bed.  Heavy meals within 1 to 2 hours of bedtime can disrupt sleep.  Your child should avoid caffeine (e.g., soda, tea, chocolate, etc.) at least 3 to 4 hours before bedtime.
    • Your child should spend time during the day exercising and playing outside.