UNDERSTANDING AND MANAGING CHILDREN’S SLEEP

Aims of this session

• To raise awareness of the sleep processes

• To look at why good sleep is essential and the effects of disturbed sleep

• To think about the modern barriers to good sleep

• To be familiar with what Cerebra sleep service offers, along with the charity as a whole

What is sleep?

A state of rest characterised by unconsciousness.

Def: Collins English Dictionary

A reversible state of reduced awareness of,

and responsiveness to the environment, usually

occurring when lying down, quietly with little

movement.

Def: Oxford Specialist handbook of Paediatric Neurology

Why is sleep essential?

• Sleep is still a biological enigma, it is still not fully understood, but we do know it is essential to life

• Growth hormones are released, usually during deep sleep

• Consolidation of memory and learning

• Essential to emotional well being

• Good concentration and behaviour

How the sleep-wake cycle usually works

• Circadian rhythms are biological cycles that repeat about every 24 hours

• They include patterns of sleeping, waking, activity, rest and eating

• A person’s ability to fall asleep and stay asleep is very much linked to the timing of their biological clock, which is reset each day by the use of cues i.e. Meal times, bed and waking time.

Melatonin and the sleep-wake cycle

• The timing of sleep (not its amount) is regulated by our circadian clock in the suprachiasmatic nucleus (SCN) of the hypothalamus in the brain. This clock also controls other biological rhythms such as body temperature and cortisol production, with which sleep-wake rhythm is normally synchronized.

• Melatonin is a hormone that is produced and released as darkness falls. It is produced in the pineal gland during darkness. It is suppressed by bright, natural or artificial light.

Sleep Disturbance in Children and Adolescents with Disorders of Development: its Significance and Management. Pages 12 &13. Gregory stores and Luci Wiggs

The two different states of sleep

NREM Non rapid eye movement

Stages 1 - light sleep, easily woken

Stage 2 – deeper but still quite easily woken

Stage 3 & 4 - deep slow wave sleep, blood pressure, heart rate and breathing slow, very difficult to wake

REM Rapid eye movement Skeletal muscle virtually

paralysed

Variable heart rate, blood pressure and respiration

Body temperature regulation impaired

Nightly sleep cycles

Indicators of regular sleep disturbance

Affect on a child:• Grogginess, confusion on morning

waking• Grumpy/unhappy • Excessive daytime sleepiness• Accident prone• Can’t concentrate well• Prone to sickness/coughs and colds• Displays of negative behaviour• Easily provoked to tears• Can’t easily retain information

learned form the day before

• Often hungry for sugary snacks

Affect on the family:Tiredness/ stressAccidentsPoor emotional and physical healthSibling rivalryBreakdown in relationships within family unitFinancial difficulty

The modern day culprits that can be barriers to good sleep

• TV, DVD, Computer and x-box, especially those in a child or young persons bedroom

• Mobile phones • Inappropriate expectations of

tired parents• Separation and loss• De-motivation of parents(maybe

depressed, stressed or ill)• Chaotic households/family

breakdown• A lack of wind down activities

and lack of daily bedtime routine

• Unhealthy diet and drinks• Lights being left on in

bedroom• Cluttered bedrooms full of

toys etc – busy decor and wall posters

• Medication

Sleep management – things to consider

• Timing of physical activity• A healthy diet/drinks• Timing of medications• Relaxing activity at least an hour before routine starts• Bedroom environment• Wake the child at a regular time in the morning• Ensure the child falls asleep alone• Use communication the child understands• Celebrate small steps• Consistent messages – parents saying the same things to their child• Timings – is this the appropriate time to start a sleep programme• What is appropriate for the child

Difficulty settling Difficulty settling Night wakingNight waking Difficulty sleeping aloneDifficulty sleeping alone

Early risingEarly rising

Unsuitable roomUnsuitable room

Ineffective routineIneffective routine

Reinforced wakingReinforced waking

Sleep onset association disorder

Sleep onset association disorder

Lack of understandingLack of understanding

See: Realistic expectations and reduction of bedtime

See: Realistic expectations and reduction of bedtime

Unsuitable bedtimeUnsuitable bedtime

Terrors/Night-mares/Pain/Bed wetting. See: Sheets (IS 3,4,5,6)

Terrors/Night-mares/Pain/Bed wetting. See: Sheets (IS 3,4,5,6)

See: Advisable bedroom environment

See: Advisable bedroom environment

See: Consistent structured routine and info sheet (IS1)

See: Consistent structured routine and info sheet (IS1)

See: Scheduled wakingSee: Scheduled waking

See: Robotic parenting technique and behaviour

See: Robotic parenting technique and behaviour

See: Gradual withdrawal technique and info sheet (IS7)

See: Gradual withdrawal technique and info sheet (IS7)

See: ToolsSee: Tools

See: RewardsSee: Rewards

IS1. Good sleep hygiene

IS1. Good sleep hygiene

IS2. Difficulty with night waking

IS2. Difficulty with night waking

IS3. Night terrorsIS3. Night terrors

IS4. NightmaresIS4. Nightmares

IS5. AnxietyIS5. Anxiety

IS6. Night time enuresis

IS6. Night time enuresis

IS7. Encouraging children to sleep alone

IS7. Encouraging children to sleep alone

FLOW CHART

Unsuitable bedtime

Unsuitable bedtime

Unsuitable bedroom

Unsuitable bedroom

Ineffective routine

Ineffective routine

DIFFICULTY SETTLINGDIFFICULTY SETTLING

Unsuitable bedroom

An advisable bedroom environment:

• Plain neutral walls, carpet and duvet cover, minimal furniture

• No toys or other stimulating objects in the room, or for toys to be out away in cupboards, boxed up or at least covered over at bedtime

• Black out blinds to ensure that the room is dark

Unsuitable bedtime

• Have realistic expectations

• Putting a child to bed when they are physically tired is going to be the right time for that child

• Signs of being tired are the rubbing of eyes, yawning and ‘grumpy’ behaviour

• If a child is in bed for a longer period than 15 minutes, they

are going to sleep, and are probably not tired.

Ineffective routine

A structured routine is very important. A routine should include a set waking up time every morning and a set going to bed time. An ideal bedtime routine would include:

• Quiet time (TV off)• Have a light snack/drink (avoiding caffeine)• Take a bath ensuring that it is relaxing rather than stimulating• Put on bedclothes• Brush teeth• Read a short story• Make sure the room is quiet and a comfortable temperature• Put the child to bed• Say goodnight and leave the room

Terrors/ nightmares/

pain/

bedwetting

Terrors/ nightmares/

pain/

bedwetting

Ineffective routine

Ineffective routine

Reinforced waking

Reinforced waking

NIGHT WAKINGNIGHT WAKING

Terrors/nightmares/pain/bedwetting

Scheduled waking technique:

• This involves waking your child sometime prior to a sleep waking episode, generally when the child is waking up at the same time each night

• Determine the time or times when the child tends to wake during the night(use a sleep diary if required)

• Wake the child approximately 15 minutes before typical waking time. Do not fully wake the child, just gently touch them or speak to them until they become awake and then let them fall straight back to sleep.

• If the child fully wakes up, alter the timing the next night to approximately 25 minutes before their normal wake time. Continue with this until the child is no longer fully waking, and then gradually remove the scheduled waking.

Reinforced waking• Robotic Parenting Technique: After you have said goodnight,

become ‘robotic’ by keeping conversation, eye contact and cuddles to an absolute minimum or even better to zero!

• Behaviour Including the ABC model: A parent’s response to a child once they have said goodnight to a child is crucial, as without even realising it, a parent can create and maintain as unwanted behaviour in their child.

Sleep onset association

disorder

Sleep onset association

disorder

Reinforced waking

Reinforced waking

Difficulty sleeping aloneDifficulty sleeping alone

Sleep onset association disorderNeeding something or someone in order to get to sleep:

• Gradual withdrawal technique.

• Gradual withdrawal of an object (e.g. bottle or person)

• Removing parent - start off next to your child and gradually move away from your child over a period of time, remaining in each position for 3-4 days at a time.

• Removing a bottle - either dilute the milk gradually or you can reduce the amount of milk gradually.

Lack of understandingyour child may not realise that they should stay in bed, or what you expect of them when

they wake up.

Lack of understandingyour child may not realise that they should stay in bed, or what you expect of them when

they wake up.

If it is light outside the child may believe it is morning, if they wake up and feel alert they may also assume it is morning and time to get

up.

If it is light outside the child may believe it is morning, if they wake up and feel alert they may also assume it is morning and time to get

up.

Early risingEarly rising

Lack of understanding

ToolsTools

There are many bed time tools on the market that can aid in helping your child to understand that it is still bedtime, including alarm clocks, such as the bunny alarm clock and the Gro light clock.

RewardsRewards

These can include praise, stickers, toys, money or food, to name a few. Or you could implement a reward chart. Try to remember that what a child finds rewarding can change regularly, so make sure your child is motivated for their reward.

Remember..........

• If you put your child into their PJ’s just after tea and then they watch TV and play before going to bed, they will not recognise getting ready for bed as a trigger or cue to bedtime.

• A lot of children need help in recognising these cues, i.e. A child with visual impairment may not see darkness fall.

• A consistent bedtime routine helps the child to understand what is expected of them, it can make them feel safe and secure.

The role of the sleep practitioner

• To help parents of children aged 0-16 yrs, who have a neurological condition, learning difference or developmental delay.

• To offer information and guidance to families, by post, telephone, email or face to face.

• To set up and run sleep clinics across the country, offering one to one appointments.

• To offer sleep workshops and talks to groups of parents/carers or professionals, to raise awareness about sleep related issues.

• Most services offered by Cerebra are FREE to parents.

What we don’t do

• Move in

• Provide medical advice

• We do not provide equipment at this time

• Offer 24 hour support

Who to contact:What next?

If you would like further information please do not hesitate to contact us:

• Sleep team contact (general) – sleep@cerebra.org.uk

• Moira Draper (North) moirad@cerebra.org.uk 01942 719887 – 07818 829299

• Patricia Everitt (Central) patriciae@cerebra.org.uk 07920106217

• Marion Miller (South) marionm@cerebra.org.uk 01935 824764 – 07827 829300

• Sarah Gait (South West) sarahg@cerebra.org.uk 07780983122

A mother’s feedback

“ Thank you for helping livia and our family. Our little girl’s condition made it difficult for her to sleep through the night. Cerebra’s sleep practitioners came to visit us at home and listened to our problems and are existing routine. We put a new routine in place and although I had my doubts it would work at first, within just a few nights we were all getting a full nights sleep! Everyone is now much happier thanks to the advice and support from Cerebra’s sleep team. “

Cerebra - what the charity can do to help

Support Information(social media,

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Contact Cerebra:

FREEPHONE 0800 3281159

Cerebra, FREEPOST SWC3360, Carmarthen SA31 1ZY

www.cerebra.org.uk