Think you are a magician at solving childhood sleep problems? It may not feel that way with the next evasive 11-year-old you see. With school-aged patients, you may need to figure out some "sleep secrets" to be of help with this extremely common, important, and fixable problem.
Parents often do not even know about how their children are sleeping, even though they live with the consequences of irritability, fights in the morning, dropping grades, and reports from school about sleeping in class.
Sleep issues in older children highlight the importance of starting the visit by talking to the child. When the history turns to the parent, the child knows their game is up, and answers are less likely to be complete.
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I like to fit sleep in with questions about other aspects of the child’s functioning, such as homework and friendships. Ask what time he heads for bed on weekdays, and ask separately about weekends. What time is he finally asleep? What is he doing between getting in bed and falling asleep, such as listening to music, watching a movie, texting/sexting friends, or worrying? Once asleep, does she stay asleep? If not, is he: frightened (anxiety, posttraumatic stress disorder [PTSD], sleep apnea)? Coughing (asthma)? In pain (arthritis, eczema, tumors)? Not sleepy (caffeine, nicotine, other medicines, phase shift, exercising too late in the day)? Doing homework (forgot, attention-deficit/hyperactivity disorder [ADHD], obsessive compulsive disorder [OCD])? Hungry (on stimulants, deprived)? On the computer (socializing, defiant, avoiding parents)? Receiving calls from friends whether wanted or not? Writing the Great American Novel (bipolar)?
What time is she waking up? Does he feel rested? How late does she sleep in on weekends? Does he fall asleep in class? After school? In the car? For no reason (narcolepsy)?
Parents will be needed to report on snoring, restless sleep, sleepwalking, or night terror behaviors of which the child is unaware.
Of course, you don’t need to ask all of these questions at every visit, but if the answer to "How many hours of sleep in a row do you get on weekdays?" yields less than 8 or there are behavior, academic, or mood problems, it is worth getting the complete picture. Using a sleep questionnaire such as Sleep Habits Questionnaire and a sleep diary when working on these issues makes the exploration more efficient.
Sleep classification systems usefully distinguish issues with sleep onset (insomnia), during sleep (parasomnia), and daytime alertness. Sleep problems often are combinations requiring combined management.
Although the sleep-delaying effects of caffeine, nicotine, naps, and exercise within 2 hours of bedtime may be known to doctors, children are not aware, and parents may not realize that their child has indulged. Simple education to refrain after 6 p.m. may suffice, although the motivation to stop tobacco is more complex.
Some school-age or teen sleep problems can be solved by parent interventions such as setting/enforcing regular bedtimes, closeting electronics and cell phones after 9 p.m., and regular waking 7 days per week. It is always best to involve the child in negotiating the plan with the goal of helping them feel better, function better at school, or have help setting limits on friends. Even teens may appreciate being able to blame not answering their phone on their "mean parent" or doctor! As an advocate for the child, you can help moderate the plan from the parent’s suggestion of an 8:30 bedtime to a more realistic goal of 10 p.m. in order to help it succeed.
Insomnia can be very distressing to the child, and distress can both cause and exacerbate the problem. Many of these children are anxious types for whom a soothing bedtime routine (one is never too old to benefit from being read a story), a back rub, or a chance to debrief the day to relieve stress that might otherwise keep her awake can be very helpful. Simply removing the alarm clock or turning it around for the time to be hidden may help the child anxious about getting enough sleep. Some children with insomnia have anxiety at the disorder level that is problematic in several aspects of their lives, such as school performance or awkwardness with peers, that deserves cognitive behavior therapy or antianxiety medication.
Although 85% of children with ADHD have preexisting sleep problems, adjusting their stimulant (remembering that sometimes another dose after dinner helps them settle to sleep), improving the sleep routine, or adding melatonin or clonidine 1 hour before bedtime may be necessary to getting enough rest. Other over-the-counter (Benadryl) or prescribed theophylline medications also need to be considered as reasons for insomnia.