Download Sleep Deficit and School Performance

Sleep Deficit and
School Performance
By: Mike Goff
Case Study – Sick Kids Hospital
►8
year old boy
► Parenting
complaint
 Very sleepy during the day. Falls asleep
at school.
 Healthy child -- cause of sleepiness is not
clear.
 Parents are very tired and very anxious.
► Bedtime
routine
► Bath, book, bed
► Sleeps in his own room and bed at 9pm
► Falls asleep easily with in 5 minutes
► Wakes at 11pm-1am and again at 2-4 am
► Fully aware – TV, computer, snack, parent’s
bedroom
► Falls asleep again 5 minutes to 2 hours later
► Very difficult to wake up in the morning
► Daytime






Tired and sleepy during the day
Allowed to nap at school (10 minutes)
2-3 hour nap after school
Poor concentration at school
Irritable during the day
Recently been diagnosed with a learning
disability
► Further
History revealed…
 No snoring, no crowding of upper airway, no
mouth breathing, not overweight (no risk
factors/symptoms of obstructive sleep apnea)
 Normal, conversive child
 Manages to wake himself up for karate class
 Still needed a daytime nap on the weekend
 No history suggestive of parasomnias or seizures
 No symptoms of Narcolepsy (sudden falling
asleep, sleep paralysis or hallucinations)
 No life events, no anxiety
► Strategies
employed by parents prior to
seeking medical help
 Prevention of nap
► No
change in night awakenings but…..
► Overall not tolerated, became very upset
► Requested school allow him naps.
 Earlier bedtime
► Not
tired so would not sleep
 Limit setting – not allowed into parents bedroom
► Adhered
to but no other limits set (TV, computer &
snack persist)
► Strategy
suggested provided by Sleep
Specialist
 To begin on the weekend
 Strict sleep hygiene
►Strict





bedtime, strict wake up time
Discontinue naps
Earlier bedtime
Cannot leave bedroom at night
Reward system to stay in room
Prohibit snacks, TV, computer
► Specific
Parental Advice
 Difficult challenge as employing
behavioural change
 Perseverance required
 Will take at least one month
 Do not disrupt cycle as one occasion can
reverse change
 Can call Sleep Specialist if concerns
► Phone
follow up one month later
 Doing better, more alert and better
concentration at school
 Short daytime nap of one hour
 Not allowed out of his bedroom
 Decreased frequency of awakenings
 Stricter sleep hygiene
What are Normal Sleep
Patterns?
► decreased
sleep duration from infancy to
adolescents
► dramatic decline in daytime sleep (scheduled
napping) between 18 months and 5 years
► irregular sleep-wake patterns between school and
non-school nights (going to bed later) and
oversleeping in the morning for middle ages
children and adolescents
► A gradual shift in later bedtimes
Changes in Sleep Patterns over
Time
► Evidence
to suggest sleep patterns and behaviours
have changed for children and adolescents from
previous generations
► Sleep durations have decreased but not sleep
needs – later bedtimes
► Cultural differences in sleep patterns
- co-sleeping of infants and parents
- available technology (cribs, monitors)
- normal vs abnormal sleep perceptions
How Much Sleep Should Children be
Getting?
INFANTS
(0 to 2 months): ................10.5 to 18 hours*
(2-12 months): ...........................14 to 15 hours*
*this number includes naps
TODDLERS/CHILDREN
(12-18 months): ........................13 to 15 hours *
(18 months-3 years): ...............12 to 14 hours*
(3-5 years): ..................................11 to 13
hours*
(5-12 years): ....................................9 to 11
hours
*this number includes naps
ADOLESCENTS (12-18 years): 8.5 to 9.5 hours
 With
puberty comes a delay in the
timing of teens' internal body
clocks, or circadian clocks, which
regulate sleepiness & wakefulness.
 Teenagers
aren't able to fall
asleep until after 10 p.m. or later,
and require a longer sleep period.
ADOLESCENTS
Unfortunately, with their school, work and
social commitments our teenagers are
deprived of the sleep that they naturally
require on a nightly basis.
Symptoms of Sleep Deficit
* Daytime symptoms are the same – disorder or
poor sleep hygiene
► Adults – yawning or complaining of fatigue
► Children
• Increased activity
• Low frustration tolerance
• Emotional flatness
• Increased aggression
• Functional deficits – mood, attention cognitive and
behaviour
Impact of Sleep Deficit
►
►
►
►
►
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►
►
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Daytime sleepiness
Moodiness
Hyper activity
Difficulties concentrating and focussing
Reduced coping skills
Behavioural problems
Performance deficits in social and academic areas
Distress for families
Studies have found a correlation between early rise times
and difficulties in attention and concentration in 5th graders
Prevalence
►
25 % of all children experience some type of sleep problem
at some point during childhood (Owens, 2005)
►
•
Recent studies
Over 14000 school ages children were questioned and
20 % of 5 yr olds and 6% of 11 yr olds had sleep
problems.
Another study found 43% of 8-10 yr olds had sleeping
difficulties.
•
•
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30-50% of children with severe mental disabilities
50-70% of children with autism
Sleep Deficit
►
1.
2.
Causes of sleep deficit
Poor Sleep hygiene
Sleep Disorders
Poor Sleep Hygiene
bedtimes are too late
 too much available to child in the room
- tv’s / dvd player
- computers
- cell phones / ipods
 socio-economic reasons – single parent needs to
drop child off at babysitters before work too early


Treatment - education
Sleep Disorders
There are 2 most common sleep disorders
in children.
1.
2.
Sleep Apnea
Restless legs / periodic limb movements
Restless Legs / PLM’s
►
►
►
Restless legs – the constant need or urge to move your legs when
awake
PLM’s – periodic limb movements while asleep
very abnormal disorder in children
Signs and Symptoms
-
sleep onset difficulties
Itchy or achy legs
“destroyed” bed in the morning
limbs hitting the wall
Difficulties getting back to sleep if awakened during the night
Obstructive Sleep Apnea
OSA
Obstructive Sleep Apnea is a
disorder in which a person stops
breathing during the night, perhaps
hundreds of times, usually for
periods of 10 seconds or longer.
Sleep Apnea
Signs
- Snoring
- Snorting / gagging
- Periods of silence between snores
-
Wakes up due to snoring
Case Study - 10 year old boy
► Parenting
complaint
 Heavy snoring occurring for duration of 2 years.
 Apnea was not witnessed by parents, however they
were concerned that he seemed to be “working very
hard to breathe during sleep”
 Very sweaty during the night
 Not sleepy during the day
 Had become irritable and moody
 Having trouble concentrating and was doing poorly in
school
► Physical
examination
 enlarged “kissing”
tonsils obstructing the
upper airway
 increased nasal mucosa
 otherwise healthy
► Sleep
Study
 Moderate Obstructive Sleep Apnea with an Apnea
Hypopnea Index (AHI) of 5/hour
 Long periods of snoring
 Shallow breathing
 Increased CO2 in the hemoglobin
 Oxygen levels drop due to apneas.
► Treatment
 Patient was referred to an ENT surgeon and
tonsillectomy plus adenoidectomy was
performed.
► Outcome
 Patient was monitored in an ICU overnight and
oxygen level remained normal.
 Within days his disposition, behaviour and
school work improved
 He slept better.
Treatment
►
Referred to a sleep lab
for a sleep study
 Involves staying over night
 Electrodes connected to
head, chest, legs
 Monitors brainwave patterns
(sleep), breathing, limb
movements, oxygen levels
and heart rate
 Produces a record of sleep
that is analyzed
 Report is generated
Treatments
Restless Legs / PLM’s
•
•
•
Gold standard in adults is
medication if showing symptoms
Always hesitant to medicate
children
Check blood levels (iron)
Sleep Apnea
•
If no facial abnormalities
•
Tonsils and adenoids removal –
cures 80-90%
•
Surgery to fix abnormalities
Meds to treat nasal
obstruction (allergies)
•
•
Weight loss
Insomnia
Insomnia – the perception that it takes too long to fall
asleep or that it is difficult to maintain sleep.
most often a symptom of another disorder
psychiatric problems or the treatment for them
(medication)
• Perception – parents or child perceives they are having
difficulties falling asleep or maintaining sleep.
• Problems in the family – marital, severe illness of a parent
• Anxiety – school
• Treatment – treat the cause (behaviour modification,
counselling)
•
•
Parasomnias
1. Nightmares - bad or frightening dreams occur during
REM
2. Night Terrors - anxiety or fear that occurs during
slow wave sleep
3. Sleep walking
4. Confusional arousals
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Are not disorders and do not cause sleep fragmentation.
Often occur during first third of the night
Sleep deficit or stress can increase frequency
Studies
► Many
studies have shown children with sleep
apnea demonstrate learning difficulties, inattention
and hyperactivity as daytime symptoms
► Studies
in the early 80’s showed some of the
children had been diagnosed with ADHD before
the sleep study – after treatment ADHD symptoms
greatly improved or disappeared altogether
What to do with the Information?
Conversations with parents need to
include questions about sleep patterns.
Teachers need to educate children about
good sleep hygiene and what is normal in
sleep – how much, what is abnormal
(childhood snoring, daytime sleepiness)
Websites
►
National Sleep Foundation - www.sleepfoundation.org
►
Canadian Sleep Society - www.css.to
►
American Sleep Apnea Association - http://www.sleepapnea.org/
►
National Sleep Foundation for Children - www.sleepforkids.org