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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 ► ► ► ► ► ► ► ► ► 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. • • • 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 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