2016 CAPHC Annual Conference

October 23-25, 2016

Halifax, NS

Sleep Disorders in Canadian Children:

What Can We Do to Ensure Better Nights and Better

Days for Children and their Families?

Penny Corkum, PhD, Registered Psychologist

Professor, Department of Psychology & Neuroscience; Psychiatry

Dalhousie University

IWK Scientific Staff; CEH ADHD Clinic

Shelly Weiss, MD FRCPC, Pediatric Neurologist

Professor, Faculty of Medicine,

Hospital for Sick Children, University of Toronto

1

Outline

Introductions & Objectives

Xavier’s story

Importance of sleep

Access to services in Canada

Barriers to care

Guidelines for pediatric sleep

Service delivery models

Introduction to Better Nights, Better Days

Discussion/Questions

2

Main Goal for Workshop

Determine how we can all work together (as

administrators, policy makers, researchers,

clinicians, and families) to improve paediatric

sleep assessment and treatment in Canada so that

there is access to services for all in need, no matter

where they live

3

Importance of Sleep

Causes of Sleep

Disorders/Problems

Prevalence

25% of typically developing children

≥ 80% of children with physical and

mental health disorders

Causes

Sleep disorders

Lifestyle factors

5

Classification

DSM-5 (2013) / ICSD-3 (2013)

10 different sleep disorders/sleep disorder groupings

1) Insomnia Disorder

2) Hypersomnolence Disorder

3) Narcolepsy

4) Breathing-related sleep disorders

5) Circadian rhythm sleep-wake disorders

6) Non–rapid eye movement (NREM) sleep arousal disorders

7) Nightmare disorder

8) Rapid eye movement (REM) sleep behavior disorder

9) Restless legs syndrome

10) Substance/medication-induced sleep disorder

6

Insomnia

Most common sleep disorder in TD children and children with mental health and physical health disorders

Criteria

Reports of difficulties falling asleep, staying asleep, and/or early waking

Daytime consequences of sleep problem

Adequate opportunity for sleeping

Frequent (≥3x/wk) and chronic (≥3 mos)

Not explained by another sleep-wake disorder, medical condition or mental health disorder

7

Lifestyle Factors

People of all ages are sleeping less now than ever before

Sleeping about 1 hour less now than at the beginning of

the century

Reasons…

Electronics

Sleep not seen as a priority

Extra-curricular activities

Social activity

School start times

Results in a Social Jet Lag & Sleep Debt

8

Factors Affecting Sleep in Children

Sleep

Genetics

Sleep Environ-

ment

Family/ Parents

Health

Develop-ment

Social –Emotional

Social –Cultural

Sleep Practices

Slide courtesy of Jodi Mindell

9

Chronicity of Sleep Disorders

Transient and persistent sleep problems

Genetics may play the largest role in stability of

sleep problems

Stability depends in part on the type of sleep

problem and the treatment provided

Even when a sleep problem does not persist it

predict later behavioral/mental health problems

10

Cognition/

Learning

Mental

Health

Physical

Health

Quality

of Life

Consequences of Sleep Disorders 11

Consequences of Sleep Disorders

Community

School

Family

Child

12

Importance

Sleep problems could put individuals at risk for mental

health or physical health disorders

Sleep problems could mimic mental health disorders and as

such need to be considered as a differential diagnosis

Sleep problems could exacerbate mental health

problems/increase symptoms severity and chronicity

Treatment of sleep problems may reduce impairment and

may even act as an enhancement therapy (e.g. make other

therapies more effective)

The treatment of mental health problems with medication

may increase sleep problems

13

How could poor sleep in

children affect your

service?

14

Access to Services

in Canada

Facts about the gaps in

Canadian resources for sleep

Despite high prevalence of sleep

disorders/problems, chronicity, and significant

impact, they are often unrecognized and under

treated by clinicians

Main Reasons

Limited awareness and knowledge of the importance

of sleep

Limited skills in this area for health care providers

Limited access to services and resources/tools

16

Access to services to diagnose

Obstructive Sleep Apnea in

Canadian children

What is the gold standard for diagnosis?

Where are the sleep clinics?

Where are the pediatric sleep practitioners?

17

PSG is gold standard to

diagnose OSA

18

Canadian Sleep Society Clinic Map

www.css-scs.ca

19

Western Canada 20

Eastern Canada21

22

Pediatric sleep resources for

OSA in Canada

Survey study of pediatric sleep practitioners and sleep

laboratories

Results

No sleep practitioners (for OSA) or PSG available in

Yukon, NWT, Nunavut, Saskatchewan, Nova Scotia, New

Brunswick, PEI, NFLD/Labrador

Wait time for PSG varied from < 1 months to 1.5-2 years

Lack of resources and services for pediatric sleep

disordered breathing has great geographical disparity

23

24

Service Providers

CSS listing for sleep clinics, insomnia treatment providers, dentists (searchable by province)

https://css-scs.ca/resources/types-of-providers

Diagnosis

Physicians

Psychologists

Treatment

Physicians

Psychologists and other allied health professionals

Dentists

Sleep Consultants

http://goodnightsleepsite.com/toronto/

Others (e.g., naturopath, chiropractor)

Main concern – Lack of regulation of field and some service providers!

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Barriers to Care

Limited awareness and

knowledge of the importance of

sleep

27

28

29

30

Methods

124 Canadian health care providers were surveyed

about barriers and facilitators

Included: physicians, nurse, psychologist, social

workers

31

32

33

New RCPSC initiative in sleep

education

Currently no route to certification for subspecialist physicians who practice sleep medicine in Canada

As of July 2016, there will be a AFC (Area of Focused Competence/Diploma) in sleep medicine

1 year – include ongoing maintenance of certification

Eligible for physicians who are specialists in : ENT, respirology, psychiatry, neurology, developmental pediatrics

34

Guidelines for

Pediatric Sleep

http://sleepfoundation.org/ho

w-sleep-works/how-much-

sleep-do-we-really-need

Suggestion: Monitor sleep

amounts and mood over a few

days during which time the

child is allowed to sleep until

he/she awakens

spontaneously (during

vacation is best)

Concern: Sleep duration

recommendation for school-

aged children previously was

10-11 hours but now 9-11 and

even 7-12

36

Participation 2016 Report Card37

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Recommended hours of sleep

Age 5-13 years: 9-11 hours

Age 14-17 years: 8-10 hours

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• Healthy sleep is the goal for all infants, children and adolescents

• Guidelines to evaluation and treatment of sleep disorders

• Position statement endorsed by College of Family Physicians, Canadian Psychiatry Association and Canadian Sleep Society

• Endorsement by Canadian Pediatric Society (pending)

Published Jn Can Acad Child and Adol Psychiatry, Vol 23 (3), 2014

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41

What do you see as the

main barriers to sleep

services in your

communities?

42

Service Delivery Models

Current Service Delivery

Large differences between provinces and regions

(urban/rural)

Focus on obstructive sleep apnea

Use of medications that do not have efficacy data to

support their use in children

Limited access to behavioural treatments

44

Measurement of Sleep

PSG ActigraphySleep Diary

Questionnaires

Interviews

Objective Subjective

45

Best Practices – Assessment

• PSG/MLST

• Actigraphy/ Videography

• Interviews/ Sleep Diaries

• Screening/ Questionnaires

46

Best Practices – Assessment

• PSG/MLST

• Actigraphy/ Videography

• Interviews/ Sleep Diaries

• Screening/ Questionnaires

47

Best Practices –Treatment

• Medication

• Specific behavioural sleep interventions

• Implement healthy sleep practices

• Psycho-education

48

Best Practices –Treatment

• Medication

• Specific behavioural sleep interventions

• Implement healthy sleep practices

• Psycho-education

49

Suggested Model: Stepped Care

Individualized intervention provided by sleep medicine

specialist

Individualized intervention by highly trained health professional

(non-sleep specialist)

Manualized in-person individual or group intervention provided by trained health

professional (non-sleep specialist)

Self (parent) administered interventions with human support (non-specialist)

Self (parent) administered interventions (no direct human support) BNBD-TD / BNBD-NDD

Public education/ prevention/ screening

*adapted from Espie, C.A. (2009). “Stepped Care”: A health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep, 32(12), 1549-1558.

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Introduction to

Better Nights,

Better Days

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http://betternightsbetterdays.ca/

http://ndd.betternightsbetterdays.ca/

Session 1: Sleep Information

Session 2: Healthy Sleep Practices

Session 3: Settling to Sleep

Session 4: Going Back to Sleep

Session 5: Looking Ahead

Z

ZZZ

BNBD Intervention Program

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Program Tools and Supports

Daily online Sleep Diary

allows participants to track their

results and see patterns in their

child’s sleep and behaviour Sleep Diary

Weekly

Activities

and Reviews

Track Your

Progress

Participants receive feedback on their

progress

Activities help participants

make positive changes to their

child’s sleep

• Learn how to create sleep

routines, a healthy sleep

environment, and practice

techniques to reduce stress

54

BNBD-TD

Randomized Control Trial

Goal: 500 participants

55

Who Can

Participate

http://betternightsbetterdays.ca/

56

Steps to Study ParticipationWebsite Self-Screen

Screening

Eligibility Assessment

Baseline

Randomization

Better

Nights,

Better Days

Intervention

Usual Care

4 Month Follow-Up

8 Month Follow-Up

Study End 57

Recruitment and Enrollment Update

• As of Oct 21, 2016, we have had:– 852 parents express interest in the study– 503 consent to screening– 293 consent to participate in the study– 204 deemed eligible– 196 start baseline

• Recruiting 400 English-speaking parents/guardians from 4 Canadian regions (Atlantic, Central, Prairies, West Coast/Northern) – 100 parents per region– Atlantic Canada region has met quota and is not closed

• Recruiting 100 French speaking parents across Canada (Winter 2017)

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Discussion/

Questions

How to improve awareness and knowledge of the

importance of sleep?

How to train health care providers in sleep assessment

and treatment?

How to increase equitable accesses to services and

resources?

How to work together to to improve paediatric sleep

assessment and treatment in Canada so that there is

access to services for all in need, no matter where they

live?

What would you need to make a stepped care model

for pediatric sleep work in your service?60

Thank you

Web Resources

Canadian Sleep Society http://www.css.to/

National Sleep Foundation http://www.sleepfoundation

.org

Star Sleeper http://www.professorgarfiel

d.org/pgf_StarSleeper.html

Insomnia Rounds http://www.insomniarounds

.ca

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penny.corkum@dal.ca

http://myweb.dal.ca/pvcorkum/