Sleep Deficit and Sleep Deficit and School School

PerformancePerformance

By: Mike GoffBy: Mike Goff

Case Study – Sick Kids Case Study – Sick Kids HospitalHospital

►8 year old boy8 year old boy

►Parenting complaintParenting complaint Very sleepy during the day. Falls Very sleepy during the day. Falls

asleep at school. asleep at school. Healthy child -- cause of sleepiness is Healthy child -- cause of sleepiness is

not clear.not clear. Parents are very tired and very Parents are very tired and very

anxious.anxious.

► Bedtime routineBedtime routine► Bath, book, bedBath, book, bed► Sleeps in his own room and bed at 9pmSleeps in his own room and bed at 9pm► Falls asleep easily with in 5 minutesFalls asleep easily with in 5 minutes►Wakes at 11pm-1am and again at 2-4 amWakes at 11pm-1am and again at 2-4 am► Fully aware – TV, computer, snack, Fully aware – TV, computer, snack,

parent’s bedroomparent’s bedroom► Falls asleep again 5 minutes to 2 hours Falls asleep again 5 minutes to 2 hours

laterlater►Very difficult to wake up in the morningVery difficult to wake up in the morning

►DaytimeDaytime Tired and sleepy during the dayTired and sleepy during the day Allowed to nap at school (10 minutes)Allowed to nap at school (10 minutes) 2-3 hour nap after school2-3 hour nap after school Poor concentration at schoolPoor concentration at school Irritable during the dayIrritable during the day Recently been diagnosed with a Recently been diagnosed with a

learning disabilitylearning disability

► Further History revealed…Further History revealed…

No snoring, no crowding of upper airway, no No snoring, no crowding of upper airway, no mouth breathing, not overweight (no risk mouth breathing, not overweight (no risk factors/symptoms of obstructive sleep factors/symptoms of obstructive sleep apnea)apnea)

Normal, conversive childNormal, conversive child Manages to wake himself up for karate classManages to wake himself up for karate class Still needed a daytime nap on the weekendStill needed a daytime nap on the weekend No history suggestive of parasomnias or No history suggestive of parasomnias or

seizuresseizures No symptoms of Narcolepsy (sudden falling No symptoms of Narcolepsy (sudden falling

asleep, sleep paralysis or hallucinations)asleep, sleep paralysis or hallucinations) No life events, no anxietyNo life events, no anxiety

► Strategies employed by parents prior to Strategies employed by parents prior to seeking medical helpseeking medical help Prevention of napPrevention of nap

►No change in night awakenings but…..No change in night awakenings but…..►Overall not tolerated, became very upsetOverall not tolerated, became very upset►Requested school allow him naps. Requested school allow him naps.

Earlier bedtimeEarlier bedtime►Not tired so would not sleepNot tired so would not sleep

Limit setting – not allowed into parents Limit setting – not allowed into parents bedroombedroom►Adhered to but no other limits set (TV, computer Adhered to but no other limits set (TV, computer

& snack persist)& snack persist)

►Strategy suggested provided by Strategy suggested provided by Sleep SpecialistSleep Specialist To begin on the weekendTo begin on the weekend Strict sleep hygieneStrict sleep hygiene

►Strict bedtime, strict wake up timeStrict bedtime, strict wake up time

Discontinue napsDiscontinue naps Earlier bedtimeEarlier bedtime Cannot leave bedroom at nightCannot leave bedroom at night Reward system to stay in roomReward system to stay in room Prohibit snacks, TV, computerProhibit snacks, TV, computer

►Specific Parental AdviceSpecific Parental Advice

Difficult challenge as employing Difficult challenge as employing behavioural changebehavioural change

Perseverance requiredPerseverance required Will take at least one monthWill take at least one month Do not disrupt cycle as one occasion Do not disrupt cycle as one occasion

can reverse changecan reverse change Can call Sleep Specialist if concernsCan call Sleep Specialist if concerns

►Phone follow up one month laterPhone follow up one month later

Doing better, more alert and better Doing better, more alert and better concentration at schoolconcentration at school

Short daytime nap of one hourShort daytime nap of one hour Not allowed out of his bedroomNot allowed out of his bedroom Decreased frequency of awakeningsDecreased frequency of awakenings Stricter sleep hygieneStricter sleep hygiene

What are Normal Sleep What are Normal Sleep Patterns?Patterns?

► decreased sleep duration from infancy to decreased sleep duration from infancy to adolescentsadolescents

► dramatic decline in daytime sleep dramatic decline in daytime sleep (scheduled napping) between 18 months (scheduled napping) between 18 months and 5 yearsand 5 years

► irregular sleep-wake patterns between irregular sleep-wake patterns between school and non-school nights (going to bed school and non-school nights (going to bed later) and oversleeping in the morning for later) and oversleeping in the morning for middle ages children and adolescentsmiddle ages children and adolescents

► A gradual shift in later bedtimes A gradual shift in later bedtimes

Changes in Sleep Patterns Changes in Sleep Patterns over Timeover Time

► Evidence to suggest sleep patterns and Evidence to suggest sleep patterns and behaviours have changed for children and behaviours have changed for children and adolescents from previous generationsadolescents from previous generations

► Sleep durations have decreased Sleep durations have decreased butbut not not sleep needs – later bedtimessleep needs – later bedtimes

► Cultural differences in sleep patterns Cultural differences in sleep patterns

- co-sleeping of infants and parents- co-sleeping of infants and parents

- available technology (cribs, monitors)- available technology (cribs, monitors)

- normal vs abnormal sleep perceptions - normal vs abnormal sleep perceptions

How Much Sleep Should How Much Sleep Should Children be Getting?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 With puberty comes a delay in

the timing of teens' internal the timing of teens' internal body clocks, or circadian clocks, body clocks, or circadian clocks, which regulate sleepiness & which regulate sleepiness & wakefulness.wakefulness.

Teenagers aren't able to fall Teenagers aren't able to fall

asleep until after 10 p.m. or later, asleep until after 10 p.m. or later,

and require a longer sleep period. and require a longer sleep period.

ADOLESCENTS

Unfortunately, with their school, work and social commitments our teenagers are deprived of the sleep deprived of the sleep that they naturally require on a that they naturally require on a nightly basis. nightly basis.

Symptoms of Sleep DeficitSymptoms of Sleep Deficit

* Daytime symptoms are the same – disorder * Daytime symptoms are the same – disorder or poor sleep hygieneor poor sleep hygiene

► Adults – yawning or complaining of fatigueAdults – yawning or complaining of fatigue► ChildrenChildren• Increased activityIncreased activity• Low frustration toleranceLow frustration tolerance• Emotional flatnessEmotional flatness• Increased aggressionIncreased aggression• Functional deficits – mood, attention Functional deficits – mood, attention

cognitive and behaviourcognitive and behaviour

Impact of Sleep DeficitImpact of Sleep Deficit

► Daytime sleepinessDaytime sleepiness► MoodinessMoodiness► Hyper activityHyper activity► Difficulties concentrating and focussingDifficulties concentrating and focussing► Reduced coping skillsReduced coping skills► Behavioural problemsBehavioural problems► Performance deficits in social and academic areasPerformance deficits in social and academic areas► Distress for familiesDistress for families

► Studies have found a correlation between early rise Studies have found a correlation between early rise times and difficulties in attention and concentration times and difficulties in attention and concentration in 5in 5thth graders graders

PrevalencePrevalence► 25 % of all children experience some type of sleep 25 % of all children experience some type of sleep

problem at some point during childhood (Owens, problem at some point during childhood (Owens, 2005)2005)

► Recent studies Recent studies • Over 14000 school ages children were questioned Over 14000 school ages children were questioned

and and 20 % of 5 yr olds and 6% of 11 yr olds had sleep 20 % of 5 yr olds and 6% of 11 yr olds had sleep

problems.problems.• Another study found 43% of 8-10 yr olds had sleeping Another study found 43% of 8-10 yr olds had sleeping

difficulties.difficulties.

• 30-50% of children with severe mental disabilities30-50% of children with severe mental disabilities• 50-70% of children with autism50-70% of children with autism

Sleep DeficitSleep Deficit

► Causes of sleep deficitCauses of sleep deficit

1.1. Poor Sleep hygienePoor Sleep hygiene

2.2. Sleep DisordersSleep Disorders

Poor Sleep HygienePoor Sleep Hygiene

bedtimes are too latebedtimes are too late too much available to child in the roomtoo much available to child in the room

- tv’s / dvd player- tv’s / dvd player- computers- computers

- cell phones / ipods- cell phones / ipods socio-economic reasons – single parent socio-economic reasons – single parent

needs to drop child off at babysitters before needs to drop child off at babysitters before work too earlywork too early

Treatment - educationTreatment - education

Sleep DisordersSleep Disorders

There are 2 most common sleep There are 2 most common sleep disorders in children.disorders in children.

1.1. Sleep ApneaSleep Apnea

2.2. Restless legs / periodic limb Restless legs / periodic limb movementsmovements

Restless Legs / PLM’sRestless Legs / PLM’s

► Restless legs – the constant need or urge to move your legs Restless legs – the constant need or urge to move your legs when awakewhen awake

► PLM’s – periodic limb movements while asleep PLM’s – periodic limb movements while asleep ► very abnormal disorder in childrenvery abnormal disorder in children

Signs and SymptomsSigns and Symptoms- sleep onset difficulties- sleep onset difficulties

- Itchy or achy legs- Itchy or achy legs

- “destroyed” bed in the morning- “destroyed” bed in the morning

- limbs hitting the wall- limbs hitting the wall

- Difficulties getting back to sleep if awakened during the night- Difficulties getting back to sleep if awakened during the night

Obstructive Sleep ApneaObstructive Sleep ApneaOSAOSA

Obstructive Sleep Apnea is a Obstructive Sleep Apnea is a disorder in which a person stops disorder in which a person stops breathing during the night, breathing during the night, perhaps hundreds of times, perhaps hundreds of times, usually for periods of 10 seconds usually for periods of 10 seconds or longer. or longer.

Sleep ApneaSleep Apnea

Signs Signs - Snoring- Snoring

- Snorting / gagging- Snorting / gagging

- Periods of silence between snores- Periods of silence between snores - Wakes up due to snoringWakes up due to snoring

Case Study - 10 year old boyCase Study - 10 year old boy

► Parenting complaintParenting complaint Heavy snoring occurring for duration of 2 years. Heavy snoring occurring for duration of 2 years. Apnea was not witnessed by parents, however Apnea was not witnessed by parents, however

they were concerned that he seemed to be they were concerned that he seemed to be “working very hard to breathe during sleep” “working very hard to breathe during sleep”

Very sweaty during the nightVery sweaty during the night Not sleepy during the dayNot sleepy during the day Had become irritable and moodyHad become irritable and moody Having trouble concentrating and was doing Having trouble concentrating and was doing

poorly in schoolpoorly in school

► Physical Physical examinationexamination enlarged “kissing” enlarged “kissing”

tonsils obstructing tonsils obstructing the upper airwaythe upper airway

increased nasal increased nasal mucosamucosa

otherwise healthyotherwise healthy

► Sleep StudySleep Study

Moderate Obstructive Sleep Apnea with an Moderate Obstructive Sleep Apnea with an Apnea Hypopnea Index (AHI) of 5/hour Apnea Hypopnea Index (AHI) of 5/hour

Long periods of snoringLong periods of snoring Shallow breathingShallow breathing Increased CO2 in the hemoglobinIncreased CO2 in the hemoglobin Oxygen levels drop due to apneas.Oxygen levels drop due to apneas.

►TreatmentTreatment

Patient was referred to an ENT surgeon Patient was referred to an ENT surgeon and tonsillectomy plus adenoidectomy and tonsillectomy plus adenoidectomy was performed.was performed.

►OutcomeOutcome

Patient was monitored in an ICU overnight Patient was monitored in an ICU overnight and oxygen level remained normal.and oxygen level remained normal.

Within days his disposition, behaviour and Within days his disposition, behaviour and school work improvedschool work improved

He slept better.He slept better.

TreatmentTreatment

► Referred to a sleep lab Referred to a sleep lab for a sleep studyfor a sleep study

Involves staying over Involves staying over nightnight

Electrodes connected to Electrodes connected to head, chest, legs head, chest, legs

Monitors brainwave Monitors brainwave patterns (sleep), patterns (sleep), breathing, limb breathing, limb movements, oxygen movements, oxygen levels and heart ratelevels and heart rate

Produces a record of Produces a record of sleep that is analyzedsleep that is analyzed

Report is generatedReport is generated

TreatmentsTreatments

Restless Legs / Restless Legs / PLM’sPLM’s

• Gold standard in adults is Gold standard in adults is medication if showing medication if showing symptomssymptoms

• Always hesitant to medicate Always hesitant to medicate childrenchildren

• Check blood levels (iron)Check blood levels (iron)

SleepSleep ApneaApnea

• If no facial abnormalitiesIf no facial abnormalities

• Tonsils and adenoids removal Tonsils and adenoids removal – cures 80-90%– cures 80-90%

• Surgery to fix abnormalitiesSurgery to fix abnormalities

• Meds to treat nasal Meds to treat nasal obstruction (allergies)obstruction (allergies)

• Weight lossWeight loss

InsomniaInsomnia

InsomniaInsomnia – the perception that it takes too long to fall – the perception that it takes too long to fall asleep or that it is difficult to maintain sleep.asleep or that it is difficult to maintain sleep.

• most often a symptom of another disordermost often a symptom of another disorder• psychiatric problems or the treatment for them psychiatric problems or the treatment for them

(medication)(medication)• Perception – parents or child perceives they are Perception – parents or child perceives they are

having difficulties falling asleep or maintaining sleep. having difficulties falling asleep or maintaining sleep. • Problems in the family – marital, severe illness of a Problems in the family – marital, severe illness of a

parentparent• Anxiety – schoolAnxiety – school• Treatment – treat the cause (behaviour modification, Treatment – treat the cause (behaviour modification, counselling)counselling)

ParasomniasParasomnias

1. Nightmares - bad or frightening dreams occur during1. Nightmares - bad or frightening dreams occur during REMREM2. Night Terrors - anxiety or fear that occurs during2. Night Terrors - anxiety or fear that occurs during slow wave sleepslow wave sleep3. Sleep walking 3. Sleep walking 4. Confusional arousals4. Confusional arousals

Are not disorders and do not cause sleep Are not disorders and do not cause sleep fragmentation.fragmentation.

Often occur during first third of the nightOften occur during first third of the night Sleep deficit or stress can increase frequencySleep deficit or stress can increase frequency

StudiesStudies

►Many studies have shown children with Many studies have shown children with sleep apnea demonstrate learning sleep apnea demonstrate learning difficulties, inattention and hyperactivity as difficulties, inattention and hyperactivity as daytime symptomsdaytime symptoms

► Studies in the early 80’s showed some of Studies in the early 80’s showed some of the children had been diagnosed with ADHD the children had been diagnosed with ADHD before the sleep study – after treatment before the sleep study – after treatment ADHD symptoms greatly improved or ADHD symptoms greatly improved or disappeared altogetherdisappeared altogether

What to do with the What to do with the Information?Information?

Conversations with parents need to Conversations with parents need to

include questions about sleep patterns.include questions about sleep patterns.

Teachers need to educate children aboutTeachers need to educate children about

good sleep hygiene and what is normal ingood sleep hygiene and what is normal in

sleep – how much, what is abnormal sleep – how much, what is abnormal

(childhood snoring, daytime sleepiness)(childhood snoring, daytime sleepiness)

WebsitesWebsites► National Sleep Foundation - National Sleep Foundation - www.sleepfoundation.orgwww.sleepfoundation.org

► Canadian Sleep Society - Canadian Sleep Society - www.css.towww.css.to

► American Sleep Apnea Association -American Sleep Apnea Association - http://www.sleepapnea.org/http://www.sleepapnea.org/

► National Sleep Foundation for Children - National Sleep Foundation for Children - www.sleepforkids.orgwww.sleepforkids.org