Lil Bro: Mummy – I can’t sleep
Me: Please, its past nine o’clock, what are you doing still up? You have to go to sleep now or you’ll be exhausted at school tomorrow! [Plus I just got started on this week’s episode of “This is US” and a tub of ice cream and I really fancy a rest!]
Lil Bro: But I can’t sleep.
Me: Just close your eyes and lie still! [Grrr]
I’m sure many of you are nodding in sympathy at this experience. Lil Bro who usually has no difficulty getting to sleep is having a spate of “I can’t get to sleep”. We have tried cuddling, cajoling, comforting, reassuring and now we are at the frankly fed up stage.
Children with poor sleep can have difficulties with poor concentration, over-activity, behavioural problems, day-time sleepiness, bed-wetting, obesity, increased clumsiness, depression and worse academic performance. Equally bad, the lives of their parents and entire family are also grossly affected. As parents of infants, we have all been there, but somehow I’ve taken immense umbrage at this recent spell of poor sleep because Lil Bro is now 7 years old and well able to put himself to sleep.
When Big Sis was a wee mite, I was the rabid sleep-deprived mother heckling the sleep experts flown in from abroad to teach us doctors about sleep EEG’s: “Can you tell me why, WHY, how, HOW can a baby go from stage 4 deep sleep to AWAKE and CRYING just by a 10 degree tilt to lay them in the cot????!!!! Give me the EEG on how that happens…!!!! What’s the possible mechanism???!!!”….zzzzzzzz – bonk.
So, I must now be the envy of most mums, as for the last few years I have had the pleasure of working with Paul Gringras a.k.a. the Professor in charge of the national Sleep Medicine centre at The Evelina Children’s Hospital. I have been working with him on an international multi-centre drug trial for sleep medication in children with neurodisability (mainly autism), which he is leading. His centre is hi-tech with observational sleep bays where children can sleep-over and be observed on video to capture what is going on, often plugged into electronic equipment that monitors breathing, brain and movement activity and I was fortunate enough to be able to sit in on consultations with Consultant Paediatrician Dr Mike Farquhar. It all sounds very medical. What then has a shrink got to do with sleep?
Well, it turns out that the majority of sleep problems in children are “behavioural”. Yes, there are known medical causes of disturbed sleep, e.g. restless leg syndrome, obstructive sleep apnoea, sleep walking and so on, but for the majority of cases in children who are otherwise fit and well, it is what children and their parents are in the “habit” of doing that is keeping them all awake.
What constitutes a sleep problem?
The definition of a “good night’s sleep” is variable from person to person. As a student, a full 10 hours was a requisite for me often causing tardiness to morning lectures. At weekends waking before 10am was unheard of. As a junior doctor, 4 hours sleep constituted immense good fortune and developed in me the very useful skill of being able to sleep anywhere, anytime – zzzzzz-bonk. These skills came in handy with babies that hadn’t read Gina Ford. The early years of parenthood are a sleep-deprived blur, but once the youngest had reached the milestone of 3 years, a more acceptable routine of 10 hours of continuously sleeping children was established –albeit the 6am wakenings were still somewhat painful.
In reality sleep requirements differ between children of different ages, but also between different children. Average daily sleep duration ranges between 10-17 hours at 6 months to 8-11 hours at age 11 years. This variability colours people’s ideas of what constitutes a sleep problem, and I am often bemused by some parents who come in desperation seeking medication for 10 year old children that sleep from 7:30pm to 6am: thinking with a mix of incredulity “What planet are you on? That’s almost a full 11 hours!” and admiration “Please tell me how on earth you get a 10 year old to go to bed at 7:30pm!” With these children who are getting hours of sleep within the acceptable range, the sleep is only classified as problematic if it represents a dramatic change to sleep pattern and/ or if there is any evidence of daytime sleepiness. If the answer to both is “No”, then one should feel reassured. However, for a psychiatrist, we know that often a parental cry for help of “My children don’t sleep!” is actually a cry of “I’m struggling to cope with my children when they are awake!” This differentiation is critical as the treatment strategies for the two problems are entirely different.
Aside from these perceptual sleep problems, the three main problems involving sleep are: struggling to fall off to sleep, waking in the middle of the night and co-sleeping.
Struggling to fall off to sleep
Problems falling off to sleep are often cited as a struggle. Sleep latency (to give it its fancy name) averages 19 minutes in 0-2 year olds and 17 minutes for 3-12 year olds. Anything over 30 minutes is classed as problematic. However, these average latency numbers involves the child actually wanting to fall asleep and lying in their bed in the dark, and any of the children’s wonderfully inventive delaying tactics “One more story”, “I need the toilet”, “I need a drink”, “Mummy sing to me” are clearly “behavioural” and not really to do with a “medical” sleep problem.
As part of our natural sleep cycle, we all wake at some stage in the night. Most of us are able to close our eyes and will quickly fall back to sleep again such that we don’t realise that we were ever awake or close to waking. Where night waking is problematic is where children are unable to settle themselves back to sleep and start playing the drums and waking the entire neighbourhood in the middle of the night. Typically these children then decide to fall asleep at around 7am, just when they need to go to school, and then they either miss school as their parents are unable to drag them there, or they doze off in the classroom and can’t learn effectively. You can imagine the impact of this on their parents.
OK I am as seduced by the lovely mental images of canoodling up with my young children for a snooze as the next parent. Many parents are seduced into this as children love it and it often helps them to fall asleep more quickly, but each time you get the inkling that this might not be such a bad idea, I would like you to imagine you sleeping with your 15 year old son or daughter. If you don’t do something to nip it in the bud while your children are young, they might not “grow out of it” and it will be a battle to get them out of your bed and are not used to falling asleep alone. I would suggest that you turf them out of sleeping in your bed by age 7 years otherwise it may get horribly entrenched. Of course, the early morning “I’m awake” cuddles in bed are still fine!
So what can we do to help our children to sleep?
My paediatric colleague Dr Jess Turnbull who is starting up the community Evelina Sleep Centre off-shoot in my work-place has the following advice for encouraging good sleep habits:
- Physical exertion in the afternoon – encourage daily exercise in children in the day-time. This will wear them out and make them physically ready to sleep.
- Consistent daily bedtime – as with all things behavioural, if there is an established routine and children know what is going to happen and that they cannot get out of it, then compliance is more forthcoming.
- Last drink 1-1.5 hours before bed – this reduces the likelihood of children needing to get up to go to the toilet in the night, which may make it harder for them to fall back to sleep.
- Avoid sugar/ caffeine – fairly obvious really.
- Try and have a routine wind-down regime in the hour before bed time (calming activities such as reading, bath, calming music). The idea is to try and calm your child down so that they are in the right physical and mental frame of mind to sleep.
- NO SCREENS (TV, phones, tablets) for at least an hour before bed. TV programmes, phones and tablets are all designed to capture interest, attention and brain activity. Ideally, you want to be winding down your child’s brain activity in the hour before bed so turning off screens is desirable. I know that many parents are tempted by having a TV in a child’s bedroom to keep them quiet and contained in the day, but it then requires discipline for children to stop watching it late into the night. Only be happy to provide a child with a TV in their room if they possess such discipline or you are happy for them not to sleep.
- Having a transitional object (eg. a soft toy) to develop sleep confidence and a healthy sleep association. This can be particularly helpful for younger children.
- Working towards your child falling asleep by themselves in their own bed. If a child is used to sleeping with you, then you should gradually withdraw yourself. For instance, first get the child accustomed to sleeping with you sitting next to them, then in a chair in the room, then outside the room in sight, then outside the room out of sight. It takes time, patience and grit to do this as some children will really dig their heels in, but if you view this as ultimately for their own good (which it is) then it is more possible to undertake.
- Limit setting on ‘fussing’ after ‘lights out’. If you draw out the bedtime process with attending to the child’s fussing, then it defeats the purpose as it will get later and later and only teaches children that you will give them attention for their fussing which encourages them to continue to do it.
- Reducing attention given after ‘lights out’ to prevent reinforcing messages of attention (e.g. avoid eye contact and conversation): good old pursed lips and silent treatment. There is a rule in my house that after the official bedtime, “Nice mummy” goes to bed and “Horrible mummy” her doppelganger comes in her stead. Nice mummy cannot be accountable for the actions of horrible mummy and so it is much better for children to just go to sleep.
But I had done all this and still, Lil Bro could not get to sleep. This was even more annoying and I was starting to put it down to “naughtiness”.
The next day, I was lucky enough to be chairing a talk on Smith Magenis Syndrome (a genetic disorder which was frequently associated inverted sleep cycle – i.e. day time sleepiness and night time waking) and my colleague Paul Gringras was the invited expert. Half-way through his talk, he spoke about the solution to keeping these children awake in the day was by using blue light to cut off melatonin secretion in the day. Melatonin is the natural hormone our pineal glands secrete to tell us it is night time and aids sleep. It’s pharmaceutical form can be bought over the counter in the USA as a treatment for jet-lag and is a commonly prescribed sleeping tablet.
Hang on a minute, Lil Bro had recently been given a fantastic blue Star Wars light sabre light that he had been insisting on turning on as a night light when he went to bed….this type of blue light is used to KEEP CHILDREN AWAKE….aargh. We had been inadvertently switching off our son’s natural melatonin secretion via Luke Skywalker’s weaponry.
I double checked Jess Turnbull’s list of advice and saw that I had overlooked: “Use a red coloured light if night light is needed (does not interfere with natural melatonin production)”. That evening, I told Lil Bro that an important sleep expert had told me that his special blue light was keeping him awake. Lil Bro likes science and reason and he felt good that there was a reason for his insomnia and that it was not just “bad behaviour”. It’s silly mummy’s fault for letting you have that light on (he likes not being to blame). Releasing him of anxiety about insomnia and allowing the release of melatonin by switching off the offending blue light sabre led to zzzzzz-bonk!
The info from this post came from: Turnbull & Farquhar 2016. Fifteen-minute consultation on problems in the healthy child: sleep. Arch Dis Child Educ Pract Ed 101: 175-180.
Today, I have been at the British Mecca for Psychiatrists, the annual conference of the Royal College of Psychiatrists. We have taken over the ICC in Birmingham where the entrails of the Tory party conference are still being tidied away. I did have a double take moment of “Lord, I’m at the wrong conference” when I was greeted with the “A Country That Works For Everyone” signage which dwarfed our college’s diminutive logo. The juxtaposition being even greater because within the medical profession, the psychiatrists are probably the most left leaning, our life’s work being in the care of some of the most discriminated and disadvantaged in society who are not usually the Conservative party faithful.
I’m not really a “conference” person. Brown-nosing and networking brings me out in hives, but I have been around long enough to know just enough people to make small talk to. At shrink-fest this usually involves grumbling about:
- Lack of in-patient beds
- Being mistaken for a psychologist
- Not being recognised as “proper doctors”
- Lack of medical students wanting to train in our wonderful specialty
Mostly, I am robust enough to endure colleagues darting-off mid conversation to talk to someone else of greater importance. Occasionally, I bump into old supervisors and I have to admit to them that I’ve chucked in my research and pretend to be blissfully happy about this decision. Other times I catch sight of another female ex-researcher and we indulge in metaphorical hand-holding and sighs of “it’s so hard with children”. If it gets too much, I hide out in the loos checking social media. People post me pictures of dead animals (anti-hunting friends – don’t ask).
It might sound awfully depressing, but I also learnt these amazing nuggets:
From the wonderful Dr Andrea Danese, an Italian contemporary who heads up the Stress Lab at the Institute of Psychiatry. He once gave me a good recipe for pesto and today, he taught me this:
- If you get a nasty cut that gets infected, the skin gets red and “inflamed”. If we took a sample of your blood, we would find raised levels of proteins e.g. C-Reactive Proteins which are called inflammatory markers.
- Stress can cause an inflammatory response, just like an infection in quality but milder. This is to prepare the body to fight stress, in the same way that your body prepares itself to fight an infection.
- Children and adults with depression have raised inflammatory markers.
- These markers are even more raised if there was evidence of early life stress such as childhood maltreatment.
- Adults with raised baseline inflammatory markers are more likely to have recurrent and chronic depression which does not respond to traditional anti-depressant treatments.
- Anti-inflammatory agents usually used as pain killers after surgery (COX-2 inhibitors) have been successful in treating depression, particularly in people with high baseline inflammatory markers.
I know, this sounds dull to you, but to shrinks this is like: Yay! Another drug (cheap too) – maybe they won’t confuse us with psychologists anymore?
I also learnt from Professor Ian Goodyear (Head of Child Psychiatry at Cambridge University) that in his longitudinal studies of depression he divides us parents into the following groups which form a measure of “suboptimal family environment”:
- Optimal (that’s me of course)
- Aberrant (well-meaning but missing in action or clueless)
- Discordant (bickering and self-interested)
- Hazardous (deliberately cruel and abusive)
- Not surprisingly, the majority of children raised by “hazardous” parents end up with all kinds of mental health problems.
And from Professor Eric Taylor, the grand don of my field neuropsychiatry:
- 20-70% of children with ADHD continue to have symptoms into adulthood.
- 50% have another psychiatric diagnosis by age 27 years (mainly anti-social behaviour, drug misuse or depression).
- Children with ADHD with no friends and unsupportive, hostile parents at age 7 years are more likely to develop conduct problems and antisocial behaviour.
- If a child with ADHD lasts to age 17 years without engaging in anti-social behaviour, their parents can heave a large sigh of relief because they will very unlikely ever engage in this type of behaviour (they may still be susceptible to depression unfortunately).
The best part of conference?
The hotel to retire to overnight. Totally kid-free: gym, luxuriating bath, telly, bed and totally guilt-free and legitimate because “I’m working!”.
Roll on day 2!
I recently read an article from the British Medical Association which advised that obesity in children needed to be tackled by all doctors, teachers and social workers, much in the same way as child protection matters; that the crisis in childhood obesity was such that it was beyond something that only health professionals should help manage.
The facts on childhood obesity and its negative impact on health outcomes are overwhelming. In 2012 almost 30% of children aged 2-15 years were estimated to be obese (Solmi 2015); and childhood obesity is associated with adult obesity and negative outcomes including diabetes, heart disease, stroke, asthma, polycystic ovaries, joint problems, poor mental health and cancer (Solmi 2015). Worryingly, with the increase in children’s waistlines, some of these conditions, only associated with adult poor health when I was at medical school (e.g. type 2 diabetes), are now regularly seen in childhood and adolescence (Solmi 2015).
And yet, as a clinician who is aware of all this, I still find it hard to do what the British Medical Association advises me to do. How exactly do I tell a teenage girl presenting with depression and low self-esteem in my clinic “Err, by the way, on top of everything else, you are over-weight.” You can see why that might not go down so well. Of course, if a child brings it up themselves, we jump at the chance to provide help, and in instances where children are clearly obese, I muster the courage to bring it forward as an issue, but where a child is just “overweight” rather an obese; I struggle to bring it up if it is not brought forward as an issue. Who wants angry parents shouting “We came here for your advice on mental health and you tell us our son is fat?” It’s not necessarily how I’d like to spend a morning, and yet, the best prevention for obesity is to curtail problems at this “over-weight” point before “obesity” has set in and psychological and behavioural patterns are entrenched. A quick consult of my medical colleagues and they say the same, unless the condition being consulted on is related to obesity, it is not brought forward routinely. Not many GPs are saying “Here’s the antibiotic for your chest infection, and by the way, I notice you are overweight so would you like a diet plan too?” I wonder if any teachers are actively calling out students and advising them of their weight issues, I would think that that was also pretty hard. Yet, if people in frontline contact with children getting increasingly poorer in health before their eyes do not stop to notify or intervene, what hope is there for prevention? Further as overweight children become the norm, we start to adjust our markers of normality and children who on measurement are overweight go unnoticed.
The issue of weight is a tricky one because of the links between weight, body image and self-esteem. Can you inform someone of their increasingly dangerous weight without affecting their self-esteem? If my own cowardly inaction is representative of most people, it would seem that most people think that you cannot; and there is a strong public perception that preserving self-esteem is more critical than informing someone that their current lifestyle choices may lead them to an early grave. The fear of precipitating low self-esteem and an eating disorder tends to ride high in people’s minds. Yet the prevalence of eating disorders is minute compared to the overwhelming problem of obesity. Reports indicate that even amongst the most at risk groups (females aged 10-19) the highest reported rates of anorexia only reach 34.6 per 100 000 population and bulimia 35.8 per 100 000. Do the maths, and that’s less than 1% of the population compared to 30% suffering from obesity.
The weight issue came up for me a few years back. My frugal upbringing meant that I grew up with the mantra of “Finish everything on your plate” and wasting food was a cardinal sin. I was denied chocolates and cakes, not because of worries about the waistline but purely because my parents couldn’t afford treats. The two unfortunate consequences of this upbringing on my own parenting were a) I continued my parents’ line of a waste not want not attitude to food; but b) I wanted to indulge my children with the cakes I never had.
So it shouldn’t have been such a surprise when Big Sis came home with the school health visitor card showing that she was 50th percentile for height but 75th percentile on weight; but it was a big surprise to me (it is optimal health-wise to be on the same percentile for weight as height). In my eyes, she did not look in any way over weight, yet, on paper, her percentiles were heading that way. When I told other mums about it, they all without fail thought denial was an appropriate option. “No, she’s fine, you shouldn’t worry.”; “It’s a mistake” or “You mustn’t let her know.” The thing was, I wasn’t worried, but there was no way that I was going to be in denial about it, and I worry that this type of supportive advice from other parents whilst well-intentioned is counter-productive. It may dissuade parents from taking action and lead to a false sense of security.
That night as Banker piled Big Sis’ plate up high with pasta and insisted she finish it as it was a waste to leave it, I made skewed eyes at him and squeaked side-ways out of my mouth “She doesn’t have to. If she’s full, she doesn’t have to finish it.” From then on, I consciously ensured that there were more healthy snacks around the house and *tried* to curtail the grandparents’ habit of allowing children free reign to chocolate and Oreos. The whole family got involved in more sport at the weekends. It wasn’t a big deal, but it needed to be in my consciousness so I could act. I don’t think that Big Sis’s self-esteem is linked to her weight and I hope to prevent it ever becoming so.
I do wish that we could talk more openly about weight without hurting people’s feelings. I hope that one day society can move towards consciously uncoupling self-esteem from weight; and weight can become a purely physical health concern (like a verruca?), and maybe then doctors, teachers and parents could better prevent this major and deadly health problem.
Currin, Schmidt, Treasure & Jick. Time trends in eating disorder incidence. The British Journal of Psychiatry Jan 2005, 186 (2) 132-135.
Solmi & Morris. Association between childhood obesity and use of regular medications in the UK: longitudinal cohort study of children aged 5–11 years. BMJ Open 2015