Learn how clinicians can enhance their patient’s quality of life by improving sleep outcomes.
Published On: 02/20/2023
Duration: 18 minutes, 48 seconds
Dr. Feder: At this very moment, we are in the midst of the “The Great Sleep Recession”. Children and adolescents who suffer from sleep problems can have a wide range of issues negatively impacting their day-to-day lives. So, how can clinicians enhance their patient’s quality of life by improving sleep outcomes? Well, this is exactly what Mara and I are going to dive into on this episode of The Carlat Psychiatry Podcast, brought to you by the Child Psychiatry team.
I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice and the brand-new book, Prescribing Psychotropics.
Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice.
You might be wondering why Dr. Feder referred to our current time period as “The Great Sleep Recession”. He said that because, over the past 20 years, adolescents have been reporting less and less sleep each year. And the likelihood of reporting less than or equal to 7 hours of sleep per night is more pronounced in certain adolescent groups.
Dr. Feder: Definitely! For instance, a multicenter, cross-sectional study of US teens analyzed data obtained recorded every year from 1991 to 2012. In addition to finding a steadily decreasing trend in hours of sleep per night, they found that girls, racial/ethnic minorities, students living in urban areas, and teens of lower socioeconomic status were more likely to report getting less than or equal to 7 hours of sleep per night compared to boys.
Mara: What about middle school aged children? Are they getting enough sleep at night?
Dr. Feder: Well, not exactly. The prevalence of short sleep duration among middle school students is around 58%. And, unfortunately, that number increases when we look at short sleep duration in high school students. Among the high schoolers, 73% experience short sleep duration, with sleep deprivation being more prevalent in girls than boys, where about 76% of girls versus 70% of boys aren’t getting enough sleep at night. That's still most of them.
Mara: What's the recommended amount of sleep children and adolescents should get each night?
Dr. Feder: So for children (ages 6-12), the recommended total hours of sleep per night is anywhere from 9 to 12 hours, while teens (ages 13-18) should be getting 8 - 10 hours of sleep per night. That's a lot more sleep than they are getting!
Mara: Okay, well what are some of the consequences adolescents might experience if they aren’t getting their 8 - 10 hours per night? Besides being all grumpy and sluggish throughout the day.
Dr. Feder: Yeah, we’ve all at some point felt grumpy or sleepy when we didn’t get enough sleep over the previous night. But, while sleep deprivation may seem benign, it can have serious short-term and long-term effects.
For example, a meta-analysis with over 500,000 participants found an inverse relationship between sleep duration and suicidality in adolescents. And the risk associated with the creation of a suicide plan decreased by 11% for every 1-hour increase in sleep duration. Which just shows the power and importance of adequate sleep.
Mara: Furthermore, other studies have shown that automobile accidents and cognitive difficulties are linked to sleep deprivation in adolescents. Lack of sleep also leads to greater risk-taking behavior, including substance use, and it’s associated with obesity, diabetes, sports injuries, and poor academic performance.
Dr. Feder: That's right, Mara. You know, you end up with sleep debt. By the end of the week, people haven't slept, you know, for night after night, after night, then they get one long day you know, sleeping in on the weekend, and that's not a fix, and it doesn't get you prepared for the next week.
You're messy when you're not sleeping during the week.
Yeah, I gotta say your point about the driving to me is a big one. Drowsy driving kills so many people and it's teens who tend to be among the big offenders. You know they're not very experienced as drivers to begin with. They don't know how tired they might be. They get in a car, maybe it's late at night, maybe they've had a drink or two. That's a recipe for disaster. And really every year in our community we have kids who crash and die you know, after a party on a Saturday night, or you know, driving home from something early in the morning after they've stayed out all night. Those kinds of things really are a big problem.
Adding to your point on poor academic performance, inadequate sleep may mimic ADHD and aggravate mood disorders. And that can lead to a vicious cycle since the medications we commonly prescribed for ADHD often interfere with sleep, further worsening the patient’s symptoms.
Mara: Wow, whoever thought that all of that could be brought on by not catching enough Z’s. Dr. Feder, how can we assess our patients for sleep deprivation?
Dr. Feder: We had a great article by Dr. Rafael Pelayo who talked about four essential components of sleep history that need to be reviewed when assessing a sleep problem.
The first is the patient’s total amount of sleep. The second and third components are sleep quality and sleep timing (what time of the day you are sleeping). And, lastly, we want to assess the patient’s state of mind with regard to their sleep.
Mara: Let’s break that down some more.
When assessing sleep amount, you really want to pin down how much sleep your patient is getting. Sleep-deprived adolescents are grumpy, have difficulty concentrating, and often sleep-in excessively on weekends. Younger children and adults rarely do this. Their recall may be inaccurate so ask families to keep a diary record over at least a couple of weeks or use electronic sleep tracking devices such as wearables or smartphone-based applications. Although electronic devices are far from perfect, they can show trends in sleep. Some versions have been recently validated, including Fatigue Science Readiband, Fitbit Alta HR, Garmin Fenix 5S, Garmin Vivosmart 3.
Dr. Feder: In regards to sleep quality, get a sense of how effective your patient's sleep is. Some patients report fatigue no matter how much they sleep. Kids may sleep poorly despite adequate sleep time. If a child snores or sleeps with their mouth open, they may have sleep apnea: the more they sleep the less they are breathing. If you suspect sleep apnea or some other physiological disorder, contact the primary doctor to arrange a sleep assessment. Note that home-based sleep studies are not well-validated in children or adolescents, and they are not typically reimbursed by insurance companies either.
Mara: To assess sleep timing, figure out when your patient sleeps. Sleep timing may reveal a circadian sleep disorder. The circadian system synchronizes biological rhythms to the day/night cycle. It’s harder to ‘go to bed earlier’ unless a person is very sleep deprived. It’s easier for teens to push away sleep and sleep later than it is for them to fall asleep earlier at night. But sleeping in or oversleeping in a child is a sign of sleep deprivation. The COVID-19 pandemic has disrupted sleep times for many children and adolescents, with variable school start times and having to alternate between virtual and in-person classes. Establish a consistent wake up time first to anchor the circadian system and make nighttime sleep easier.
Dr. Feder: Yes you know covid-19, we are coming up on 3 years since the beginning of the pandemic and people are still thrown by this.When evaluating your patient’s state of mind concerning sleep, ask yourself “Whose idea was it to make the appointment initially - the child or the parents?”. Parents may recognize the connection between sleep and other problems. Children or teens who want help with sleep may be suffering from internalizing problems such as depression or anxiety that are harder for parents to recognize. Determine what your patient’s motivation is for going to sleep and getting out of bed. Is the patient looking forward to going to sleep? Are they staying up to engage on the computer or to talk with friends? Are they dreading the next day? Waking up is biological but getting out of bed is volitional.
Mara: Alright, so let’s say that I perform a thorough assessment of my patient’s sleep history, and, afterwards, I conclude that my patient’s sleep deprivation is seriously hurting their quality of life. What’s my next step? Should I consider prescribing a hypnotic?
Dr. Feder: You might want to hold off on the hypnotics.There are no FDA approved hypnotics for children. We recommend avoiding hypnotic medications when possible in children and teens. Off label use of medications such as guanfacine or clonidine are best used as time limited approaches.
Keep in mind that people are more alert for about 2 hours before sleeping. If a medication shortens sleep latency by only 20 or 30 minutes, patients may report that the medication exacerbated their symptoms or that it causes them to behave strangely. Perhaps, causing them to experience hypnagogic hallucinations. That's when you're starting to fall asleep and you got those weird hallucinatory experiences.
Mara: This can occur when the family gives the medication too early, out of fear that the hypnotic might cause next day sedation. Similarly, giving a low dose may result in the child being disinhibited but not falling asleep. The same medication given at a more appropriate circadian time and/or dose may be effective.
Dr. Feder: It’s important to acknowledge that if a child does not intend or want to sleep, then they may resist the drowsy feelings produced by the hypnotic medication and become upset. Consider short term use of the supplement melatonin (1-3 mg), which should be given 90 minutes before bed.
Medications may have a role for insomnia, narcolepsy, parasomnias, and sleep-related movement disorders, however, parents and healthcare providers often use hypnotic medications without adequate application of behavioral techniques, and without taking into account circadian modulation of alertness.
Mara: Okay, so what behavioral techniques or psychotherapies have evidence for improving sleep in children and adolescents?
Dr. Feder: Conversations about sleep often center on sleep hygiene rules such as ‘turn off and put away the electronics two hours before bed’ and ‘don’t lay awake in bed.’ But according to the American Academy of Sleep Medicine’s clinical practice guidelines, relying solely on sleep hygiene is usually ineffective. Patients, parents and clinicians are aware of these rules and have attempted to utilize them without success. For instance, many clinicians and families do not replace using a phone for an alarm with a $10 alarm clock. Our patients need a more comprehensive approach such as Cognitive behavioral therapy for insomnia, or CBTi.
Mara: CBTi, the CBT that is specific to addressing the thoughts, behaviors, and emotions related to sleep, has a good track record in adults and has been adapted for children and teens. Clinicians can use basic CBT-i in the office.
Here are some typical CBTi techniques:
Dr. Feder: Sleep Restriction/Delayed Bedtimes: Assess how much time in bed is actual sleeping, and adjust to better match the time sleeping. The goal is to make the time devoted to sleeping more efficient.
For example, you can advise a patient to stay out of their bed until their set bedtime. And, they should know that when their alarm goes off in the morning, they should immediately hop out of bed, rather than laying in bed on their phone or repeatedly hitting snooze.
Mara: Stimulus control: Strengthen the connection between bed and sleep by changing the location of other activities so that the bed is only used for sleeping. Patients should try to do their homework, draw, or play video games at a desk or in a chair instead of doing these activities in bed.
Dr. Feder: Gradual extinction: For a young child in a parent’s bed, take a slow stepwise approach to moving the child to their own bed. More steps are more effective. Start with placing a mattress near the parent’s bed and, week by week, move it somewhat farther from the parent's bed, out the door, along the hall and into the child’s room. For a child who needs their parent laying down with them, gradually shift to sitting, then a hand on the child, then sitting nearby, then farther away.
Mara: Cognitive restructuring: Identify distorted thoughts about sleep and challenge, replace, or reframe them. Reframe your patient’s thoughts from “I never sleep” to “I worry when I lay awake so when that happens I will get out of bed and do something quiet”.
Dr. Feder: Address barriers to sleep hygiene: Individualize implementation of usual recommendations by creating a workable plan for restricting evening electronics. Rather than simply stating “No electronics for 2 hours before bed” establish a ‘screens basket’ to collect all phones, tablets, remotes or place a screen lock on all devices for early evening.
Mara: Relaxation Techniques: Teach progressive muscle relaxation (PMR), deep breathing, and visualization, to be practiced when the person is not trying to sleep so that they can become proficient. There are many scripts and videos that cover PMR for kids. For example, you can have the parent and child take 15 minutes daily after school to practice progressive muscle relaxation together. After a few weeks add it to the nighttime plan during the hour before bed.
Dr. Feder: Still, CBTi can take weeks to implement and if the child is not responding, referral to a more specialized practitioner is challenging as the small number of these clinicians cannot meet the clinical demand. If you are interested in working with a sleep specialist, then check out the link in the description.
Mara: Sleep problems have lifelong complications. The sleep medicine field has matured and can help most of our patients. Screen for sleep disorders in all patients at every visit.
Dr. Feder: Use CBTi or other non-pharmacologic techniques rather than repeating sleep hygiene rules and try to avoid using medications. By addressing our patient’s issues revolving around sleep, we can improve their overall mental health and help them reach their full potential during the day.
Dr. Feder: The clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully people check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
And we have some exciting news for you! The podcast now has CME credits of its own. To get your credits for listening, follow the Podcast CME Subscription link in the show notes. It will link you to a CME post-test for this episode and for future episodes.
Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.
Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information you can trust.
Mara: As always, thanks for listening and have a great day!
Resources: Society of Behavioral Sleep Medicine Members, United States