Wednesday, February 15, 2012

To Sleep, Perchance to Dream

I briefly treated a little girl earlier this school year who unfortunately did not make much progress while participating in occupational therapy.  She missed many sessions because her mother could not persuade her to put on her coat and shoes and leave the house to come to the clinic.  Most days were met with severe temper tantrums, with the child refusing to allow her mother to dress her or to eat breakfast.  When she did come to OT, she would not let me get near her.  Any attempt to help her take off her coat and shoes or to engage her in any play was met with hysterical tears and crawling under her mother's chair.  Therapeutic brushing helped somewhat, but it was still a walk on eggshells to even be allowed into her personal space.  She was over three years old, but had almost no language.  When she wanted to express herself, she could only cry, "Mer!  Mer!"   She could not even say no.

She made no progress with the speech therapist, either.  I sat the mother down after a few weeks and asked about the little girl's diet and sleep patterns in order to get a better sense of what was behind her behavioral difficulties.  It turned out that this mother was letting the little girl go to bed when she did, which was generally around midnight, and waking her up at seven thirty the next day. No wonder the child was delayed in her motor and speech development, and always so resistant! She was chronically sleep deprived.  Unfortunately, the mother, a recent immigrant from a culture that does not operate on fixed schedules,  did not follow my suggestion that the child be put to bed much earlier so that she could get the twelve hours of sleep she needed.  

A few weeks later, the child was removed from my caseload due to a scheduling conflict.  She continues to work with the speech therapist, and continues to make no progress.

How much sleep should a child get?  Toddlers and preschoolers should get about twelve hours of sleep.  School aged children should get about ten hours of sleep.  High school students should get about eight or nine.

Less sleep than this on a regular basis can cause a host of problems, including a compromised immune system,  delays in language acquisition and neurological development, socialization and learning issues, anxiety, poor attention span and frustration tolerance, emotional fragility,  impulsivity, and poor self regulation.

Many of the children I treat are not very good sleepers.  They have trouble transitioning to bedtime, they have a hard time falling asleep once they get in bed, they wake up during the night, and they are crabby, irritable, and hard to get going in the morning. 

If your child habitually wakes up tired, cranky, and hard to get going, he is either not getting enough sleep or the sleep that he does get is not resting him properly.

Unfortunately, modern life interferes with circadian rhythms and healthy sleep patterns.  We no longer spend our time out of doors using our bodies for hunting, gathering, and planting, going to bed with the chickens and waking up with the roosters.   Electric lights mean that we  no longer need to obey the natural rhythms of the sun and moon, retiring when it is dark and being naturally awakened by light.  Staying up late to work or read before the advent of electricity was uncomfortable, a strain on the eyes, and an enormous outlay of effort and expensive fuel.   Since the advent of the light bulb and cheap electricity, it is thoughtlessly easy to stay up long past the time when we should be in bed.  

Most children sit inside all day at school and then go home and sit and watch television, play video games and do homework until it's time to go to bed, so they don't really get physically tired enough to allow their brains and bodies to slow down.  On the weekends, many of them are seduced by the addictive power of video games, computers and television, and stay inside on the couch when they should be outside running around and playing.  Add to this the tremendous amount of pressure children are under these days to adhere to rigorous academic standards and social behaviors that are often beyond their developmental abilities, being over scheduled with too little down time to relax and play, and you have a perfect recipe for insomnia.

In order to fall asleep easily, the brain must be quiet and peaceful, with no stressful thoughts racing through it, and the body must be tired and relaxed.

Do you ever take vacations that involve lots of outdoor fun, like skiing or swimming?  Ever notice how you can barely keep your eyes open at night after dinner, how happily exhausted you feel, how you can hardly wait to tumble into bed, and how rested and refreshed you feel in the morning?  A day full of physical activity is the best way to ensure a healthy night's sleep.

A child who gets plenty of outdoor exercise and eats nutritious food will have a much easier time of it transitioning to bed and sleeping soundly than a child who has been inside all day long watching television or playing video games and eating processed foods pumped full of chemicals, fat, salt, and sugar.  

If you want your child to get a good, full night's sleep on a regular basis, he has to go outside to play every single day.  I recommend that a child who does not walk to school be taken to the playground for half an hour or so before the bell rings and be given an opportunity to run around and play on the equipment before school begins, and again on the way home.  Can you arrange for a few other mothers to join you?  The children can have a quick soccer game, jump rope, or a game of freeze tag or statues.  If exercise and movement has an energizing effect on your child, make sure it happens early enough in the day so that he is happily tired when it's time to sleep.

For an anxious child, who can't stop his mind from racing,  exercise is doubly important. { I can speak from experience here:  whenever I am under a lot of stress, the only way for me to cope successfully is to tire myself out enough during the day so that I can sleep at night. }

In direct contrast to television, which imposes a state of mindless relaxation, {which is why we call it "vegging out" in front of the TV,} computers and video games engage the waking, thinking part of the brain, making it difficult to relax and drift off.  In order to allow the brain to slow down enough for the body to follow,  computers and electronic devices should be turned off a minimum of two hours before bedtime.

Some foods and substances are excitatory to the nervous system and should be avoided in the evenings.  Sugar, caffeine, sodas, and highly processed foods tend to increase alertness and arousal and to rev up our engines.   

A full stomach before bedtime can prevent restful sleep.  Dinner should be finished by a minimum of two hours before bedtime.  Bedtime snacks should be light and healthy: a little yogurt with naturally sweetened jam, a whole grain cracker with almond butter, a small handful of nuts and dried fruit, a half of a banana.

A child who needs a tremendous amount of structure and predictability in order to function would benefit from a bedtime routine consisting of the exact same things in the exact same order at the exact same time every evening.

A warm bath with Epsom salts and a few drops of essential oil {valerium, sandalwood, chamomile, and bergamot are all good choices for promoting sleep} is very relaxing before bed.

Bedding and pajamas should be made of natural fabrics and washed in unscented laundry soap, preferably one from the health food store with a short list of ingredients.  Avoid fabric softener sheets, which are full of nasty chemicals.

If your child is not allergic, down pillows are the best. 

Points to consider:  Is the room adequately ventilated?  Is the room temperature too warm?  {In New York, I have to keep my bedroom windows open all year long because the heat, which I can't control, is suffocating.}  Is the air too dry? Is the room dark enough? {Leaving a bright light on while the child sleeps may cause visual problems and should be avoided.}  Is there too much visual stimulation?  {Too many toys and objects in plain sight are overwhelming and distracting when it's time to sleep.}  What is the noise level in the room?  Could the child benefit from ear plugs, a white noise machine, or some soothing music?

Remove all televisions and electronic equipment from the child's bedroom.  Bedrooms should be just for sleeping if at all possible, so that the child associates that particular space only with bedtime.

Some children like very heavy blankets and find the weight reassuring.  An anxious child might like to play sandwich before bedtime:  Place a sofa or heavy cushion on top of him while he lies on his belly on the floor or on the bed.  That is the bread.  He is the filling.  Put condiments on him {"Here is some catsup!"} by pressing firmly in a downward direction all along the length of his back and legs either with a therapy ball or with your hands.

Anxious children are often not such great breathers, so I often recommend that bath time include playing with bubbles or whistles.
This one looks like fun.

I'm a big, big proponent of books and reading, and a bedtime story and a snuggle is a wonderful ritual.  This is something to look forward to and can motivate the child to get into his jammies and get teeth his brushed so he that can hear the next chapter.

If your child is a snorer and his breathing during sleep is labored and irregular, he may have sleep apnea.  This is a condition in which the child's airway becomes obstructed while he sleeps, which prevents him from breathing.  This causes interruptions in the child's sleep, does not allow him to sleep deeply, and interferes with his oxygen intake, which in turn affects his brain functioning.  A visit to an ENT and a sleep study, if recommended, may be in order.

Chronic ear infections also make it difficult to fall asleep due to the pain.  If your child has a very high pain threshold, he may not be letting you know what the problem is until his ears start draining.

If your child is on a therapeutic brushing program, I highly recommend that he be brushed as a part of the bedtime ritual.  The deep pressure will help him with the transition to bed.

In Manhattan, I see babies and small children being strolled and rolled around  while their parents and nannies ignore them and chat on their cell phones and play on their Ipads and Blackberries.  Is your child resisting bedtime in the hopes of getting some much needed attention and physical affection?  Before strollers and car seats, we used to carry children on our hips and talk to them.  Now we isolate them and immobilize them for long, long stretches every day.  Judging from the desperate hugs I get from many of the children I treat,  not only is this interfering with their neurological and language development, we are depriving them of sufficient human touch, ratcheting up their anxiety levels.

Are there things going on in your child's life that are genuinely worrisome?  Children are extremely sensitive to what is going on around them.  If there is a problem and the adults are stressed out, the child will pick up on it.  Simple explanations and reassurances, along with hugs and kisses, are always a good strategy to calm an anxious mind.


Babajeza said...

Oh dear

It's time for me to go to bed. I'm so tired and happy after a day outside (skiing in the mountains). And it is so quiet and peaceful in my home, I will fall aslpeep in no time.

Interesting post as always. I think there are a lot of problems due to too less sleep.

Gillian in Wales said...

I so wish my child would sleep more. He does not have any of the major issues that some of your clients have exhibited, but he is 4 and only gets 10-11 hours per night.

He plays outside, goes to sleep very easily at about 7, but often has disturbed nights (which mean I do) and then is up and playing 5:30 - 6am.

You are so right when you talk of high pain thresholds. He indeed used to have ear infections when the first I knew of it was brown gunk in his ear.

Now it appears to be bedding thrown off if he gets hot and him getting too cold.

But he seems to be doing fine himself, so perhaps it is just *me* that needs more sleep!!