Can We Talk About Sleep?

December 30, 2014
by: Peg Dawson

When parents bring their children to me for an evaluation because they are concerned about possible executive skill weaknesses, I spend the first part of the assessment process interviewing them about their child. Parents know their children better than any teacher, psychologist, or therapist ever will, and I get a great deal of useful information from that interview.

That said, it took me longer than it should have to realize that one of the questions I need to ask parents is about sleep. First of all, I didn’t learn about sleep at all when I was in graduate school, so maybe that’s my excuse. But once I realized I needed to ask about sleep, it began opening windows for me. I had no idea how many children can’t fall asleep at night without a parent lying down with them, or how many kids crawl into bed with their parents in the middle of the night, or may even sleep in their parents’ bedroom. More recently, I’ve come to understand that way too many children have technology in their bedroom—televisions and computers that are too tempting to set aside even as the lights should be turned off. And too many teenagers are bringing their smart phones to bed with them, remaining engaged with social media far into the night.

And then there’s the whole issue of sleep disorders, which I believe are probably under-diagnosed in children. These include sleep apnea (where the child stops breathing multiple times per hour and has to wake up in order to start breathing again), restless leg syndrome (which may be misdiagnosed as ADHD), and a circadian rhythm disorder called delayed sleep phase syndrome (which means the body is not ready to fall asleep at the normal bedtime). The prevalence rate of delayed sleep phase syndrome in teenagers is about 7 percent: it’s almost as common as ADHD, yet nobody knows about it.

But what does this have to do with executive skills? Just this: when the brain is deprived of sufficient sleep, executive skills are the first brain functions to suffer. Research indicates that a number of cognitive skills are diminished when individuals lack sufficient sleep on a regular basis. The impacts of sleep deprivation include: 1) daytime sleepiness (which is most problematic during periods of low stimulation); 2) tiredness or fatigue (which makes it difficult to initiate or persist at certain types of behavior, especially tasks deemed boring or tedious); 3) emotional factors (which can include depressive symptoms, low tolerance for frustration, as well as increased irritability); and 4) changes in attention and performance (which can produce ADHD-like symptoms and which can have a particularly negative effect on an individual’s ability to performance complex tasks or those requiring divided attention).

Given the symptoms of sleep deprivation described above, there’s not one of the 11 executive skills we write about that aren’t impacted. If parents are serious about helping their children improve executive skills, the first step they should take is ensuring that their children are getting an adequate night’s sleep on a consistent basis.

So how do we do that? The American Pediatric Association developed some guidelines for parents to help them improve sleep hygiene in the home. For youngsters who resist going to bed or who need the presence of adults in order to fall asleep, pediatricians generally recommend the following conditions be put in place (adapted from an article that appeared on the Medscape website):

1. Establishing a consistent bedtime routine. A regular and well-structured set of pre-bedtime activities usually helps settle children and promote sleep onset. This may include bedtime stories and being “tucked in.” Stimulating activities, such as vigorous play or watching cartoons, should be avoided due to their potential alerting effect. Keeping the routine quiet and regular helps young children achieve a quiet, relaxed state more conducive to sleep onset.
2. Maintaining a regular sleep schedule. Consistent bedtime and waking time 7 nights a week is usually helpful. Eliminating late sleeping and any daytime napping that is inappropriate for age may increase the chance that a child will be tired at the usual bedtime. In addition, regularity of sleep schedule may help promote the stabilization of biological rhythms that will make sleep onset come more quickly.
3. Maintaining a sleep environment conducive to sleep. Quiet, dimly lit environments make it easier for children to fall asleep than noisy, brightly lit environments (although nightlights can be appropriate for children who are afraid of the dark). Experts generally recommend that children be put to sleep without a parent remaining in the room since this provides the child with an opportunity to learn to fall asleep independently and to minimize dependence on parental presence. Another reason for this is that it helps children learn to confront their fears or anxieties and learn to “self-soothe” rather than rely on external supports for this.
4. Using limit setting. Children who stall, cry, or leave the room at bedtime in an attempt to stay up later will sometimes repeat this behavior to the point where a parent or caregiver “gives in” and allows the child to stay up. For some children, this pattern of behavior may be repeated nightly to the point of causing consistent delay and disruption of sleep onset. Setting and enforcing appropriate limits on inappropriate bedtime behavior are crucial for the effective treatment of limit-setting sleep disorder. Limits must be enforced consistently by all caregivers, usually for periods of days or weeks, for maladaptive bedtime behaviors to subside. Parents should be aware that temperamental and agitated behavior often transiently worsen during the first days of treatment before gradual improvement becomes evident, making the initial days of treatment the most difficult.

In September of this year, the American Pediatric Association addressed the issue of school start time for the first time. As children enter adolescence, their sleep patterns change. Now, the typical teenage body wants to fall asleep around 11. Sleep experts state that teenagers still need 8-9 hours of sleep a night, which means that too many high school students are living with chronic sleep deprivation because early start times at most high schools don’t permit them to get their full ration of sleep. They accumulate sleep debt as the school week progresses and then they try to catch up on weekends by sleeping in. While this may address the problem of sleep debt, it exacerbates the problem during the school week because on Saturday and Sunday, they’re often sleeping until late morning and on Monday they have to wake up very early to go to school. Some sleep experts have described this as similar to what it would feel like to fly from Hawaii to New York every weekend.

Where schools have addressed this problem and pushed school start times back, they see immediate gains in all kinds of ways: fewer school absences, better report card grades, higher standardized test scores—and even lower incidents of unwanted pregnancy and delinquent behavior (since it turns out these problems typically occur during after school hours before parents get home from work).

Influencing school boards to look seriously at the issue of high school start time is a worthy endeavor. But for individual parents who can only control what happens within the walls of their own homes, ensuring that their children get a good night’s sleep will reap dividends in many domains—including executive functions.