The list of new concerns for older children is long: school assignments, organized after-school activities, individual lessons, parties, more homework, dating, driving cars, drugs, and alcohol. Health habits may appear to be less important to parents than the development of children's academic, social, athletic, or artistic skills. But as you will see, the contribution of healthy sleep habits to a child's well-being does not diminish with age.
Years Seven to Twelve:
Bedtime Becomes Later
School-age children are sleeping less and less as the bedtime hour gradually becomes later and later. Most twelve-year-olds go to sleep around 9:00 P.M.; the range is from about 7:30 to 10:00. The range for total sleep duration for most twelve-year-olds is about nine to twelve hours. These data, from a large survey I performed of middle-class families, are in close agreement with the data from an ongoing study at Stanford University. Researchers there have shown that the prepubertal teenager needs nine and a half to ten hours of sleep in order to maintain optimal alertness during the day.
If healthy sleep habits are not maintained, the result is in-358 creasingly severe daytime sleepiness.
Difficulty Falling Asleep
In one survey of about 1,000 children, where the average age was between seven and eight years, about 30 percent of the children resisted going to bed at least three nights per week. This was the most common sleep complaint of the parents. About 10 percent of the children had difficulty falling asleep once they were in their beds. Many took up to an hour to fall asleep on more than three nights per week. Some children both resisted going to bed and had difficulty falling asleep, and these children had a host of other problems: fears, anxiety, night wakings, need for reassurance, closeness of parents, complaints of fatigue, and a history of difficulties of not being able to successfully self-soothe.
PRACTICAL POINT
As your preteen grows older, he will need more sleep, not less, to maintain optimal alertness.
If your child resists bedtime and does not have difficulty falling asleep, then treatments such as an earlier or more regular bedtime and the other strategies described later in this chapter and in previous chapters are likely to help. But if your child also has difficulty falling asleep, has never slept well, and exhibits chronic mild anxiety-related symptoms, then consulting with a child psychologist or other mental health professional may be needed.
This study also confirmed other observations that night wakings in early childhood tend to persist. Persistence of sleeping problems is a theme in many reports, and it is only ignorance among some professionals that leads to the advice “Don't worry, he'll outgrow the problem.”
Two other sleep surveys of about 1,000 preadolescents, one each from Belgium and Taiwan, show additional findings. School achievement difficulties were encountered significantly more often among poor sleepers compared to good sleepers. For those children on a college path, the more academic pressure they felt, the fewer the hours slept. So it's a global concern: Young children who have difficulty sleeping become older children with more academic problems. But children who are academically successful risk not getting the sleep they need!
Recurrent Complaints
Many children in this age range complain of aches and pains for which no medical cause can be found: abdominal pains, limb pains, recurrent headaches, and chest pains. Children who suffer from these pains often have significant sleep disturbances. Stressful emotional situations thought to cause these complaints include real or imagined separation of or from parents; fear of expressing anger that might elicit punishment or rejection; social or academic pressures; or fear of failing to live up to parents’ expectations.
These are real pains in our children, just as real as the tension headaches adults get when they work too hard or sleep too little. All laboratory tests or studies during these episodes of tension headache will have normal results. All tests will also show normal results in children who have similar somatic complaints. Unless there is a strong clinical sign pointing toward organic disease, performing laboratory tests to rule out obscure diseases should be discouraged, because of the pain of drawing blood, the risks of irradiation, the expense, and, most important, because of the possible result of creating in the child's mind the notion that he is sick. Also, a slightly abnormal test result might lead to more and more tests, all of which, in the end, are likely to show basically normal results.
Adolescence: Not Enough Time
to Sleep, Especially in the Morning
Surveys of the sleep habits of teenagers show that the gradual decline in total hours of sleep flattens out around age thirteen or fourteen. In fact, many fourteen-to sixteen-year-olds now actually require more sleep! Research has shown that most teenagers would probably be much better rested if they were allowed to sleep longer in the morning. Starting school or sports early in the morning often causes teenagers to have to nap in the afternoon, which interferes with going to bed at a reasonable time.
In a study of about ten thousand Japanese junior high and high school students, 50 percent napped after school at least once a week. Because the late naps made the bedtime later, the result was shorter sleep at night. This probably caused less sleep overall. My impression is that it would be better not to nap, to go to bed earlier, and wake up much earlier to do the unfinished homework. I think doing homework late at night, after a brief nap, is much more inefficient than very early in the morning after many hours of sleep.
PRACTICAL POINT
Many teenagers over age fifteen require more sleep than in previous years to maintain optimal daytime alertness.
Excessive tiredness, daytime sleepiness, or decreased daytime alertness develops in many adolescents—there simply are not enough hours in the day to do everything. The time demands for academics, athletics, and social activities are enormous. Even without worrying about sex, drugs, alcohol, and loud music, parents worry that their teenagers may become burned out from lack of sleep.
PRACTICAL POINT
Social pressures and early start times for schools cause reduced sleep times and chronic sleep deficits.
Chronic sleep deficits were observed in 13 percent of teenagers in a Stanford University study that included over 600 high school students. These poor sleepers attributed their sleep problems to worry, tension, and personal, family, and social problems. The students appeared to be mildly depressed. Of course, we don't know which came first, disturbed sleep or the mood changes. Perhaps both the mood changes and the sleep disturbance develop from the same endocrine changes that occur naturally during adolescence. But healthy lifestyle habits, including sensible sleep patterns, might prevent or lighten the depression seen in so many adolescents. Here's how the Stanford sleep researchers defined chronic and severe sleep disturbances in adolescents:
1. Forty-five or more minutes required to fall asleep on three or more nights a week
or
1. One or more awakenings a night followed by thirty or more minutes of wakefulness occurring on three or more nights a week
or
1. Three or more awakenings a night on three or more nights a week
So, if your teenager has this kind of sleep pattern, don't consider it a “normal” part of growing up.
In New Zealand, as in California, about 10 percent of teenagers had sleep problems. They appeared anxious, depressed, and inattentive, and they had conduct disorders more often than those without sleep problems. Anxiety and depression were also common symptoms of poorly sleeping teenagers in Italy, where about 17 percent of all teens met research criteria for sleep problems.
Solid research, published in 1991, has documented that students’ sleep time has decreased one hour over the past twenty years. The evidence is clear, whether it's from Belgium, Taiwan, China, South Africa, New Zealand, or Italy, that teenagers are increasingly at risk for becoming overtired.
In two separate studies of sleep restriction in children ten to fourteen years of age, the researchers either limited the night sleep to seven hours for three days or five hours for a single night. Although routine performance was maintained, higher cognitive functions such as verbal creativity and abstract thinking were impaired. This highlights an important point, that our children can and do perform quite well even when mildly sleep-deprived as long as they are not too challenged academically to write or be creative.
Thus, mild sleep deprivation is often trivialized or overlooked because more routine memorization tasks and athletic performances are successfully accomplished.
Another experimental sleep restriction study was performed on eleven-and twelve-year-olds. Comparisons were made between sleeping ten hours on six nights versus six and a half hours on six nights. The sleep restriction caused measured inattentiveness, irritability, noncompliance, and academic problems. A separate survey study of 3,136 children between ages eleven and seventeen showed that 17 percent were having nonrestorative sleep just as in the Italian study.
In Israel, starting times in school were examined in children ten to twelve years of age. One group started at 7:10 A.M. at least two times a week and the other group always started school at 8:00 A.M. The children in the early start time group had less total sleep, more daytime fatigue and sleepiness, and complained more about difficulties in attention and concentration compared to the later start time group. Dr. Mary Carskadon, a pioneer in adolescent sleep research, points out that earlier start times for school is a fairly recent development and its impact on sleep deprivation for older children is only now being appreciated.
Dr. Carskadon had also identified irregular sleep times at night to be a significant problem independent of short sleep duration. Her research showed that the more irregular the bedtime hour, the more impairment of grades, the more injuries associated with alcohol or drugs, and the more days missed from school. Previous research among preschool children also focused on the importance of bedtime regularity regarding school adjustment behaviors.
Teenage behavior can be stressful for parents; however, if you start early, as did the family in the following report, some of the sleep issues are more manageable.
WITH PRIVILEGE
COMES RESPONSIBILITY
As the parents of five children ranging in age from eight to fifteen, my husband and I still incorporate the wisdom of Dr. Weissbluth with the sleep routines established in our home many years ago.
We started learning the sleep process fifteen years ago with our oldest daughter, Trisha. Dr. Weissbluth taught us how to recognize her fatigue and get her to sleep before she became overtired. When her sister, Julia, was born, we thought she would show the same signals and enjoy the sleep routine we had set up for Trisha. Boy, were we wrong. Although her routine was different the method was the same. Identify fatigue and put to bed before she became overtired. By the time our fifth child was born we felt like pros.
My husband and I noticed each child, as toddlers, had a “cue” that would signal nap time or bedtime. One son would start to run his fingers through his hair, one would rub his eyes, and another would climb onto the nearest lap. Again, letting us know it was time to rest. At this age actions speak louder than words.
The learning has not stopped. As the children age, we adjust their sleep habits, yet remain cognizant of the fact that overtired children are not happy, productive people. This has proven especially true with teenagers. Sometimes the privilege of staying up late will have an adverse affect on their lifestyle. An overtired and crabby teen may not do so well in a sporting event or on an exam. Emotions run high during these years, and we find it is best to have the child well rested in order to face the daily challenges of a growing body. As parents we try to convey the idea that with privilege comes responsibility. Teens need to learn to act responsibly to themselves (this includes a healthy diet as well as a good sleep routine). Although we do allow flexibility in the bedtime routines on special occasions and during school breaks, we always just naturally slide back into a routine.
Dr. Weissbluth once told me that when a child says he is bored it is usually fatigue. If my children mention that they are bored, I suggest they take a nap.
Sleep in our home is as important as good eating habits, regular exercise, and good moral behavior.
In addition to difficulties falling asleep and staying asleep, there are other abnormal sleep patterns and problems that begin in preadolescence or adolescence.
Delayed Sleep Phase Syndrome
Do you notice that your teenager is going to bed later and later? Eventually she might consider herself to be a night person. You may have heard of “owls” and “larks,” and if you yourself are an owl, you might consider this tendency of your teenage daughter to delay going to sleep as normal. But what may be occurring is the development of an inability to fall asleep at a socially and biologically appropriate time. Alternatively, a biological process associated with the development of puberty might cause a shift to a later bedtime. If this is the case, then the late bedtime is not the problem; rather, it's the too early start of the school day that's causing problems.
In delayed sleep phase syndrome, the child has no difficulty falling asleep or staying asleep, but only when sleep onset is delayed, maybe to 1:00, 2:00, or 3:00 A.M. When she tries to go to sleep earlier, she can't. On weekends and vacations, she'll sleep later, so her total sleep time is about normal. But on school days it's always a struggle to get her up for those early classes.
As a consequence, schoolwork suffers and the child's moodswings widely—the long-term result of brief sleep on school days and a chronically abnormal sleep schedule. As I'll discuss in the “exercise” section of Chapter 11, some teenagers try to combat the fatigue with internal stimulation (anger or elation) or external stimulation (sports or exercise).
Kleine-Levin Syndrome
This is a rare condition, but it may be mistaken for other psychiatric or neurological illnesses. The major features include excessive sleepiness, overeating, and loss of sexual inhibitions. The exact cause of this problem is not known, but if you notice dramatic abnormalities in sleeping, eating, or other behaviors, do not simply assume this is a teenage “phase.” Other uncommon disorders involving abnormal sleeping might be associated with changes in temperature sensitivity, thirst, or mood.
Fibromyalgia Syndrome
Fibromyalgia syndrome is an uncommon sleep problem that occurs mostly in preteen and teenage girls, and sometimes in their mothers. Children with fibromyalgia syndrome feel fatigue and diffuse pain. They “feel tired all the time” or they “hurt all over.” The pain occurs on both the right and left sides of the body, and above and below the waist. In addition to this diffuse aching pain, they have specific tender points that, when pressed, cause much more intense localized pain.
All of these girls have disturbed sleep. For many years, their parents may have noticed these girls moving around a lot during sleep. This restlessness, or “motor agitation,” causes the sheets and blankets to be thrown all about and is a characteristic feature of fibromyalgia syndrome. Further, they usually awaken in the morning feeling tired or “unrefreshed,” as if they had not had a good night's sleep. The nonrestorative sleep is another characteristic feature of children with fibromyalgia. Some children also have night awakenings. Other symptoms include morning stiffness, morning fatigue, headaches, lack of energy, a sense of sleepiness during the day, negative mood, and depression. These children are disabled because of their chronic pain; they cannot comfortably participate in the activities most teenagers enjoy.
Interestingly, the pattern of restless sleep with the sheets and blankets strewn about or night waking is usually not recognized by the child as a problem because it is long-standing. Because she has always slept like this, the child or parents often think it is “normal” for her. These children do not complain of sleeping poorly; instead, they complain of fatigue and pain. The physician's evaluation usually reveals the sleep disturbance.
The fatigue and pain may cause the child to miss school, not participate in social activities, and avoid sports. This may lead to lower self-esteem and a “deconditioned” body, both of which superficially resemble the symptoms of depression. Remember, children with fibromyalgia syndrome are most often preteen or teenage girls, and many of the symptoms may be misattributed to changes associated with adolescence.
Because the cause of fibromyalgia syndrome is not known, there is no specific cure or treatment. But the good news is that improvement tends to occur over time in response to treatment. Rheumatologists in pediatric centers specialize in treatment with exercise programs, and sometimes they prescribe antidepressant medications. This can help these children get through difficulties that disturb their sleep, such as final exams. Most children improve after about two years of treatment.
Curiously, there is a predicable sequence of improvement. First, the sleep disruption improves. Second, weeks later, the skeletal muscle pain symptoms start to improve. When the sleep disturbance does not improve, it is much less likely that the other symptoms will decrease. This observation that sleeping better needs to precede improvement in fatigue and pain reduction suggests that poor-quality sleeping might cause the other symptoms. Furthermore, among adults who suffer with this disease, the poorer the sleep, the more extreme the pain. This again suggests that there is a causal link between disturbed sleep and the other symptoms of fibromyalgia.
Chronic Mononucleosis
Infectious mononucleosis is caused by a virus. Children as young as fourteen have been identified as having a chronic condition, following the acute infection, characterized by disabling daytime sleepiness. Because of the daytime sleepiness, the child's school performance deteriorates. Not surprisingly, misdiagnoses of depression are sometimes made among these children. The correct diagnosis is made only after blood tests confirm the viral infection.
Preventing and Solving Sleep Problems
Let's look at the two major areas of concern for children in this age group, namely, falling asleep and maintaining a healthy sleep schedule. In treating these sleep problems, we attempt to break the self-perpetuating sequence in which sleep disturbances cause hyperarousal, which further interferes with sleeping well.
Falling Asleep
Working with a therapist, older children can learn to sleep better through relaxation training techniques similar to those used by adults. The attempt is to reduce the level of arousal, therefore permitting the sleep process to surface. Here are a few techniques:
1. Progressive relaxation is a method whereby you tense individual skeletal muscle groups, release the tension, and focus on the resulting feeling of relaxation.
2. Biofeedback involves focusing on a visual or auditory stimulus that changes in proportion to the tension within skeletal muscles. Both progressive relaxation and biofeedback techniques can help reduce muscle tension and thus make it easier to fall asleep.
3. Self-suggestion to produce relaxation involves repeating suggestions that your arms and legs feel heavy and warm.
4. Paradoxical intention is based on the idea that trying hard to spontaneously fall asleep might create a vicious circle, which can be broken by focusing on staying awake.
5. Meditative relaxation procedures vary, but simple instructions to focus on the physical sensation of breathing seem to help some people fall asleep.
Stimulus Control and Temporal Control
Stimulus-control treatment tries to make the bedroom environment function as a cue for sleep. Spending lots of time in bed watching television, reading, or eating directly competes with sleeping, and therefore these activities must be discontinued. Temporal control means establishing a regular and healthy sleep schedule.
Richard R. Bootzin, a psychologist specializing in insomnia, incorporates the elements of stimulus control in the following instructions he developed.
STIMULUS-CONTROL INSTRUCTIONS
1. Lie down intending to go to sleep only when you are sleepy.
2. Do not use your bed for anything except sleep—that is, do not do homework, read, watch television, eat, or worry in bed.
3. If you find yourself unable to fall asleep, get up and go into another room. Stay up as long as you wish and then return to the bedroom to sleep. Although you should not watch the clock, you should get out of bed if you do not fall asleep immediately. Remember, the goal is to associate your bed with falling asleep quickly! If you are in bed for more than about ten minutes without falling asleep and have not gotten up, you are not following this instruction.
4. If you still cannot fall asleep, repeat step three. Do this as often as necessary throughout the night.
5. Set your alarm and get up at the same time every morning, irrespective of how much sleep you got during the night. This will help your body acquire a consistent sleep rhythm.
6. Do not nap during the day.
Dr. Rosalind Cartwright, a pioneer adult-sleep researcher, teaches a variation of Richard Bootzin's stimulus control that has helped some children fall asleep easier.
1. Do something that is pleasurable for a limited amount of time, using a timer set for fifteen to twenty minutes. Do anything you want, but not in your bedroom.
2. Take the hottest lavender bubble bath you can tolerate for fifteen to twenty minutes. This is for relaxation, so don't read a book or listen to music while you're in the tub. The bath helps prevent the storm of thoughts and worries that strike the brain like meteorites when the protective shield of activity, sports, or homework is down.
3. After the bubble bath, immediately get into bed. Don't start any other activities—no books, no music, no telephone calls. Close your eyes and try to sleep.
If these instructions do not provide help, consider encouraging your child to get involved in sports programs, to increase the amount of physical exercise he gets. If this fails and your child still can't sleep well and appears exhausted, too tired, and not interested in outside activities, ask yourself whether the problem might not be depression.
Children do get depressed, and some crazy, risk-taking “accidents” in overtired teenagers are really deliberate suicide attempts. If this is a concern of yours, seek outside help immediately. Start with school social workers, your physician, or local suicide prevention centers.
Maintaining a Healthy Sleep Schedule
As already discussed, some teenagers suffer from what we call delayed sleep phase syndrome. This occurs when teenagers are unable to fall asleep at a desired conventional clock time but have no difficulty falling asleep long after midnight. On vacation, they sleep a normal duration, do not wake up at night, and feel refreshed in the late morning or midday, when they awaken. The problem lies in the disrupted sleep schedule that often develops during the school year, when sleeping late is not possible.
Treatment is called “chronotherapy,” or resetting the sleep clock. Let's say your child can easily fall asleep at 2:00 A.M. The therapy consists of forcing him to stay up until 5:00 A.M. and then letting a natural sleep period follow. (Obviously, we don't do this during the school year!) The next time sleep is allowed to start is at 8:00 A.M. the following day and at 11:00 A.M. the day after that. In other words, you are allowing sleep to occur about three hours later every cycle. Over the next few days, sleep begins at 2:00, 5:00, 8:00, and finally 11:00 P.M. Now, keeping careful watch over clock time, always try to have the child go to sleep at 11:00 P.M. YOU have shifted the sleep clock around to a more conventional time, and usually this can be maintained by sustaining a regular nighttime sleep schedule.
Drugs and Diet to Help Us Sleep
Drugs don't solve sleep problems. Diphenhydramine or other antihistamines are often used to induce sleep in children. The common situation is for these drugs, or others, to be thought of as a temporary, short-term measure, “just to give everyone a break.” It sounds great—get your strength back to muster up enough courage to try to correct problems caused by your own mismanagement—but I have observed many times that those parents who demand drugs most strongly are those who are least likely to change their behavior, so the basic sleep problems continue. No study has shown that sleep-inducing drugs are really useful and safe for children. Diphenhydramine has been shown not to be an effective hypnotic in adults. Hypnotic drugs such as phenobarbital can actually cause sleep disturbances, daytime fussiness, and irritability.
PRACTICAL
POINT
Don't depend on
drugs to solve
your child's
sleep problems.
Other drugs that can interfere with good sleeping include nonprescription decongestants, such as Sudafed and caffeine. So let's sleep better by not taking any drugs. An important exception might be drugs used by an allergist or pediatrician to help a child breathe easier at night if he is suffering from allergies.
Dietary changes that are known to make some people sleepy include high-carbohydrate meals and foods high in the amino acid tryptophan. It is possible that the contents of a nursing mother's diet affect the carbohydrate content of her breast milk, and this may indirectly influence the levels of tryptophan in the baby. In one study of infants, tryptophan caused the babies to begin quiet sleep twenty minutes earlier and active sleep fourteen minutes earlier. But the total amount of sleep time was not affected. So giving tryptophan to infants or other children will probably not make them sleep longer. Furthermore, tryptophan administration in adults has been associated with severe diseases, even though tryptophan is a naturally occurring amino acid. Melatonin is another naturally occurring chemical that has been popularized as a sleep aid. The safety and effectiveness of melatonin have not been established for infants or children.
The effects of high-carbohydrate or high-protein meals in adults show differences between the sexes and differences based on age. There is no scientific data on nutrition in children that could be translated into a sleep-promoting diet. Eliminating refined sugar, because of the commonly held belief that this makes children hyperactive, also does not appear to have any effect on sleep patterns.
Another report suggested that cow's milk allergy could cause insomnia. But the results of the study could have been caused by a placebo effect, because the parents knew when they were giving a cow's milk challenge and when they were eliminating cow's milk from the diet. Dietary challenges and elimination diets are best performed when both the parents and the researchers, at the time of the challenge, are ignorant of whether the child is or is not receiving the substance in question. Only then can bias or wishful thinking be reduced.
Many school-age children have difficulty falling asleep because they worry about their grades, test scores, appearance, or sports skills. Anxiety about not doing well academically or athletically might lead to impaired performance. This is called “performance anxiety.” Impaired sleeping likewise occurs when there is too much worrying or nagging about not getting enough sleep. Worrying too much about not sleeping well creates anxiety or stress, interfering with the relaxation needed to successfully perform the task, which is to fall asleep. Feel free to call any child psychologist for information about the solution, which is called “relaxation training.” If your child, at any age, appears to need more sleep, and he wants to sleep but cannot easily fall asleep, please consider working with a professional to help your child learn to relax and avoid performance anxiety.