Kids with ADHD sleep less well than other kids. Why is this?
Before we address this question, let’s back up and ask some preliminary questions:
- Is it true that kids with ADHD sleep less? Yes, the evidence suggests this is true.
- Is ADHD a real disorder? Some experts claim there is no such thing as ADHD. They argue that what we call “ADHD” is causing the sleep problems we see.
A study published in the June issue of the Journal of Sleep Research presents some evidence that might help answer these questions.
These Danish investigators found that there is something funny about the way kids diagnosed with ADHD sleep. There are some notable and very important features of this study. The first has to do with the way researchers recruited families to participate.
Parents and pediatricians referred children to a clinic because of problems with attention. None of them had a diagnosis of ADHD. They filled out questionnaires and agreed to let their children have sleep studies. They did all of this before they had a diagnosis. In other words, the subjects were “blinded” to their placement in the study. This type of blinding helps remove any unconscious bias the parents may have had when answering the questions. By the end of the study, investigators had data from 76 children, average age nine. That’s not a huge study, but it is the largest study of ADHD sleep patterns to date.
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Parents kept a 1-week sleep diary, logging hours of sleep and various other data points. Then investigators fitted children with take-home sleep study (polysomnography) machines. Though not the most comfortable devices, most children tolerate them well. The machines measure brain wave activity, breathing and oxygen levels, among other things. Finally, researchers invited the children to a sleep lab to perform a Multiple Sleep Latency Test (MSLT). It’s a long name for a test that simply measures how long it takes you to fall asleep when you take naps during the day.
The investigators also diagnostic tests for other disorders, such as autism, anxiety, and depression. They also performed intelligence tests and excluded children who scored an IQ less than 70. Investigators did not explain why they excluded mentally retarded children from the study. No part of the exams required any cognitive ability on the part of the child at all.
It turned out that 55 percent of the children with ADHD had some other diagnosis as well, called a “co-morbidity.” Before the study started, the investigators had guessed that children with multiple diagnoses would have more trouble sleeping.
To their surprise, investigators found that children with multiple diagnoses had the same sleeping patterns as children with only an ADHD diagnosis.
Children with ADHD did not sleep as long as children in the control group. On average the 76 children with ADHD slept 501.9 minutes (about 8 hours and 20 minutes). Control children slept an average of 543.6 minutes (just over 9 hours).
Children in the ADHD had more sleep cycles (6.2) than the controls (4.4). In other words, the rise and fall of sleep, also called “sleep architecture” was significantly different.
It takes 10 minutes longer for children with ADHD to fall asleep at night, compared with control children.
By contrast, when taking the MSLT test, children with ADHD fell asleep faster, suggesting they are sleepier during the day despite being reported as more hyperactive and restless.
Taken together, these results suggest that the sleep of children with a diagnosis of ADHD may sleep differently than other children. What does this mean?
Is ADHD a problem with the part of the brain that controls attention and alertness? This has been the theory for decades. This theory is the basis of ADHD treatment with stimulants.
Sleep is more complex than this. Many parts of the brain are involved. Could it be that the symptoms of ADHD are caused by some other oddity in the way the brains of ADHD kids work?
The results of this study are interesting, but raise more questions than they answer. At the end of the paper, investigators admitted that “it remains unclear whether sleep disturbances in ADHD are an aetiological (causal) factor, a co-morbid disorder or the result of an overlapping neurodevelopmental disorder of the brain.” In other words, the investigators cannot say whether kids with ADHD sleep poorly, or whether kids who sleep poorly have symptoms of ADHD.
This study provides another nail in the coffin of the “chemical imbalance theory“. This theory stated stated that ADHD was caused by too little stimulatory neurotransmitter in the brain.
Investigators also avoided making an obvious point: If symptoms of ADHD correlates with a sleep disorder, then giving amphetamine-based medications to children probably will not correct the underlying problem. The opposite is more likely. Indeed, insomnia is a well-known side effect of Ritalin and other ADHD drugs.
And lack of sleep never helped a distractible child.
We humans value our power of speech. We say that words have power. Words have consequences. And yet the truth is that most of us have a hard time understanding each other when we speak. Anybody who is or has been married knows what I’m talking about. We search for meaning in the things other people say that the speaker never intended. This is especially true, for some reason, with sleep talking.
The aptly-named 1980’s New Wave band The Romantics seemed to think so. They even wrote a song about it.
When you close your eyes and you go to sleep
And it’s down to the sound of a heartbeat
I can hear the things that you’re dreaming about
When you open up your heart and the truth comes out
You tell me that you want me
You tell me that you need me
You tell me that you love me
And I know that I’m right
‘Cause I hear it in the night
I hear the secrets that you keep
When you’re talking in your sleep
I hear the secrets that you keep
When you’re talking in your sleep
What’s So Special About Sleep Talking?
I have bad news for The Romantics. The truth does not really come out. Most of the talking that people do in their sleep is gibberish. If people do make sense when they speak, the words almost never have any meaning that is useful to the wide-awake listener. Courts won’t admit testimony about utterances spoken during sleep talking episodes.
Sleep talking is very common. The highest estimates I found put the number at 60% of all individuals at some point during life. Like many of these sleep behaviors, sleep talking tends to run in families. If one or both parents sleep-talked, the chances are greater that the child will sleep talk as well.
I know that I’m right, ’cause I hear it in the night
The triggers for sleep talking are obscure, but we know some factors that make it more likely to happen.
- Sleep deprivation: Exhausted children who fall into very deep Stage IV sleep can have sudden partial awakenings which will cause them to talk in their sleep.
- Stress: Even though we do not believe that sleep talking and the other parasomnias signal psychic distress, we know that stressed people are more likely to do things in their sleep.
- Sleep apnea or other disruptions of the sleep cycle will make sleep talking more likely.
- Medications like antihistamines are known triggers as well.
You tell me that you love me
Is there anything parents need to worry about? If the sleep-talker shares a room, and annoys his roommate, this may present a problem. Some parents have tried a white noise machine to drown out the sound of the human speaker. Others have tried ear plugs.
In adults, there have been reports of people who have awakened exhausted by all the speaking they have done in the night. I suspect these cases are very rare and probably do not affect children.
I can hear the things that you’re dreaming about
Much sleep talking occurs during rapid eye movement (REM) sleep. In these cases, it’s quite possible that the sleep talker’s speech might be related to his dreams. There are no good studies to back up this claim. However, there are now smart phone apps designed to record sleep talking. Reviewers did not say specifically that they remembered dreaming about what they recorded themselves saying. It’s more useful for amusement purposes, and to self-monitor one’s own snoring!
The bottom line is that sleep talking is absolutely nothing to worry about, and doesn’t require any therapy. If, on the other hand, there is an underlying sleep disturbance that is leading to this behavior, I can help you sort through it. Feel free to contact me!
I’ll let The Romantics take us home.
Hallucinations scare people. At least they do in most of the Western world. For us, hallucinations mean insanity, or signal drug use. But there are many places in the world where seeing or hearing things that are not there is considered normal. Even in the West, visions upon waking up are common, especially in children. Most experts consider sleep hallucinations in children to be part of normal development. We estimate that between 10-25% of the population has sleep hallucinations during their lifetime.
What are Sleep Hallucinations?
Children who report seeing things usually do so when waking up. Smaller numbers do so when falling asleep. If you hook the child up to an EEG, as you would during a sleep study, you would find that the child is technically asleep when having a vision. It’s most useful, however, to think of the hallucinator as hovering between sleep and wakefulness.
These episodes can be especially frightening for a child because they are often associated with “sleep paralysis”. The child reports seeing a scary image but is unable to move! Most children who have sleep hallucinations along with sleep paralysis eventually being diagnosed with narcolepsy.
Reality or Fantasy?
Children younger than 7 often have difficulty figuring out if what they have seen is real or was a dream. The child will often report to parents that they’ve seen bizarre or impossible things in their room as they woke up. She may be convinced that what she saw was real.
I once saw a 9-year old girl who had sleep hallucinations. Her parents had consulted me because of excessive daytime sleepiness. In the course of asking questions, the girl offered that she would see Jesus Christ hovering over her bed every morning. She had even told her parents about this.
This story put me in an difficult position as a sleep coach. I could not tell the family that I thought the girl’s visions were not normal. Doing so would surely offend them. But at the same time, I believed that her sleep hallucinations were related to the sleep problem she was having. She turned out to have obstructive sleep apnea (OSA). Her sleep-wake cycles were totally disrupted by her difficulty breathing at night. As a result, she became more susceptible to parasomnias like sleep hallucinations.
The girl eventually had her tonsils and her adenoids removed. Her daytime sleepiness went away, and so did her visions.
Causes of Sleep Hallucinations
In addition to conditions like OSA, stress and sleep-deprivation can make sleep hallucinations more common. Certain medications, particularly anti-histamines, seem to make children more susceptible as well.
Anxiety and sleep hallucinations are a bad combination. An anxious child who is scared by her visions may balk at going to sleep. Many anxious children are mistakenly prescribed medications to help them fall asleep. This is usually not a good idea. Sedative-hypnotic drugs and anti-anxiety medications tend to make parasomnias worse, not better!
Most children with sleep hallucinations do not need particular treatment. Many children who report seeing things actually sleep quite well. Nevertheless, it’s a good idea to investigate whether some correctable condition may be playing a role. This was the case in the 9-year old girl with OSA. Often we uncover a source of underlying stress, in which case we refer the family to a therapist.
As with most sleep problems in children, the best way to start managing sleep hallucinations is to return to the basics:
- Establish a regular bedtime. The remainder of the day should be as regular and as predictable as possible.
- Make sure the child gets plenty of vigorous exercise.
- They should eat a healthy diet with plenty of protein and vegetable-based carbohydrates.
- Make the hour(s) between dinner and bedtime as quiet, calm, and un-stimulating as possible.
If you need any help doing these things, contact me!
You’ve heard about sleepwalking, night terrors, possibly even sleep eating. These are all what experts call “parasomnias“, a code word for “unwanted behaviors you do in your sleep.” What do all these parasomnias have in common? They are all kinds of confusional arousals. Because I am a lumper and not a splitter, I tend to look at these sleep behaviors as variations of the same thing, rather than as separate disorders. It’s not that the rest of the world are splitters. It’s only that for centuries humans have observed their family members doing weird things in their sleep. They did not realize that all these weird things were somehow connected. The version of these behaviors in babies and toddlers is not as dramatic as sleepwalking or screaming in a night terror. So in the little ones, we simply call them “confusional arousals”
Confusional Arousals: What’s the Connection?
What all confusional arousals have in common is that they are caused by a transition from deep sleep to shallow sleep. Sometimes deep sleep is called “non-REM (NREM) sleep” to indicate that we are not talking about “rapid eye movement” sleep. In children, NREM sleep tends to be deeper than in adults. It is much more difficult to awaken a child in NREM sleep. Did you ever move a sleeping child from the car to her bed and wonder why she didn’t wake up? Deep NREM sleep. That’s why.
We all cycle between the various stages of sleep, up and down, as in a wave. Children, and some adults, cycle out of NREM sleep only partially, and sort of get “stuck” between sleep and wakefulness. They aren’t really awake, but they aren’t completely awake either. It’s an altered state of consciousness. Dr. Ferber calls these events “sudden partial awakenings“.
It is during these sudden partial awakenings that parasomnias like sleepwalking happen. They occur mostly in the first half of the night, during the first or second sleep cycle. A major difference between these parasomnias and other sleep disturbances like nightmares is that sudden partial awakenings happen in the first half of the night and nightmares tend to occur in the early morning.
Most adult sleepers wake up enough to behave more or less normally, though confused. Ferber tells the story of the mother who must wake up in the middle of the night to give an ill child her medicine. She gets out of bed, shuffles to the kitchen, and then forgets why she is there. This is a classic confusional arousal.
Most of the other parasomnias are variations of confusional arousals. They only differ by degree, or as Ferber would say, by their intensity. He considers night terrors to be more intense confusional arousals than, say, teeth grinding. Somewhere in between we find sleepwalking. Ferber and I agree that these sleep behaviors all fit somewhere on a spectrum. This is because they all result from the same oddity of sleep cycles. And, more important, the treatment of all of them is basically the same (see below).
What About Babies?
Is there a group of children who have the type of sudden partial awakenings we would call simply “confusional arousals”? Yes. That would be the toddlers.
In toddlers, the only sign you may see is a child who sits up suddenly in bed. Maybe she will mumble incoherently (as opposed to other toddlers, who of course are completely clear when they speak!) Sometimes they will moan and thrash. These episodes tend to be short, a few minutes in length at the most. But occasionally, the period of confusion will last up to 30 minutes. You cannot communicate with a child in this state, and it’s not a good idea to try and wake her. The effort will probably fail, and if you do succeed, you’ll only frighten the child.
What Causes Confusional Arousals?
No one really knows why children do this. There does not seem to be any evolutionary explanation for why children and some adults have such deep NREM sleep, and then experience sudden partial awakenings. We do, however, know some things that make confusional arousals more common.
Sleep Deprivation – All kinds of disruptions in a child’s day can make confusional arousals more likely, but sleep deprivation is a major cause. The theory is that an exhausted child will sleep more deeply than normal. Then when she has a sudden partial awakening, she won’t quite wake all the way up, leading to moaning or thrashing.
Emotional Stress – Unfortunately, even toddlers and small children experience stress as well. For reasons that we do not fully understand, stress during the day can lead to parasomnias at night. Some kinds of stress are not avoidable. But it’s always best to try and keep a child’s day as peaceful and stress-free as possible. Children are often made stressed-out by parental stress. So it’s important to be aware of your own stress level and ask yourself if you are showing it to your child.
Medications – The ingredients of many cold medicines can cause sudden partial awakenings. Antihistamines are fairly common suspects. This is not the main reason why cold remedies are not recommended for small children, but it’s a pretty good reason to avoid them.
Is There Any Treatment?
The good news is that confusional arousals is that they are not harmful to the child, so there is no pressing reason to treat them. Even better news is that the child is likely to grow out of them.The exception are the children who have what Ferber calls “intense” sudden partial awakenings. Some children might thrash around to the point that they could harm themselves on furniture. For these children it makes sense to do some strategic child-proofing in her room.
For the rest, it’s important to remember that these behaviors can be triggered by some sleep behaviors that can be fine-tuned by parents. As usual the basic rules of healthy sleep apply.
- Make the child’s day as regular and predictable as possible: Children thrive on regularity and consistency.
- Keep a consistent bedtime: If at all possible, make sure she does not become sleep-deprived.
- Stress-reduction: The routine from the beginning of dinner until the moment of sleep should be calm and relaxing. Avoid too much excitement. Even funny books can rev a child’s motor too much! If you find that the child is reading your own stress, you might consider looking into stress-reduction techniques for yourself.
- Avoid giving medications that can disrupt your child’s sleep, such as antihistamines.
Have you tried all these things and your child is still having confusional arousals? Contact me. I can help.
Huh? REM Sleep Behavior Disorder?
“Rob, I just want to know why my daughter kicks her sister in her sleep!” Until this mother brought me the unusual case of Julia (all names have been changed), age 9, I had never heard of REM sleep behavior disorder either. I referred Julia and her mom to an internationally-recognized sleep center in Boston to make the diagnosis. But I’m getting ahead of the story. Here’s what happened:
When Julio and Maria, Julia’s parents, bought a new king-size for themselves, they decided to keep their old queen-size mattress and give it to their daughters Julia and Junissa. This would save the couple space and laundry. And the girls were enthusiastic about sharing a bed.
That is until the middle of the night in August when Junissa ran to her parents bedroom crying.
“Julia hit me! Julia hit me!”, she kept sobbing.
Maria and Julio didn’t quite know what to think. The girls loved each other. They got along well, even unusually well. They had never so much as pushed one another in the 7 years since Junissa was born.
Junissa was telling the truth. She had a bruise coming up on her leg in the shape of Julia’s foot. Her parents rushed to the girls’ bedroom and found Julia asleep.
Maria shook her and raised her voice, demanding that Julia explain what happened. Julia woke with a jolt. The poor girl was confused and scared. She swore she didn’t do anything to her sister.
“But I had a dream…”
The next morning, Julia explained to her parents and her sister that she had been dreaming about playing soccer, as she had been earlier the previous day. In the dream her friend passed her the ball and she wound up and made a huge kick toward the goal. This must have been when she kicked her sister.
Julia’s parents believed her, and left things as they were. But a week later, again after a soccer day, Julia began kicking wildly in her sleep, this time narrowly missing her sister each time.
That’s how the family came to me. I took a detailed history and asked all the questions I usually do, but I was stumped. Then I remembered ages ago learning about REM Sleep Behavior Disorder (RBD). I had never seen it before. Was I seeing it for the first time?
What is REM Sleep Behavior Disorder?
Rapid Eye Movement (REM) is that stage of sleep when people dream vividly. It’s also a stage of sleep when people tend to have very low muscle activity, except for their eyes (hence the name). In REM Sleep Behavior Disorder, by contrast, people retain muscle control, and tend to move as though they are acting out their dreams. If the dreams are especially exciting or violent, the dreamer could hurt herself or bedmates, as in our girl’s case, or damage property.
Originally thought to occur only in middle-aged and older men, RBD is now recognized to occur in children as young as 7. RBD has been associated with parasomnias like Restless Legs Syndrome, as well as developmental problems such as autism, or brain diseases. Certain medications also give RBD as a side-effect. Julia had been sleepwalking since she was 5. On deeper questioning, her parents revealed that both of them had been sleepwalkers, unbeknownst to each other!
Treatment of REM Sleep Behavior Disorder
According to the literature, and to the sleep center in Boston, the only known therapies for RBD involved taking medication. Maria brought this issue up with Julia’s pediatrician, and they had a frank discussion. Julia’s parents and the pediatrician decided that the possible side-effects of the medications were more serious than Julia acting out her dreams.
Instead, the family decided to sell the queen-size bed that the girls shared, and to buy them matching twin beds. This would reduce the immediate risk of Julia kicking her sister after game day. They also installed a video monitor in the girl’s room. If Julia began to thrash or kick, one of her parents would stand guard to make sure she did not get out of bed and harm herself. I thought it was a terrific decision.
I suggested to the parents that Julia adopt a sleep schedule. She would go to bed at the same time every night, and keep her daytime as regular and predictable as possible. She cut back on one of her extra-curricular activities that might have been adding to her stress. And she began eating less junk food, especially before bed.
In about 6 months, Julia stopped having RBD events. When Junissa turned 9, she began doing the same as her sister! Again, with modification of her sleep schedule and diet changes, or maybe because of some other mysterious reason, Junissa began to sleep peacefully as well.
Do you or your kids act out their dreams? If so, I’m here to help.
There are two types of teeth grinding: the kind you do during the day, and the kind you do at night. It turns out these are different conditions, with different causes and treatments. The effects on teeth, unfortunately are the same. We will focus here on teeth grinding in children, particularly the kind that happens during sleep.
Because everything in medicine has to have a Greek or Latin name in order to bedazzle us normal people, teething grinding is officially known as “Bruxism”, from the Greek word meaning “bite, or gnash”. The word has been in use only since 1930. But humans have been teeth grinding forever.
Nighttime Teeth Grinding in Children
Teeth grinding in children is very common. Best estimates put it at 20-30% of all children do it. During the day, babies will grind their brand-new teeth together once they get a matching set of top and bottom teeth. Why do they do this? The truth is that no one knows. But I have a theory.
Stupid Baby Tricks
I believe babies grind teeth during the day simply because they can. It’s one of those cool things to do with their body that gives an effect they didn’t expect. I lump it in the same category as head-bonking and self-gagging. Collectively I call them “stupid baby tricks”, not because the baby is stupid, but because the trick is pretty dumb. One important feature of stupid baby tricks is that the baby gets bored with them quickly. Because they’re dumb! But they will continue to grind their teeth for you (and other things) in proportion to the response it gets from you. It’s as if the baby says to herself “I don’t really like grinding my teeth but Gee! What a response it gets from Mom! I’m gonna keep doing this!!!”
Why at night?
But surely the baby doesn’t do this on purpose in her sleep! What causes nighttime teeth grinding in children?
The honest answer is “nobody knows”.
There was a theory that teeth grinding was caused by teeth being out of alignment. Other theories suggest that stress is the cause. The truth is that we cannot pinpoint any cause for nighttime teeth grinding. Most sleep experts claim that nighttime bruxism is a parasomnia, like sleepwalking or sleep-eating. If this is true, children do this because they sleep very deeply and then have “sudden partial awakenings” in which they rise up quickly from deep sleep but never quite reach full wakefulness.
How do we even know it’s going on?
Most of the time, parents hear the child grinding her teeth in her sleep. If the theory is correct, and this teeth grinding is from a sudden partial awakening, it will occur in the first half of the night, 2-3 hours after the child falls asleep. An older child may complain in the morning that her jaw hurts. In extreme cases, the child will develop temporomandibular joint dysfunction (TMD), with headaches and difficulty moving the jaw.
The good news is that your child will probably not do this for very long. Most kids stop grinding their teeth in sleep by the time they have all their adult teeth. This is about the time that all the other common sleep problems of childhood go away, like sleepwalking.
In the meantime, we don’t really know how to prevent or treat nighttime teeth grinding. The majority of sleep experts suggest that the child be relaxed and relatively stress-free at bedtime. This is good advice, but I would argue that it’s good advice for any child before bedtime! There’s no good evidence that this will reduce teeth grinding, but it’s not a bad idea.
There’s some suggestion as well that relative dehydration may lead to teeth grinding, so that a child should drink plenty of fluids before bed. I’m not crazy about this idea, particularly if one of the sleep problems you are dealing with is bedwetting.
In the more severe cases, the dentist may suggest a mouth guard for the child. These are used to prevent any further damage to the teeth, even if they are baby teeth. If you go this route, you may do better to have a specially-fitted appliance for the child. The mouth is a sensitive place and mouth guards can be very uncomfortable if they don’t fit properly. Before you make your decision, find out if an appliance will be covered by your insurance. They can be very pricey.
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- Though daytime teeth grinding is related to stress, the nighttime version probably is not
- It’s probably a “parasomnia” related to sleepwalking
- You can’t really prevent your teeth grinder from doing it, you can only reduce the damage
- With time, teeth grinding goes away on its own
Why would someone eat buttered cigarettes? Maybe they’d do it as a prank, or to pledge at a sorority. But who would do this at night in the kitchen with nobody watching? You’d do it if you had sleep-related eating disorder (SRED).
What is sleep-related eating disorder?
SRED was not described in the medical literature until 1991. Up to then, experts only recognized “night eating syndrome” (NES). NES is now considered an eating disorder, like anorexia and bulimia. In contrast, sleep-related eating disorder is now considered to be a parasomnia, similar to sleepwalking.
The difference is important. People with NES are awake and aware of what they are doing. They may be unable to sleep because of hunger. Often they are struggling with weight issues and the difficulties of dieting. By contrast, people with sleep-related eating disorder are actually asleep.
Most people diagnosed with SRED are women in their 20s or 30s. But when you ask the right questions, you find that almost all of these had been sleep-eating since childhood. Substantial number of sleep-eaters also have other eating disorders. It’s a shame that sleep-eating is not recognized sooner. By the time the correct diagnosis is made, the majority of sufferers are already obese, with all the health problems that go along with it.
Sleep-eaters most often do not remember any of the details of what they do at night, though most people with the disorder sleep-eat every night, sometimes more than once per night. The episodes have nothing to do with hunger or thirst. This is another important difference between SRED and NES.
Sleep-eaters will often eat more than half their daily calorie intake at night. And it tends not to be the healthiest food: Typically, sleep-eaters chow down on foods high in sugar and complex carbohydrates. It’s not unusual that sleep-eaters will become obese, mostly because of food they don’t remember eating.
Some of the things sleep-eaters indulge in are not exactly delicacies. They’ve been known to eat buttered cigarettes and frozen food (meaning food that is actually frozen when they eat it!)
And sleep eaters risk harming themselves in the kitchen. They’ve been known to cut themselves on sharp cans, or burn themselves on stovetops or toasters. I’ve read reports of sleep-eaters waking in the morning with their hands and face covered in chocolate. And sleep-eaters tend not to clean the kitchen either.
Who gets sleep-related eating disorder?
Like other parasomnias, SRED often happens in conjunction with other unwanted sleep behaviors, like sleepwalking and restless legs syndrome. Like NES, it’s more common in people with eating disorders. Episodes are more likely to happen during periods of stress. It’s possible that some sleep-eaters are struggling with some psychological conflict, having to do with control and loss-of-control. It’s possible these conflicts are played out in sleep.
Also like other parasomnias, SRED occurs in the midst of “sudden partial awakenings“. These events are defined by rising quickly out of very deep sleep, but not completely. The sleep-eater is then caught between sleep and wakefulness, and is for all intents and purposes unconscious. Though some people are prone to sudden partial awakenings, others can be induced if their sleep-wake cycle are disrupted. Sometimes the disruptions are purposeful, as with college students who keep irregular hours. Others experience disruptions because of sleep medications (!) like Ambien.
Diagnosing sleep-related eating disorder
The first step in diagnosis is recognizing that something is going on. The sleep-eater will probably not remember what she has done. The evidence may be found in a messy kitchen. Sometimes the only evidence is a child gaining weight for no apparent reason. If the child is known to sleepwalk, or there is a family history of parasomnias, you might suspect sleep-eating.
The clincher for a diagnosis is a sleep study. This is an overnight test performed in a laboratory. The sleeper is observed with all kinds of monitors attached. The key part of the test is an EEG. This will indicate if the sleeper is having sudden partial awakenings.
Treating sleep-related eating disorder
Once the correct diagnosis is made, the key is to identify the underlying triggers. For many sleep-eaters, this means locating sources of stress and anxiety. Easier said than done, I know, but you don’t do a child any favors by treating a symptom and ignoring the causes.
In the meantime, it’s important to make the kitchen as safe as possible. Keep cabinets locked. Secure cooking devices that could cause burns. Hide away or otherwise secure sharp objects.
Some medications have been used successfully in the treatment of SRED. These are psychiatric medication, so we do not know how or why they work. I counsel clients to resort to medications only if the weight problem is threatening health problems that are worse than the side-effects of medication.
Finally, the basic rules apply: make the child’s day as regular and predictable as possible. Have a consistent bedtime. Make sure she is eating a healthy diet during the day. This will help reduce night-time sub-conscious urges. And make sure she gets plenty of vigorous exercise.
Once any potential medical problems have been ruled out, a sleep coach can help you fix the sleep problem. I’d be happy to help you! Check out our sleep packages.
There’s something important about insomnia that I did not know before I studied it.
I confess I thought of insomniacs as people who stayed up all night because they did not get tired. I was wrong. People with insomnia are not merely tired. They are exhausted. They want to sleep desperately but cannot. The less they sleep the worse a person suffering with insomnia feels.
Worst of all, perhaps, children suffer from insomnia too. And it’s more common in children than I ever imagined. Some experts believe that as many as 30% of children suffer from insomnia or other significant sleep disturbance.
Insomnia in Children is Different from Adult Insomnia
…in some ways at any rate. It is often the parent, not the child, who first notices that there is a problem. And children have a type of insomnia that develops with the “help” of their parents. I’ll get to that a little later. But many of the causes are very similar to the things that keep adults awake. In fact, many adults report that they’ve had trouble sleeping since childhood.
The simple definition of insomnia is “habitual sleeplessness”. But embedded in that simple definition is the entire field of sleep problems in children. The problem is most often lack of sleep, or absence of enough sleep. The trick is to figure out what makes the absence of sleep “habitual”.
In children, we tend to define insomnia by its effects, not by its duration. If the sleeplessness has a negative effect on the child or her parents, it does not matter how recently it started or how long it lasts.
Long- and Short-term
Having said that, sometimes it’s useful to ask how long the child has had trouble sleeping. Short-term reasons for sleeplessness include illness, or a medication the child is taking. The sleep problem will often go away when the child recovers or stops the medication. But if the child is not sick or taking medication, and yet the sleep problem happens at least three times per week, and/or lasts more than a month, there might be another problem that deserves medical attention.
Need a SLEEP COACH?
I firmly believe that sleep is the natural condition. Children (and adults) sleep naturally unless there is something keeping them from sleeping. So it’s essential to figure out what is keeping the child awake.
In children, you are less likely to have her come up to you and say “Gee, mom, I’d really like to sleep but I can’t!” More likely, you’ll notice something is wrong before she does. Common symptoms in children include:
- Early Waking: Typically, we’re talking about a child who awakens at 3:45 AM and appears to be up for the day. This may appear first as an annoyance to parents. It’s important to realize the child is not doing this on purpose!
- Anxiety about going to bed and being able to fall asleep: The child knows they’ll have trouble falling asleep and they’re anxious about it. These anxieties can take the form of fear of the dark, or fear of monsters under the bed. The more anxious they become, the tougher it gets for them to fall asleep!
- Daytime Sleepiness: Even if you believe the child is sleeping at night, they might not be getting enough restful sleep. They’ll tire out during the day.
- School or behavior problems: Sometimes the first sign of a sleep problem will be notes coming home from school. Or you may notice the child misbehaving when she never did before. Or she’s misbehaving more often than before.
- Irritability/mood swings: Irritability simply means sensitivity to changing moods quickly. This is different from simple grumpiness. The parent reports that the child is “easily set off”, or that she “flies into a rage” over seemingly small things. Lack of sleep will do this to a child (or an adult, for that matter!)
- Depression: Sometimes the sleepless child will not be irritable or badly behaved. She’ll just have a flat, or depressed mood. It’s difficult sometimes to know which caused which, lack of sleep or the depression (more on this below)
- Hyperactivity: It’s not unusual for children to misdiagnosed with ADHD. To some extent, this is understandable. Lots of things are mistaken for ADHD. Narcolepsy and Restless Legs Syndrome, for example. But neither is this an excuse. Whenever teachers or any other authority suggests to you that your child may have ADHD, it’s necessary to rule out other causes for the behaviors.
- Decreased attention span: It’s difficult to concentrate when you haven’t slept. Most of the time the child herself will not realize she cannot stay on task. It will be pointed out to her by others.
- Aggression: This is a product of the irritability mentioned above. A previously docile child may lash out unexpectedly. This is a red flag that should always raise concerns about a sleep disturbance.
- Memory problems: There is a close association between sleeplessness and memory problems. It is suspected that a normal sleep pattern is necessary for solidifying memories. This is important to remember for students pulling “all-nighters”. Lack of sleep never helps memory.
- Making errors or having accidents: This is a particularly serious, potentially deadly sign in young drivers. Attentiveness, distractibility, and reaction time are all affected by sleeplessness.
What Causes Insomnia in Children?
- Stress: We like to think of childhood as carefree and blissful. Sadly this is a myth. It always has been a myth. Childhood is stressful, more or less for many, if not most children. Children have a limited number of ways to communicate that things are not okay in their world, and loss of sleep is one of them (the others are acting out and refusing to eat).
- Caffeine or other stimulants: Many parents do not realize just how much stimulant their children are consuming in the form of soda and so-called “power drinks”. Leave aside the issue of sugar, and the damage it wreaks! You should always examine the diet of a child who cannot sleep.
- Medications: The treatment for ADHD is notorious for causing insomnia. The medications are amphetamine-based stimulants. One thing for certain is that no inattentive child is made more attentive by losing sleep! These medications should be very closely monitored to say the least, if not eliminated entirely.
- Medical causes: Difficulty breathing is a common, often unrecognized cause of sleeplessness. Sometimes sleep disturbance is the first sign of asthma in children. Children with obstructive sleep apnea often have a great deal of difficulty staying asleep. If a child is too itchy from her eczema, or too uncomfortable with her heartburn (reflux), she may have trouble falling asleep and staying asleep. Finally, thyroid problems may cause sleeplessness. All these potential causes should be addressed with a physician.
- Psychiatric causes: Depressed children often do not sleep well. Their anxiety and irritability may be worse at night when they are not distracted by daytime activities. And then there is the cause no one wants to talk about, physical or sexual abuse. Nevertheless, abuse is a cause of sleeplessness and we should take it seriously.
- Environment: Places that are too loud, too hot, too cold, or too light are difficult to sleep in. So are places where electronic devices are too close by!
The Special Cause of Childhood Insomnia
There is one cause of sleeplessness in which the parents are very much part of the cause. Many children cannot sleep because their parents did not allow them to learn to fall asleep on their own. These are the parents who, with the best of intentions, allow their children to develop bad sleep associations. The problem may be that the child needs contact with parents to fall asleep. Or perhaps the child needs to have a bottle or pacifier. These dependencies often lead to sleep problems that the parents end up wishing they never got into.
Another cause is parental lack of limits-setting at bedtime. Again, I’m sure this is done with the best of intentions, but the results can be devastating for sleep. For example, the child who asks for glasses of water repeatedly, or who is allowed to wander the house at bedtime.
Treating Insomnia in Children
The treatment is based on fixing the cause or causes. That’s why it is so important to understand all the possible ways that a child can lose sleep. Regardless of cause, there are some basic sleep techniques that are always helpful:
- Set a consistent bedtime and routine: Everybody, child and adult, sleeps better when their day is regular and bedtime is is the same time every night. The bedtime routine should be the same as well. It should be as calm and as free of stimulation as possible. If the problem is truly that the child is not tired, try moving bedtime later, by 15 minutes at a time, until the child is good and ready for bed!
- Comfortable sleep environment: Not too hot, not too cold, quiet and dark! It’s a good idea to keep clocks out of the room of a person who has trouble sleeping. This is especially true of clocks that glow in the dark. It goes without saying that devices with screens must be eliminated. They are the enemies of sleep!
- Relaxation techniques: Most parents do not know how to teach relaxation. But there is an entire industry of relaxation products available that can help teach a child (or an adult for that matter) how to relax at bedtime. An easy way to start is to make the time between dinner and bedtime as boring and non-stimulating as possible.
- No tossing and turning! If a child will toss and turn instead of sleeping, have her get out of bed and do something relaxing but boring, like reading in low light. Try this for 20 minutes at a time. If this does not work, have the child repeat at least twice.
- Cognitive Behavioral Therapy: If medical causes have been ruled out, and you cannot help the child using these techniques, it may be useful to seek the help of a therapist. If nothing else, a therapist may help a child manage the anxiety that so often magnifies sleeplessness.
- The Bell on the Door: For the child who insists on sleeping with you, I recommend calmly but firmly leading the child back to bed. No arguments, no explanations. You can even tie a bell to the child’s door and respond immediately when you hear it ring. If you do this correctly and do not give in, the child will give up trying to sleep with you.
What About Medications?
I and most sleep experts caution strongly against the use of medications to treat insomnia in children. The first and most important job of the physician and the sleep coach is to find the cause and to treat it. Only in the rarest circumstances, and only as a last resort, should you medicate a child for sleeplessness. The downsides outweigh the upsides. As with teaching a child to sleep on her own when she’s a baby, so it is with curing insomnia. If it is a medical problem, it should be identified so you can treat it. If it is a problem of environment or diet, these should be adjusted.
And if the problem is simply that you’ve developed bad sleep associations or poor limits-setting, these should be reversed. In some ways, these are the toughest causes of insomnia to fix. But fix them you must. The entire family’s sleep depends upon it.
What if I told you there was a condition called exploding head syndrome?
Take the case of Jamie (not his real name), a 16-year old boy I met several years ago.
Jamie woke his mother up at midnight, telling her he heard an explosion in his room. His mother had heard nothing. Jamie was clearly spooked by what had happened. He swore he heard what he heard. He was afraid he was going crazy. He had been up late several nights working on a project for a class, but he promised his mother he hadn’t been doing drugs or drinking alcohol. She believed him. So did I. Jamie had his first ever episode of exploding head syndrome.
What the Heck is Exploding Head Syndrome?
Exploding head syndrome is a parasomnia. A parasomnia simply means unwanted events that come along with sleep, like sleepwalking. People report a hearing an incredibly loud noise just before falling asleep, or just before waking. It can seem like a shotgun firing in one’s head. Unfortunately, these events happen to children as well.
Other people describe have described the sensation as:
- A painless loud bang
- A clash of cymbals
- A bomb exploding
Or, it could be a less alarming sound. Even so, episodes can scare the &%$@ out of people. Some observers think that exploding head syndrome might explain alien abduction claims! Others think that they are having a stroke. The number of attacks varies. They can happen very rarely. They can also occur many times in one night. Having many episodes can greatly disturb your sleep. Some people report having a cluster of attacks over several nights. Then a few weeks or months will pass before it occurs again.
A flash of light may come along with the sound. A muscle twitch or jerk may also occur. The event is normally painless. A sudden stab of pain in the head has at times been reported. Some people are unfortunate enough to experience the event along with an attack of sleep paralysis.
What, You’ve Never Heard of Exploding Head Syndrome?
Join the club. You don’t read a lot about it. But it is a real thing. It’s more common in adults, but it does occur in children, down to age 10.
It turns out to be more common than you might imagine. A study of college students in 2015 found that 18% of the group reported having been awakened by an imagined loud noise at least once in their lives. A substantial number of these young people reported several such episodes.
Need a SLEEP COACH?
It happens more often in people who are anxious, or fatigued, or stressed. The boy Jamie I opened this piece with fit into all three categories. He had been up late several nights in a row working on a project for school. He was unusually stressed out about it.
The diagnosis is difficult to make. There is no test for exploding head syndrome. We have only the patient’s word for it. If there will be any testing, it will by a sleep study. Physicians want to make sure that there is not another type of sleep disorder going on, or another medical condition. They will want to if you are taking any medications, which can give these symptoms as a side-effect. They will want to know if you are taking any drugs as well.
Finally, the doctors may want to perform an EEG. The purpose would be to make sure that the event was not a type of seizure.
Uh-oh. You Mean There’s No Treatment?
That’s correct. There is no treatment for exploding head syndrome. Part of the problem is our ignorance of the cause. Most of the time in medicine, if doctors can’t figure out what the cause is, they can’t very well find a cure.
If We Can’t Treat It, Can We at Least Manage It?
Sure. There are a number of things you can do. These may sound familiar, but that should not come as a surprise. To fix almost any sleep problem you have to go back to basics.
- Try to stick to a regular routine. Consistency, regularity, and predictability are the friends of good sleep. And their absence is the enemy. To the greatest extent possible, get the child to sleep at the same time every night (not too late!)
- Feed your child healthy food. Avoid processed food and other junk.
- Make sure the child does vigorous exercise regularly. It helps; trust me!
- Reduce stress. This is perhaps the toughest of all. Some sources of stress are harder to remove than others. If the child is doing too many activities, you may consider cutting back. If this isn’t possible, try stress-reduction classes like yoga or controlled breathing.