5 minute tips on sleep

Please read our introductory post before reading this

As always, you need to know

a) generic advice

b) a formulation that tells you why this child has problems now.

You can then adapt the former according to the latter.

Generic advice

Sleep schedule: Your child’s bedtime and waketime should be about the same time everyday. There should not be more than 1 hour’s difference in bedtime and waketime between school nights and non-school nights. Make your child’s bedtime early so that he can get enough sleep.
Bedtime routine: Your child should have a 20-minute to 30-minute bedtime routine that is the same every night. The routine should include calm activities, such as reading a book or talking about the day, with the last part occurring in the room where your child sleeps.
Bedroom: Your child’s bedroom should be comfortable, quiet, and dark. A nightlight is fine, as a completely dark room can be scary for some children. Your child will sleep better in a room that is cool (less than 75°F). Also, avoid using your child’s bedroom for “time out” or other punishment. You want your child to think of the bedroom as a good place, not a bad one.
Snack: Your child should not go to bed hungry. A light snack (such as milk and cookies) before bed is a good idea. Heavy meals within an hour or two of bedtime, however, may interfere with sleep.
Caffeine: Your child should avoid caffeine for at least 3 to 4 hours before bedtime, although it’s best to avoid it totally. Caffeine can be found in many types of soda, energy drinks, coffee, iced tea, and chocolate.
Evening activities: The hour before bed should be a quiet time. Your child should not get involved in high-energy activities, such as rough play or playing outside, or stimulating activities such as computer games.
Television: Keep the television set out of your child’s bedroom. Children can easily develop the bad habit of “needing” the television to fall asleep. It is also much more difficult to control your child’s television viewing if the set is in the bedroom. Keep all other electronic devices out of the bedroom too, such as computers, cell phones, and hand-held computer games.
Naps: Naps should be geared to your child’s age and developmental needs. However, very long naps or too many naps should be avoided, as too much daytime sleep can result in your child sleeping less at night.
Exercise: Your child should spend time outside every day and get daily exercise.

Sleep problems resistant to first-line advice

Most parents presenting with young children with sleep problems are frustrated by the child’s inability to settle to sleep alone, or by their frequent night wakings. We will not discuss infant sleep, but concentrate on the pre-school child.

Social factors: Historically and cross-culturally, it is highly unusual to expect young children to sleep alone. Nonetheless that is the UK norm, and it is acheivable for most families.

Psychological: Going to sleep alone is a form of separation, and like all separations must be prepared for. If the child is in an anxious or fearful state this will require very slow withdrawal of the protective adult. Usually, if the fear is external to the adult, e.g. of the dark, gradual withdrawal is effective, but where the fear is of the adult, or more commonly about the adult, e.g. in domestic violence, then more specialist work may be needed.

Sleep is also a habit, and habits form very strongly in pre-school children. If sleep is usually with an adult, or in the light, changes to this should be carefully applied one at a time. Likewise, if the physical situation (light, noise, presence of adult) is different between sleep onset and the (normal) awakenings that occur every 1-2 hours, then full arousal will often result.

There is an association between some forms of insecure attachment and sleep problems, and also maternal depression. The precise relationship is unclear, however, and probably varies from family to family.

Biological:sleep is a biological phenomenon, and is therefore affected by biological mechanisms. Chronic symptoms e.g. pain or GI symptoms may prevent sleep, but equally phenomena such as epileptic seizures can disrupt the diurnal rhythm. A far more common way to interfere with sleep initiation is to watch a back-lit screen close to bedtime. These appear to suppress endogenous melatonin secretion, and thus the psysiological ‘cue’ to sleep, and so should be avoided within an hour of bedtime.

Example case:

Louie, 4, has a tantrum every night at bedtime. His health visitor has advised mum to shut the bedroom door and ignore him, but it’s not working.

4p grid constructed as follows:

 

  Biological/ developmental Psychological Social
Predisposing Preterm birth Maternal anxiety  
Precipitating   Break-up of parents’ relationship Domestic violence
Perpetuating Screen use in bedroom up till bedtime Anxiety re: mum Mum unavailable due to depression
Protective Healthy, good communicator Good relationship with mum during the day Family well-supported by grandparents

 

This leads to some simple, hopefully helpful interventions:

  • Stop screen time
  • Mum to seek counselling/ treatment for depression.
  • Grandparents asked to help with domestic tasks so mum can spend time with Louie
  • Gradual withdrawal of mum from bedroom at bedtime, following good ‘wind-down’.

 

5 minute tips for anxiety in children and young people

This post allows you to give brief advice if it send that a child has problems with anxiety. It should be read after you have gone through our introductory post, and is intended for non specialists working in health services.

When to think of anxiety
Excessive anxiety is common in childhood, but is particularly common in chronic or recurrent pain (up to 80%) and in developmental conditions, especially autistic spectrum disorders.

What are the key questions to ask
Worries: in quiet moments, does the child worry about going to school, harm coming to their family or themselves, any imaginary creatures or anticipated events
Avoidance: anything that the child doesn’t do, or doesn’t want to do
Sleep: difficulty settling, frequent waking, nightmares
Eating: restrictive patterns, poor appetite

Safety checks: (seek advice if these are happening)
Is the child harming themselves, or consider doing so?
Does the child feel worthless?

What advice can you give?

There are two main forms that therapy takes, both of which can be applied in a ‘low-voltage’ fashion in non-specialist settings.

Firstly, it is helpful to draw out the thoughts and beliefs that underlie the anxiety.  This is not so that the adult can dismiss them as silly or mistaken, but so the child can be helped to compare the harmful cognitions with their other beliefs and feelings (e.g. monsters aren’t real) which can then be used to challenge the anxiety. Equally, it’s important when a child is worried about a particular event to talk through what consequences may result, and again check that the child really thinks these consequences are likely, and plausible. In some cases, especially involving social situations, it may that the child’s fears are justified, in  which case negotiation with third parties (teachers, family) would be useful.

Secondly, some kind of graduated exposure is often helpful. Say the child is scared of going to the toilet alone. Going with a parent, but with the parent then standing in the doorway would be a good start, which the child could be rewarded for. Next time, they would need to tolerate the parent being in the hallway in order to earn a reward, and so on.

These techniques are explained further in resources

Resources

This fact sheet can be a useful start for parents . Simple-ways-to-help-children-with-fears-and-anxieties

Cathy cresswell’s article in the Archives of Disease in Childhood is very good, as is her book for parents

The Mind Ed portal has a lot of information on anxiety. It’s designed for professionals, but there is really no reason why a motivated parent can’t access it, especially

The worried child

Anxiety disorders

The session on school avoidance is excellent, and there are loads of generalisable tips in it

Introducing… 5 minute tips

Emotional and behavioral problems in children and young people are complex. Specialist assessments and treatments are time-consuming and increasingly hard to obtain. And yet the vast majority of children with children with these problems get nowhere near a psychologist or psychiatrist. They are looked after as best they can by teachers, doctors,  nurses,  family support workers, and above all parents. But the training of this informal workforce is inconsistent,  and often messages are mixed and contradictory.
We in the PMHA know that the system needs radical overhaul and investment,  which is why we’ve been involved in the future in mind report produced by the Department of Health.
But any system needs to be built on the foundation of everyone who works with families knowing the basics,  and being able to communicate consistent messages.
Our small contribution is 5 minute tips. We will produce a number of blog posts over the next few weeks to communicate important messages that you can transmit to families in a fairly short time (although we can’t guarantee the 5 minutes!).
This post,  though, is background for you to read first. Because in order to produce sharp advice,  You need to be able to understand the family’s story, and help them make sense of it. And yes, that part does take longer than 5 minutes!
These are complex problems, but it is a myth that you need to be a specialist to understand them.
What you do need to do is learn to think in a particular way. paediatricians like me are trained to think about symptoms and signs, find a cause, and apply a treatment; but these situations just aren’t like that, and you need to adopt approaches from other disciplines.
If you asked a historian why the first world war happened, and she simply said ‘Franz Ferdinand got shot’ then you might not think much of her skills. Instead we would expect her to tell a story, firstly outlining the predisposing factors which made 1914 so combustible, describing the chain of events which led to (precipitated) the declaration of war in September, and then explain the factors that perpetuated the conflict and made it so devastating. A good historian would range across economic, political and military aspects to really give the story explanatory power. In the same way, professionals need to create a story with families about how the child was predisposed to difficulties, how the difficulties were precipitated, and how they are being perpetuated. To generate a compelling story you need to range over biological aspects, psychology (that is the child’s own thoughts and emotions), and their social context and interactions, both within the family and outside. This sounds complex, but most of it falls out when you apply your curiosity and common sense to some of these questions.

  • What is the problem?
  • How does the problem affect the child and family?
  • Who is in the family? Are there other problems in the family?
  • Has the child themselves suffered any adversity?
  • How did the current difficulties start?
  • What else was happening at the time?

Doctors reading this may have switched off a bit. This is standard medical history stuff. You can wake up now.

  • Next ask: how do people respond to the problem?
  • What do you think about the problem? What does the child think?
  • What worries everyone most?
  • What are you doing about it already?
  • Are there any times when it gets better?

These deceptively simple questions, if pursued with follow up enquiries, will allow you to populate, either in your head or on paper, something that looks a bit like this.

Biological/ developmental Psychological Social
Predisposing factors
Precipitating factors
Perpetuating factors
Protective factors

You can then use the information you have to agree a story with the family about what is happening.
Why have I told you all this? Because out of this story will fall useful interventions, and adaptations to the generic advice that will be contained in the 5 minute tips. The problem with generic advice on its own is that it treats people as if one size fitted all, which of course it doesn’t. By combining your own on the ground understanding of this family’s predicament with the evidenced advice, you can make a huge difference to families, believe me.

Let’s take a short example of this process:

Ahmed, 4, has a tantrum every night at bedtime. His health visitor has advised his mother to shut the bedroom door and ignore him, but it’s not working. Table 4 shows her 4p framework.

Table 24. Use of 4p framework for Ahmed

Biological/ developmental Psychological Social
Predisposing Preterm birth Maternal anxiety
Precipitating Break-up of parents’ relationship Domestic violence
Perpetuating Screen use (TV) in bedroom up till bedtime Anxiety of mother Mother unavailable due to depression
Protective Healthy, good communicator Good relationship with mother during the day Family well-supported by grandparents

This leads to some simple, hopefully helpful interventions:

  • Stop screen time before bedtime
  • Mother to seek counselling/ treatment for depression.
  • Grandparents asked to help with domestic tasks so mother can spend time with Ahmed
  • Gradual withdrawal of mother from bedroom at bedtime, following good ‘wind-down’.

Please see our upcoming post on sleep problems for more details!

We hope that you can see that by adopting this narrative approach and combining it with generic advice (and a flexible approach to finding sources of support!) then you can achieve an awful lot for children and families.

Of course this approach won’t work for everyone, but it’s always a good starting point, from which other interventions and assessments can build.

Got it? Have a look at our anxiety post. More to come.