Transcription:
Childhood Insomnia and Pediatric Sleep Issues

Melanie Cole (Host): There's no handbook for your child's health, but we do have a podcast, featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole and today parents, we are talking about how to bring children back to a normal sleep schedule, how to address anxiety at bedtime and even pediatric insomnia. Joining me is Dr. Corinne Catarozoli. She's an Assistant Professor of Psychology in Clinical Psychiatry at Weill Cornell Medicine. Dr. Catarozoli, thank you so much. This is a really great topic for parents. Tell us a little bit about pediatric insomnia. Do we know why some kids have trouble sleeping and others don't? Tell us a little bit about what this is and why it sometimes happens.

Corinne Catarozoli, Ph.D. (Guest): Thank you for having me, Melanie. Pediatric insomnia is when children have difficulty falling asleep or staying asleep or waking up too early in the morning. And there's a number of different factors that can contribute to sleep issues overall. But the most common that we see causing insomnia in children are problems with sleep onset associations and stress or anxiety.

Host: Well, you just mentioned something that a lot of parents may not know what it is. And I didn't know what it was until I looked it up. What is sleep onset association?

Dr. Catarozoli: Sure. These are conditions that we need present in order to fall asleep. So, for instance, most of us need a dark room, a quiet environment and without these it's really difficult to fall asleep at night. And kids sometimes develop associations like rocking or having a bottle or a parent laying next to them that they need to fall asleep. And then these associations eventually become problematic because what they rely on at bedtime are then needed in the middle of the night. So, when a child briefly rouses between sleep cycles, which we know is normal and happens to all kids in the middle of the night; if that association isn't present, if their parent isn't there, they don't have a bottle, they're going to awaken even more and then might cry or try to seek out their parents.

Host: Hey, you're giving me anxiety here. I remember those middle of the nights crawling around looking for binkies that fell out of the crib until I started putting like 10 of them in there so that they couldn't all fall. And then you crawl out of the room, so the kid doesn't see you. That's not the advice listeners. That's not what we're doing here, so, okay. So, sleep onset association, the child gets used to something. And so this is how they fall asleep. So, now what do we do? How can we help them if they're having trouble falling asleep? Are there treatments or what do you want parents to do? And you're right in the thick of this as well.

Dr. Catarozoli: Yeah. So, the way we treat this is really by teaching children to fall asleep on their own. And this is true for everybody, from babies to toddler, the teenagers. Falling asleep is a skill that every child needs to master, just like walking and talking. So, for a child who has a sleep association, for instance of a parent laying with them, we might use an approach called gradual withdrawal, which is where we slowly remove the parent's presence at bedtime, not by crawling out of the room and hiding, but first maybe sitting in a chair next to their child's bed, maybe patting them on the back, giving them some verbal reassurance, and then they gradually move that chair further and further away from their child's bed or crib every few nights as their child adjusts until eventually they're by the door with the door open and then maybe outside the door with the door open and eventually out of the room.

So, the child gets used to this at each stage. So, that's one option. Parents can also use a checking technique where they leave the child alone to fall asleep and check on them in increasing increments of time. So, if their child cries, first they might check after five minutes and then let them cry for about 10 minutes and so on and so forth. So, this gives their child some reassurance while still giving them that space they really need to learn to fall asleep on their own.

Host: I'd like to delve into that just a bit because there are those methods, the Cry It Out. And I definitely tried that with my son. And it's hard on a parent, Dr. Catarozoli. That is hard on a parent to let them cry and to hear them, even if you're sitting right outside their door for the entire night. I will say it worked for us, but it took a while, but I loved that tip about gradually moving the chair until you're just right outside the door. And then that child learns to self-sooth. What do you tell parents when they ask you about some of those Cry It Out methods?

Dr. Catarozoli: Yeah, Cry It Out is an effective method. And we know that it's usually harder on the parents than it is on the child. One minute of crying can feel like an eternity for a parent, but things that I like to tell parents to reassure them, that it is a safe method. We have actually lots of research that shows us that kids who are sleep trained in that way, don't have any issues down the line. They don't have fears of abandonment or things like that. In fact, they typically are really well adjusted because they've learned how to fall asleep on their own. But that said, Cry It Out is not for everybody. It can be really hard to tolerate, like you said, your child crying for any extended period of time.

So, there are these more gradual methods that you can opt for if that feels like a better fit for your family. The most important thing is that whichever method you choose, you're consistent about it. That's probably even more important than the specific method you choose, in general, but just that you're doing it consistently so your child is really learning what to expect.

Host: I can certainly attest to that because both of my kids are great sleepers and I did that and yes, what she said is true. Parents, it's hard, but it does work. So, there are all of these different methods. Now, maybe we've gotten our kids to bed. Maybe we've gotten them even to fall asleep, but what do we do once we've moved them into that little toddler bed and they're constantly getting out of bed and wandering around?

Dr. Catarozoli: Yes, this is a tricky one. Once your child is no longer contained by that crib, then you can get into the coming out of the room, asking for a drink of water, for another hug, for another book. The delay and procrastination methods, or just when they really can't fall asleep on their own needing that association of having you there. So, what we want to do, if a child is continually getting out of their bed and coming to find you is repeatedly walking them back to their room, really trying not to speak to them too extensively, not engaging with them, keeping a really dim environment. We basically want them to learn that this is a boring time.

This is not a time that mom or dad are going to play with them. So, we want to keep showing them it's time for sleep. It's still nighttime. Go back to bed. So, other tips that you can try or offering your child a sleep pass, which is where they can come out of their room one time and get that extra hug or that extra glass of water. But if they don't use their sleep pass, then they can exchange it for a prize in the morning. So, that incentivizes them a little bit to stay in their bed rather than get out. And in general, using rewards for kids who are toddler age and above once they can really understand the connection between the behavior and the reward, is a really effective strategy that increases their motivation. So, they can earn a small prize if they fall asleep on their own, or if they stay in their bed the whole night. In the morning, they can get that sticker or that treat.

Host: Well, I can tell you from experience, once they're teenagers, it reverses, then you can't get them out of bed. And then boy, there's no incentive to get out of bed at all. So, that's good. That was really a great tip. So, now for kids that really don't want to go to bed. They're afraid. Maybe they're afraid of the dark, maybe something, you know, really anything, kids can be afraid of. So many things. Tell us about bedtime anxiety and why it happens and what parents can do about that particular situation.

Dr. Catarozoli: Sure. I think about bedtime anxiety as falling into a couple different categories. There are those fears that you mentioned, fear of the dark, fear of monsters under the bed, which are really quite typical for young kids. And then there are children who worry that they won't be able to fall asleep once they get into bed. They're afraid that they're going to be sitting there all night, not able to fall asleep. And then there are kids who have more generalized anxiety, more global fears that tend to flare up at night. And the scenario where kids are repeatedly having trouble falling asleep, they tend to expect this to happen.

So, they start to develop these worries of what if I'm up all night, I'm going to be so tired tomorrow. They continually check the clock and sure enough, what does this do? It makes them more stressed, more anxious, and even harder to calm down, back to sleep. Now the other type of anxiety in children who just tend to be worriers in general, bedtime is usually where these worries surface. So, they might be nervous about something happening in school tomorrow, or a test coming up, or a birthday party. Teenagers might be worrying about friends, family, college applications, graduation, and all of these spike at bedtime, once our head hits the pillow invariably. So anxiety and stress release activate our body. They make our heart rate increase. Our blood pressure goes up, all of which is the antithesis of what we need to fall asleep. So, that is really what causes all of this tossing and turning.

Host: Wow. That is so interesting and so true. So, how do we help them with that? Because that's really something that is a little bit more difficult than just Cry It Out, or gradually letting them fall asleep or even sleep hygiene, which we're going to discuss. But what do we do about that type of anxiety when it comes from within? And when do we reach out to our pediatrician for help?

Dr. Catarozoli: There are a couple of different strategies that parents can encourage their children to do at bedtime to help calm down. Things like diaphragmatic or deep breathing, progressive muscle relaxation, where they practice squeezing their muscles, and then relaxing them, guided imagery where they picture a really calming scene and use all of their senses to imagine that. All of those are types of activities that will help them to relax and be able to fall asleep.

Now, a more cognitive approach for worry are using things like reassuring or brave thoughts. So, encouraging your child to have statements they think to themselves, like I know I will fall asleep eventually. Mom and dad are just down the hall. I'm safe in my room. All of these can really relieve some of that worry and teach them how to reassure themselves. Most importantly though, while it might be intuitive for a parent to feel like they should stay with that anxious child at bedtime, or even invite them into their own bed, the parent's bed; this often backfires because it reinforces the anxiety and it sends that child a message that no, you can't manage this on your own. You can't cope with it by yourself. And the child never really gets the opportunity to learn how to cope independently with this anxiety. So, really try to resist the urge to have them come into your bed. That can start vicious cycle of them then relying on that.

Host: Well, it certainly can. And what a great guest you are, Dr. Catarozoli. This is all such usable information for parents. I'd like to move up the chain here a little bit to teenagers and to our tweens. Right now in this COVID time, sleep schedules have been, gone out the window. I mean, kids are doing school from home. In many cases, they are trying to do bed school. They're really getting up and just turning on their computer. And so they feel like they don't have to go to bed very early. And it's very difficult to get this sleep schedule into some sort of a routine.

Can you give us some advice on getting our kids to sleep now during these unprecedented times and add in about sleep hygiene, cutting down on those computer lights and their cell phones and Twitter and Tik Tok and Snapchat, and all of these things that are keeping them up at night?

Dr. Catarozoli: Yes. COVID it has really wrecked havoc on sleep schedules. Like you mentioned, bedtimes are later, the daily schedule is different. There's less physical activity. All of these reasons, most of all, that there's more stress and more anxiety. And for something like sleep, that's so highly connected to structure and predictability and routine, this causes a great deal of disruption. So, the important thing is maintaining that consistent schedule. Have your child wake up. Eat a real meal, put on real clothes. Don't sit in their pajamas all day, sit at a desk to do school. Basically, we want to mimic the schedule of a normal day, even though they're home.

And, you mentioned bed school and this can become a real problem because when teenagers are using their phone in bed, their laptops in bed, this really trains their brain to think this is a place to be awake and they start to develop that as an association with their beds. So, one tip is to move all of the awake activities out of bed, school, eating, homework, Facetiming, all of that should happen elsewhere. And the only thing going on in bed should be sleep. So, we create that really strong, powerful association. And if they have trouble sleeping, they can actually get out of bed when they're tossing and turning and getting really frustrated. Do a quiet activity, no screens. Do a quiet activity until they feel drowsy and then get back in bed.

Now you mentioned screens, and this is probably my most unpopular recommendation, but it's true. Teens should put away their devices at least an hour before bedtime. That's both because of the blue light, that disrupts melatonin that makes them feel drowsy, and also the content that they're consuming. You mentioned Tik Tok and Snapchat and Instagram. All of these activities tend to be activating rather than calming. So, we want them to be doing something quiet, something even a little bit boring that doesn't involve a screen in that hour leading up to bedtime.

Melanie Cole (Host): Dr. Catarozoli, this has been such a great episode for parents. As we wrap up, can you give your best advice for sleep hygiene, anxiety, insomnia, schedules for our kids? So, parents can get their own good night's sleep because it's so important and it's not always easy to get our kids to get that good night's sleep. So, give us your best advice here.

Dr. Catarozoli: The take home message here is that learning the skill of falling asleep on their own, is a huge developmental milestone that we want our children and our teenagers to achieve. Sometimes parents ask me, will my child grow out of this sleep issue if I don't do anything about it? And truthfully, these sleep issues persist into adulthood if we never learn that skill. So, it's best to address these during childhood and your child or teenager will take that with them and have that for the rest of their life. Maintaining that consistent sleep schedule and having a really consistent bedtime routine, having a room that is cool, dark and quiet. All of these things are going to contribute to better sleep for kids, which we know equals better sleep for parents.

Host: Thank you so much, Dr. Catarozoli for joining us today. What an informative episode. Parents really, share this show with your friends. Because we are all learning together from the experts at Weill Cornell Medicine and Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine. Thank you so much to our guest and to our listeners. That concludes today's episode of Kids Health Cast. Please remember to download, subscribe, rate, and review Kids Health Cast on Apple podcasts, Spotify, and Google podcast. For more health tips, you can always visit Weillcornell.org and search podcasts. And don't forget to check out Back to Health. I'm Melanie Cole.