Better Nights, Better Days –

What, Why & How

Penny Corkum, PhD (Psychologist)

Professor, Department of Psychology & Neuroscience, & Psychiatry,

Dalhousie University

Scientific Staff, IWK Health Centre

Director, Colchester East Hants ADHD Clinic

92nd Annual Dalhousie Fall RefresherDecember 6-8, 2019 │Halifax, NS

• I have no actual or potential conflict of interest in relation to

this presentation

• Research funding from Canadian Institutes of Health Research,

Kids Brain Health Network (a National Center of Excellence),

Nova Scotia Health Research Foundation, IWK Health Centre,

& Dalhousie’s Psychiatry Research Foundation

Educational Objectives

At the end of this session,

participants will be able to:◦ Have increased knowledge about

the prevalence and impact of sleep

problems, particularly pediatric

insomnia

◦ Understand best practice to

treatment of pediatric insomnia

and barriers to the provision of

this care

◦ Become familiar with the Better

Nights, Better Days programs and

future plans for sustainability of

these program

Session Overview

Refresher re: sleep

structure

Sleep disorders

Insomnia – contributing

factors and consequences

Assessment

Treatment

Questions & Answers

10-year-old boy

Only child

Parents divorced; Alex lives mostly with mom but stays at his dad’s house every second weekend

Bedtime 9:30pm; Wake time: 6:30am

Trouble falling asleep (60-120min)

Once asleep stays asleep (used to have night awakenings)

Trouble waking up in morning, results in lots of stress

Parents and teachers think that at times Alex seems tired and other times he seems revved up

Has ongoing academic problems, attention problems and at times he’s irritable

▪ REM (20-25% of total sleep; 4-6 episodes)

▪ High levels of cortical activity

▪ Paralysis

▪ Episodic bursts of eye movements

▪ Occurs 70-100 min after sleep onset

▪ Function

▪ Learning, memory consolidation

▪ NREM (75-80% of

total sleep)

▪ 3 stages (previously

considered 4 stages)

▪ Low brain activity

▪ Body movements are

preserved

▪ Function

▪ Restoration of body

functions

▪ NREM/REM alternate through the night in cycles

▪ Cycles of about 90-100 minutes

▪ Brief arousal and return to sleep every cycle (4-6 times)

▪ Early sleep mostly NREM, later sleep mostly REM

http://sleepfoundation.org/how-sleep-

works/how-much-sleep-do-we-really-need

9

https://www.participaction.com/en-ca

0-3 months: 14-17 hours

4-11 months: 12-16 hours

1-2 years: 11-14 hours

3-4 years: 10-13 hours

5-13 years: 9-11 hours

14-17 years: 8-10 hours

10

• Children’s sleep duration has decreased between 30 minutes to one hour in recent decades

• 31% of school-aged children and 26% of adolescents in Canada are sleep-deprived

• 36% of Canadian 14-17 year olds find it difficult to stay awake during the day

• 43% of Canadian 16-17 year olds are not getting enough sleep on weekdays

• 33% of 5-13 year olds and 45% of 14-17 year-olds in Canada have trouble going to sleep or staying asleep at least some of the time

• Sleep is an essential component of healthy cognitive and physical development

• …because many kids are too tired to get enough physical activity during the day, and not active enough to be tired at night – it’s a vicious cycle.

DSM-5 (2013) / ICSD-3 (2013)

◦ 10 different sleep disorders/sleep disorder groupings

1) Insomnia Disorder

2) Hypersomnolence Disorder

3) Narcolepsy

4) Breathing-related sleep disorders

5) Circadian rhythm sleep-wake disorders

6) Non–rapid eye movement (NREM) sleep arousal disorders

7) Nightmare disorder

8) Rapid eye movement (REM) sleep behavior disorder

9) Restless legs syndrome

10) Substance/medication-induced sleep disorder

Maski, K., & Owens, J. (2018). Pediatric sleep disorders. CONTINUUM: Lifelong Learning in Neurology, 24(1), 210–227.

Kotagal, S. (2017). Sleep-wake disorders of childhood. CONTINUUM: Lifelong Learning in Neurology, 23(4), 1132–1150.

Disorder Prevalence

Narcolepsy .05%

Restless Leg Syndrome/PLMD 2-6%

Sleep Disordered Breathing 2-3%

Circadian rhythm disorders 7%

Parasomnias

NREM

REM

13%

5%

Insomnia 20-30%*

American Academy of Sleep Medicine. International classification of sleep disorders

(ICSD). 3rd ed; 2014. Available in:http://www.aasmnet.org/library/default.aspx?id=9

* 70%+ for children with NDDs

Criteria (ICSD-3 & DSM-5)

◦ Difficulties falling asleep/difficulty initiating sleep without parent/caregiver intervention, staying asleep, and early waking (resistance to going to bed; ICSD-3 only)

◦ Impairment/Daytime consequences of sleep problem (e.g., daytime sleepiness, attention problems, mood disturbance/ irritability, behaviour problems, low motivation/energy/initiative)

◦ Sleep problem cannot be explained by inadequate opportunity for sleeping

◦ Frequent (≥3x/wk) and chronic (≥3 mos)

◦ Not explained by or occur exclusively during another sleep-wake disorder, medical condition, or mental health disorder

Children

◦ sleep-onset association

◦ limit-setting

Adolescents

◦ sleep hygiene problems

◦ delayed sleep phase

Young Adult

◦ psychophysiological insomnia

Developmental Stage Prevalence

Infants/Toddlers ~30%

Preschoolers/School-aged ~15%

Adolescents (peak at puberty) ~30%

Adult ~15%

15

Sleep

Genetics

Sleep Environ-

ment

Family/ Parents

Health

Develop-ment

Social –Emotional

Social –Cultural

Sleep Practices

Slide courtesy of Jodi Mindell

3 “P”s:

Predisposing

Precipitating

Perpetuating

Cognition/

LearningMental Health

Physical

Health

Quality of

Life

Community

School

Family

Child

Consequences of Sleep

Problems/Disorders

Interviews &

QuestionnairesSleep Diary Actigraphy PSG

Subjective Objective

SCREENING

▪Ask about sleep!

19

Owens, JA. & Dalzell, V. (2005). Use of the ‘BEARS’ sleep screening tool in a pediatric resident’s continuity clinic: A pilot study. Sleep Medicine, 6 (1), 63-9.

Lewandowski et al., 2011

◦ Review of Pediatric Questionnaires (n=21)

◦ Multidimensional sleep measures received the highest ratings

◦ 6 “Well Established” Brief Infant Sleep Questionnaire (Sadeh, 2004) (0-29 months)

Infant Sleep Questionnaire (Morell, 1999) (12-18 months)

Child Sleep Habits Questionnaire (Owens et al., 2005) (2.5-10 years)

Preschool Sleep Questionnaire (Chervin, 1997) (2-18 years)

Sleep Disturbances Scale for Children (Bruni, 1996) (5-15 years)

Pediatric Daytime Sleepiness Scale (Drake et al., 2003) (11-15 yrs)

Ji & Liu, 2016

◦ Review of Adolescent Questionnaires (n=13)

◦ Most validated questionnaires Cleveland Adolescent Sleepiness Questionnaire (Spilsbury et al., 2007) (11-17yrs)

Chronic Sleep Reduction Questionnaire (Dewald et al. 2012; Meijer, 2008) (12-16.5 yrs)

Lewandowski, A. S., Toliver-Sokol, M., & Palermo, T. M. (2011). Evidence-based review of subjective pediatric

sleep measures. Journal Of Pediatric Psychology, 36(7), 780-793. doi:10.1093/jpepsy/jsq119

Ji, X. & Liu, J. (2016). Subjective sleep measures for adolescents: a systematic review. Child: care, health and

development, 42, 6, 825–839

Total Sleep Disturbances

(Cutoff=41)

Bedtime Resistance

Sleep Onset Delay

Sleep Duration

Sleep Anxiety

Night Wakings

Para-somnias

Sleep Disordered Breathing

Daytime Sleepiness

Owens, JA., Spirito, A., & McGuinn, M. (2000). The Children’s Sleep Habits Questionnaire (CSHQ):

Psychometric properties of a survey instrument for school-aged children. Sleep, 23(8), 1-9.

45 Items

• Record of sleep and wake times and related information

• Completed by parent and/or child

• Commonly used in clinical practice

• Examines for patterns across days/weeks

http://www.sleepforkids.org/pdf/SleepDiary.pdf

http://www.sleepforkids.org/index.html

Corkum, et al. (unpublished)

• An actigraph is a wrist-watch like device with an accelerometer used to measure movement.

• Computer algorithms are used to interpret accelerometer-based findings as measures of sleep and waking.

• Actigraphy has become an increasingly popular method for estimating sleep parameters in both research and clinical studies over the past 30 years.

Considered the gold standard for measuring sleep

Measures:◦ Brain waves/activity

◦ Oxygen level

◦ Breathing

◦ Heart rate

◦ Eye and leg movements

10-year-old boy

Only child

Parents divorced; Alex lives mostly with mom but stays at his dad’s house every second weekend

Bedtime 9:30pm; Wake time: 6:30am

Trouble falling asleep (60-120min)

Once asleep stays asleep (used to have night awakenings)

Trouble waking up in morning, results in lots of stress

Parents and teachers think that at times Alex seems tired and other times he seems revved up

Has ongoing academic problems, attention problems and at times he’s irritable

What diagnosis do you think

is most likely?

What assessment approach

would you take to determine

his diagnosis?

What additional information

would you want?

Best Practice Treatment

30

Psycho-education

Healthy Sleep Practices

Behavioural Strategies

MedicationLess than 15% of children

with insomnia receive

evidence-based treatment

Sometimes sleep problems are a result of lack of knowledge and due to faulty beliefs, for example…◦ Expect the child to sleep too long/too little

◦ Lack of understanding of circadian rhythms and sleep pressure

◦ Expect child to have same chronotype as parents (e.g., owl/lark)

◦ Think that keeping child up later will result in the child sleeping in later in the morning

◦ Think that arousals at night are not typical (rather than seeing this as self-soothing problem)

◦ Not understanding the biological shift in sleep time during adolescents

Handouts for parents

◦ Mindell, J. A., & Owens, J. A. (2010). A clinical guide to pediatric sleep: Diagnosis and management

of sleep problems (1st ed.). Baltimore, MD: Lippincott Williams & Wilkins

Resource List

◦ Corkum LABS

Websites◦ Canadian Sleep Society

Brochure and eBook - https://css-scs.ca/resources/brochures

Insomnia Rounds - https://css-scs.ca/resources/insomnia

◦ Pediatric Sleep Council

https://www.babysleep.com/

◦ Sleep for Kids

http://sleepforkids.org/

◦ Participaction

https://www.participaction.com/

◦ National Sleep Foundation

https://www.sleepfoundation.org/

https://www.sleep.org/

◦ Better Nights, Better Days www.betternightsbetterdays.ca

www.facebook.com/betternightsdays

Age-appropriate

Bedtimes, wake-times and naps, with

Consistency

Schedule and routines

Location

no Electronics in the bedroom or before bed

Exercise and diet

Positivity and relaxation

Independence when falling asleep

Needs met during the day

….all of the above equals Great sleep!

Bessey, J. Coulombe, A. & Corkum, P. (2013). Sleep Hygiene in Children with ADHD: Research Findings and Clinical

Recommendations. ADHD Report, 21 (3).

Allen, S., Howlett, M., Coulombe, A., & Corkum, P. (2015). ABCs of Sleeping: A Review of the Evidence Behind

Pediatric Sleep Practice Recommendations. Sleep Medicine Reviews.

35

Step 1: Online Questionnaire

Step 2: Report Card

Step 3: Handouts

If you are interested in

participating, please

contact us at

sleepABCs@dal.ca

Vriend, J. & Corkum, P. (2011). Clinical management of behavioral insomnia of

childhood. Psychology Research and Behavior Management. 4, 69-79. Doi:

http://dx.doi.org/10.2147/PRBM.S14057

Corkum, P., Davidson, F., Tan-MacNeill, K., & Weiss, S. (2014). Sleep in Children with

Neurodevelopmental Disorders: A focus on insomnia in children with AD/HD and ASD.

Sleep Medicine Clinics. 9(2), 149-168. Doi: 10.1016/j.jsmc.2014.02.006

Goal typically involves some combination of developing positive

sleep-related associations, establishing routines, and

implementing relaxation/self-soothing skills

Strong evidence for sleep intervention programs- with TD

◦ 94% of studies found behavioural interventions to be effective

◦ 80% of children had clinically significant improvements

◦ Improvements in sleep onset latency, frequency and duration of night

wakings and sleep efficiency (not sleep duration)

◦ Improvements lasted 3 to 6 months

◦ Few studies on children with special needs

Learning

Principles

Unmodified

Extinction

Extinction

with parent

presence

Graduated

Extinction

Bedtime

Fading

Stimulus

control

Sleep

Scheduling

Sleep

restriction

Cognitive

Strategies

Relaxation

Training

Reward

Programs

Specific Sleep Strategies

39

Intervention Description

Unmodified Extinction Infant is placed in bed while awake, left alone until asleep, and night-wakings are ignored. Infant learns to

self-soothe once realizing that nighttime crying does not result in parental attention.

Extinction with parent

presence

Parent remains in room during extinction, acting as a reassurance for the child but providing little

interaction.

Graduate Extinction This involves ignoring negative behaviors (i.e., crying) for a given amount of time before checking on the

child. The parent gradually increases the amount of time between crying and parental response. Parents

provide reassurance through their presence for short durations and with minimal interaction.

Bedtime Fading Operates by delaying bedtime closer to the child’s target bedtime. The goal of this treatment is for the child

to develop a positive association between being in bed and falling asleep rapidly. Bedtimes can be gradually

moved earlier.

Stimulus Control Making the bedroom/bed a discriminant stimulus for sleep by only using the bedroom/bed for sleep (not

play, time-outs, etc.)

Sleep Scheduling Scheduling regular, appropriate sleep and wake times that allow for an adequate sleep opportunity.

Sleep Restriction Restrict time in bed to build sleep pressure and gradually lengthen time in bed as sleep efficiency improves.

Contraindicated in youth with parasomnias, seizure disorders, OSA, mania

Cognitive Strategies These strategies are used to address non-productive beliefs about sleep, including the belief that the child

cannot change their sleep difficulty. Coping strategies are also included (e.g., relaxation skills such as

abdominal breathing).

Relaxation Training Teach diaphragmatic (belly) breathing and progressive muscle relation to reduce arousal. Need to practice

regularly before introducing at bedtime.

Reward Programs Reinforce healthy sleep practices, appropriate time in bed, etc.

GREAT SLEEP CHART

40

0 – 19 No reward20 – 39 $5 gift certificate from Blockbuster or Empire Theatres40 – 59 $10 gift certificate from Blockbuster or Empire Theatres60 – 70 $20 gift certificate from Blockbuster or Empire Theatres

Community Mental Health

◦ https://novascotia.ca/dhw/mental-health/children-and-

youth.asp

Private Practice Psychologist

◦ http://apns.ca/search-psychologist/

Canadian Sleep Society Service Providers Map

◦ https://css-scs.ca/resources/provider-map

42

http://betternightsbetterdays.ca/http://ndd.betternightsbetterdays.ca/

42Better Nights, Better Days

44

http://betternightsbetterdays.ca/

http://ndd.betternightsbetterdays.ca/

Better Nights, Better Days

www.ndd.betternightsbetterdays.ca

www.facebook.com/betternightsdays

https://twitter.com/betternightsday

https://www.instagram.com/betternightsbetterdays/

https://www.pinterest.com/betternightsbet/

bnbd.participate@dal.ca

bnbd-youth@dal.ca Adolescents: 14-18 yearsYoung Adults: 19-24 years

48

Children presenting with insomnia are being prescribed

medication at high rates, especially when child has a NDD

(Stojanovski et al., 2007; Owens et al., 2010)

◦ e.g., antidepressants, atypical antipsychotics, anticonvulsants,

beta-blockers

No FDA approved medications for treatment of insomnia in

children and there are concerns about the safety and side effects

of these medications (Owens et al., 2010)

Pharmacological treatments may have rapid short-term effects

on sleep problems, but typically do not have long-term positive

effects on sleep

Nunes, N.L. & Bruni, O. (2015). Insomnia in childhood and adolescence: clinical aspects,

diagnosis, and therapeutic approach. J Pediatr (Rio J). 2015;91(6 Suppl 1):S26---S35

Pelayo, R., & Yuen, K. (2012). Pediatric Sleep Pharmacology. Child Adolesc Psychiatric Clin N

Am 21, 861–883

Troester,M.M. & Pelayo, R. (2015). Pediatric Sleep Pharmacology: A Primer. Semin Pediatr

Neurol, 22,135-147

https://choosingwiselycanada.org/

Melatonin

• Melatonin is secreted by the pineal gland in response to darkness and is involved in maintaining the circadian rhythm of the sleep-wake cycle

• Melatonin supplements provide much larger amount than what is typically secreted

• Studies that exist find benefit and few side-effects• Short-acting forms used to treat sleep onset problems and

long acting forms to treat sleep maintained problems• However, studies include small sample sizes and do not assess

long-term use• Canadian Pediatric Society Position Paper re: Melatonin

◦ http://www.cps.ca/documents/position/melatonin-sleep-disorderschildren-adolescents

• First step in management of all sleep disorders is

establishing good sleep hygiene

• All studies have involved small numbers of subjects and

address only short-term use

• No good data concerning the safety and efficacy of long-

term melatnoin use

• Further studies are needed to confirm the usefulness and

safety of melatonin for sleep disorders in children and

adolescents2012, Reaffirmed 2015

10-year-old boy

Only child

Parents divorced; Alex lives mostly with mom but stays at his dad’s house every second weekend

Bedtime 9:30pm; Wake time: 6:30am

Trouble falling asleep (60-120min)

Once asleep stays asleep (used to have night awakenings)

Trouble waking up in morning, results in lots of stress

Parents and teachers think that at times Alex seems tired and other times he seems revved up

Has ongoing academic problems, attention problems and at times he’s irritable

What treatment plan would

you suggest for Alex?

How would you change your

treatment approach in these

situations?• Alex has ADHD and is on stimulant

medication?

• Alex has ASD and an anxiety

disorder?

Resources

Durand VM. When Children Don’t Sleep Well: Therapist Guide: Interventions for Pediatric Sleep Disorders (Treatments that work). New York: Oxford University Press; 2008.

Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

Sheldon SS, Ferber R, Kryger MH. Principles and Practice of Pediatric Sleep Medicine. 1st ed. Philadelphia, PA: W.B. Saunders; 2005.

Stores G, Wiggs L. Sleep Disturbance in Children and Adolescents with Disorders of Development: Its Significance and Management. London, UK: MacKeith Press; 2001.

Autism Speaks Sleep Tool Kit◦ https://www.autismspeaks.org/science/res

ources-programs/autism-treatment-network/tools-you-can-use/sleep-tool-kit

55

penny.corkum@dal.ca

http://myweb.dal.ca/pvcorkum/