Aishworiya, Chan, Kiing, Chong, Laino and Tay assert that “sleep plays an integral role in the normal development of children” (2012, p. 99). Sleep disturbances in infancy and early childhood are correlated with increased incidence of anxiety and depressive symptoms in children three years of age (Jansen, Saridjan, Hofman, Jaddoe, Verhulst & Tiemeier, 2011). Children who have irregular sleep patterns or sleep disturbances are more likely to injure themselves unintentionally than children with better sleep habits (Koulougloit, Cole & Kitzman, 2008). There are several factors that can have a profound impact on an infant or toddler’s ability to fall asleep and stay asleep such as gastrointestinal reflux, maladaptive routines, and sensory issues.
Gastrointestinal reflux can have a profound impact upon sleep and rest. This may be caused by a weak lower esophageal sphincter. The stomach acid that flows back in the esophagus can wake a sleeping infant. Infants and toddlers with gastrointestinal reflux (GER) are likely to have issues with sleep (Fonkalsrud & Ament, 1996). Often medical intervention such as reflux medications are needed to address the underlying issue.
Sensory processing can affect the activities that a child and family perform when getting ready for sleep and going to sleep. Children with a high arousal level have difficulty with organizing their bodies and relaxing at nap or rest time and before bedtime. Liu, Hubbard, Fabes and Adam (2006) report that “multiple neurodevelopmental, medical, psychosocial and environmental factors may be associated with increased risk for sleep disorders in children with autism” (p.180). Sensory processing disorder is very prevalent among children with autism. They are more sensitive to environmental stimuli such as light, sound and touch than typically developing children (Lui et al., 2006). Sensory issues can lead to behavioral issues that also need to be addressed and bedtime routines can be incredibly stressful for parents. Children with sensory processing issues tend to be more rigid and inflexible. They can have a heightened emotional response to situations that neurotypical children do not. The combination of behavioral and sensory issues is a recipe for disaster at bedtime. Hoffman, Sweeny, Gilliam, and Lopez-Wagner (2006) validated the prevalence of sleep disturbance in children with autism. According to Hoffman et al. (2006) “parents of children with autism reported that their children have more difficulty with sleep then did parents of typically developing children” (p. 150). Specifically, the findings suggest that children experience challenges with sleep onset and sleep duration. Additionally, they experience more anxiety around bedtime routines, and they have more frequent night awakenings. Children with learning disabilities such as attention deficit hyperactivity disorder with co-morbid attributes of sensory processing issues also have poor quality of sleep (Dorris, Scott, Zuberi, Gibson & Espie, 2008; Weiss & Salpekar, 2010).
The physical environment can have a significant impact upon sleep and rest in infant and toddler populations. For a sample of nursery school and kindergarten children in a suburban community in Japan, environmental attributes such as sharing a bed and the amount of television played a more prominent role in sleep than the occupations of their parents or the family’s socioeconomic status (Kosuke, Akiko & Shihore, 2007). Mann, Haddow, Stokes, Goodley and Rutter (1986) conducted a study to determine the effect of alternating night and day on sleep, feeding and weight gain. The researchers found that when light and noise was reduced during nighttime hours, infants slept longer, required less time for feeding and gained more weight. Changes to a child’s environment may include adjustments in temperature, light, sound and even clothing.
Children with sensory processing issues and other developmental disabilities can present with challenges that lead to maladaptive routines and habits. Sleep is a co-occupation for newborn babies, young children, and their parents. That is, it can be viewed as a shared occupation. Both parent and infant need to get an optimal amount of sleep and rest to function in daily life. If a baby or toddler is not sleeping through the night, both mother and child can be irritable and lack the energy to engage in other meaningful or essential occupations that would normally take place during the day (Komada, Adachi, Matsuura, Mizuno, Hirose, Aritomi & Shirakawa, 2009).
Napping has been demonstrated to have positive effects on long-term memory (Hupbach, Gomez, Bootzin & Nadel, 2009). It also has a significant impact upon the social emotional development of premature infants. Schwiztenberg, Shah and Poehlmann (2013) note that infants who sleep more during the day have more opportunity to “regroup” and reorganize” and have more secure attachments with their mothers. Berger, Miller, Seifer, Cares & Lebourgeoise (2012) found that removing naps results in substantial changes in the emotional responses of relatively well rested children. The effects of sleep restriction were significant and resulted in a 34% reduction in positive emotional responses and a 31% increase in negative emotional responses. Research demonstrates a link between increased parental involvement at bedtime and decreased self-soothing during night waking which leads to a subsequent deficit in the ability of toddlers to settle themselves. Interestingly the daycare staff of the same toddlers with difficulty settling themselves at night were shown to provide increased staff involvement during nap time. The researchers concluded that increased adult involvement in the settling process at nap time and bedtime may lead to decreased self-regulation and self-soothing. They further supported findings in previous research that poor sleep at night corresponds to decreased adjustment during the daytime and correlates with increased problematic behaviors (Hall, Schar, Zaidman-Zait, Espezel & Warnock, 2011).
The most common interventions for sleep disturbances fall into the following three categories: sleep hygiene, behavioral plans, and sensory strategies. Sleep hygiene is an intervention strategy that targets performance patterns. It is important to set up realistic expectations and parameters for bedtime routines. Suggestions for activity modification prior to bed are a part of this strategy. An individualized list of relaxation activities to engage in before bedtime can be helpful. One such activity may be to take a warm bath or read a story. This approach has been demonstrated to be an effective intervention choice in the literature (Weiss, Wasdell, Bomben, Rea and Freeman, 2006).
Sleep restriction “involves restricting the amount of time in bed to the total amount of time asleep, thus reducing or eliminating time spent awake in bed” (Christodulu & Durand, 2004, p.131). This approach has been shown to demonstrate improvements in children’s behavior at bedtime and increased parental satisfaction with bedtime routines. Children required less time to fall asleep and they had longer duration of uninterrupted sleep or less night waking.
Occupational therapists educate families in the use of sensory strategies or techniques to support nighttime routines. Piravej, Tangtrongchitr, Chandarasiri, Paothong and Sukprasong (2009) conducted a randomized controlled trial (RCT) to examine the effects of Thai traditional massage on autistic behaviors. They found a significant improvement in sleeping behavior after eight weeks of intervention but could not definitively conclude that it was due to the massage versus traditional occupational therapy sensory integration treatment. Other massage techniques such as Qigong massage have been shown to yield positive results and the effects have been demonstrated to last ten months after the intervention (Silva, Schalock, Ayres, Bunse & Budden, 2009). Jorge, de Witt & Franzsen (2009) found that parent education and the use of sensory diets had a positive impact upon the sleep patterns of infants in a relatively small sample of children with regulatory sensory processing disorder. A cursory review of social media sites provides anecdotal evidence to support the use of weighted blankets as parents report improvements in sleep behavior. Swaddling is a form of deep pressure that can be effective in helping infants to maintain quiet sleep (Gerard, Harris & Thach, 2002). Using a sensory integrative approach that promotes opportunities for movement experiences such as swinging can be an effective method to improve the nighttime routines in children with autism or sensory processing disorder (Schaaf, Hunt & Benevides, 2012).
Are sleep issues common in children?
Yes, as noted above there are a number of factors that can impact upon the quality of sleep in children.
Do electronics interfere with sleep?
The blue light emitted from electronic devices can disturb sleep and electronic devices should be shut down at least an hour before bed.
Is co-sleeping detrimental to my child's sleep?
Co-sleeping is a matter of choice. It is common in many cultures for children and parents to share a "family bed".
What is sleep hygiene?
This is the most effective method for addressing sleep and it involves establishing patterns and routines for bed time that remain consistent; consistency is the key to success.
CAN OCCUPATIONAL THERAPY HELP WITH SLEEP?
Yes, sleep and rest are within the scope of occupational therapy
It is a kind gesture to give a friend or peer a Valentine. Some children make Valentine cards and others purchase packs of them at the local CVS. It is a great occasion to work on fine motor skills. Valentine's Day crafts are a favorite amongst my occupational therapy staff as they can make cards to give out and this activity addresses a plethora of skills from fine motor to visual perceptual abilities. It provides an opportunity to use social thinking and encourage our children to consider the feelings of others around them; feelings of other children. Let’s expand on that last point.
While there are certainly a lot of positive merits to celebrating Valentine's Day, this day is not always filled with the same excitement and admiration of everyone. For some it can be a very anxiety provoking experience. Many children and particularly those with special needs can feel excluded and isolated when other children in the room are receiving Valentine’s cards and they are not. It can become a popularity contest that only serves to further perpetuate an imbalance between those who are different and those who are considered part of the “in” crowd. So I feel it is important that teachers, parents, grandparents, aunts and uncles foster social thinking in our children and have them consider the thoughts and feelings of others. If you are going to give out cards at school, have enough cards for everyone in your child’s class. Do not contribute to another person’s “Valentine Blues”.
Parents, if you have a child who does not receive a Valentine's Day card this Sunday, respond to this blog and my staff or clients will send them one. No one should be excluded on this occasion.
There is a growing body of literature to support the use of high intensity exercise to improve self-regulation, cognition, and mental health in children (Lubans et al., 2016). Researchers have found that aerobic activity improves behavior in children, and it has been particularly beneficial to children with ADHD. Manville moves is a cyber cycling intervention that has yielded positive behavioral outcomes amongst children with behavioral health disorders (Bowling et al., 2017). Dr. Amy Wheadon is a former doctoral student of mine and she created the Kidshine Bootcamp program in 2016 based on the premise that intense physical exercise can improve self-regulation in children with sensory processing disorders. As part of her doctoral program at New England Institute of Technology (NEIT) she conducted research at my clinic in Warwick, RI to investigate the efficacy of her program; the results were significant. Children in the Kidshine Bootcamp groups improved in numerous areas of sensory processing. For a more detailed description of the study, it can be found on research gate. The Kidshine Bootcamp program draws upon a variety of theories and it includes interventions that target social skills, sensory processing, motor planning, coordination, self-esteem, self-confidence, and self-regulation. This unique program is designed and implemented by occupational therapists who are trained to treat children holistically.
I personally attend classes at Orange Theory Fitness (OTF) in Medway, Massachusetts. Orange Theory Fitness is a high intensity interval training for adults. I joined OTF to achieve personal fitness goals but in reflecting about my own personal experience I realize that it has offered so much more. I feel more regulated when I go to class in the morning. Attending OTF has also had an impact upon my mental health. I enjoy connecting with the coaches and the other members. I feel like I am part of a community. Through this pandemic we have supported and encouraged each other. Staff and members have diligently maintained an atmosphere of safety while we work out in our masks behind plexiglass barriers. Participating in classes help us meet our fitness needs, social emotional needs and the need for routine and normalcy during this past year. I may not be the fastest or strongest athlete but my tribe at OTF makes me feel like I can do anything.
The parallels between OTF and Kidshine Bootcamp are many. If children at my clinic can reap the benefits of intense exercise just as I have through my involvement in OTF, it is obvious, I have to offer it. If your children would benefit from enhanced motor planning and coordination, improved sensory processing and self-regulation, increased self-confidence, and self-esteem, look for a Kidshine Bootcamp program at a clinic near you.
Dr. Randal FEdoruk
I am a pediatric occupational therapist. I have worked with children in various settings for over twenty years. I am a professor and I teach pediatrics and mentor Doctoral students completing research with a pediatric focus.