Sleepless Nights

​        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