September 16, 2011

“Blessed are the sleepy ones…”

“Blessed are the sleepy ones, for they shall soon fall off.’

- Nietzsche

An attending physician once told me that if a child isn’t sleeping, all bets are off on an accurate diagnosis. Because I myself was so severely sleep deprived at the time, that adage didn’t immediately penetrate my mental fog; but as I’ve practiced medicine and started raising my own kids, the paramount importance of sleep cannot be overemphasized.

Our society as a whole seems to be sleep deprived, a trend likely reflected in our excessive caffeine consumption/dependence (estimates are that between 80-90% of adults and children habitually consume caffeine).   It is no coincidence that mental illness diagnoses are also on the rise, especially the concerns for overly hyperactive children.   According to the Sleep in America polls, about 20% of Americans report getting less than 6 hours of sleep per night (on average).  Surveys from the National Sleep Foundation estimate that half of all adolescents get less than 7 hours of sleep on weeknights, with high school seniors averaging just slightly more than 6.5hours/night.

According to Dr. Scott Shannon’s book Please Don’t Label My Child, our sleep needs are as follows:

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Sleep Requirements per 24-hours:

Infant to 6 months:                16-20 hours

6mo to 2 yrs:                          roughly 15 hours

2 to 6 yrs:                               10-12 hours

Grade School (7 to 13 yrs):     9 to 11 hours

High School (14 to 18 yrs):    roughly 9 to 10 hours (may vary greatly day by day)

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Those surveys reveal  a major deficit in an essential function for our mental and physical well being. This deficit will take its toll on our mental health.  According to Dr. Sadeh of Tel Aviv University, “a loss of one hour of sleep is equivalent to [the loss of] two years of cognitive maturation and development. (“Snooze or Lose” New York, Oct 7, 2007).    Just looking at test score differences between the well-rested and  the un-rested draws shockingly similar comparisons to the cognitive deficits from lead poisoning.

Sleep deficits often masquerade as, and certainly contribute to, many “psychiatric” ailments, including ADHD, irritability and mood swings, behavioral problems, cognitive deficits, enuresis, depression, anxiety, and psychosis (and this is by no means a complete list, but you get the idea- pretty much anything in the DSM-IV).  Unfortunately, all of the above disorders (and the medications used to treat them) can also contribute to sleep disorders, making disentangling the cause-effect relationship next to impossible.   Fortunately, helping someone to get better sleep always helps their mental health.

In general, adults that are sleepy tend to know it and can accurately describe being tired.  The venti coffee in hand at all hours is also a good outward manifestation of the inner struggle.  In general, becoming sleepy in the car (as a passenger or driver), sleepy after you eat, and sleepy watching tv or reading (save for when it’s late at night) are common signs of sleep deficiencies.

With kids, it’s a little trickier.  Certainly the above signs can apply. If a child falls asleep in school everyday, he’s likely not getting enough sleep at night.  Same goes for falling asleep on short car trips, like to the grocery, or being excessively cranky and difficult to awaken in the morning. What makes finding pediatric sleep disorders harder is that kids with sleep deficiencies often present in exactly the opposite way you would expect– with excessive hyperactivity.  Think about the fidgeting you yourself did in a boring lecture just to stay awake.  This is in part due to the body’s release of cortisol (your stress hormone) when it’s tired. Cortisol makes you hyper. This most obviously manifests at night when their natural sleep time is missed.  The child will get briefly calm or slightly withdrawn at his appropriate bedtime, say 730, but if not in bed and settling for sleep,  he will spring to excessive life and subsequently be difficult to settle until the wee hours.  I often hear this from frustrated parents bringing me their 4 year-old with “ADHD” concerns- “my kid just doesn’t sleep,” describing his hyperactivity until well past midnight, only to awaken early in the morning to repeat the hyperactive saga   A nascent bipolar showing the early decreased need for sleep? Highly unlikely.  Unfortunately, and contrary to logic, putting the child to bed later in the hopes that he will sleep in the next day doesn’t help, as the circulating cortisol disrupts the normal sleep stages and then causes the early morning awakening; whereas putting the child to bed much earlier, like at his natural time, allows his body to settle naturally and to get the restorative sleep he needs.  And almost all kids that are sleep deprived are irritable, frustrated, and distracted.  Makes sense that stimulants often treat this sleep-deprivation-masquerading-as-ADHD phenomenon by helping keep you awake and feel “rested,” and likely why we’ve see such a major increase in their use roughly corresponding with national trend in sleep deficiencies.

For details on sleep physiology, treatments, and almost all things related to pediatric sleep,  I highly recommend Dr. Marc Weissbluth’s book, “Healthy Sleep Habits, Happy Child.”

So, one of the first things to address in dealing with psychiatric problems, especially in kids, is SLEEP.