Dr. Pelayo: What I teach is to always think of sleep in terms of 4 components. For patients who come to you with sleep concerns, you have to think about: 1. the amount of sleep; 2. the quality of their sleep; 3. the timing of their sleep; and 4. their state of mind. These are key areas you need to cover when getting a patient’s history.
CCPR: Let’s start with amount of sleep. I know many of us think between 8–10 hours, depending upon age. Is this actually correct? Does less sleep than the recommended amount automatically raise a red flag for you?
Dr. Pelayo: The more important issue is not so much the number of hours of sleep; it’s whether the child wakes up refreshed or not. Sleeping is about restoring the brain. Think about why we tell kids they have to sleep: to make themselves feel better or to recharge their batteries. That’s the way we need to look at it. When I asked one 3-year-old patient, “Why are you here?” he looked me in the eye and said, “Doctor, sleeping makes me tired.” The mother of another child said, “I don’t know what’s wrong. He sleeps more than the other kids. He still naps. Some of his friends have stopped napping already. He’s always tired.” It turns out that although this kid was logging a lot of sleep hours, the quality was bad because he had undiagnosed sleep apnea: The more hours he slept, the worse he was breathing, the more tired he felt.
CCPR: So what’s a better approach than asking how much sleep a patient is getting?
Dr. Pelayo: I ask the parents (or the patient if it’s a teenager), “Do you ever wake up refreshed, or are you always tired?” If they say, “If I can get enough hours of sleep, or if I’m on vacation, I sleep better,” then there is a behavioral component. But, if they always wake up tired no matter how many hours they sleep, there may be an organic issue going on, and you’re almost automatically going to order a sleep test, because you want to measure the quality of their sleep. A sleep study is not to study their sleep habits, it’s to determine the quality of their sleep once they are asleep. It’s also important to think about the entire family’s sleep when you consider amount and quality of sleep aspects.
CCPR: Why is that?
Dr. Pelayo: It’s a mistake to just hone in on the child’s sleep, because they don’t sleep in a vacuum; they sleep in a family. For many families, the only break parents get is when the child is sleeping. The more impaired the child is with sleep, the greater the pressure to sleep in a predictable pattern to take stress off the family. Parents often feel guilty, knowing it’s not the child’s fault; sometimes they blame themselves. On the other hand, sometimes the child is sleeping fairly well, but the parents are complaining because they themselves have unaddressed sleep problems. For example, parents who have occasional bouts of insomnia may be unable to return to sleep if their child wakes up and then wakes them up, so the parents’ insomnia worsens. Along that same vein, you might have a parent who has unaddressed sleep apnea with already brittle sleep that is easily interrupted by the child waking up. So I always think about the overall picture of the entire family’s sleep dynamics.
CCPR: So we discussed the amount and the quality of sleep. The third component you mentioned is the timing.
Dr. Pelayo: The timing often gets overlooked. When you get a history, you need to know whether the person sleeps differently on weekdays or weekends, and also whether parents have unusual sleep patterns. For example, a shift worker may come in late from work and want to spend time with the child—that throws off the cycle. Or, if the parents are divorced, a kid may have different sleep routines and patterns at each home. Regarding timing of sleep, I focus more on the wake-up time than the time of sleep onset. A lot of times parents will say, “Well, I let the child sleep in if he’s had a bad night of sleep, because we all need our rest.” But that means the wake-up time is varying, and you want to lock in a regular wake-up time.
CCPR: What about the fourth component, state of mind?
Dr. Pelayo: What trumps everything is the child’s state of mind. You have to ask the parent, “Does your child look forward to sleeping?” and, “Do they dread the next day?” And ask the child, “Are you scared of sleep?”
CCPR: Can you give us an example?
Dr. Pelayo: Sure. One of my patients was a child who had trouble falling asleep certain nights of the week. It turned out that, in this family, as in many families of children with psychiatric problems, putting the child to bed was not a pleasurable experience; it was a chore, so parents took alternated nights. It turned out that the father was a stickler about how the kid brushed his teeth, and on those nights, instead of looking forward to sleeping, the child got apprehensive and could not sleep well. Things like this will happen, especially if you have a nonverbal kid, such as a child with severe autism. Autistic kids may have plenty of neurological or psychiatric issues, but they can also, like any kid, have a simple fear of the dark or a fear of being alone. So I suggest asking, “Does this child enjoy going to bed?” and, “As it gets closer to bedtime, does the kid seem to get excited or tense, or does the kid seem to look forward to it, yawning and pointing to the bed or the crib?” It’s also important to ask about the experience of getting out of bed in the morning. I always ask the parents, “What’s your child’s motivation to get out of bed? Are they looking forward to their day, or do they dread it? Do they like school?”