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Dr. Sharp: [00:00:00] Hello everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

This podcast is brought to you by PAR.

Use the FACT to help kids who are experiencing trauma. The FACT Teacher Form measures how stress and trauma impact students specifically at school leading to better interventions. Learn more at parinc.com\fact_teacher.

Hello and welcome back to The Testing Psychologist podcast. We’re talking about a topic today that we somehow have not covered on this podcast. I keep saying that, and it is amazing how many testing topics are out there for us to dive into.

Today we are talking about pediatric [00:01:00] sleep assessment and treatment. My guest, Dr. Andrea Roth, is the Director of Thriving Minds Behavioral Health in Livonia, Michigan, where she specializes in treating children with anxiety, OCD, and selective mutism. She also runs the pediatric behavioral sleep treatment program. Andrea graduated with her doctorate in school psychology and clinical child psychology from Yeshiva University/Albert Einstein College of Medicine in 2014 before relocating to Michigan with her family in 2018.

This was such a fabulous episode, y’all. We talked about many aspects of sleep in kids. We talked basics: why it’s important, why we need to care about it, different types to pay attention to, or types of issues rather. We talked about assessing sleep, diving deep into all the questions that we could ask about sleep in our interviews and when to refer to a sleep study, things [00:02:00] like that, when medical intervention is necessary, and we also talk about treatment for sleep.

There may be some surprising information in there for you if you think you know about treatment for sleep in kids. So, lots to take away from this one. I really enjoyed this one. Andrea is a dynamic guest and clearly has lots of expertise.

Before we get to the conversation, as usual, I will invite any of you who might want some help and support in building or growing your practice to check out The Testing Psychologist mastermind groups. Cohorts typically start in the summer and early spring, and there are levels for anybody wherever you’re at in your practice development: beginner, intermediate, advanced. You can go to thetestingpsychologist.com/consulting and schedule a pre-group call to see if it’s a good fit.

Okay, let’s talk about sleep with Dr. Andrea Roth.

Hey, Andrea, welcome to the podcast.

Dr. Andrea: Thank you. I’m so excited to be here.

Dr. Sharp: Thank you. I’m excited to chat with you. Somehow, I haven’t spent a lot of time on sleep on this podcast, even though I think about it quite a bit and consider myself pretty intense about sleep in my personal life and with my clients. So I am thrilled that we’re here to chat about sleep in our evaluations.

I always start with the question of why this is important to you. I’d love to hear that, why you spend your time in this area of all the things that you could do in our field.

Dr. Andrea: I think it’s a really great question. [00:04:00] When I was reflecting on that, knowing that you would ask, I realized that the reason for me is a little bit different than the reason for why should we care about this. The reason for me and why I care about this is that this is a family business. I grew up with a father who was in sleep research. So my whole life, just as you said, you’re intense about sleep in your personal life, we were always intense about sleep in our family life as well.

I think I had a bedtime until I was well into high school. So it’s always been something that I’ve cared about. It’s always been something that’s there. And so I, after my undergraduate, went into sleep research, and graduate school stuck with it. And then recognized that I wanted to take the more clinical route with sleep but always really was drawn to it, switched from adult research into pediatric practice and really recognized that it was so [00:05:00] necessary and it was underserved and it was just so relevant.

So then I think that that translates into why do we all care? Why should we care? The research will say anything from as low as 25% to as high as 40% of kids will experience some sort of sleep difficulty in their life. I’m sure you see this in clinical practice, but I would think that within clinical practice, at least 75% of our population has some difficulty with sleep at some point. So it’s just everywhere. As adults, we spend a third of our lives asleep, and kids even more so. So how could we not care?

Dr. Sharp: Ooh, that’s a good way to put it. How could we not care? Yeah, it comes up so often. Like I said, I’m pretty militant about my sleep schedule but one of our kids has really struggled with sleep and more on the anxiety front than anything but it disrupts sleep and it seems like it’s all over the place.

Dr. Andrea: Absolutely.

[00:06:00] Dr. Sharp: Let’s see. I’m going to resist asking about the sleep dynamics in your family growing up. I’m sure there have been stories about that, but we’ll save that for another day maybe.

Let’s transition though into sleep and talk about this whole topic. You started to share why sleep is important but can we put a little finer point on that? For us as psychologists or neuropsychologists doing these evaluations, why should we care about sleep in kids?

Dr. Andrea: Okay, like I said, adults, a third of our lives, kids, even more so. You remember when your children were infants, when they’re brand new, they spend more time sleeping than awake. By the time they’re two, they have actually spent half of their lives asleep. And then it starts to even out a little bit more.

It’s so present when they’re young. We want to get this right. Why do we want to get this right? We know that [00:07:00] insufficient sleep, and chronic sleep deprivation in children can lead to a myriad of consequences. It can lead to academic difficulty. It can lead to physical health conditions like obesity. It’s been linked to behavioral difficulties, increased anxiety in adolescents, and increased high-risk behavior like substance use and abuse.

In the past few decades, there’s been more research and attention paid to misdiagnosis of ADHD. Talk about neuropsychology and testing, misdiagnosis of ADHD is something that the pediatric sleep community is really starting to take notice of.  So, it’s very present and linked to so many potential difficulties. Sleep difficulties early in life, in childhood, have been strongly linked to continued sleep difficulties in adulthood as well. So it’s a lifelong thing.

Dr. Sharp: Hmm. Can you tell me more about that? When you say [00:08:00] that childhood sleep difficulties are linked to adult sleep difficulties, what are the details with that?

Dr. Andrea: I definitely think it’s at, if I was a little better with numbers, I could give you the exact statistics, but what I can tell you is that there has been a massive amount of research that shows that good sleep habits and sufficient sleep in infancy, toddlerhood, early childhood, primary years is linked to better sleep in adulthood and later on in life. Whereas children who don’t have routine and structure, have later bedtimes, and insufficient sleep are more likely to continue on with these habits as they age.

I think that there are probably some confounding variables and there that would be interesting to look at in terms of the reason why they get more sleep is because they tend to have parents maybe that are paying more attention to research, [00:09:00] paying more attention to good habits. So there might be some secondary gains there as well but there is absolutely research that shows us children that not just have good sleep habits, but actually go to sleep earlier in early childhood have improved sleep habits, increased total sleep time into their primary years, into their adolescence, and then into adulthood, which I think is the coolest thing ever that what I’m doing with my child and my infant and toddler and their sleep is going to positively impact them for such a long time. I just feel like it’s such a gift that we can give them.

Dr. Sharp: That’s a really nice way to think of it. And it validates all the struggles that we’ve gone through as parents to get our kids in bed at a certain time with a certain routine even though it continues to be hard.

Dr. Andrea: Absolutely.

Dr. Sharp: You talked a little bit about mental health concerns that overlap with sleep. There’s certainly the ADHD piece, there’s anxiety. Are there other mental health [00:10:00] issues that we need to be particularly aware of as being related to poor sleep in either direction?

Dr. Andrea: Yes. I think that the diagnosis that we tend to see the most comorbid in childhood or in children with sleep difficulties are, as you’ve mentioned, ADHD. And then the other one that we actually tend to see a lot are children on the autism spectrum who tend to have a lot of difficulty with sleep. There’s this myth that kids on the spectrum actually require less sleep but in reality, it’s just that it’s that much more difficult for them. And so we see really high comorbidity of kids on the spectrum and kids with ADHD with sleep difficulties or sleep disorders.

And then with anxiety and depression, gosh, tell me one kid that suffers from anxiety and depression and doesn’t have sleep difficulties. Hugely comorbid, very bidirectional anxiety. For me, that’s always like the chicken or the egg. My kid is anxious and now they don’t sleep well or [00:11:00] my kid does not sleep well and now they’re anxious. It’s prevalent with almost every pediatric diagnosis. It’s hard for me to think of one that doesn’t have a comorbidity of sleep difficulties often.

Dr. Sharp: That’s a good point. It seems like all of them are bidirectional. That’s what makes it so challenging.

Dr. Andrea: Absolutely.

Dr. Sharp: I think a lot about causality or correlation or whatever you want to say but with sleep, it seems like it is truly bidirectional in almost every case. Not sleeping well is going to make anything else worse, and anything that is going on mental health-wise is going to make sleeping worse. And then you’re in this terrible cycle that feeds on itself.

Dr. Andrea: Absolutely. And it makes it hard to almost decide sometimes what’s the first step that we take. We deal with this in clinical practice all the time. Other clinicians will say, I’m working with this child that has anxiety, let’s say, but their sleep is also terrible. And so I know that their sleep is making this worse. Do you think that they should meet with you first [00:12:00] and work on their sleep or do you think that they should meet with me first and get a little improvement with their anxiety?

And I think it’s really hard. I think really straight down the line sleep specialists, sleep researchers will say, oh, sleep, do it. I live in the camp of, it’s got to be case by case. And I think that I have the benefit of that working in private practice. I think that I have the benefit of saying, why don’t we take a look at this? Why don’t we look at this a little more closely? Why don’t you and I consult with each other, keep in touch with each other, talk to each other as you’re getting into your treatment, and we can make a decision about when it’s right to start making these adjustments?

Dr. Sharp: That’s reasonable. So you’re telling me there’s no concrete answer.

Dr. Andrea: No, I know.

Dr. Sharp: There’s no rule that I can follow. I want to follow rules, Andrea.

Dr. Andrea: I know. Me too. I was having this conversation with a clinician the other day of how I think I really have the benefit of being in private practice, even with people that do behavioral sleep medicine like I do in a hospital system, I think I [00:13:00] still have the advantage of doing it this way because I just have so much more freedom and time and flexibility to have a real team approach and collaborate and really talk to their primary clinician about when do we want to implement certain things.

So, no, I apologize. I am a rule follower too. I’m deeply concrete and no, I don’t have. Different people would give you different answers, but I say no. No one size fits all.

Dr. Sharp: Okay, that’s fair. I guess I’ll have to live with that. I wanted to circle back quickly to talk a little bit about age differences in sleep. You talked about infancy and toddlerhood and we’re, as parents, going through a transition now where it feels like our kids are, they’re 10 and 11, so they’re pushing from childhood bedtime, wanting to stay up a little later, and it feels like a fight [00:14:00] every night. I’m guessing others have experienced that, but I’m curious from a research perspective or practice perspective, how to handle that, as kids get older and want to change their sleep habits, what is important to know through that process?

Dr. Andrea: As you were saying that your kids are 10 and 11, I think I was giggling to myself a little bit because I really get a good number of kids in that age bracket for sleep. I think that a lot of people would assume that it’s a lot of really little kids or really old kids, but I find a lot that come or parents will bring them to me in between bracket. 

I look at that middle school, that 10, 11, 12, 13 is those in-between years were developmentally. They are straddling two lives, two arrows of I’m a kid versus I’m an adolescent. And I just think that this is another symptom of that at times [00:15:00] because their sleep needs are shifting and changing. They don’t require as much sleep.

In addition to that, the demands that are placed on them are changing. They are getting more homework. Their activities, their clubs, and their sports are heavier. They are probably later in the evening. Their social demands are really starting to grow. They might have something like cell phones. At that age that’s going to have an effect as well.

When we talk about childhood versus adolescence when they’re evolving and growing, it’s not just a difference in the presenting problem and what they’re having issues with, from my perspective, more importantly, is the modality of treatment that we use and how we approach it. How much are we going to involve the child? How much say do they have in treatment?

When your kid was three years old, you could pick them up and put them in their crib. When your kid’s 10 or 11, you’re not picking them up and putting them in their bed. So the modality [00:16:00] really has to change a lot from my perspective, I think.

Dr. Sharp: Yeah, that’s reasonable. It’s funny when you listed off all those things, it’s like you have a camera into our house. I feel so torn and I think probably a lot of parents do, a lot of practitioners do, where you want your kids to be active as both of our kids are but they get out of their sports at 7:00, 7:30, 8:00, sometimes 8:30, and that’s bedtime for us. That’s historically been bedtime for us, and so now it’s pushing into nighttime and the whole thing with sleep hygiene of don’t exercise right before bed. It’s really a colliding set of priorities and it’s hard to navigate.

Dr. Andrea: It is. I can do nothing because if I start talking, I actually won’t stop talking about my feelings on things like that. All I can do in this moment is say, yeah, I feel you. I hear you. I feel you.

Dr. Sharp: That’s fair. Let’s see. I do want to talk a little bit about screen time and sleep. I feel like [00:17:00] that is pretty big. It’s a hot topic. In our pre-podcast chat, you mentioned that the research might be changing a little bit or the field might be shifting a bit. I’m curious how you are looking at screen time and sleep these days.

Dr. Andrea: Okay. So upright, obviously a hot topic. Obviously, everybody talks about this. I think it’s the first change that families will make in an attempt to help their children sleep, which I think is wonderful.

I think if we look at the current recommendations for screen time and sleep, and I think what the general public sticks to, we all know that bright light screens in the hour, two hours before bed is a no-no. We don’t do that. Blue light that is produced by our screens much like the sun will reduce the production of melatonin, which is what we need, that chemical we need to get drowsy and fall asleep.

So we know that it’s not a good thing. [00:18:00] However, that is a recommendation. I think that the field is changing. I think that as practitioners, we are changing because being that rigid about anything, any hard and fast rule like that is never good because it leads to fighting potentially with your kid, it leads to a certain level of rigidity about sleep that could lead to anxiety around sleep. That’s not good.

I don’t love any recommendation that is like, you have to do this, you have to do it this certain way. You have to do it in that amount of time. It’s never good. I don’t think that’s a great idea. So how the field has shifted is interesting. We are looking not just at the light production of a screen, but we’re also looking at the content of the screen. We’re looking at apps versus maybe just watching something on a tv.

So [00:19:00] any app and good, gosh, this took me a while to understand. I think it was because I’m a little bit older maybe, a younger clinician of mine said this to me: Any app that’s created is inherently created to keep you there. And that’s not just games, that’s games, shopping, and watching YouTube, the whole point of an app financially is to keep you on that app.

And so they are by nature, almost addictive. So you’re either doom scrolling on social media or the news, or you’re playing a game that has no inherent end because you respawn over and over and over again. Or you’re watching something on a streaming service that gives you 2.5 seconds to indicate if you want to stop or watch another one before it just starts playing the next one.

And so that in addition to the light production is behaviorally really difficult for us to stop. We’re looking at can we make shifts and changes in that. Can we make adjustments in terms of our two screens created equally? If I have [00:20:00] my cell phone or my tablet six inches from my face, that’s way worse than me sitting in a dimly lit room watching something on a TV that has a very controlled beginning and end. I would much prefer that.

And then just the use of technology is being integrated more, not a screen, but technology is being integrated more into bedtime routines. The last pediatric sleep meeting, there was a panel where I think 4 of 6 of the panelists raised their hand and indicated that they actually integrate technology into their recommended bedtime routines for their patients in terms of relaxation, meditation, bedtime stories, things like that. So, we have to keep up with the times. This abstinence-only policy of screens is not going to help anyone.

And then taking it back to even a previous question, when I work with an adolescent or even maybe the age of your kids, I know that I need buy-in from them because we cannot make [00:21:00] them do anything. So this can be a little bit of a bargaining chip I find. If mom and dad or parents or caregivers are saying no screens two hours before bed and then they come meet with me and I say, okay, what if I get you back an hour of Netflix on the couch in the living room with the family, if you will agree to try to go to bed 30 minutes earlier?

It’s a give-and-take in clinical practice. I don’t want a kid having poor sleep hygiene because they’re in bed on their phone chatting, Snapchatting, whatever, six inches from their face right before they go to bed. That’s not great. But again, I think that there’s a little bit of wiggle room here.

Dr. Sharp: Yeah. Two things jumped out from what you just said. One was the idea that being super rigid about screen time before bed can lead to more anxiety or more conflict. And we know that elevated emotions before bed are not going to [00:22:00] do us any favors to get our kids to sleep. That really jumped out to me. And then the piece about using technology is really cool as well. We do utilize podcasts for our daughter specifically. She really likes to listen to Sleepy Time Podcast before she goes to sleep.

Dr. Andrea: I love that.

Dr. Sharp: That seems to work pretty well, although then I think, okay, is this becoming a crutch? Will she ever be able to just fall asleep on her own? You don’t have to answer that question. I’m not going to use this podcast as a counseling session for my children, but these are questions that I think probably come up for…

Dr. Andrea: Why? The cashier at Target uses that moment as a session. I’m always ready for a sleep session.

Dr. Sharp: Nice, just add me to the list. It’s one of those things. It’s something we spend a lot of time on each day and I talk with parents a lot about in our sessions. [00:23:00] It’s funny, it makes me think about how parents will sometimes say there aren’t any manuals for parenting. There’s no manual and I respond sometimes with, well, I think there are actually too many manuals. There are too many guidelines and we don’t know which one to pick and like what’s important or what’s not important. This is one of those areas you can just go super deep and try to figure out.

Dr. Andrea: I love that. I think that’s so interesting because even on our practices website, we have little quotes and things like this, or we have little snips about what it’s like working with us. And I actually say that. I tell my clients all the time, I was not given a manual with my kids when I brought them home.

But you’re totally right. I really like that perspective. There are too many manuals out there. There are way too many recommendations out there. So when families ask me which to look at, my rule of thumb is always to look for the one that [00:24:00] is not so definitive, is not so black and white, it’s not so, you must do it this explicit way. I think one that takes individual differences into account is one of the better ones you’ll find probably.

Dr. Sharp: Agreed. Let’s transition a little bit more to the clinical side of things. We have this opportunity in our evaluation intakes to learn a lot about many things for our clients but I’m really curious what we should be focusing on with regard to sleep. Maybe we just start with some of the questions that you might ask when you’re assessing sleep during an intake.

Dr. Andrea: Okay. I think the important pull-apart is why is the kid coming to me? Are they coming to me specifically for sleep or are they coming to me just for a general intake, which your clients might be more? I think if it’s that side, I can touch on that very quickly.

First, [00:25:00] we want to primarily ask, does your kids struggle with sleep, either initiating sleep or falling asleep or maintaining sleep or staying asleep throughout the night? We then also want to ask if they experience any excessive daytime sleepiness, if they seem overtired during the day. But I think also what’s really interesting, recently we have added it to our general intake, is do they suffer from chronic or disturbing nightmares? There’s a lot of pathological stuff, psychiatric stuff, I think that we’re really seeing comorbid with, like I said, chronic or disturbing nightmares. We try to ask that.

If we then shift into this child is coming to me for sleep, it’s a lot. We ask a lot. We find out a lot and we find out in two different modalities. If we’re talking about the intake paperwork in the interview, what I want to know about is family history, what is floating about their family sleep-wise, and their general schedule.

I want to differentiate weekdays [00:26:00] from weekends or holidays. I want to know obviously what time they’re going to bed, what time they’re waking up. If there are night wakings, what do those look like? When? How long? When they wake up in the morning, are they waking up independently or do they need to be woken? Are they being woken up by an alarm or a caregiver? Are they napping? Are they taking any medication? Specifically, are they taking any medication to aid in sleep? Have they ever taken any sleep medicines before? I do ask what electronics they have access to in their room. I want to know about their bedtime routine, and I think this is an important one to stop at for 30 seconds.

In the paperwork, I say, what is your bedtime routine? In that first meeting, I say, what is your evening routine? Tell me about what happens right after dinner ends. I don’t want to know those 20 minutes before bed, I want to know what the whole evening looks like after dinner. I think [00:27:00] that’s a little bit of a differentiation.

I want to know things like, are they sharing a room? Are they sharing a bed? Do they have behavioral resistance at bedtime? Are they engaging in behavioral resistance, be curtain calls? Are they coming out of their room? Are they calling out to you?

And then again, I ask more about daytime sleepiness. The bigger indicators of excessive daytime sleepiness are, are they falling asleep accidentally during the day? For children, I always ask, if you’re getting into the car, they get into their car seat, maybe not the car seat just into the car, are they falling asleep? Are they falling asleep in class? Are they falling asleep in front of the tv? Again, either intentionally or unintentionally falling asleep during the day.

The other thing we look at is, are they really crashing on the weekends? They have to wake up at 7:00 AM, 6:00 AM for school, are they really then compensating and crashing out on the weekends? That’s another indicator of the [00:28:00] fact that they’re may be a little bit chronically overtired.

I want to know what their sleep looked like early in life. That’s more for my gain. I want to know if the parents did anything for sleep training either in infancy or toddlerhood. It gives me a sneak preview of like, what am I working with here? A great way to remember this, Jodi Mindell coined the term BEARS to help us remember the big points and its bedtime problems, excessive daytime sleepiness, awakenings during the night, regularity and duration of sleep and snoring. So it’s our little BEARS.

And that snoring piece is really important as well. Before I get a family even through my door filling out my paperwork, I always get on the phone with them for about 10 to 15 minutes beforehand to tell them a little bit about the process but also to screen for potential medical things [00:29:00] very briefly for any obvious red flags that would have me send them to an M.D before they come to me.

So I ask, does your child snore consistently outside of allergies or sickness, which would be indicative of potential sleep apnea. Healthy children should not be snoring consistently. I don’t think that the general public knows that fact. I don’t think pediatricians necessarily always tell us that fact.

Do your children complain of itchy or restless limbs? I usually say something like, do they say that their arms or their legs feel creepy, crawly, or like there’s buggies on them? Is your kid a really intense mover and shaker overnight? Have they ever had a history of anemia or low iron? Because that would indicate potential red flags of restless leg, restless limb.

And then finally I ask if they have a medical condition that would make it uncomfortable to sleep, reflux uncontrolled eczema, et cetera, because [00:30:00] they answer yes to any of these questions I will say, you need to go to either the ENT or your pediatrician before to let’s cover some of our bases first, and then we can do some behavioral sleep work. So that is my exhaustingly long answer to your very simple question.

Dr. Sharp: No, I love it. There’s so much to take away from that and just the definition of what a red flag would be for us to know, hey, we need to pause and go get some medical intervention or at least explore that possibility was really helpful. I do want to get back to two things and double-click on two points.

I wonder if we could veer off just quickly and talk about melatonin. You mentioned medication and anything to aid in sleep. I feel like melatonin got super popular about 10 years ago, 10, 15 years ago, and everybody got on it and now there’s maybe some second thoughts around is this helpful? I would love to hear, as a sleep specialist, [00:31:00] where we’re at with melatonin and kids right now.

Dr. Andrea: Okay, I have to obviously start with CYA. I am not a medical doctor. I’m not an M.D. I can never comment or make any recommendations on medication. Nobody needs to be sued. What I will say, observationally, and anecdotally, research is showing us that there is a higher rate now of legit overdosing on melatonin in children.

There are many families that are not using an appropriate dosage of melatonin because, I can’t say exactly why, I can’t pinpoint the error. I don’t know if it’s that medical professionals aren’t making clear enough recommendations to their families or their patients. I don’t know if people are just giving more and more as they see fit but what we know is that in pediatric populations, the dosage is supposed to be so very minimal.

[00:32:00] The other thing that I know and the research shows us is that the pediatric populations that we tend to see using melatonin in a more “long-term way” are two of those populations that we touched on before; kids with ADHD, kids that are on the autism spectrum because they have difficulty with sleep and wake. They have difficulty with physical restlessness. They have physical calming and slowing. So these are the populations that really end up using it and benefiting from it more.

I don’t feel so strongly one way or the other in terms of recommending it, yes or no. My job is to give the facts of why is your child taking it? What are we thinking it helps with? Is it your goal as a family to continue to take this or would you like to stop taking this? That’s where I live and it’s reflecting the current [00:33:00] literature on the appropriate dosage, on the fact that there’s not really a lot of longitudinal research out there on the chronic use of melatonin in children. It just doesn’t exist yet.

I’m giving you the vaguest of answers. Mostly, like I said, as a CYA but the research has shifted, like you said. It became really big about 10 years ago and more recent literature is suggesting that we are using it too much too often and it’s not healthy for our children. I think it’s worth noting that in other countries, melatonin lives behind the counter.

Dr. Sharp: That is interesting. Two questions to follow up on that as much as we can, we could call it hypothetical but it sounds like the two problems are overdosing in quantity and frequency. I’m curious about the dosage and if you have ideas on that. When you [00:34:00] say overdosing, it should be a minimal amount for kids, are we talking like 1 milligram, 3 milligrams, 5 milligrams a night? What constitutes overdosing as far as you can tell?

Dr. Andrea: In the research and being told by pediatricians, the absolute maximum we should ever see a child on is 5 milligrams. And in reality, under 3milligrams is best. I work with children that are on 0.5 milligrams and it’s perfectly effective for them.

Dr. Sharp: Sure. We give our daughter 0.25 milligrams probably 3 to 4 nights a week at least lately and it works fine.

Dr. Andrea: Yes. And so what I will say is the way that I, if a family comes to me and they’re already taking melatonin, the dosage is an appropriate amount and from a values-based perspective, they have no difficulty with continuing on the use and they like using it, [00:35:00] I always try to make sure that they are using it properly and they understand what it’s for.

I think that there’s this misconception that this dosage of melatonin is meant to be like an Ambien, like a sleep aid. And that’s genuinely not what melatonin is. And I don’t think that people recognize that. The kid’s supposed to be going to bed at 9:00 o’clock, so the kid takes it at 8:58. That’s not how melatonin works. Melatonin is meant to be taken 45 to 60 minutes before bed because it’s not meant to aid in initiating sleep. It’s meant to create melatonin which just makes us drowsy.

So I want to make sure that they’re using it in an appropriate way at appropriate times, and they’re not giving it too close to bed or at all different times of night on different days. Melatonin should be taken consistently at the same time as best we can. And like I said, about 45 to 60 minutes before bed.

Dr. Sharp: As best we know, what are the dangers of overdoing melatonin either [00:36:00] the overdosing like we’re talking about, or long-term use, do we know that stuff yet?

Dr. Andrea: We don’t know the long-term use. Like I said, there’s not a lot longitudinally out there. Overdosing, I’ve not read too much into the medical side of it, but I do know it’s dangerous. These kids end up in the hospital for this. I don’t think it’s as severe as an opioid overdose but these kids are ending up in the ER because they’re overdosing on it.

I have a colleague who I think says this well, it is a medication, period. It is not without side effects. And I think that we forget that. We look at it and we go, oh, this is just like a Flintstone vitamin. It’s a medication and it’s not without side effects ever. Anecdotally, there are people that talk about horrific nightmares, and worse sleep. There’s a lot out there that can happen. [00:37:00] Tummy issues. There are a lot of potential side effects of this which are just exacerbated when we’ve taken too much. Adults overdose on melatonin, so it’s not just a pediatric-specific problem.

Dr. Sharp: Sure. And I’ve heard tales of some tolerance developing for some individuals and increasing dosage.

Dr. Andrea: Absolutely.

Dr. Sharp: So maybe the takeaway is just to be careful and do due diligence.

Dr. Andrea: Be careful. Talk to your pediatricians.

Dr. Sharp: That applies to a lot of things.

Dr. Andrea: Right.

Dr. Sharp: One other thing I wanted to ask you about that you mentioned earlier is the chronic nightmares and that may or may not be related to moving around and talking during sleep, like excessive moving and talking during sleep. So let’s tackle the nightmares first. You said that you have started asking about chronic nightmares more lately, what is the implication of that? Why is that important? What would we do with that information?

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Dr. Andrea: Unfortunately, there is a pretty strong link between chronic and distressing nightmares and suicidality. So we would like to know, and you said before correlation, causation, we’ve seen correlation. So we want to make sure that this is not happening. Our population knows that PTSD obviously has a very strong link with nightmares but there is a [00:39:00] lot of literature more recently that is really showing the link between chronic and distressing nightmares with suicidality. So we want to make sure that that’s not happening and that there is really strongly supported treatment for nightmares that should and could happen. So we are always asking for that now.

Dr. Sharp: Okay. I did not know about that link between nightmares and suicidality. That’s striking.

Dr. Andrea: The owner of our practice, Dr. Kotrba, two years ago, sent me an article and she said, she’s like, “Did you know this? Should we be asking about this more?” And I said, “Yeah, probably.”

Dr. Sharp: Let me shift to the second part of that with excessive movement, talking, I’m going to expand into night terrors and sleepwalking. Those are a lot of different points to cover, but I’d love to touch on each of those and how much we need to be concerned about each of those as we [00:40:00] work with kids.

Dr. Andrea: Okay, if we want to just hit on this movement piece, what I had mentioned before was I pre-screen for RLS or periodical movement. And so I want to know if that’s present. The questions I ask are: does your kid complain about itchy or restless limbs? Are they really moving a ton during the night? Have they had a history of anemia?

The reason why we ask these things is good news. If they go to their pediatrician, it’s actually just a simple blood test. They check their ferritin levels and can most often be treated with just an iron supplement and we see a decrease in those symptoms which is wonderful. So their quality of sleep improves. So that’s one piece. But this other piece, what you are talking about are parasomnias, sleepwalking, talking, sleep terrors, and things like that, this is a totally different ballgame, totally different category.

[00:41:00] How much do we have to be concerned about them? We should be concerned about all of it but parasomnias are really interesting and very unique and can very, I should say easily, well be treated with behavioral sleep strategies. Parasomnias, like everything, come from a variety of factors. There is a pretty strong hereditary loading for parasomnias. So if a genetic parent is a sleepwalker, solid chance that your kid might have some sleepwalking or solid chance your kid might have some sleep terrors, unfortunately.

What we also know is that potentially if there’s not some genetic loading, it is a pretty solid red flag that that kid might be chronically overtired. The first line of treatment for parasomnias is actually just to increase the total sleep time. [00:42:00] And so if we can clean up sleep and put in some good strategies and bump up that TST, we see these parasomnias falling away most often.

What I should asterisk in there is for something like sleepwalking where there are safety concerns, the actual first line of treatment is just making sure that your kid is safe. Like putting a door alarm to know that they’re moving, and put the baby gates back up. Make sure that the floor is clear and their room, so they’re not going to home alone themselves.

That’s actually the first line of treatment. I feel like I’m morally obligated to say that, but then it’s increasing their total sleep time and these things can fall away. Also, sleep terrors that are more chronic and aren’t as impacted by increasing total sleep time and there is this genetic loading, kids tend to grow out of these, which is great.

So the second line of treatment, I guess I would say is intense psychoeducation for parents. [00:43:00] I think that that applies for all of these concerns as you’ve discussed but particularly around sleep terrors. Parents always come in and say, sleep terror or nightmare, what am I dealing with here? What’s going on? And it’s pretty easy to pull apart, which is very cool, I think because I like you, like you said, like rules. I like black and white.

There’s a pretty solid equation for this. The first and easiest question you can ask is who remembers it? If the kid remembers it, it’s a nightmare. If the parents remember it, it’s a sleep terror. And that’s it. The end. What my young people say here now, full stop. That’s it. But we can also ask, what time of night does it happen? Parasomnias like sleep terrors happen in the first chunk of the night, the first third-ish of the night. Nightmares happen in the later part coming into the morning.

And then finally, can the child be roused? If you go into the room and the kid’s screaming and you [00:44:00] can’t wake them, they’re not coming around, that’s a sleep terror. If you go in and you say, I’m here and the kid pops awake and they’re coherent and they are there, more likely a nightmare.

So those three questions are really the things we ask but in reality, that first question of who remembers it is the real biggest one. Kids don’t remember sleep terrors. So that’s the biggest piece of psychoeducation that we can provide to parents. It’s always like increase their total sleep time and then do less. It’s always, do less.

Don’t talk to them about it during the day because that can, understandably so, increase sleep anxiety because if you’re going to your kid going, hey, last night, do you remember screaming at the top of your lungs and crying for 20 minutes? Of course, Johnny’s going to then be scared to go to bed the next night. He had been a full exorcism. So don’t talk to them about it.

Do not wake them up because that can prolong the experience. Don’t comfort them. Quite [00:45:00] honestly, don’t go to them. Leave them alone and it will stop. They don’t remember these. These are not psychiatrically damaging to them.

I’ve had full, not arguments, but just real conversations with parents of how can this not be psychologically damaging for my child. I should be comforting them and hugging them and making it stop but in reality, all they’re doing is prolonging the sleep terror and scaring the heck out of the kid because it’s not that these kids are completely unable to be roused, it just takes a lot. So they are waking up to their parents violently shaking them, screaming in their faces. That is traumatic.

Dr. Sharp: Talk about traumatic.

Dr. Andrea: Yeah, right?

Dr. Sharp: Right.

Dr. Andrea: It’s a lot of do less. Make sure they’re safe, let’s increase their total sleep time and just leave them alone. They don’t even know this is happening. If we do all these things and they’re still sleepwalking, still having sleep terrors, still having enuresis or bedwetting, we can do [00:46:00] scheduled awakenings.

I have, in clinical practice, never ever done that. These are for kids who we’ve done all of this and they are having the exact same parasomnia every night at the same time. You can do a scheduled awakening where you go in and lightly rouse them. Ballpark 15 minutes before it typically happens, it pulls them into a, “lighter stage of sleep” where they’re not going to have the parasomnia and they bypass it for the night.

Again, clinical practice, I’ve never done it. It’s rare. Most of the time you increase the total sleep time and it either totally dies off or really decreases. So to answer your initial question, how much do we care? We care. How much is it going to impact them? Not so much. It’s more just an indicator that they’re probably chronically sleep-deprived and they need a little bit of work.

Dr. Sharp: Yeah, that’s a nice takeaway. I think this stuff is really distressing for parents and hard to soothe those nerves, right?

Dr. Andrea: Yeah.

Dr. Sharp: So this is good information. I’ve talked about our [00:47:00] kids a lot and our daughter quite a bit. She’s the sleep struggler in our family but we’ve had so many instances of her, I guess you’d call it sleepwalking, where she just gets up out of bed, comes to our room, wakes us up, talks to us, and has no memory of it. So we just guide her back to her room and put her in bed and then go back to bed and that’s just what happens. It’s probably once a month

Dr. Andrea: She’s done the wiser. Yes. Oh, once a month. I would bet if you started tracking that you would catch some trend of like it’s after a sleepover or she’s got a test and so she’s a little bit stressed or she’s sick or something. I would bet you could catch a trend in the two days or day before in her sleep.

Dr. Sharp: That’s interesting. I want to talk a bit about sleep studies. I hear a lot about sleep studies. I refer to sleep studies [00:48:00] and I think that, at least in my case, I have used it as a little bit of a blunt tool without really knowing exactly why. In the past, just in the interest of self-disclosure, if I hear some of those red flags like snoring, gasping, apnea, stuff like that, that’s when I’ll say, okay, maybe we should do a sleep study.

I would love to hear from you, is there a more fine-tuned rubric that we can use to refer for a sleep study? What is actually happening in a sleep study? Are there different kinds? What information do we get back? I feel like clients come back and they’re like, we didn’t find anything. We got nothing. Take those questions in any order you would like to.

Dr. Andrea: Okay, let’s start simple, different kinds of sleep studies. When you go into a sleep clinic, the most common types type of sleep study is a PSG. They [00:49:00] are hooking you up with electrodes. It’s crazy looking. I’ve seen this my whole life. It’s come a long way but effectively you have electrodes all over your head that are, gosh, in my mind, I want to say cemented because that’s what they looked like when I was a kid. 

It’s watching and monitoring. It’s recording your different sleep stages. Depending on what they’re looking at, there are monitors that are on their legs. There are oximeters that are measuring their breathing, like you said, snoring, gasping, et cetera, looking for OSA. The sensors are secured, like I said, it looks like cement. I think it’s actually like a gel. They’re on their, I got leg, I got where else? I have it written down, chin, legs, chest, and near the eyes because I always forget because I don’t see a lot of sleep studies.

They’re not painful taking them up, putting them on, taking them off, it’s not painful. Their oxygen levels will be monitored. [00:50:00] And there’s always a staff, they’re called sleep techs who are always there, who do the hookups to explain everything to the kid. The best pediatric sleep programs have videos which your kid can watch beforehand, so they feel a little bit better about it. I have been told differently that in some pediatric sleep clinics, the parent can stay with the kid and I have been told that some pediatric sleep clinics that they cannot stay with the kid. So I can’t give a real general answer on that.

The other one that they use is something called an MSLT, which is a Multiple Sleep Latency Test which is more generally referred to as a nap study. Like I had mentioned, when we’re looking for excessive daytime sleepiness, we always ask, does your kid fall asleep during the day accidentally or intentionally? In MSLT, they will have them get into the bed at prescribed times or intervals effectively to see will they fall asleep, yes or no. And then neurologists do [00:51:00] EEGs and that’s I think, in my experience, looking more for those more neurologically bound things, nighttime seizures, et cetera.

I think the most common thing that you are probably seeing when someone comes back and says, my kid had a sleep study. They had a PSG done.

And so when do we send for those? Let’s go there. As I mentioned, we’re screening. I screen on the phone for snoring, gasping, holding their breath, potential RLS, or restless leg. And then these medical uncomfortable things, reflux, eczema.

The number of times I have actually sent a kid for a PSG, I can count on one hand because if parents say yes to me to any of these things, I say, go to your pediatrician. If we do a full “round” of behavioral work and we are not seeing any improvement, I will say, you need to talk to your pediatrician, [00:52:00] your pediatrician will refer you, or I can sometimes directly get them through to a PSG.

Again, I can count on one hand. I will politely say that sometimes there are parents that are insistent that their kid needs a PSG or needs a sleep study and they’re maybe not doing what I ask them to do. And so I will say, okay, you should go get a sleep study and you’re right, let me know what they say and then we get to work because to be honest, more often than not, like you said, they come back and they say, wow, they didn’t find anything medically wrong going on. They recommended behavioral sleep therapy. And I go, you don’t say. So I can really count on one hand the number of times I’ve sent a kid for a sleep study.

Dr. Sharp: Great. So you send them to the pediatrician first?

Dr. Andrea: I send them to the pediatrician first.

Dr. Sharp: Yeah. That’s great clarity. Thank you.

Dr. Andrea: No problem.

Dr. Sharp: Okay. Let’s see. We are covering a lot of ground but I do want to transition to treatment before we totally wrap up this podcast on sleep. I [00:53:00] think treatment-wise, of course, we hear a lot about sleep hygiene and we can talk about that. I’m curious, there’s CBTI or cognitive behavioral therapy for insomnia and maybe some other things. Let’s tackle each of those and dive into treatment for a bit.

Dr. Andrea: My favorite, what I do all day long, I love it. CBTI I’ll start there because that’s a more widely known intervention. CBTI is more for adults/adolescents. It has to do with strategies/techniques are sleep restriction, stimulus control. There are certain aspects of CBTI that we would not use for children.

Stimulus control is the idea of very loosely, if you’re not falling asleep, get out of bed, move to a dimly lit space until you feel sleepy again, and then get back into bed. We don’t do that with kids because [00:54:00] that would probably require oversight. They probably don’t have the ability to manage that themselves.

Sleep restriction is a huge part of traditional CBTI, which is limiting the amount of time that the individual spends in bed. And we don’t do that to kids because they need sleep more for growth for everything. They can’t function on little sleep like we can. And of course sleep restriction in CBTI is time-limited, it’s not forever, but we still don’t do it with children. We just don’t.

There are certain aspects of CBTI that we just don’t do. So if you ever come across a pediatric clinician that’s like, I work with elementary kids, we do CBTI, I would maybe inquire further. There are so many aspects of CBTI that we just can’t use with kids from just a developmental perspective. So we do a lot of behavioral strategies.

From my perspective in the years that I have been doing this, something that I think I have the unique benefit of my [00:55:00] dual training. So my doctorate is in clinical child psychology. I primarily work with kids, not primarily, it’s probably 50/50 at this point. I’m trained to work with kids with anxiety, depression, behavioral difficulties, OCD, et cetera.

I find that to be quite advantageous because I really think that the first piece of sleep treatment has to be why. Why is this happening? Why is my kids struggling to sleep? They will, almost all of them, if I’m talking about elementary-aged kids or even kids that are your children’s age in middle school, late elementary will say things like, I’m scared. I don’t like the dark. I don’t want to be alone.

I think a lot of what they say can just singularly be perceived as oh, sleep anxiety or they’re scared. And I think if we get into it further and we look further and more closely at what’s going on, we start to understand it falls [00:56:00] more into the camp of true anxiety bound difficulty or more behavioral resistance. And like so many things, there is no one size fits all.

We should not treat a child who has legitimate fears and anxiety around bedtime, the bedtime process, and overnight the same as we treat a child with behavioral resistance. It’s why the treatments for generalized anxiety and like ADHD or conduct disorder are different. For me, sleep difficulty in childhood is the exact same thing. It has to be treated in the exact same thing. So I want to understand what’s going on.

So I almost have like a choose your own adventure when I do an intake with families. I’m asking them my seven bazillion questions about their kids’ sleep, and then I’m looking at the sleep diary because I always want quantitative data as well. If I had millions of dollars, I would also have good actigraphy or active watches but I don’t have that sort of money.

I look [00:57:00] through all of that. And then I talk to the parents and I ask a lot of questions about, okay, well what do they look like during the day? What of this behavior that we see at night, do we see during the day? Talk to me, would you describe your child as being an anxious child? Are they reluctant? Do they have a history of difficulty with separation? How are they with trying new things?

When they are telling you they’re fearful at night, what does your parental instinct say? What do their faces say? What’s the tone of their voice like? Do we see these defiant behaviors? During the day, I get a lot of qualitative information on like, what does the structure of the day look like? Is this a set of caregivers that engage in a lot of empty threats, maybe don’t have a lot of structure, maybe have a lot of defiance all around? These are very different things.

And so again, I really have a choose your own adventure. And so for me, I like to do foundational work that’s going to either a) increase brave behavior via [00:58:00] reward systems and very minimal exposure of like having fun in the dark games. It’s like a very toe dip into exposure. Really helping them strengthen that brave muscle, or I’m doing a little foundational work that is improving flexibility, and compliance during the day and in the evening before we get into sleep work.

Once I’ve done that foundational work, then I move into legitimate sleep treatment. So we are working on effectively that skill of independent sleep, starting at bedtime, we always just start at bedtime. If Johnny is struggling to fall asleep alone and stay in bed all night, we just start at bedtime. There are a few different strategies that we can use, almost similar to infant toddler sleep training, where we can do parental presence, where I think it puts what most parents try like for three nights, I sit in bed. For the next three nights, I sit 6 feet away, three nights I sit in the doorway.

[00:59:00] We can do checks almost like Ferber. We can do the break method where we sit with the kid for about 10 minutes. It’s actually half of the sleep latency or half of the amount of time it takes them to fall asleep. And then we take a break, each night that lengthens, lengthens, lengthens.

There’s different strategies that we can use to increase that independent sleep. Foundationally, we’ve already put a reward system in place, so every time they follow along with this, they get a $1 or a point or some sort of reward every time they’re compliant then, and we’ve already got bought in from that foundational work. Once we get bedtime cleaned up, we move to the middle of the night, which effectively usually is just rinsing and repeating, whatever we used at bedtime, we’re then going to use in the middle of the night.

So, there are a lot of strategies we use. I can get into this for 20 more minutes. I’m like, what are the specific things we use for nightmares? What’s bedtime fading? What if my kid will fall asleep, but it takes them forever to fall asleep. With adolescents and phase delay, there’s chronotherapy, there’s bright light therapy. There’s [01:00:00] melatonin.

I could talk about this forever, but I think what’s important for people to know is that with, well, I want to go back to this idea of too many manuals. With the fact that sleep is everywhere now, it is so tempting to go online and find recommendations on sleep that are so definitive on do this and in this amount of time, that’s it. For a laid-back child who is experiencing minimal difficulties with sleep, that might work.

I think that if you have a child that is genuinely really struggling with their sleep, it is so much more important to dig into the why, because then I think that you can make a much more tailored plan to help them with it. And more than anything, it’s slow and steady. It’s so slow and steady. I think families really want instant fix with their kids.

You got an infant? Sure. We can actually fix this probably within, [01:01:00] research indicates improvements within 5 to 7 days. Older kids, think about how long it took them to develop that habit. It’s really slow and steady. Again, I could spend 20 more minutes talking about specific sleep interventions, but if I could emphasize one thing, it’s two things, slow and steady, and it’s got to be tailored and really look at the why the child is struggling.

Dr. Sharp: Well, I think that really speaks to the rationale for assessment in general and that this is just a microcosm of the macro process that we got to know the why before we recommend intervention for any number of things and it’s just another example of that.

Dr. Andrea: Absolutely.

Dr. Sharp: I love that question or that point that you made about, are these behaviors happening during the day as well? I think sometimes it’s easy to isolate bedtime problems and just link them to sleep but is the child struggling with this stuff during the day as well? It makes sense. It [01:02:00] makes intuitive sense but it’s easy to forget.

Dr. Andrea: Right, because I think that it’s not for no reason, all these problems are amplified at bedtime because the kids are then sleep deprived. Of course, it’s going to be way worse at night, way more prominent at night. I don’t think it’s any fault to the parents, and it’s the thing that disrupts them the most because they’re not sleeping too.

Dr. Sharp: Absolutely. Yes.

Dr. Andrea: I think there are tons of clues during the day. I actually, even to get back to your point of what do we do with sleep hygiene? I almost work under the assumption now that every parent knows what good sleep hygiene is. I’ve never actually come across a parent that’s like, well, I’m giving my 8-year-old a latte at 9:00 PM, is that a problem?

I think the general public knows about good sleep hygiene now. They know we should be limiting exercise. They know we should be limiting screens. They know we should not be having caffeine. The one thing that sometimes I feel is a little bit helpful for them is to understand that [01:03:00] sleep schedules, both bedtime and wake time, should remain fairly consistent seven days a week.

And especially for teenagers, sleep is for bed. Some older teenagers, oh my God, they hate me when I say it. Sleep is for bed and sex because that’s what we say to adults. Especially during earlier days of COVID, it was really a battle for all of us. Sleep is for bed period. And so that’s a huge piece of sleep hygiene that maybe is not commonly known.

Dr. Sharp: That’s fair. Well, this has been great. I feel like we have covered a lot of ground related to sleep. I know there’s plenty more that we could talk about. There were lots of nuggets to take away from our conversation today, and it will change some of the things that I’m doing in my practice tomorrow.

Dr. Andrea: Oh good.

Dr. Sharp: So that’s fabulous.

Dr. Andrea: Great.

Dr. Sharp: Yes. And in my home, this is a great and nice conversation.

Dr. Andrea: Great.

Dr. Sharp: Yeah, thanks Andrea.

Dr. Andrea: Even better.

Dr. Sharp: This is great.

Dr. Andrea: No problem.

Dr. Sharp: No, I really appreciate your time [01:04:00] and expertise. If folks want to reach out, are you open to people reaching out? Do you do any kind of training or are there resources if folks want to learn more?

Dr. Andrea: Absolutely, on both ends. At our website for thrivingmindsbehavioralhealth.com, we have resources both for parents and professionals. I think that’s something that our practice does is really emphasizes parental support. So there are lots and lots of resources for parents, both free and paid. And then likewise for professionals, we offer one-on-one consultation. We offer pre-recorded webinars. There’s lots more that can be done. Again, it’s on our website, thrivingmindsbehavioralhealth.com. I’m always around.

Dr. Sharp: Yeah. Great. We’ll definitely put it in the show notes for folks who want to check it out. Well, thanks for your time again. This is fantastic. I appreciate you.

Dr. Andrea: Thank you. It’s been great. I could talk about sleep forever and ever and ever.

[01:05:00]Dr. Sharp: All right, till next time. All right y’all, thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.

If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcast.

And if you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development; beginner, intermediate, and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for [01:06:00] a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. [01:07:00] If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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