Staff Perspective: “If I’m Not Sleeping, Nobody’s Sleeping”: An Interview with Pediatric Behavioral Sleep Expert Dr. Brandy Roane
“If I’m Not Sleeping, Nobody’s Sleeping” read a baby onesie I once saw. If you have been around little ones with sleep problems, you unfortunately know exactly what this means! Sometimes it may even seem a parent’s life and sanity revolve around getting their child to go to sleep.
For military families, while there has been much attention paid to how military service can impact the Service member’s sleep, aspects of military service such as deployments, TDYs, PCSs, long hours, and stress on a Service member can also impact his or her children’s sleep. That is, on top of normal pediatric sleep issues, children in military families can face additional challenges to sleeping well.
So, I decided to increase my knowledge in this area by going straight to the source and interviewing a subject matter expert on pediatric behavioral sleep medicine, Dr. Brandy Roane, Ph.D., CBSM. Dr. Roane completed a pediatric psychology internship at the University of Nebraska Medical Center and did her post-doctoral training at the Alpert Medical School of Brown University specializing in sleep. She is currently an assistant professor at the University of North Texas Health Science Center where she conducts a children’s sleep clinic, actively engages in sleep research, and supervises students, and she is certified in behavioral sleep medicine.
DCD: What are the most common contributors to pediatric sleep disturbances in general?
BMR: It really comes down to inconsistency, whether that’s with bedtimes, where the child sleeps, or sleep-related rules/limits. Kids might give off an air that they dislike structure, but most thrive in an environment where routine exists. Bedtime is no different.
DCD: In working with adults in a military context, I often think of obtaining sufficient sleep as a “force enabler”. What is the range for a healthy amount of sleep for children, and what is the benefit of obtaining sufficient sleep in that range?
BMR: There are guideposts for a healthy amount of sleep; for example, over a 24-hour period infants should sleep 16 hours, toddlers 12 ½ hours, school-aged children 11 hours, and teenagers 9 ½ hours, in comparison to adults who need about 8 ½ hours, but of course there are ranges from short to long sleepers. In my clinical practice, I’ve found there’s a mismatch between how much sleep parents may think their kids need and how much they actually do. Kids respond paradoxically to sleep loss versus adults; adults don’t get hyperactive, run around and bounce off the walls when sleep deprived! Because of this “second wind” parents may think their children are not tired or don’t need sleep. However, with insufficient sleep kids become noncompliant, inattentive, emotionally labile, and may stare off into space or take longer to complete tasks. In school-aged kids, grades may drop. In other words, they are likely to not listen when spoken to, refuse to do things they are told to do, and have temper tantrums. Don’t get me wrong, kids who get sufficient sleep are still going to misbehave, but it is much easier to get a kid who has had sufficient sleep back on track than it is for one who hasn’t gotten enough sleep. Additionally, sleep deprivation in children can lead to sleep experiences such as sleep walking or night terrors, although parents may think these are just nightmares.
DCD: In a study of Army spouses with elementary school-aged children whose active duty spouse was currently deployed, 56% reported their child had difficulty sleeping (Flake et al, 2009). Does this surprise you? Why or why not?
BMR: Yes, I’m actually surprised it’s not more! In general, the average pediatrician’s office has anywhere from 30-50% of the children report sleep difficulties. Military families face challenges like deployment and extended time away from the family for the Service member; this is similar to families with a single parent household, where there may be a lack of consistency related to sleep as the parent who is not deployed no longer has someone to back them up, especially at the end of the day when he or she is tired, and may go with what seems easier short-term. The difference in military families is that there is a separation and reintegration period to navigate, and so the rules and who is enforcing them may change, leading to more inconsistency. Additionally, parents’ health impacts kids’ sleep, so if the caretaker parent is anxious or distressed during the deployment cycle, children may develop anxiety manifested around sleep, including fear of the dark, needing multiple nightlights, an elaborate winddown routine, etc.
DCD: What sleep disturbances might you expect to see in young children and teenagers related to a major stressor like a military parent’s deployment?
BMR: Most commonly insomnia pops up, and younger kids will engage in all kinds of behaviors to delay bedtime and develop sleep onset associations. That is, they may want another hug or kiss or may “need” a parent to be present in order to fall asleep. Parents may also see sleep talking, sleep walking, and perhaps bedwetting if the child is getting insufficient sleep, especially if there is a prior history of these behaviors. General stress from the deployment cycle can contribute to these sleep problems. Additionally, keep in mind that the parents are dealing with their own stress and possible sleep problems as well, and children may respond to this example, particularly older children and teenagers.
DCD: What can military parents do to proactively improve their child’s sleep?
BMR: Have a bedtime routine they can follow regardless of whether or not both parents are home. Keep things consistent as much as possible, in general and during deployment and reintegration. Consistency is also important during the day-if parents are flexible with non-sleep related rules, kids may figure they can test sleep rules, too. Parents can also implement a reward schedule during deployment or other periods of stress; even though children are expected to follow the routine, the reward is for sticking to that routine despite the stressful situation.
DCD: What can military parents do when difficulty falling or staying asleep is already occurring for their child?
BMR: For many kids, re-establishing a consistent bedtime and waketime schedule can help with problems. Start by setting up an expectation and then following it through. Think “same bat-time, same bat-channel.” It may take at least a week and there may be an extinction burst, or time when the child escalates to try to return to the old behavior. Parents should expect some push-back as change is not always liked. So, dig-in and stick with the plan! Parents may want to support themselves during this time, set up notes around the house or reminders to stick with it even when the child is fussy,
DCD: What are some sleep-related signs parents should bring their child in to their PCP for further assessment or referral?
BMR: If there are problems that are not behavioral in nature. For example snoring, pauses in breathing, difficulty breathing, obstructed airways, and, in fact, frequent sweating and bed-wetting (or frequent nocturnal urination), may be a sign of obstructive sleep apnea (OSA). OSA may also correspond with partial arousals or difficulty maintaining sleep. Other problematic signs include excessive daytime sleepiness despite sufficient total sleep time. Although it would be rare, further assessment may be needed if insomnia symptoms do not resolve after maintaining a consistent schedule.
DCD: Do you have any suggested readings or resources related to pediatric sleep problems?
BMR: One book that might be useful for parents is a book by Patrick Friman, Ph.D., called “Good Night, Sweet Dreams, I Love You, Now Get Into Bed and Go to Sleep.” This book helps parents with things like a consistent pre-bedtime routine, establishing a consistent sleep location, and other key pieces that can make bedtime easier for the parent and child.
Diana C. Dolan, Ph.D., CBSM is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
“If I’m Not Sleeping, Nobody’s Sleeping” read a baby onesie I once saw. If you have been around little ones with sleep problems, you unfortunately know exactly what this means! Sometimes it may even seem a parent’s life and sanity revolve around getting their child to go to sleep.
For military families, while there has been much attention paid to how military service can impact the Service member’s sleep, aspects of military service such as deployments, TDYs, PCSs, long hours, and stress on a Service member can also impact his or her children’s sleep. That is, on top of normal pediatric sleep issues, children in military families can face additional challenges to sleeping well.
So, I decided to increase my knowledge in this area by going straight to the source and interviewing a subject matter expert on pediatric behavioral sleep medicine, Dr. Brandy Roane, Ph.D., CBSM. Dr. Roane completed a pediatric psychology internship at the University of Nebraska Medical Center and did her post-doctoral training at the Alpert Medical School of Brown University specializing in sleep. She is currently an assistant professor at the University of North Texas Health Science Center where she conducts a children’s sleep clinic, actively engages in sleep research, and supervises students, and she is certified in behavioral sleep medicine.
DCD: What are the most common contributors to pediatric sleep disturbances in general?
BMR: It really comes down to inconsistency, whether that’s with bedtimes, where the child sleeps, or sleep-related rules/limits. Kids might give off an air that they dislike structure, but most thrive in an environment where routine exists. Bedtime is no different.
DCD: In working with adults in a military context, I often think of obtaining sufficient sleep as a “force enabler”. What is the range for a healthy amount of sleep for children, and what is the benefit of obtaining sufficient sleep in that range?
BMR: There are guideposts for a healthy amount of sleep; for example, over a 24-hour period infants should sleep 16 hours, toddlers 12 ½ hours, school-aged children 11 hours, and teenagers 9 ½ hours, in comparison to adults who need about 8 ½ hours, but of course there are ranges from short to long sleepers. In my clinical practice, I’ve found there’s a mismatch between how much sleep parents may think their kids need and how much they actually do. Kids respond paradoxically to sleep loss versus adults; adults don’t get hyperactive, run around and bounce off the walls when sleep deprived! Because of this “second wind” parents may think their children are not tired or don’t need sleep. However, with insufficient sleep kids become noncompliant, inattentive, emotionally labile, and may stare off into space or take longer to complete tasks. In school-aged kids, grades may drop. In other words, they are likely to not listen when spoken to, refuse to do things they are told to do, and have temper tantrums. Don’t get me wrong, kids who get sufficient sleep are still going to misbehave, but it is much easier to get a kid who has had sufficient sleep back on track than it is for one who hasn’t gotten enough sleep. Additionally, sleep deprivation in children can lead to sleep experiences such as sleep walking or night terrors, although parents may think these are just nightmares.
DCD: In a study of Army spouses with elementary school-aged children whose active duty spouse was currently deployed, 56% reported their child had difficulty sleeping (Flake et al, 2009). Does this surprise you? Why or why not?
BMR: Yes, I’m actually surprised it’s not more! In general, the average pediatrician’s office has anywhere from 30-50% of the children report sleep difficulties. Military families face challenges like deployment and extended time away from the family for the Service member; this is similar to families with a single parent household, where there may be a lack of consistency related to sleep as the parent who is not deployed no longer has someone to back them up, especially at the end of the day when he or she is tired, and may go with what seems easier short-term. The difference in military families is that there is a separation and reintegration period to navigate, and so the rules and who is enforcing them may change, leading to more inconsistency. Additionally, parents’ health impacts kids’ sleep, so if the caretaker parent is anxious or distressed during the deployment cycle, children may develop anxiety manifested around sleep, including fear of the dark, needing multiple nightlights, an elaborate winddown routine, etc.
DCD: What sleep disturbances might you expect to see in young children and teenagers related to a major stressor like a military parent’s deployment?
BMR: Most commonly insomnia pops up, and younger kids will engage in all kinds of behaviors to delay bedtime and develop sleep onset associations. That is, they may want another hug or kiss or may “need” a parent to be present in order to fall asleep. Parents may also see sleep talking, sleep walking, and perhaps bedwetting if the child is getting insufficient sleep, especially if there is a prior history of these behaviors. General stress from the deployment cycle can contribute to these sleep problems. Additionally, keep in mind that the parents are dealing with their own stress and possible sleep problems as well, and children may respond to this example, particularly older children and teenagers.
DCD: What can military parents do to proactively improve their child’s sleep?
BMR: Have a bedtime routine they can follow regardless of whether or not both parents are home. Keep things consistent as much as possible, in general and during deployment and reintegration. Consistency is also important during the day-if parents are flexible with non-sleep related rules, kids may figure they can test sleep rules, too. Parents can also implement a reward schedule during deployment or other periods of stress; even though children are expected to follow the routine, the reward is for sticking to that routine despite the stressful situation.
DCD: What can military parents do when difficulty falling or staying asleep is already occurring for their child?
BMR: For many kids, re-establishing a consistent bedtime and waketime schedule can help with problems. Start by setting up an expectation and then following it through. Think “same bat-time, same bat-channel.” It may take at least a week and there may be an extinction burst, or time when the child escalates to try to return to the old behavior. Parents should expect some push-back as change is not always liked. So, dig-in and stick with the plan! Parents may want to support themselves during this time, set up notes around the house or reminders to stick with it even when the child is fussy,
DCD: What are some sleep-related signs parents should bring their child in to their PCP for further assessment or referral?
BMR: If there are problems that are not behavioral in nature. For example snoring, pauses in breathing, difficulty breathing, obstructed airways, and, in fact, frequent sweating and bed-wetting (or frequent nocturnal urination), may be a sign of obstructive sleep apnea (OSA). OSA may also correspond with partial arousals or difficulty maintaining sleep. Other problematic signs include excessive daytime sleepiness despite sufficient total sleep time. Although it would be rare, further assessment may be needed if insomnia symptoms do not resolve after maintaining a consistent schedule.
DCD: Do you have any suggested readings or resources related to pediatric sleep problems?
BMR: One book that might be useful for parents is a book by Patrick Friman, Ph.D., called “Good Night, Sweet Dreams, I Love You, Now Get Into Bed and Go to Sleep.” This book helps parents with things like a consistent pre-bedtime routine, establishing a consistent sleep location, and other key pieces that can make bedtime easier for the parent and child.
Diana C. Dolan, Ph.D., CBSM is a clinical psychologist serving as an evidence-based psychotherapy trainer with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
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Additional Tips for Parents of Teens
I wanted to add some additional tips Dr. Roane shared for parents of teens. Per Dr. Roane, teenagers are already predisposed to a delayed bedtime, so they benefit from limiting light after bedtime. Especially in today’s technology-heavy environment, where teens are exposed to constant stimulation and “light boxes”-phones, tablets, TVs. Teens can wear sun glasses while playing evening video games, and electronics should be shut off 20-30 minutes prior to bedtime and turned over to parents in a central location outside of the teen’s bedroom (yes, this means they will need to use old-school alarm clocks). Dr. Roane has had teenage patients so attached to their cell phones that they purposely fall asleep holding their phones so that the vibration from an incoming text message or call will wake them up!
Good sleep practices for adults work well with teenagers, too, such as using a fan to block out noise, dark curtains, etc. Teenagers may be at an age where parents have a harder time implementing a routine as they cannot physically force consistency, but setting up expectations, rewards, and consequences can be used.