Is Sleep Quality Causing Your Child’s Behavior & Health Issues?

Episode Transcript

Dr. Nicole Beurkens 

Hi, everyone. Welcome to the show. I am Dr. Nicole, and on today’s episode, we are talking about one of my favorite topics: Sleep. We all know how important sleep is for our health and our functioning. But in my experience, sleep issues are one of the most overlooked and under-appreciated factors when it comes to challenges and symptoms that kids might be experiencing. Whether we are talking about attention, anxiety, mood, learning, behavior, or anything else, the research is really clear that sleep plays a major role for kids. And I have been hoping for a long time that somebody would write a book about this. Not just about how to get kids to sleep, because there are lots of books on that, but why it’s so important, all the ways that can go wrong, and most importantly what we can do to help with these sleep issues in kids. And now, Dr. Chris Winter has written it, and so I am thrilled to have him on the show today to delve into all things sleep with us. Let me tell you a little bit about him.

He is a neurologist and double board-certified sleep specialist who sees children and adults in his sleep clinic. He has been involved in sleep research and science since 1992. In addition to his clinical work, he serves as the sleep specialist for many professional sports organizations, including the 2020 World Series champion Los Angeles Dodgers, yay. He is the author of the critically acclaimed The Sleep Solution: Why Your Sleep Is Broken and How To Fix It, a book that New York Magazine named the best book on insomnia in 2018. He is also the author of the recently released book, The Rested Child: Why Your Tired, Wired or Irritable Child May Have a Sleep Disorder and How To Help. I have been waiting to do this interview. So excited to have you here. Welcome to the show, Dr. Winter. 

 

 

Dr. Chris Winter 

Thank you, Nicole, you can call me Chris, if you like.

 

 

Dr. Nicole Beurkens 

Awesome, so great to have you here. I would love to just start out by having you share with our listeners how you became interested in sleep. I mean, you trained as a physician, but what got you so invested in sleep?

 

 

Dr. Chris Winter 

It was kind of accidental. I was an undergraduate student, I had a plan to become a physician, but I wasn’t really sure exactly what. I was interested in pediatrics, but I was also kind of interested in Surgery and Dermatology, and it’s easy to decide you are going to be a doctor when you have no idea what’s going on. Both of my parents are school teachers, so it’s sort of this idea. And so when I got to the University of Virginia, my advisor said “You should maybe do some research with some doctors and see what they do, and if you do like it, it will give you something to put on your resume or whatever.” And so I started working with this guy named Paul Suratt, he ran the sleep center at the University of Virginia, a wonderful friend and mentor. And I thought, “This is the coolest field!” We were doing sleep research on pigs and doing all these great protocols. So I never really intended it to be a career, but when I went to medical school down at Emory, I started working with the sleep doctors down there, Don Bliwise and Dave Rye, so I just never left the field. It was always like “Well, I will just do this to earn some money for takeout on Friday night, get something to put on my resume. But at some point, I will go on and become this other thing.” And at some point, I was like “I have been in the field for 12 years, am I just going to leave and not do it anymore?” And so it’s a great field full of really, really kind people and encouraging. And I think we all kind of feel like you said, that it’s sort of an ignored thing. And so we all kind of have this shared idea that we have got to get good information out there about sleep and help people kind of figure it out. And it’s probably more true than ever. 

 

 

Dr. Nicole Beurkens 

Oh, I think absolutely. Especially after the last 18 months or so. And I do think it’s one of the things that people don’t —professionals and parents don’t really appreciate enough in terms of the impact that it has on kids. It’s just sort of inherently we know, “Oh, yeah. Sleep is important”. Even adults, so many people are walking around sleep deprived, and going, “oh, I will deal with my sleep at some point.” And I really think we have lost an appreciation for how much sleep does for us, and what the impacts are that we are experiencing, even as adults from not getting good quality sleep, even when I start talking with adults about that. They just sort of think, “Well, this is just how I function/how I feel now.” But I wonder how that would be different if you actually slept at night. I just don’t think that we really appreciate the role that it plays for us. 

 

 

Dr. Chris Winters:

That is absolutely true. I mean, I don’t think that we are particularly good as a collective at identifying things that operate slowly. A migraine or a heart attack gets everybody’s attention and really scares people. But something that quietly eats away at something is sort of a different story. And there are definitely people who don’t really understand what it feels like to feel rested, and we see that in a lot of disorders of people who are excessively sleepy, that if you sort of adjust your baseline to meet where you are at, you don’t really know. I tell people all the time, I don’t think I am missing out on being tall. That has never been something that I have really struggled with. I am a short man. Everybody in my family is much taller than I am, including my wife and my little kids who are now a foot taller than I am, but I don’t think that I am missing out on anything. But if you made me tall for a month, magically, I found some slippers that I put on my foot, and maybe 6’6” for a month, I may never want to go back. “This is the best thing! People take me seriously, I can reach things on the highest shelf! This is awesome!” So, I think it’s dangerous to make assumptions about things when you are kind of in the middle of it, and you don’t really know. And that is one of the rewarding things about being a sleep physician, is that the patients we treat come back and say, “I had no idea”. I keep a little folder of letters I have gotten from parents and teachers. “Ever since this thing happened with this child, he or she is a different student.” And one of my favorite things that was not put into the book was a young woman sent me a letter and a transcript from her college experience and she had annotated, “This is where I met you, this is where you tried this treatment, this is where you did this.” And all through the transcript, her grades just kept getting better and better to the point where she is making straight A’s. And she said, “I don’t think I would have graduated, had I not found you. And I would have always assumed that this thing that I was dealing with, which was a treatable sleep disorder, was just kind of how I am built.” That is really disappointing and sad.

 

 

Dr. Nicole Beurkens 

I think there are so many people who think that. When I do intake appointments with parents and kids, I’ll ask a lot of questions about sleep. And I learned early on in my career that I had to get really specific because when you just say, “Well, how does your child sleep?” People go “Oh, you know, fine.” Or when you ask adults, “How do you sleep?” “Oh, you know, I sleep okay.” And then when you start getting into it and saying, “Well, tell me more about that. How long does it take you to fall asleep? Do you stay asleep? How long do you sleep?” Suddenly, you are going “Oh my gosh, you think this is fine. But actually, I don’t think you have had a decent night’s sleep or your child hasn’t had a decent night’s sleep in their entire life.” And there just isn’t awareness around the fact that that is even happening.

 

 

Dr. Chris Winter 

And it’s strange for as much as we to participate in things like sleeping or sex, we don’t talk about it. There is no sort of dialogue about that. So to your point, somebody sits down and starts telling you that they are good sleepers, I guess. And then when you start asking questions, you are thinking to yourself, “You are an awful sleeper.” But it’s sort of you don’t really know, because you don’t go to the dinner party, “How’s everybody sleeping lately? What’s your efficiency? How long is it taking you all to fall asleep? Mine’s gotten a lot better over the last….”, you don’t talk about that. It’s what your kids are doing, and how your job is, and I don’t know what you talk about, but nobody really talks about that. So, culturally, having dialogues like this that people are interested in, hopefully kind of bleeds into the culture where we start to kind of identify if somebody said, “I am doing just fine, I just got blood coming out of my ear. Just a little bit. It ruins a shirt a week”, you would say, “Whoa, that is that is so abnormal. You shouldn’t just accept that. Let’s take a look at that and figure out somebody who can help you with that.” But the sleep thing, we have not gotten to that level yet of helping people recognize what might be outside of that bell curve distribution, I think.

 

 

Dr. Nicole Beurkens 

Yeah, I think it’s true in our professional realms, as well as just in popular culture as well, which is why I am so passionate about getting this information, having these conversations so that parents can be aware because to me, when we look at the hierarchy of interventions or things that we can use for kids who are having behavioral struggles, learning challenges, whatever it might be, sleep is the low hanging fruit. Where if we identify that there is a sleep problem or a sleep disorder going on and we can tangibly address that, it can often, as you mentioned, completely change the trajectory of their symptoms of their life without banging our head against the wall doing a whole bunch of other interventions that probably aren’t going to get the best results because we didn’t address this foundational piece of this as a child who is not getting enough good quality sleep at night.

 

 

Dr. Chris Winter 

Yeah, I always thought about that during my neurology training. Neurologists are sort of notorious for thinking about things a lot, but not really doing much. Let’s think about this stroke that we can’t really help you with, but man, it’s fascinating because it hit this one blood vessel and these nerves were affected, but not these. We can map it out to this great new way. So to me, it was always like this big funnel. You think, think, think, think, think but it always comes down to about five different medications and three different interventional studies. MRI, CT, angiogram, some anticonvulsant, some anti-seizure med, whatever. So it doesn’t matter what all happened down here, it’s all about what are you going to do for this person? And sleep is something that you can do a lot for people, and like you said, it’s usually pretty low down. We are not going to have to open anybody up and stitch them back together. These are things that are pretty accessible to people. And when you sort of map out ease of intervention and potential benefit, it’s the best of both. It’s easy and can make massive improvements in terms of health. And then it also kind of lends itself to a more appropriate view that person has of themselves. So as somebody gets to treat adults and kids, we get to see the adults that didn’t have their sleep problems managed properly when they were little, and just how it not only just kind of festers in and of itself, but becomes kind of part of that person. “Oh, I am just I am just not good at school.” “Why do you say that?” “Well, I had to drop out my second year, I just was making terrible grades.” Well, it looks to me you were making terrible grades, because you couldn’t stay awake during your classes, not that you were a bad college student. So you have kind of created this identity for yourself that is not a true identity. You are an intelligent, capable person. You have got a disability, though, that makes it difficult for you to make it through a day like everybody else in the class, and just be awake, and take in information, and remember it for a test. So it’s always interesting to deal with adults and fix their problems and see this sort of identity crisis that kind of happens, “Oh, I always thought I was this thing, but maybe I am actually this other thing”, which is really tragic sometimes.

 

 

Dr. Nicole Beurkens 

Absolutely. I think that highlights the importance of looking at and addressing these things when kids are young, so that they kind of prevent them from having decades of their lifespan thinking that they are just X, Y, or Z when in fact they have an undiagnosed untreated sleep issue that is impacting them. I want to talk about what we really mean when we say kids are having sleep problems. What’s the difference between just maybe a sleep issue that we don’t need to be concerned about, versus a sleep disorder? How prevalent are these things when we look at all kids across the board? How often do kids have these issues? Let’s kind of delve into some of that.

 

 

Dr. Chris Winter 

So I will go backwards. They are massively prevalent. I mean, it’s estimated that two out of three kids will have a sleep disorder by the time they go off to college or those years. So that is 66-67% of people. Let’s cut it in half and say that is an overestimation. We will call it 33%. I mean, we consider obesity an epidemic and it’s 18-19%. I think diabetes is 0.25%, depression 4-5%, ADHD 9%, maybe 10%. So the scale of this problem is huge. And I don’t think it’s a big shock to people. I mean, I have three children. They don’t have diabetes, but they have all struggled with their sleep at some point. I think it would be strange to run into a parent of two kids who said they slept perfectly since they were born and never had any struggles. “Wow, you are the outlier. It’s the only person with no sleep problems. Good for you. Don’t talk a lot about it to your friends because they will hate you. So just keep that to yourself or make something up for God’s sake, and move on.” So they are very prevalent disorders, but the problem becomes — I think earlier before we started recording, you used the word dark ages or a dark place in terms of our professions and sleep, and I believe that deeply that there is not a lot of education about sleep. I was fascinated about sleep. I was doing sleep research when I was an undergrad. When I got to medical school, we got one lecture on sleep. That was it. Four years, one lecture. So you think, okay, well, I guess sleep is not something we are going to really see as doctors. And when you look at adult doctors and kid doctors, these are some of the most common complaints that doctors see. I mean for adults, two out of seven patients will have some sort of sleep problem: Can’t fall asleep or too sleepy during the day and can’t stay awake. And kids are absolutely no different, they just look differently sometimes. Lids don’t do that thing where they are kind of nodding off in class all the time. They can actually look quite un-sleepy. I don’t have to tell you as somebody who works in the mental health space, that is where kids sort of present in terms of it’s a manifestation of anxiety or concentration problems or depression. And that can be mistakenly diagnosed as depression or kind of a real reactive depression. “I want to go out with my friends, I want to go to see movies, I want to do well in school, but I am so sleepy that what I really want to do more than all that is go home and take a nap.” And it’s depressing, “You should come yesterday! We watched all the matrix movies, one after the other, it was so much fun, everybody came!” and you wanted to come, but in the moment you thought, “Oh, I’m really just too tired, I am just going to go take nap.” Then your grades are not good. And so it’s amazing how we kind of turned our eye on that. It’s been estimated that pediatrician say that on average, they have gotten about four hours of training on sleep in their programs, with about a quarter of them never having any training. In fact, I was doing a radio interview on Sirius XM with the head of pediatrics for a big east coast hospital, and he made some comment about melatonin. And I said, “Oh God, if somebody says melatonin gummy bear, I am going to leave this broadcast.” I made some joke about it. And he said, “Oh, I guess I guess my residents aren’t going to like to hear that.” He said, “That is pretty much their go-to for any sleep problem.” I said, “Do people know what they are doing with it?” He said, “Probably not. But it’s harmless. It’s not going to hurt anybody.” So you got a parent saying “My kid won’t sleep”, melatonin gummy bear. So at least you have done something even though you really haven’t done much of anything. And maybe you have done harm in terms of putting ideas in somebody’s head that you need chemicals to sleep, not really figuring out what the problem is and what we are dealing with here?

 

 

Dr. Nicole Beurkens 

It’s so true. And that mirrors my experience, both personally with my own four kids, as well as professionally working with so many kids. And I find that when parents do bring sleep concerns up, usually it’s around behavioral issues with sleep, right? “My kid won’t go to bed” or whatever. And so they are given some basic parenting strategies around that. But the focus tends to be on, “Well, is your kid going to bed when you want them to? And getting up?”, as opposed to really digging into “Maybe your child is in bed for the right number of hours a night, but the quality of their sleep is terrible.” Those are the kinds of conversations that when I start digging into that and talking with parents about that, they are like, “Oh, my gosh, nobody ever asked that/I never thought about that/I am not sure.” And sometimes I will even ask the kid a question during the session about, “Okay, so your parents are putting you to bed at 8:30 or 9:00. How long before you fall asleep? And they will be like, “oh, I look at the clock until it’s 11 or midnight”, or they will say, “Oh, no, I am up for three hours in the middle of the night.” And the parents are going, “What? I had no idea.” And the kid just thinks, “Well, this is what it is, this is always how I have slept. Is that a problem?” And so I think the importance of having this conversation around what it means for a kid to be getting good sleep, what we want that to look like, and then how do we know when something has sort of veered off the path? So let’s go to this piece of: What should our kids’ sleep look like? And obviously we can talk about little ones versus teens and young adults. But how do we know? What does it mean for our child to have good, quality, restful sleep?

 

 

Dr. Chris Winter 

Yeah. You bring up a lot of points there. I mean, people come to our clinic, not because they can’t sleep. It doesn’t exist in nature. Can’t sleep is not a real thing. What they come for is because their sleep is inefficient and unpredictable, either to themselves or to their parents. What’s going to happen when you go to bed at night? If somebody asked me, I am going to bed around 11:30, I am going to fall asleep pretty quickly. And if I don’t, I really don’t care. I like being in bed awake. It’s lovely, frankly, in my experience. So a lot of times, like you said, it’s some sort of expectation that we have of our kid. Like you said, your kid goes to bed every night at 8:30, and it takes them two hours to fall asleep. How was 8:30 decided upon as the bedtime? Where did that come from? And it’s amazing the looks you get, “I don’t know”. And to your point, a lot of times it’s “Well, Dad or Mom have got things to do at 8:30, so we need the kids to go to bed at 8:30 so we can have some time and do our own thing. So I think what quality sleep looks like is kind of as memorable as brushing your teeth. To me, if you said, “Is this good, brushing your teeth?” “Look I don’t know, I just do it, and then I don’t get cavities.” It’s almost forgotten. And to me, that is what sleep should be. It shouldn’t be a huge topic of concern, and consternation, and stress, and anxiety. It’s “How do your kids sleep?” “I don’t know, they go to bed, and then when we check on them, they are pretty much asleep and well adjusted, and doing well in their lives and healthy” That to me is kind of how it looks. And you can get more detailed about it: Are they able to stay awake in class? How is their behavior and their school performance? Do you find them to be relatively easy to get along with, or do they struggle with things like anxiety, depression, and their attention? Whether or not at night they have unusual behaviors. Do they talk in their sleep, walk and go places when you wake them up? Do they destroy their bed and they are turned all around? So there are all kinds of things to look for. 

I think that quality sleep basically is a time period that is not always eight hours, that allows us to give our bodies the regeneration and the recovery that we need to do well the next day and into the future. And there are all kinds of ways that we can monitor that. You can do sleep studies, but there are all kinds of technology that people wear. It’s really opened up all kinds of windows if you have the right question, meaning that, “My kid doesn’t sleep well, so we bought him this thing, and he is still not sleeping well.” What did you think this was going to do? Zap his brain? But you see, a lot of times people have questions, “We spent a night in a hotel room with our son, and he was just so restless, that we bought this and we realized that was kind of a one off. I think the bed was hot or, “Oh my gosh, his results are so different from the other kids who wore it for a couple of weeks, we think there is something going on. And he has not been feeling great. He is often very irritable, his grades have dropped a little bit.” That is what we want to be on top of.

 

 

Dr. Nicole Beurkens 

Yeah, absolutely. So let’s give people some clear things like what do you feel are clear red flags? You sort of alluded to some of them, restlessness, and those kinds of things. But for parents who are listening to this and realizing, perhaps for the first time, “Wow, I think maybe my kid isn’t sleeping well. Maybe sleep is a piece of all of the challenges that we are dealing with.” What are some of those key things that they should be looking for or thinking about that would indicate that maybe my child does have a sleep disorder?”

 

 

Dr. Chris Winter 

Sure. So I think that at any point, health issues, chronic health issues, my kid is always sick, my kid doesn’t feel well, my kid gets a lot of headaches. My kid is not growing. He was growing on that little growth chart at the pediatrician’s office, and all of a sudden, he has been kind of dropping off that. I think in any situation like that, it is fair game to say to the provider, “What do you think about a sleep disorder that can be kind of hiding in there?”, and I think the good provider would be like, “That is a good thought. I don’t think that patients ever brought something up to me that is within the realm of reality that has been like, “Oh, I have got a headache, I would like to get an MRI.” “Well, if you want to, we can talk about that. But if that would make you feel better.” So I always think that we need to listen to parents when they have these ideas about stuff. So to me, the other thing that you would look for is behavioral changes. That is a big one with kids. Defiance, irritability, fighting, arguing, I mean, kids do these kinds of things, I am sure. But a lot of times sleepiness can kind of really affect their ability to have patience and attend to things. I think that school performance, grades are another big indication that kids are struggling with their sleep. And then just listening to kids. I mean, a lot of kids have tremendous anxiety about their sleep. The flip side? The wonderful thing about there being so much attention for sleep right now. Tom Brady tweets out, “Sleep is the biggest part of me getting ready for a season”, or LeBron James says, “I don’t ever sleep less than eight hours. I believe in myself too much to ever sacrifice my sleep.” I mean, these kinds of luminaries are doing more work than I will ever do in my career to sort of highlight the importance of sleep, and kids are paying attention to it. And so there is a bit of performance anxiety that goes along with it. So if you have got a child who is saying, “I am struggling to fall asleep, or I wake up and I can’t get back to sleep.” Now I talk a lot about this in the book. The way we deal with those problems is very important. I think that some of that is completely normal. It’s like how do you deal with your kid when he doesn’t want to eat the second half of his sandwich that you pack for lunch?” I don’t think there is anything really to deal with right there. I don’t necessarily consider that to be a medical problem. Now, everyday can’t eat lunch and he doesn’t eat much breakfast, and he is losing weight? That is different. But last Tuesday, for some reason, he didn’t finish his sandwich? I wouldn’t call the doctor about that. And so we have to give our kids a sense that sleep works. It’s going to be there for you. But there is a natural variation. If you have got something on your mind, it might take you a little while to fall asleep. And that is a norm we want to embrace rather than be scared of, because really, at the root of a lot of kids’ sleep problems, which often are a result of some sort of parent anxieties, is a fear. There is something going on that we have got to deal with. 

Now, I think that it’s important too, that technology and pieces that we can control, are controlled. So this idea that your kid can’t sleep and the only thing that allows him to sleep is to play some Minecraft in his bed, I think we have to be a little bit better than that, but I do think there are a lot of obstacles. The other thing to be careful of is hypersomnolence. The kids who sleep great, they go to bed, they fall asleep in five seconds, they take wonderful naps, they fall asleep in school. The flipside that we never talked about in the media are people who are excessively sleepy, because on the surface, they look great sleepers. Yeah, my son, it takes him an hour or two to fall asleep every night, he is always complaining about it to my daughter, she is asleep before her head hits the pillow. That can be healthier, that can actually be a sign that she is looking for more sleep than she can get. And so those are the ones that often hide in plain sight. So if you have got a child that you think seems sleepier than they should, comes home from school and takes a two hour nap, does a little bit of homework, eats something, goes right back to sleep, sleeps entire weekends away, nods off in school, pay attention to that. Sometimes schools are not particularly kind to those kids. It’s viewed as sort of a flaw, like they are staying up late, they are not taking care of themselves. And so if you get any kind of reports of those types of things, I would definitely take those seriously.

 

 

Dr. Nicole Beurkens 

Great, and I think you made the important point that often fatigue or under sleeping looks very counterintuitive to us as adults, because we associate not getting enough sleep with dragging, with being tired. And actually, in kids, that can look like wired, hyperactive, very, very active and busy. And so parents will say, “Well, they can’t help it. They have way too much energy.” But actually, the opposite is true, so I think that is so important that you raised that. I am wondering about some red flags. Things like snoring, for example, or some signs of apnea. What are some of those things that parents should be just kind of watching for?

 

 

Dr. Chris Winter 

Yeah, snoring is definitely a red flag, particularly in a kid. Kids’ airways are young and sort of tight, and they don’t have that sort of laxity that adults do. So kids can have some significant breathing disturbances and not really make a lot of noise. So a lot of times these things come about because you have shared a room with somebody at Grandma’s house or something and everybody knows that, “Wow, he or she really snores a lot.” Even not snoring a lot, but noticing that there seem to be little breathing interruptions that are causing little awakenings, little movements, maybe your child is not even aware of it, I think could be brought to a doctor’s attention. And there are very easy ways for us to look at the breathing of children, and lots of easy interventions in terms of having kids who are struggling with their breathing. So sleep apnea, very common in adults, but definitely we see it in kids. Kids who move a lot or are restless, they sometimes will tell you that, sometimes it presents as growing pains. “Mom, I need to rub my legs before I go to bed every night.” They will have these kinds of ritualized things like rubbing their legs or stretching their legs and where they want heaviness on their legs. Weighted blankets sometimes are very popular with these populations of people. So there are a couple of classifications, including a new one, where kids just have more restless sleep than what’s considered to be normal. Teeth grinding and acid reflux are two things that are very common. Kids who wake up with damaged teeth or bad breath, and when they go to the dentist, the dentist is saying you look like you have some signs of teeth grinding or reflux, we might be concerned about that. You have kids with big tonsils that can interfere with those types of things as well too. Nightmares, sleepwalking, sleep, talking, sleep eating. Any kind of behavior is sort of fair game if your kid is doing it at night and either not having recollections of it or having recollections of it are very important clues as to what might be going on. And then like I said, hypersomnia. Excessively sleepy. A kid who falls asleep when his sister is opening presents on Christmas. You’re thinking wow, right? A major league baseball player’s mother tells me when he was in high school, he would sleep in the dugout between innings. And then we would just wake him up to go back out in the field. And so not only is that fascinating, but did anybody think that was something that might want to be looked into? You know sleep is sleep, it’s not it’s not a seizure kind of thing. And that is sort of the attitude that a lot of people have about that. So anything that you are seeing that sort of distressing like that or that you are noticing as a parent, again, just bring it up to your doctor and have it on people’s radar that if this thing is not getting better, and it seems to be going along with other struggles, that more intervention could be determined.

 

 

Dr. Nicole Beurkens 

That is great. And you were talking about the statistics, which actually are higher than I even thought, but it matches with my clinical experience of two out of three kids having issues. And I think that I have read in research on this, but you can correct me, that kids who have neurodevelopmental disorders, kids on the autism spectrum, kids with true ADHD, with those kinds of things, even within those populations, we see an even higher prevalence of disordered sleep. Am I right about that?

 

 

Dr. Chris Winter 

Absolutely. Yeah. And there are so many different mechanisms there. We see a lot of individuals with Down Syndrome, they have much larger tongues sometimes, and much shorter palates. So their tongue can often obstruct breathing, so sleep apnea is very common in that population. Behavioral, autism spectrum, these individuals often seem to require slightly less sleep than their counterparts without or not on the spectrum, which is this sort of double whammy. These are sometimes very difficult kids to teach and parent during the day, so naturally, the parent would be like, “I just want a little bit of a break and have them asleep so that I can get caught up on some things I need to, because they demand so much of me.” And it’s difficult when those kids are getting up at 4:45 in the morning and demanding pancakes or whatever they want in the morning for breakfast, and you are like, “How are you not sleeping enough?” So talk about dark ages, the medical community is not equipped to deal with the sleep of your special needs child. And when I wrote the book, and these are kids we see a lot, I really wanted it to be very evidence-based. Obviously, I have to put some experiences in there, and I try to be very clear: This is what I think, and this is what science would say. There is so little science about these kids. It’s like they are not even worth investigating. So it’s a very difficult space for parents to be in, trying to get good information about the sleep of their special young child, and it’s just not existent.

 

 

Dr. Nicole Beurkens 

Yeah, and I think there are so many parents listening who can relate to that, who even raise these concerns, only to be dismissed or to be told, “Yeah, give him some melatonin, give him a gummy, see if that helps.” And it’s so frustrating because the kids are struggling and the parents are struggling, and we can and should be doing better by these kids in these families when it comes to a whole lot of things, but especially with what we are talking about with sleep. So I would love to move into — Okay, parents are now aware like, “Hmm, I never put the pieces together before, and I am hearing you talking, I am thinking that sleep is really something that we haven’t looked at and need for my child.” What is sort of the progression of how to look into that? Right. So are you bringing the concern to the primary care? What should parents do if they are wondering about sleep and their kid?

 

 

Dr. Chris Winter 

I have thought a lot about this. I think what you said, and I am glad you used the word a minute ago, dismissed. I am not sure that there is any field of medicine that dismisses more people than things around sleep, both for adults and kids too. And I hate that. Anyway, our soapbox. But to me, in terms of what you do, I think that the dismissive word is important because depending upon the relationship that you have with your primary care provider, your child’s primary care provider, this can be real positive. And I can think about the referral region that I am in, just the absolute all-star pediatricians and primary care doctors that are thinking about stuff about sleep that probably I might not. “Oh this kid doesn’t have sleep problems”, then you realize, “Oh, they did. Wow, that was so good.” Dr. Smyth. I will give her a shout-out. She is on my radar. She is on top of the sleep of her kids. I have no idea what she is like as a person, or as a business manager, or as a pediatrician, but by God, if you have got a sleep problem in her clinic, she is going to sniff it out. And I always tell providers when I lecture to other doctors or pediatricians: If every kid that you send off has a sleep problem, you are missing a tie. So don’t be afraid to send somebody out for an evaluation and have them come back and say no, their sleep is wonderful. It’s a great thing for a parent to know that, “Hey, I am not sure what’s going on, why your kid is so fatigued during the day, but their sleep is gorgeous.” So to me, I think it does start with your primary care doctor. And then if it’s the pat on the head, every kid wets the bed, which in your research drives me crazy too. At what point do we get to say, “Okay, my kid is in calculus, he is still wetting the bed. Can we do something about it now?” So at what point can we not be sort of dismissive? It’s fine to look at, okay, well, we will keep it on the record here, and then in three months from now, if you still feel there is a problem, we are going to address it. If that is okay with you, as a parent, that is fine. I ask patients all the time: “I don’t think you need a sleep study. Do you want one? I don’t want to dismiss you if you are certain that your kid needs a sleep study, we can do it.” It may not be the step that I would take at this point, but I want to make sure I am listening to the parents as well, too. And we are doing things that are not only appropriate, but are sort of meeting their expectations. If you feel like you are always being dismissed about that or nothing is being done, I think you just do it yourself. You say, “Hey, I appreciate you not wanting to do that right now, but I would really like to see a sleep specialist. I know we have a great one across town, would you mind setting up a referral for that?” I think if a doctor says, “No”, I would get another doctor. Not to be too blunt about it. I mean, it’s like a patient who says, “I demand an MRI.” I am not going out on a limb to say no to a brain MRI because I have been wrong before, where the MRI comes back, and I am like “Oh, this isn’t a normal MRI.” So I can tell you, I don’t think the odds are that it’s going to be, but in the end of the day, it’s your life, it’s your body, it’s your health, and we should be supporting these things, as long as you understand the risks and benefits of the things we talked about. So to me asking for a sleep referral when you have got a concern about your child is, to use your phrase, it’s low hanging fruit. And why would a doctor argue against that? That doesn’t make any sense, but I hear it all the time. Parents say, “I had to fight for this referral.”

 

 

Dr. Nicole Beurkens 

Yeah, I see that all the time and having to step in on behalf of families and use the letters behind my name to demand that it happen or make the referral myself, and it’s just really frustrating because, yeah, I mean, if a parent is concerned about it and the child is exhibiting symptoms, even if you don’t think that sleep is the problem, why not check the box and say “We looked at it, this isn’t the issue. Now we can move on to the 18 other things that might be going on,” right? 

 

 

Dr. Chris Winter 

And in my book, I put a cause of fatigue for every letter of the alphabet. So we have ruled out sleep. I mean, I tell people all the time that I have never done a sleep study or done a sleep evaluation that I regretted, because it’s going to either show something that we can maybe fix or it’s going to be normal, which is a box checked. I am sure with mental health it’s 10 times worse, but it’s so — we have got a kid who is interested in talking to somebody about their sleep, the parents are interested. There shouldn’t be a lot of roadblocks to that.

 

 

Dr. Nicole Beurkens 

So if the physician or primary care provider doesn’t initiate saying, “Oh, yeah, let’s get this going.” And the parent is in the situation of needing to request it themselves, you are saying “Request to be referred to a sleep specialist.” Can you talk for a moment about who sleep specialists are? Are there pediatric ones? Just to give people an idea of who they are looking forward to seeing?

 

 

Dr. Chris Winter 

Yeah, so this is really a great thread of conversation because that can mean a lot of things. And so to me, that specialist can be one of many things. I talk about this towards the end of the book. Generally what we are talking about are MDs or in some cases PhDs that have some special designation in sleep. So a lot of people are surprised to find out that there is a medical — you can be a knee surgeon, you can be somebody who does reconstructive breast surgeries, or you could be a sleep doctor. These are all pathways once you walk out of medical school. One of my mentors, Don Bliwise, at Emory, was a PhD. So he was not an MD, and that comes with that they can prescribe things, and that is all state specific, we all work together, it’s not that big of a deal. But you do want somebody with sort of a specialized training there. You can sometimes run into some difficulties in terms of sleep coaches, sleep experts, sleep specialists. They mean a lot of different things. I am sure there are people out there read a lot of books about sleep and probably know more than I do, that have no degree behind their name. But when you are dealing with your kid and trying to get care for them related to a sleep problem, you probably want some sort of clinical sleep specialist with, like you said, letters at the end of their name. So in the United States, where the American Board of Sleep Medicine is now defunct, there are a lot of older doctors who have that designation, which is perfectly fine. I actually have it because I got that designation as it was going out, and the new board was coming in, which is the whole reason for the double board-certified sleep doctors, it’s kind of a joke. Sounds great, doesn’t it? I always joke with my colleagues that I really take good care of my body and my health, because I want to outlive them all and be the only double board-certified sleep doctor at some point, where I am like 82 years old. Me and this other woman, we are going to wait around to see who dies first. The last of the double board-certified! But yeah, this can be a neurologist, which I am, they can be pulmonary doctors, pediatricians, psychiatrists. And we all do things well, so I am decent at the neurology stuff. Maybe monitoring a complicated CPAP for a ventilator kind of situation might be a better pulmonary thing. If your child has a lot of asthma and a lot of coughing at night that keeps them up, a pediatric pulmonary sleep doctor could be awesome for your child. So to me, there are a lot of us out there, the American Academy of Sleep Medicine has a list. You can look up your state or your city and see who are the board-certified doctors in your area, what their specialties are, and you may need to go in there sort of equipped with that information. I can promise you, if you read my book, you will probably know more about pediatric sleep than the doctor you are talking about. That is not a knock on them, it’s just that they can’t know everything about everything, and sleep, like you said, is just kind of low down sometimes on the list there. So you may have to fight a little bit for it, but those resources are definitely out there.

 

 

Dr. Nicole Beurkens 

And once someone gets to a sleep specialist, just to give a little bit of a sense of — I think sometimes people think that the response is going to be, “Well, we will do some sort of sleep study, or well, we will take some medication.” I want to give people a sense of the breadth and depth of options because I think sometimes people make assumptions about what’s going to be recommended or what the scope of options is. And really, there are so many things that we can look at and do.

 

 

Dr. Chris Winter 

Absolutely, that is a great question. So first and foremost, seeing a sleep specialist does not necessarily mean you are going to have a sleep study. And if you don’t want to sleep study, or your kid doesn’t want a sleep study, you are not going to have one. This is always going to be your choice. To me, the bread and butter of seeing a sleep specialist is sitting down with them and spending that half hour diving into their sleep. I think it’s perfectly fine for a pediatrician not to want to deal with sleep, as long as he or she has a plan for the people that they think have a sleep problem. So “Listen, I am not a sleep specialist. I have to see a patient every seven minutes to keep the lights on around here, I am just going to send you to Chris.” Great. I would actually prefer that. You don’t want me delivering your babies, I don’t want you dealing with the sleep of our patients. Cool, you do your thing, I will do my thing. I think patients will benefit from it. So sleep studies are fine. They are often necessary to figure certain things out about sleep. They are generally very easy studies, kids usually like them, but there is a lot of anxiety about them. So one of the questions I always ask patients if we are kind of going down that pathway of thinking a sleep study might be necessary as a way to actually critically evaluate sleep and see what might be wrong with “Why does your child wake up? Why does your child wet the bed every night? There might be something going on there.” If a parent says “You have described me coming into this Hilton Hotel,” which is where our sleep center is, “and a technician taping some little wires to my child’s head, I think my kid would freak out and he would just not like that”, then we work around that. This may not be the time to do that. So, to me, parents have a tremendous amount of influence there. But most kids who do it are just lovely. And we have techs that are really good with kids, they hook their stuffed animals up for the sleep study too and all that good stuff. And so I think that all these things are sort of on the table. And then to your point, medications are too, but I always find that it’s important for individuals to understand, not just in sleep medicine, but medicine in general: You are taking four medications, what are they doing?” And the answer, “This is for sleep” is not an answer. This is like saying, “This is for heart.” What do you mean heart? You got heart failure? Or do you have high blood pressure? Or you are prone to have heart attack, angina symptoms, and you take some at night?” So we always want to be clear about “We are giving your child this medication because he is moving his legs 4-700 times a night, which is not intrinsically dangerous in any way. But every time he moves his leg, his brain wakes up, and that is why he is so tired and irritable during the day. Let’s try the medication for a period of time, see if it works. If it does great, if it doesn’t, we will do something else.” Narcolepsy, a condition where you are so sleepy during the day. I mean, these medications change lives every day. Parents say things like, “You have given me my son back.” They will literally break down talking about it. I mean, I am getting chills thinking about some of the stories we have had, we have had fathers break down and say, “I have been so hard on my son because I just felt he was lazy, I had no idea this was a medical condition. I am just a terrible person for doing this.” But they are not. We all learn these things together. So those medications can be absolutely life changing. If your kid has a breathing disturbance, some sort of surgery, a little oral appliance like a retainer or in some cases, a CPAP like an adult might wear, it can allow them to breathe properly and not wake up because they are suffocating all through the night. And a lot of those things are temporary. Several years down the line, they may not need that anymore, based upon some interventions or just natural growth. So there are all kinds of things that can be done, but we always want a parent to walk out, or parents to walk out understanding exactly what it is that is wrong with their child’s sleep, and not some sort of generic, “Well my kid can’t sleep so he takes melatonin gummy bears at night.” Something a lot more specific and real.

 

 

Dr. Nicole Beurkens 

Yes, for sure. And I think even in the realm of education about sleep hygiene, the role of screens, and all of those things are things that people within your specialty area are exploring and talking about, and so just for parents to understand that sometimes it’s pretty basic stuff that can make a big difference, and by seeing a sleep specialist, all of those things are going to be explored, and you are going to get education and help around.

 

 

Dr. Chris Winter 

The kids pay attention to it, too. I always tell parents when I am speaking, it’s okay for me to be the bad guy. I mean, some of the time, getting the technology out of a kid’s room is tough. And it’s tough for us. So it’s not just those parents, I find it too. So it’s okay. Your kids, when they are talking to the sleep doctor with the Los Angeles Dodgers World Series sign thing on the wall, it’s like, oh my gosh, yeah, I take care of their sleep. And a lot of those guys have a lot of trouble with technology because they go out there and pitch badly, and the entire world has something to say about it. So you are not the only one. So we can sometimes help out. I am always amazed by how kids respond to seeing the sleep doctor sometimes. I remember one time a little girl came in because she would always get up in the middle of the night and wake her parents up every night. And I just asked her, “Why do you do that?” And she just kind of looked at me like, “I don’t know”. “Don’t you think it’s kind of hard on your parents? I mean, do you think they can do anything about the fact that you have woken up and now you have woken them up?” And she started to cry a little bit, but it was just interesting that nobody ever really engaged with her about it outside of “Stop doing this!”, and the parents were kind of behind her like, “Oh my gosh, she is really listening and talking about this, because we can’t…”, and things got better very quickly. So a lot of times, it’s not lost on the kids that they are seeing a sleep specialist and they are having some of their problems validated, like when they see you, and you can say “Listen, you are not the only one who is struggling with anxiety right now. I am. Everybody I know is and everybody you go to school with is too, whether they are talking to you about it or not, so this is not unusual. I mean, do we adults wet the bed? It’s not that big a deal. I mean, if you are trying to impress me with bedwetting, it’s not going to happen around here. We see it all the time. You are not alone.” So I mean sometimes kind of validating what’s going on with them makes them feel better that somebody who really has some sort of degree of expertise might be able to help them. It’s comforting.

 

 

Dr. Nicole Beurkens 

Yeah, for parents, too, for sure. There are so many more things that we could talk about around this, but we are going to have to wrap up. There is so much more that is addressed and answered in the book, so I want to make sure that we tell people where they can find out more about you and the work you are doing, and about the book because I really want every person listening to this to get this book.

 

 

Dr. Chris Winter 

Sure. That’s kind of you. So you can find the book wherever books are sold on Amazon, it’s The Rested Child: Why Your Tired, Wired or Irritable Child May Have a Sleep Disorder and How To Help. So it’s in hardback now, Kindle, and Audible. My previous book, The Sleep Solution is available in the same place. I do have a web page, it’s wchriswinter.com. And then my Twitter and Instagram, which I really try to put good sleep content on those platforms is @drchriswinter on both of those things. So find me, DM me, tell me what’s going on with your kid’s sleep, and we will figure out what we can do about it.

 

 

Dr. Nicole Beurkens 

Awesome. And you do put great content out. We will put all of those links in the show notes so that people can access those. I really appreciate you taking time out of your busy schedule to have this conversation today, to share what really can be life-changing information for kids and families, and so I very much appreciate you being here.

 

 

Dr. Chris Winter 

Oh, Nicole, I appreciate your platform and your planning. You clearly thought a lot about what you were going to talk about today because I am sure you probably see it all the time. So I really appreciate your time and getting the word out. I think it’s an important book. I think the world could have lived without my first book, but this book kind of didn’t really exist. In fact, when I was talking to my publisher about it, they were like, “Oh, another book about kids and sleep?” I said, “What are you talking about? Are you talking about how to get your baby to sleep through the night? That is not really a book about kids and sleep.” When your kid graduates away from clothing that snaps in the crotch, your sleep problems are just starting. It’s not, “We are done. We got him on a nap schedule. So we are going to just take the next 18 years off and celebrate!” It’s where the real stuff begins, I think.

 

 

Dr. Nicole Beurkens 

I agree. This is for the rest of those years for sure. So thank you again, and thanks as always, to all of you for being here, for listening, for being part of this community. I look forward to catching you back here next time.