Our Son Doesn’t Sleep Well, It’s Affecting His Behavior At School And At Home

Episode Transcript

Dr. Nicole Beurkens: 

Hi everyone, welcome to the show, I am Dr. Nicole, and on today’s episode, I am answering a question from a listener. I get so many questions each week, and this is a great way to provide answers that many of you might find helpful. If you have a question you’d like me to consider answering on a future episode, email it to support@drbeurkens.com and you just might hear it on an upcoming show. 

Now, onto today’s question. This question comes from Travis and Mandy, and they write: 

“Our son is 9 years old and has never slept well, even since he was a baby. He has always been very active, tends to overreact to even small things and is irritable most days. Since he has been in school, we’ve had concerns raised by his teachers every year about his difficulty with staying still, focusing, being impulsive and getting his work done. 

We definitely see these things at home when we try to get him to do homework or focus on things he doesn’t want to do. We’re trying to get him to bed on time but he really struggles to fall asleep and then comes out of his room a lot. 

He wants to get in bed with us, which we let him do most of the time so we can get some sleep. We’ve noticed that he moves around a ton during the night and we’re constantly getting kicked. 

He wakes up grouchy most mornings and it’s really hard to get him going. 

Our pediatrician and some family members have suggested that he probably has ADHD and maybe some other kinds of behavioral issues and should be evaluated, but I can’t help but think that his bad sleep might have something to do with these problems. We’d love any insights you have on this. Thanks. Travis and Mandy.”

Well, this is a great question. Lots of things to delve into here and the key point that I want to make right out of the gate is that sleep is absolutely very connected to brain function and behavior in children. This is even more so for adults. Obviously sleep quality and sleep quantity are important for all of us, no matter what the age, but for kids, it’s especially important. They need more sleep than we do as adults, especially depending on the developmental stage they’re in. 

Young kids and teenagers tend to need a lot of sleep because those are periods of very rapid physical and brain growth and development, so you need a lot of sleep, and it needs to be good quality. So this sleep-behavior connection or this sleep-brain/sleep-mental health connection is really critical to understand. I think what Travis and Mandy are raising here is a really appropriate and relevant concern about how their son sleeps or lack of sleep, problems with sleep is impacting his ability to focus, his mood, his behavior in the classroom. 

We know from research that has been done that anywhere from 25-40% of kids who end up diagnosed with ADHD actually have an undiagnosed or untreated sleep problem. 

So when we start to delve even more specifically into the realm of ADHD kinds of issues, so impulsivity and hyperactivity and/or attention and focus problems, we see that sleep plays a huge role and the research bears that out. That means that there are lots of kids with these symptoms that end up getting a diagnosis, who actually, if their sleep issues were properly identified and addressed, would have less symptoms or maybe even no symptoms at all. So it’s a really foundational and important thing to be looking at. And not just for the ADHD pieces, as I mentioned, but also for things like anxiety. The research shows a connection between sleep problems, lack of sleep in kids and their anxiety level, certainly in their mood, in their emotional and behavioral regulation and in their learning and overall cognitive and brain development. 

Now one thing that can seem a bit unusual and maybe puzzling to adults is how sleep deprivation or sleep problems can show up in kids, because when we think about this as adults, we tend to think of “Oh, when I don’t get enough sleep or my sleep quality is poor, I feel so tired, I’m sluggish, I’m less active.” Well, in kids, often, we get this paradoxical situation where lack of sleep and fatigue can show up as hyperactive types of behavior and just lots of extra physical activity and movement. And so that can be puzzling to many adults because they think, “Well, if they’re so tired, if they’re sleep deprived, how come they are so physically active?” But that’s how it can show up for many kids. Now for some kids, obviously it can show up as really sluggish, not moving or wanting to just lie down all the time, but it can be the opposite, and kids can be very sleep-deprived, very fatigued, but that shows up as really wound up, hyperactive behavior. And any of us who have parented young kids have seen that, where a kid, if they’re getting really worn out or exhausted, maybe they’ve had a really busy day, lots of things going on, we know they are so tired. We think, “Why are you so active, running around, so wound up?” Again, that’s that sort of paradoxical effect. So it’s important to understand that sleep deprivation and poor sleep can show up differently in kids than it does in adults. 

So let’s delve into some specific problems with sleep that we want to be aware of and looking for and then address in kids. Travis and Mandy, in the questions that they asked touched on several of these. 

So kids might have trouble falling asleep. They may lie in bed for a long time, aren’t able to fall asleep in an appropriate amount of time, maybe they struggle to wind down, to actually get in bed and fall asleep. So falling asleep is one issue. The next issue is staying asleep. So some kids may fall asleep okay, but they struggle with staying asleep. They might be asleep for a bit, and then they’re up, anywhere from a little bit of time to a long stretch of time. Some kids will wake in the middle of the night and not be able to fall back asleep. Some kids have problems with both falling asleep and staying asleep. So those are some issues. 

We want to be looking at the number of hours of sleep that a child is getting, and this is going to depend somewhat on their age and developmental level, what the appropriate number of hours is for a child. But in general, infants, obviously sleep a ton. Toddlers, pre-schoolers, they absolutely should be getting 12 to even 14 hours of sleep at night. By the time kids get into those school ages, we’re looking at around 10 hours of sleep at night. 8 on the very short end to 10, sometimes even 11 or a little bit more on the higher end. As they get into the teen years, they need even more sleep. Teenagers really need, at a minimum 8 hours, but many of them do much better when they have 9 hours, 10 hours, even up to 12 hours of sleep. Again, they’re going through a rapid phase of growth and development in their body, but also in their brains, and sleep fuels that. 

Unfortunately what we see is kids get into those teen years just at that time when they need to be getting more sleep, they end up getting sleep deprived because they are in activities that go later into the evening, they have a lot of homework, they have schools that start really early in the morning. So sleep deprivation and not getting enough sleep can be a huge problem for those kids in those teen years. So the appropriate number of hours overall is another thing we’re looking at. 

So falling asleep, staying asleep, how much sleep are they getting, and then the other thing that we want to look at is the quality of their sleep. Some parents will report, “My child is in bed and seems to be sleeping for an appropriate amount of time, but when we start to look at the quality of sleep, it’s not there.” So maybe they are sleeping but they’re having a lot of restlessness or they’re staying in a lighter phase of sleep, never going into those deeper phases of sleep that they need. So quality is the other piece that we need to look at there. We need to be aware of what’s going on with that and look at how we can address that. 

Now there are a few different realms that we can look at to address these kinds of issues. In the physiological realm, there are several things that we want to be aware of or rule out if a child is having behavioral concerns and sleep issues. 

So let’s cover some of those physiological pieces, and then we’ll talk about more of the psychological pieces. So from a physiological standpoint, we want to look at “Is the child snoring?” Kids should not be snoring. People shouldn’t be snoring, but especially when we’re talking about kids. Kids shouldn’t be snoring. Snoring can be indicative of maybe enlarged tonsils or adenoids. Snoring can be an indicator of chronic congestions, sinusitis, those types of things. So there are issues that are present if a child is snoring. Now, the child who occasionally snores a bit when they have a cold or something like that, that’s not a concern. But a kid who is snoring on a regular basis, that is not something that we would consider normal and it should be looked at. 

Certainly, if the child has episodes, even momentary episodes where they seem to stop breathing during sleep — and parents will report this as “I’ll notice that my child seems to start breathing, and then suddenly gasps and takes a deep breath,” whether or not they wake up, many times kids don’t seem to be fully conscious and awake when this happens, so they’re going along sleeping., but they’re having these episodes where they’re having these brief moments where they stop breathing and they might gasp or they might twitch or have these movements to kind of — that’s their brain’s way of alerting them to take a breath. So that is an issue that certainly is indicative of sleep apnea and absolutely can be present in children even though most people associate sleep apnea with adults, it can be an issue with children and can definitely cause a whole variety of mental health, brain learning and behavior kinds of issues. 

Another physiological thing that we want to look at is how much movement and restlessness the child is having during sleep. Again, it’s normal for kids to move around a bit. But if you have a child who is twitching, thrashing, moving around constantly in bed, that is atypical. Sometimes parents say “Well, I don’t sleep with my child, so I don’t know.” Well, there are some things you can look at: Are they typically in a totally different position in the morning than they were when you put them to bed? You put them to bed with their head on the pillow and maybe you get them up in the morning or you check on them in the night and they are in a totally different position in the bed or maybe they’re on the floor or they’ve rolled themselves and wrapped themselves in their covers because they’re moving around so much. Are the blankets and things all over the floor? These are some signs that a child is having very physically restless sleep. And certainly, if you ever have the occasion to sleep in bed with the child, whether maybe that’s in your home or on a vacation, in a hotel or something else, parents will report, “Ugh, my kid kicks me all night long or is constantly moving and repositioning.” Sometimes parents will report too that they notice they can hear their child bumping into the wall on the other side of the bedroom wall, so things like that that you want to be aware of that indicate very restless, poor quality sleep. 

Recurrent night waking: Again, some kids depending on their age and development level, they may get up to use the bathroom in the night. As long as they fall right back to sleep that’s fine, but kids who are waking up recurrently, so it’s a chronic issue of them waking up, not being able to fall back asleep. Or maybe they are able to fall back asleep, but they are waking up at regular intervals, that’s something that we would want to look at. And then chronic nightmares or bad dreams. This certainly can be something that happens intermittently for kids, can be a normal phase of development, but here, we’re talking about chronic issues with that. Kids who are having lots of what we would maybe classify as night terrors, where they’re not really even aware of what’s going on, but they’re waking up and having these terror episodes on a chronic basis, or kids who are having nightmares on a very recurrent basis reporting very graphic, scary, bad dreams. These can be signs of something physiological going on, not just psychological. So we want to look at that. So again, these kinds of physiological things might indicate issues like sleep apnea, specific nutrient deficiencies, chronic congestion, sinusitis and large tonsils, other kinds of things that are going on on a physical level that could be impacting sleep. So we want to think about and rule out those things and certainly treat them if they are present.

Now in the psychological or behavioral realm, there are a variety of things that can contribute to these issues as well. One is not having good, consistent routines for bedtime or sleep. So kids really benefit from having consistent winding down routines at night. Things like quieter, more relaxing activities before bed, putting the devices away, taking a warm bath or shower, things like that that can be very supportive consistently. Having consistent times of going down to bed, consistent times of waking up. So those routines are important and that consistency. Is the sleep environment conducive? Is it comfortable? Is the bed comfortable? Some kids benefit from more weight or pressure on them, like a weighted blanket, or just more blanket, stuffed animals, those kinds of things. Is it a kid who is getting too hot at night? Is the room dark enough? 

So these are the things we want to look at in the environment. We also want to look at just basic sleep hygiene in terms of things, as I mentioned, turning devices off before bed, getting enough physical movement and sunlight during the day, not having a lot to drink in the evening hours, it’s going to wake them up in the night to use the bathroom. Not having caffeine or lots of sugar in the evening hours before bed, these are important sleep hygiene things to think about as well. 

And then the anxiety or fear kinds of issues. Some kids don’t get enough sleep or get poor quality sleep because they are afraid of the dark or they are afraid of being alone or they are having fears or anxieties around that, or it may just be an anxious kid who, once they lay down in their bed at night and everything is quiet, they start replaying a lot of anxious things in their mind that have nothing to do with sleep directly, but that prevent them from being able to fall asleep. So these are areas, some of them can be worked on on your own, and some may benefit from some professional support, depending on how severe the issues are, what you’ve tried, those kinds of things. 

So these are all things that we want to be thinking about when a child is not/doesn’t seem to be getting good sleep. 

Some of the things that tip me off in the information that Travis and Mandy shared that there may be some physiological things to look at here are the restlessness, the inability to wind down and fall asleep, and then the significant amount of movement all through the night. So those are some physical things that stand out to me. 

From the other side, from the psychological or behavioral piece is consistent routines, having a plan for what you’re going to do when your child maybe comes in and wants to stay in your bed at night, and how you are going to address that. So several things that I think can be helpful here. But the key is that it really is important to get the sleep piece going better before looking at any kind of specific mental health diagnosis or neurodevelopmental diagnosis or a diagnosis-specific treatment. 

So for Travis and Mandy, I would absolutely encourage working with professionals around identifying what is getting in the way of your son getting enough good quality sleep at night, and then see how your child does. See how he responds to that. I have seen it in my practice where it is literally a night and day difference when a kid is finally getting enough good quality sleep, and their behavior at home and in the classroom and in their learning and their focus and everything can shift literally overnight. So I think that that’s very important to address the significant issues with sleep before delving into other issues of what kind of mental health or neurodevelopmental diagnosis might be there. 

So as a starting point, I would recommend documenting your specific observations. You’ve laid many of them out in the question here, but for all of you as parents, if you’re dealing with this, document those observations and maybe even on the calendar. Keep track of how many hours of sleep they’re getting, how many nights they woke up and couldn’t get back to sleep. Whatever the issues are, make some notations on your calendar, because then you’re going to want to talk to your child’s pediatrician or healthcare provider about those concerns. If your child’s healthcare provider is dismissive about sleep or really doesn’t want to entertain the idea of looking at that, then find somebody different to work with because it’s very important to deal with the sleep issues. That can look like the healthcare provider talking about some specific strategies or suggestions that may be helpful, it could look like referring to a sleep medicine specialist who works with children to get a consultation on what might be going on. 

It could look like some lab work, some basic blood labs can be very helpful, in particular, looking at iron level. Iron is very connected to sleep and I see many, many children who are not getting enough good quality sleep, who have suboptimal levels of iron. So there is an iron panel that can be ordered to look at things like serum ferritin, to look at iron saturation, overall iron levels, and this is something that can make a huge difference for kids. If they are suboptimal or clearly deficient, and certainly if they are anemic, supplementing with iron and improving the level of iron in their diet, getting their iron levels up can make a dramatic difference in the amount and the quality of their sleep. So that’s a very important foundational lab to look at if your child is struggling with these things. Some other nutrients that can be really important are magnesium. You can test for that, but magnesium is a safe mineral to try in a supplement form, I often will use a powder called Natural Calm with kids. There are a variety of forms that you can use of magnesium. There are powders, there are liquids, there are tablets and capsules. Again, talk with your child’s healthcare provider about that. That magnesium given in the evening can be very supportive of helping to relax kids, helping to calm their anxieties, soothe and relax their body and help them fall asleep. There is also some good research on a combination of valerian and lemon balm, two herbs that can be very supportive of relaxation and sleep in children. So those are some other things that can be looked at there. Melatonin, many people ask about it. Melatonin can be very helpful and appropriate in children, depending on their needs and issues. Again, talk with your child’s healthcare provider. Most people, when they are using melatonin, they are using far too much, especially with children. Melatonin is only helpful for falling asleep. It’s not helpful for staying asleep and addressing some of these other issues we’ve talked about. There are sustained release formulas that can help with staying asleep. But again, to me, melatonin is something that we try either in combination with lots of other behavioral and sleep hygiene tools, or we may resort to that after we’ve done some other things. But that can be something to talk with your healthcare provider about. 

Also very critical in a situation like we are talking about here with Travis and Mandy’s son, to work on consistent bedtime and night time routines. That may entail finding some calming and soothing activities to do before bed, helping with that wind down time, making sure that devices aren’t being used too late, getting plenty of movement during the day. Maybe it means changing some things up about the child’s sleep environment. I have found for some kids, even moving their bed into the corner of the room so they’ve got the security of the wall there, some kids like to build a little nest and that is supportive of them in a sensory way and also just emotionally. So looking at how you can use things like calming music or maybe a mindfulness or sleep kind of story that they can listen to. These aren’t necessarily things that help instantly the first time you try them, but you’re building these routines that their brain then can consistently get used to and rely on, and helps to set the stage for them settling down and being able to have a good night of sleep. If you use music, I like to put that on repeat through the night, so if they fall asleep to music, then if they wake up in the night, that soft music is still playing, and that, again, just helps the brain to settle right back down into sleep if they do wake. And then coming to an agreement of how you’re going to handle things like night waking and your child coming into the room. There’s no one right way to handle that. Families have to decide what’s going to work best for them, but coming to an agreement about how that’s going to be handled, and then consistently implementing whatever strategy you decide on. 

So those are some things that I think, in this situation, can be helpful in both the physiological side and the psychological side. I hope that this is helpful for Travis, Mandy and any of you who have kids whose sleep might not be ideal, and who are struggling with some of these mood, learning, focus and behavioral kinds of symptoms. Remember, if you have a question you would like to hear answered on a future show, email it to support@drbeurkens.com. Thanks, as always, for listening and I’ll catch you back here next time.