A Q&A With Drs. Maida Chen and Michelle Garrison

Sleep is one of the most common concerns divulged to family providers. While parents most often ask for advice related to young children, Seattle Children’s sleep experts Drs. Maida Chen and Michelle Garrison suggest providers treat the entire family when addressing sleep issues.

Read on to learn more.

Thank you to Dr. Wendy Sue Swanson, Chief of Digital Innovation for Children’s and author of the Seattle Mama Doc blog, for submitting these questions.

How does parents’ sleep impact the rest of their family?

Dr. Michelle Garrison, principal investigator, Seattle Children’s Research Institute: Sleep problems between family members are often

interconnected, so providers should look beyond the sleep habits of a specific child and consider what’s going on in a family unit.

When sleep isn’t going well, it can create what I call a “feedback loop of despair.” When children aren’t sleeping well, it can affect parent sleep as well – and then the next day, the child’s behavior can be worse and parents may have less capacity for parenting the way they want to, because they are both tired. And in turn, those effects on behavior and parenting can make bedtime even harder the next time, and you have a feedback loop.

But families can also turn that around and develop a “positive feedback loop,” and helping parents get more sleep can sometimes be t

Michelle Garrison

Michelle Garrison

he first step. As parent sleep improves, parenting often goes more smoothly, and it can increase their capacity for making positive choices like being physically active or sharing a healthy meal with their family. They’re more likely to manage their temper and practice good role modeling for handling emotions, and have an easier time staying calm and consistent when responding to bedtime resistance. In turn, that improves the child’s sleep, which has a positive effect on the child’s behavior and emotion regulation, which all can feed back in to make parenting feel more rewarding.

Another thing to remember is research has found parents who sleep poorly tend to overestimate their children’s sleep problems. Sleep loss causes bias in their memory, so that the less sleep parents get the more they focus on negative events. The less they sleep, the less they think their children do.

Dr. Maida Chen, director of Children’s Sleep Disorders program: Children need a complete and whole version of their parents and that requires adequate sleep.

Society often portrays parents’ lack of sleep as heroic. We ought to adjust that mindset. Parents need to sleep to be their child’s best advocate and role model.

Getting an adult to change their sleep habits requires a shift in mindset. Providers may help start a conversation by asking parents, “Who are you helping when you’re sleep deprived? Who benefits from this?”

Families often ask about infants’ and toddlers’ sleep, but what advice should providers offer at well child check-ups for school-age children and teenagers?

Maida Chen

Maida Chen

Dr. Chen: When possible, providers should take the time to ask parents of children of all ages the open-ended question: How is your family sleeping?

I know there are usually a million other, more acute things that have to be addressed in a 15-minute appointment, but sleep problems are so common and affect so many aspects of health and illness, so I hope that providers will prioritize this topic.

Just the perception of a sleep problem, even if it can’t be illustrated by sleep study or other objective measure, can have a significant impact on the family as a whole.

Dr. Garrison: Sleep is a developmental skill. Being able to lay down, calm down and fall asleep quickly and independently for a good night’s sleep requires practice, and sometimes coaching, throughout childhood and adolescence.

We often expect children to suddenly switch from having their parents regulate their sleep to managing it on their own. But in reality, children need their parents to gradually step back so they can slowly increase their own responsibility around sleep in a supported way, similar to Ellyn Satter’s “Division of Responsibility in Feeding.”

Teens often stay up later than their parents, so they have an increasing responsibility to regulate their own sleep onset. This kind of self-regulation is a skill they need to learn, and it may not happen intuitively. Many youth need parents to help them learn to self-monitor and respond to signs that they are becoming tired, and to make the connections between good sleep and their own goals (whether that’s school, sports performance, or personal relationships) that can help develop the motivation for going to bed.

Age-based recommendations for sleep have varied over the last few years. Why have they changed? What should we know about recommendations for quantity of sleep?

Dr. Chen: Physiologically, nothing has changed, but our awareness of what sleep deprivation looks like across the age spectrum has developed.

The main shift has come in older children. We used to think teenagers needed the same amount of sleep as adults, but research has revealed manifestations of chronic sleep deprivation in teenagers – sleeping only seven to eight hours each night – of which we weren’t previously aware.

We used to look for signs of sleepiness in teenagers – like falling asleep at school – but now we know that’s actually a pretty late sign of sleep deprivation.

Studies published in recent years have shown teenagers who chronically get less sleep demonstrate risky behaviors such as being sexually promiscuous, abusing drugs or getting in car crashes.

We used to think of this as typical, precarious teenage behavior, but we’ve learned over time that sleep deprivation influences decision making and leads to poor judgement.

Let’s talk melatonin use and safety – how should we think about advising use for young children, school-aged children, teens and adults? Is there a duration of use you are comfortable recommending?

Dr. Chen: Evaluating the safety of melatonin is complex. At a very high level, occasional melatonin use is most likely relatively safe, otherwise it would not be widely available over the counter.. There are definitely situations in which short term use – for things like jet lag – are safe and appropriate.

My concern comes from the reason behind wanting to give melatonin – many parents request it to treat a child’s insomnia, but melatonin is just a band-aid, it does not address what usually are much deeper issues.

Additionally, short-term use is rarely well defined. It’s usually thought of as “until things get better,” and then that turns out to be years.

Dr. Garrison: There is no great data on the long-term safety of melatonin and there is conflicting evidence about possible negative effects – especially the impacts on hormones during puberty.

For many families, that’s enough reason not to use melatonin long-term, unless a child has neurologic issues that make it harder for the brain to respond to light cues in the environment with stable endogenous melatonin patterns.

There are two ways melatonin supplements are typically used. Most commonly, parents give a big dose before their child falls asleep, and it has a sedating effect. However, some studies are finding it can be more effective to administer much smaller doses much earlier – five hours before bed time – to support the body’s own melatonin rhythms.

Can you give us an update on screens, blue light, and sleep onset?

Dr. Garrison: There are several ways in which media use affects sleep, and there is variability across people. Some people might be more vulnerable to the circadian effects of the light emitted while others might be more vulnerable to the arousal effects of the content.

Research has shown using multiple media devices or apps at once does seems to increase arousal levels in the brain and makes it harder for people to calm down and sleep well.

We also know that most screen devices today are blue-light enriched – meaning the light coming from these screens has stronger intensity in the blue end of the spectrum. That part of the spectrum most disrupts melatonin and circadian rhythms. Even relatively low levels can potentially disrupt sleep, especially when they are used near bedtime.

Research has shown that blocking blue light 1-2 hours before bed can benefit sleep. If you have a child that is going to be on screens at night, think about recommending glasses or goggles that block blue light. Now that professional video gamers sometimes use these, it can be easier to get teens on board. There are also apps and devices that can reduce blue light from gadgets, but they be only partially effective.

Dr. Chen: Even as little as ten minutes of exposure can suppress melatonin for up to 30 minutes, so what can seem innocuous – like checking social media – may result in up to a one-hour sleep delay.

For teenagers, that light exposure may be synergistic with their natural tendencies to stay up later. If you put a light source in front of their brain it almost gives their brain an excuse to stay up later.

What do we know now about improving sleep onset and issues with sleep latency?

Dr. Chen: Healthy sleep is a lifestyle and not something that can be quickly applied with instant results. For patients who have long-standing habits and difficulties falling asleep, there is not one quick fix.

That’s one reason why sleep medications are so rampant, because people are looking for a magic bullet. They want to be able to be on their phones, watching TV or working on their computer – all things we know keep us awake – and then flip a switch and fall asleep.

We need our patients to understand that sleep onset and sleep maintenance are based on an intricate series of connections in your brain that need to be primed over time.

Any there any “golden rules” providers should be recommending?

Dr. Chen: Patients should try to stick to a sleep schedule. It’s important to maintain both sleep quantity and regularity. People benefit from not varying their bedtimes or wake times by more than one hour on each end.

We know our entire body works off a master circadian clock and that every cell also has its own circadian clock. When you practice healthy sleep, the master clock and the cellular clocks align. When sleep schedules become irregular, the clocks don’t synch the body is thrown into chaos.

Dr. Garrison: We know bedtime consistency matters with toddlers – but that consistency is just as important in teens and adults, and can make a big difference in being able to fall asleep quickly and soundly.

For children still napping, the time span between the end of a nap and bedtime should be the longest awake stretch of day. There are two different processes in the brain that drive whether we’re going to be able to sleep or not – the circadian sleep drive and the homeostatic sleep drive, which keeps track of how long it’s been since you’ve last slept. If the homeostatic sleep clock has not had enough time to build up strength again, you’re going to have a hard time falling asleep, even if the nap was short.

When should patients be referred to a sleep specialist?

Dr. Chen: If a family has to go through extraordinary efforts to manage their sleep and common, logical advice isn’t gaining any traction, providers should probably delve into the issue further.

To refer a patient to Children’s Sleep Disorder program please call (206) 987-5072.