The fatigue and pain may cause the child to miss school, not participate in social activities, and avoid sports. This may lead to lower self-esteem and a “deconditioned” body, both of which superficially resemble the symptoms of depression. Remember, children with fibromyalgia syndrome are most often preteen or teenage girls, and many of the symptoms may be misattributed to changes associated with adolescence.
Because the cause of fibromyalgia syndrome is not known, there is no specific cure or treatment. But the good news is that improvement tends to occur over time in response to treatment. Rheumatologists in pediatric centers specialize in treatment with exercise programs, and sometimes they prescribe antidepressant medications. This can help these children get through difficulties that disturb their sleep, such as final exams. Most children improve after about two years of treatment.
Curiously, there is a predicable sequence of improvement. First, the sleep disruption improves. Second, weeks later, the skeletal muscle pain symptoms start to improve. When the sleep disturbance does not improve, it is much less likely that the other symptoms will decrease. This observation that sleeping better needs to precede improvement in fatigue and pain reduction suggests that poor-quality sleeping might cause the other symptoms. Furthermore, among adults who suffer with this disease, the poorer the sleep, the more extreme the pain. This again suggests that there is a causal link between disturbed sleep and the other symptoms of fibromyalgia.
Chronic Mononucleosis
Infectious mononucleosis is caused by a virus. Children as young as fourteen have been identified as having a chronic condition, following the acute infection, characterized by disabling daytime sleepiness. Because of the daytime sleepiness, the child's school performance deteriorates. Not surprisingly, misdiagnoses of depression are sometimes made among these children. The correct diagnosis is made only after blood tests confirm the viral infection.
Preventing and Solving Sleep Problems
Let's look at the two major areas of concern for children in this age group, namely, falling asleep and maintaining a healthy sleep schedule. In treating these sleep problems, we attempt to break the self-perpetuating sequence in which sleep disturbances cause hyperarousal, which further interferes with sleeping well.
Falling Asleep
Working with a therapist, older children can learn to sleep better through relaxation training techniques similar to those used by adults. The attempt is to reduce the level of arousal, therefore permitting the sleep process to surface. Here are a few techniques:
Progressive relaxation is a method whereby you tense individual skeletal muscle groups, release the tension, and focus on the resulting feeling of relaxation.
Biofeedback involves focusing on a visual or auditory stimulus that changes in proportion to the tension within skeletal muscles. Both progressive relaxation and biofeedback techniques can help reduce muscle tension and thus make it easier to fall asleep.
Self-suggestion to produce relaxation involves repeating suggestions that your arms and legs feel heavy and warm.
Paradoxical intention is based on the idea that trying hard to spontaneously fall asleep might create a vicious circle, which can be broken by focusing on staying awake.
Meditative relaxation procedures vary, but simple instructions to focus on the physical sensation of breathing seem to help some people fall asleep.
Stimulus Control and Temporal Control
Stimulus-control treatment tries to make the bedroom environment function as a cue for sleep. Spending lots of time in bed watching television, reading, or eating directly competes with sleeping, and therefore these activities must be discontinued. Temporal control means establishing a regular and healthy sleep schedule.
Richard R. Bootzin, a psychologist specializing in insomnia, incorporates the elements of stimulus control in the following instructions he developed.
STIMULUS-CONTROL INSTRUCTIONS
Lie down intending to go to sleep only when you are sleepy.
Do not use your bed for anything except sleep—that is, do not do homework, read, watch television, eat, or worry in bed.
If you find yourself unable to fall asleep, get up and go into another room. Stay up as long as you wish and then return to the bedroom to sleep. Although you should not watch the clock, you should get out of bed if you do not fall asleep immediately. Remember, the goal is to associate your bed with falling asleep quickly! If you are in bed for more than about ten minutes without falling asleep and have not gotten up, you are not following this instruction.
If you still cannot fall asleep, repeat step three. Do this as often as necessary throughout the night.
Set your alarm and get up at the same time every morning, irrespective of how much sleep you got during the night. This will help your body acquire a consistent sleep rhythm.
Do not nap during the day.
Dr. Rosalind Cartwright, a pioneer adult-sleep researcher, teaches a variation of Richard Bootzin's stimulus control that has helped some children fall asleep easier.
Do something that is pleasurable for a limited amount of time, using a timer set for fifteen to twenty minutes. Do anything you want, but not in your bedroom.
Take the hottest lavender bubble bath you can tolerate for fifteen to twenty minutes. This is for relaxation, so don't read a book or listen to music while you're in the tub. The bath helps prevent the storm of thoughts and worries that strike the brain like meteorites when the protective shield of activity, sports, or homework is down.
After the bubble bath, immediately get into bed. Don't start any other activities—no books, no music, no telephone calls. Close your eyes and try to sleep.
If these instructions do not provide help, consider encouraging your child to get involved in sports programs, to increase the amount of physical exercise he gets. If this fails and your child still can't sleep well and appears exhausted, too tired, and not interested in outside activities, ask yourself whether the problem might not be depression.
Children do get depressed, and some crazy, risk-taking “accidents” in overtired teenagers are really deliberate suicide attempts. If this is a concern of yours, seek outside help immediately. Start with school social workers, your physician, or local suicide prevention centers.
Maintaining a Healthy Sleep Schedule
As already discussed, some teenagers suffer from what we call delayed sleep phase syndrome. This occurs when teenagers are unable to fall asleep at a desired conventional clock time but have no difficulty falling asleep long after midnight. On vacation, they sleep a normal duration, do not wake up at night, and feel refreshed in the late morning or midday, when they awaken. The problem lies in the disrupted sleep schedule that often develops during the school year, when sleeping late is not possible.
Treatment is called “chronotherapy,” or resetting the sleep clock. Let's say your child can easily fall asleep at 2:00 A.M. The therapy consists of forcing him to stay up until 5:00 A.M. and then letting a natural sleep period follow. (Obviously, we don't do this during the school year!) The next time sleep is allowed to start is at 8:00 A.M. the following day and at 11:00 A.M. the day after that. In other words, you are allowing sleep to occur about three hours later every cycle. Over the next few days, sleep begins at 2:00, 5:00, 8:00, and finally 11:00 P.M. Now, keeping careful watch over clock time, always try to have the child go to sleep at 11:00 P.M. YOU have shifted the sleep clock around to a more conventional time, and usually this can be maintained by sustaining a regular nighttime sleep schedule.
Drugs and Diet to Help Us Sleep
Drugs don't solve sleep problems. Diphenhydramine or other antihistamines are often used to induce sleep in children. The common situation is for these drugs, or others, to be thought of as a temporary, short-term measure, “just to give everyone a break.” It sounds great—get your strength back to muster up enough courage to try to correct problems caused by your own mismanagement—but I have observed many times that those parents who demand drugs mos
t strongly are those who are least likely to change their behavior, so the basic sleep problems continue. No study has shown that sleep-inducing drugs are really useful and safe for children. Diphenhydramine has been shown not to be an effective hypnotic in adults. Hypnotic drugs such as phenobarbital can actually cause sleep disturbances, daytime fussiness, and irritability.
PRACTICAL
POINT
Don't depend on
drugs to solve
your child's
sleep problems.
Other drugs that can interfere with good sleeping include nonprescription decongestants, such as Sudafed and caffeine. So let's sleep better by not taking any drugs. An important exception might be drugs used by an allergist or pediatrician to help a child breathe easier at night if he is suffering from allergies.
Dietary changes that are known to make some people sleepy include high-carbohydrate meals and foods high in the amino acid tryptophan. It is possible that the contents of a nursing mother's diet affect the carbohydrate content of her breast milk, and this may indirectly influence the levels of tryptophan in the baby. In one study of infants, tryptophan caused the babies to begin quiet sleep twenty minutes earlier and active sleep fourteen minutes earlier. But the total amount of sleep time was not affected. So giving tryptophan to infants or other children will probably not make them sleep longer. Furthermore, tryptophan administration in adults has been associated with severe diseases, even though tryptophan is a naturally occurring amino acid. Melatonin is another naturally occurring chemical that has been popularized as a sleep aid. The safety and effectiveness of melatonin have not been established for infants or children.
The effects of high-carbohydrate or high-protein meals in adults show differences between the sexes and differences based on age. There is no scientific data on nutrition in children that could be translated into a sleep-promoting diet. Eliminating refined sugar, because of the commonly held belief that this makes children hyperactive, also does not appear to have any effect on sleep patterns.
Another report suggested that cow's milk allergy could cause insomnia. But the results of the study could have been caused by a placebo effect, because the parents knew when they were giving a cow's milk challenge and when they were eliminating cow's milk from the diet. Dietary challenges and elimination diets are best performed when both the parents and the researchers, at the time of the challenge, are ignorant of whether the child is or is not receiving the substance in question. Only then can bias or wishful thinking be reduced.
Many school-age children have difficulty falling asleep because they worry about their grades, test scores, appearance, or sports skills. Anxiety about not doing well academically or athletically might lead to impaired performance. This is called “performance anxiety.” Impaired sleeping likewise occurs when there is too much worrying or nagging about not getting enough sleep. Worrying too much about not sleeping well creates anxiety or stress, interfering with the relaxation needed to successfully perform the task, which is to fall asleep. Feel free to call any child psychologist for information about the solution, which is called “relaxation training.” If your child, at any age, appears to need more sleep, and he wants to sleep but cannot easily fall asleep, please consider working with a professional to help your child learn to relax and avoid performance anxiety.
Other Sleep Disturbances
and Concerns
Special Sleep Problems
Specific sleep problems may occur at different ages, and it would be useful to read the earlier sections to determine whether your child's sleep pattern is appropriate for his age. Some specific sleep problems, such as sleepwalking, sleep talking, or night terrors, appear to occur more frequently when children have abnormal sleep schedules. Most of these common problems are bothersome to the family but are not harmful to the child.
However, one problem, severe and chronic snoring, may be hazardous to a child's health. Please read the section on poor-quality breathing even if your child has no specific sleep problems or you think he does not snore. Snoring is sometimes not appreciated as a problem because the child has always snored, or because allergies developed when the child was older—an older child is usually in his own bedroom and the parents are unaware of how much snoring is occurring every night because they do not go into his bedroom after he has fallen asleep.
Sleepwalking
Between the ages of six and sixteen, sleepwalking occurs about three to twelve times each year among 5 percent of children. An additional 5 to 10 percent of children walk in their sleep once or twice a year. When it starts under age ten and ends by age fifteen, sleepwalking is not associated with any emotional stress, negative personality types, or behavioral problems. Research has shown that there is a substantial genetic factor to sleepwalking, as it was found that the behavior is more common among identical twins than fraternal twins.
Sleepwalking episodes usually occur within the first two to three hours after falling asleep. The sleepwalk itself may last up to thirty minutes. Usually the sleepwalker appears to be little concerned about his environment. His gait is not fluid and his movement not purposeful. In addition to walking, other behaviors such as eating, dressing, and opening doors often occur.
Treatment consists only of safety measures to prevent sleepwalkers from falling down stairs or out of open windows. Try to remove toys or furniture from your child's path, but don't expect to be able to wake him. Rousing him won't hurt, but usually the child wakes spontaneously without any memory of the walk.
Sleep Talking
Sleep talkers do not make good conversationalists! They seem to talk to themselves and respond to questions with single-syllable answers. Adults appear annoyed or preoccupied. Children often repeat simple phrases like “get down” or “no more,” as if they were remembering important stressful events that had occurred that day.
Between the ages of three and ten years, about half of all children will talk in their sleep once a year. Older studies have suggested that sleepwalking and sleep talking tended to occur together and were more common in boys; however, newer studies do not support this association.
Night Terrors
Your child utters a piercing scream, and you rush into his room. He appears wild-eyed, anxious, frightened. His pupils are dilated, sweat is covering his forehead, and as you pick him up to hug him you notice his heart is pounding and his chest heaving. He is inconsolable. Your heart is full of dread, and it almost seems as if some evil spirit has gripped your child. After five to fifteen minutes, the agitation and confused state finally subside. This is night terror.
Night terrors, sleepwalking, and sleep talking all occur mainly during non-REM sleep and usually within two hours of going to sleep. They usually do not occur when we dream (during REM sleep); they are not bad dreams. In fact, children have no memory of them once they are awake.
Night terrors usually start between four and twelve years of age. When they start before puberty, they are not associated with any emotional or personality problems. Night terrors have nothing to do with seizures, convulsions, or epilepsy. Night terrors appear more often when a child has a fever or when sleep patterns are disrupted naturally, such as on long trips, during school vacations, during holidays, or when relatives come to visit. Recurrent night terrors are also often associated with chronically abnormal sleep schedules.
Enabling them to get more sleep is the way of treating overtired children who have frequent night terrors. I have observed that night terrors disappear when the parents moved the bedtime earlier by only thirty minutes.
Drug therapy is not warranted for most children with night terrors, sleepwalking, or sleep talking problems. Most children should be allowed to outgrow these problems without complex tests (such as CT scans), drug treatments, or psychotherapy.
Nightmares
In old English mythology, a nightmare was thought to be a female spirit or monster that beset people and animals at night, coming upon them when they are asleep and producing a
feeling of suffocation.
I myself have had nightmares of suffocation, strangulation, breathlessness, choking, being crushed or trapped, drowning, entrapment, and being buried alive—but only when I sleep on my back or have an alcoholic drink before going to bed. My wife says that at these times my breathing sounds like a diesel truck with a bad motor. When she pokes me to get me up, the nightmare ends, and I breathe normally again. You see, my nightmares occur when my upper airway is partially blocked, and this obstruction happens only when I sleep on my back or drink alcohol before bedtime. Occasionally, I have less dramatic dreams of breathlessness while running, flying (without a plane, of course), or being chased. If my wife does not awaken me, I wake up to breathe, but I have no dream recall. Maybe some children have similar nightmares when they have bad colds or throat infections that partially obstruct their upper airway.
The child with a nightmare can be awakened and consoled, in contrast to the child with a night terror, which spontaneously subsides. About 30 percent of high school students have one nightmare a month. Adults who have more frequent nightmares (more than two per week) often have other sleep problems: frequent night awakenings, increased time required to fall asleep, and decreased sleep duration. They appear more anxious and distrustful, and experience fatigue in the morning.
Healthy Sleep Habits, Happy Child Page 39