More than Meds

Sleep like a ...sea lion? (R. Brockman, 07/2011, Galapagos)

Sleep. I get calls every day about sleep problems. And for good reason; unregulated sleep often goes hand- in -hand with behavior problems.

Sometimes it is hard to know which came first.  The upset and angry teen may not be able to settle down and self- soothe enough to get to sleep, the depressed child may naturally have a poor sleep cycle, and the youngster on medication for ADHD may not sleep well because of medication side effects. But even if we do not know the “chicken or egg” answer (which came first?) we do know that establishing and maintaining a consistent sleep and awake pattern helps almost every behavior and emotional problem.

But how can we get a child or teen to adopt such a pattern?  Not easily!  Here are some ideas – these won’t fit or work for every sleep disordered youth, but the basic idea works for most.

1. Get electronics (other than a basic radio) out of the room.  No cell phone, TV, computer, game system.  Consider having books and maybe soothing music available.

This is sometimes the most difficult step and is easiest if established at a young age.  But even for older teens it is doable if you are clear that this is not negotiable.

2. Set regular sleep and awake times and be prepared to enforce them.

3. Cut out or drastically reduce sources of caffeine.

4. If there is a medication issue that may be contributing, consider changing timing of the med (talk with the child’s doctor about this.)

5. Think about bedtime routines that make sense and help implement.

And most importantly, try to enlist your child or teen into the effort.  Help them understand your concerns about their sleep and try to make a shared effort to get sleep back on track.  Celebrate with them when gains are made and help them try again if sleep remains difficult at first.

There are some medications that are used to help children restore sleep cycles, but most practitioners will ask that you try some of these other steps first. Good luck and let me know if there are other ideas about sleep out there!

Which way? (Andes Mountains, 08/2011; R. Brockman)

15 year old Shana and her mother come into my office. They explain that since beginning high school last fall, Shana’s grades have dropped, she is forgetful and having trouble keeping track of class assignments, and last week received her first-ever detention after returning to campus late from lunch. Both Shana and her mother are concerned – Shana because she has been getting in trouble at home due to the school issues and her mother because she feels, ” I know Shana can do better; could she have ADD or ADHD?”

As a psychiatrist it is my job to help Shana and others like her sort out situations like this one. Could she have a disorder of attention such as ADD? Sure! But it is equally likely that she is simply having difficulty adjusting to the demands of her new school situation and the relative freedom of high school life with an open campus and less oversight. Of course, there may be other factors at work here as well; I would want to screen for any symptoms suggestive of depression, substance use, or medical problems that could be contributing to these changes in functioning.

One of the most important diagnostic tools I employ as a psychiatrist is the ability to take a good history and place the history into context. Understanding Shana’s emotional, social and educational progression and development will most likely provide the key I need to help Shana and her family, and to decide if further testing or treatment is needed.

ADD and ADHD do not suddenly appear in teenage years; these are disorders that are present from early childhood. However, it is always possible (especially in bright children who do not have behavior problems) that the diagnosis could have been overlooked early on, and this is another reason why a careful history is so important.

Take-home message? A lack of attention, distractibility, and poor control of impulses are hallmarks of attentional disorders but the presence of these characteristics alone are not enough. It takes a careful history, screening tests and typically other diagnostic evaluations to make a definitive diagnosis. And then comes treatment…topic for another day!