The Ultimate Guide to Sleep Disorders and Sleep Problems in Children
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The Ultimate Guide to Sleep Disorders and Sleep Problems in Children

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This guide was written by Daniel Sher, a clinical psychologist at a private practice and a locum therapist at the Western Cape Health Department .

At a Glance

  • Sleep is important because it keeps our bodies and minds healthy
  • Sleep problems can lead to difficulties with thinking, disturbed mood, behavior problems, and strained relationships.
  • It’s important to recognize the signs of sleep disorders so that you can establish the correct diagnosis and get the best available treatment.
  • There are many effective strategies for treating sleep disorders, ranging from behavioral interventions and medication to light therapy and surgery.
  • There are several things that you can do to help your child get enough good quality sleep.

Introduction

Sleep problems are a widespread issue that has the potential to seriously reduce your child’s quality of life. Part of my own work as a clinical psychologist involves helping children and their families to better understand and take control of their sleeping problems.

If you have consulted Dr. Google, you’ll have experienced the massive volume of information, possible diagnoses and differing opinions that exist. This can all be a little overwhelming, right?

Regardless, if you have ever had a sleepless night yourself, you will know first-hand just how vital sleep is for our health, happiness and overall wellbeing.

In this article, we provide a detailed overview of the sleep problems and disorders that affect children and adolescents.

First, we’ll discuss why sleep is important and how children tend to be affected by sleep disorders.

Next, we’ll explore what normal sleep looks like and what happens in the brain of someone who sleeps without difficulty; as well as how much sleep children of different ages need.

Finally, we’ll list the sleep disorders that most commonly affect children and adolescents, before talking about treatment options and what you can do to help your child have healthier sleeping patterns.

Keep reading for an in-depth look at everything you need to know when it comes to supporting your child through their sleep problem.

Why is sleep important?

Sleep is one of the most basic things that we need for our health and survival, along with food, water, and oxygen.

For example, sleep is necessary for improving the functioning of our hearts and blood vessels, recharging our immune systems and helping us to ward off physical illnesses such as type 2 diabetes, high blood pressure, obesity, kidney disease and stroke [1] .

It also helps us to repair our cells and tissues, allowing for physical growth and healing; as well as keeping our hormones balanced.

Furthermore, sleep is vital when it comes to keeping our brains healthy. It allows new neural networks to be formed and aids in the process of processing and storing new memories, all of which are necessary for learning.

Getting a good night’s rest allows our children to be mentally alert, focused and able to engage in complex thought; as well as helping them to experience a healthy range of emotions and to regulate difficult feelings [2] .


What are the negative effects of sleep problems?

Impaired thinking

When we’re not getting enough sleep, our brains are running on empty. For children, this means that they lack the mental energy to concentrate and avoid distractions; to think abstractly and to make decisions.

Disturbed sleep can affect your short and long-term memory; and research suggests that your child’s brain development may be compromised as a result of sleep disorders. Naturally, all these thinking skills are incredibly important for school performance and children who aren’t getting enough sleep will often find their grades slipping as a result [3].

We know, for example, that children who get ‘A’ or ‘B’ grades in school get an average of 25-30 minutes more sleep each night, compared to their peers who got lower grades [4].

When it comes to adolescents in particular, those who struggle to achieve their academic goals may end up feeling dejected and frustrated; and many teens will act out behaviourally as a result.

Mood disturbances

Do you ever feel cranky if you don’t get enough sleep? Your child is much the same: it’s completely normal for him or her to feel irritable, moody or upset when sleep deprived.

Similarly, missing out on sleep can make your child more prone to interpreting life’s events in a more negative way, in addition to making it harder for them to regulate the inevitable emotional ups and downs that we are all prone to [5].

Behaviour problems

Because children with sleep problems struggle to regulate their emotions, they are more likely to act out what they feel.

For example, these children may exhibit aggression, tantrums, impulsivity, restlessness and oppositional behaviour. On the other hand, some children with sleep problems also tend to become withdrawn and solitary [6].

Strained relationships

Given that sleep affects our children’s thinking, mood and behaviours, it’s no surprise that those with sleep problems often find their relationships suffering as a result.

Whether in the form of conflict and irritability, or simply a tendency to withdraw socially, sleep problems can make it harder for your child to connect with peers, teachers and family.

Sleep problems can also put a strain on what is arguably your child’s most important relationship: the connection with his or her parents! As a parent, you’re likely to feel frustration and helplessness in response to what your child is experiencing.

You’re also more likely to be sleep deprived yourself, which certainly doesn’t help matters. It’s not surprising, then, that mothers of sleep deprived children are at an increased risk of experiencing stress and clinical mood disturbances [7].

Does my child have a sleep problem?

Does your child struggle to fall asleep or keep sleeping through the night?

Perhaps they have nightmares and wake up frequently, or maybe they snore and make strange breathing sounds whilst asleep?

Or maybe, it’s what happens during the day that gives you cause for concern: is your child or teen particularly sleepy, grumpy, unfocussed, hyperactive or irritable?

These are all signs that your child may have a sleep disorder and seeing this in your child can be incredibly distressing for you as a parent, especially when you don’t understand exactly what’s causing the problem and how it can be fixed.

What is normal sleep?

Normal sleep involves, first and foremost, getting enough of it!

What is enough? The amount of sleep that a person needs varies according to their age: newborn infants require the most and this amount decreases as they age. We will cover this in more detail below.

Normal sleep also involves having dreams. Yes, everyone dreams; although not everyone remembers them when they wake up.

It’s also to be expected that your child will wake up periodically – to use the bathroom, to readjust his or her bedding, or for no apparent reason at all!

If you notice your child waking up from time to time, this is no cause for concern, as long as they are getting sufficient sleep to feel alert and rested in the morning. This brings us to the final aspect of normal sleep – it leaves you feeling refreshed and ready for the following day!

Sleep stages

A sleep cycle can be broken down into five separate stages, each categorized according to the level of activity happening in your brain and body. How long does the entire cycle last?

This depends on your child’s age. Babies cycle through the five stages quickly: it takes them approximately 50 minutes to get from Stage 1 to 5! As children reach pre-school age, on the other hand, the entire cycle takes approximately 90 minutes and occurs about 5 times every night [8]. Read on to learn more about the features of each stage.

Stage 1: Drifting off

Just as we begin to drift-off we enter stage 1, which is also known as light sleep. As the name suggests, this is a period of sleep from which it’s fairly easy to be awoken. During this stage, the electrical activity in our brains has slowed down very slightly, along with our breathing, heart rate and muscle tension.

Stage 2: Relaxing further

As we pass into stage 2, our brains and bodies have relaxed even further, and we become increasingly oblivious to the external environment. Our body temperature also begins to drop in preparation for deep sleep.

Stages 3 and 4: Slow wave sleep

By the time we pass into stage 3 and 4, our brain activity has slowed down even further. This is known as ‘slow wave’, or simply ‘deep’ sleep. Have you ever woken unexpectedly and found yourself utterly confused, groggy and disorientated? If so, it’s likely that you were awoken from slow wave sleep.

Stage 5: REM sleep

Finally, stage 5 is known as Rapid Eye Movement (or REM) sleep; and it’s during this stage that we have intense dreams. Again, the name of this stage is telling: during REM sleep, our eyes dart rapidly from side-to-side. This is something you might notice in your child if you watch them closely during sleep.

Interestingly, during REM sleep our brain activity is not slowed: it’s much the same as when we’re awake. This partly explains why we have such vivid dreams during REM sleep: because our brains are, in fact, highly active, despite us being unconscious!

How many hours of sleep does my child need?

The exact amount of sleep that your child needs will depend on their age. Babies, for example, spend a large proportion of their time sleeping, partly because this enables the rapid physical growth and brain development that is happening.

importance of sleepAs your child grows, however, the amount of sleep time that they require will decrease. So, how much time should children of different ages spend sleeping? The National Sleep Foundation [9] has provided the following estimates:

Newborns (0-3 months)

Newborn babies typically require between 14 and 17 hours of sleep per day. Their sleep occurs sporadically, throughout the day and night.

Because children of this age have yet to develop an internal clock regulating their sleep-wake cycles, their sleep patterns tend to be unpredictable, as the characteristically sleep deprived parents of newborns understand all too well!

Infants (4-11 months)

Children of this age spend between 12 and 15 hours sleeping. During this phase of development, your child is starting to develop a routine whereby the majority of sleep occurs at night, with briefer naps interspersed throughout the day.

Toddlers (1 – 2 years)

Toddlers need between 11 and 14 hours of sleep per day. Whilst it’s normal for children of this age to have a nap during the day, their internal sleep clock is now largely aligned with their adult counterparts.

Preschoolers (3 – 5 years)

Children of this age need between 10 and 13 hours of sleep. As they age and become increasingly involved in preschool or related day time activities, their day time naps become shorter and occur less frequently.

School aged Children (6 – 13 years)

School aged children need between 9 and 11 hours of sleep. Despite needing more sleep than adults, they face a plethora of social, academic and recreational pressures and may struggle to get enough sleep, in light of these new demands!

Teenagers (14 – 17 years)

Most teenagers need 8 to 10 hours of sleep. Although your adolescent’s pattern of daily activity looks similar to that of most adults, teenagers still need slightly more sleep, given that the parts of their brain responsible for planning and complex thinking are still developing.

Sleep problems vs sleep disorders

A sleep problem is anything that disturbs the quality and quantity of your child’s sleep.

It’s perfectly normal to have brief periods of disturbed sleep from time to time, but a sleep problem is not the same as a sleep disorder, which is a diagnosable condition requiring treatment. So, at what point does a frustrating but manageable sleep problem become a sleep disorder?

If your child’s sleep is disturbed regularly enough that their functioning at home, school or with peers is suffering, this suggests the presence of an actual sleep disorder, rather than just a transient sleep problem [10].

In other words, a sleep disorder is a sleep problem that a) happens unusually often and/or b) interferes with your child’s life.

How common are sleep problems?

Sleep disorders represent a common challenge faced by parents all over the world. For example, one study [11] found that over a quarter of children are affected by sleep disorders; and the National Sleep Foundation estimates that 69% of children under 10 experience sleep problems!

So, whilst the statistics may vary, one thing is for sure: sleep problems affect a huge proportion of children.

How are sleep disorders diagnosed?

The process starts with you or your child becoming concerned about sleep disturbance or day time sleepiness. School age children and adolescents may be able to communicate to you that they’re struggling.

But with infants and toddlers – and in the case of certain sleep disorders that are less easily noticeable – it’s generally up to you, the parent, to notice any changes or worrying signs in terms of your child’s sleep patterns and day time functioning.

Visit your primary health care practitioner

If you think your child has a sleep disorder, you should pay a visit to your GP or primary health care practitioner for a professional opinion. Although in this article we give you an in-depth overview of sleep disorders this information should not be used instead of a medical consultation.

Following a clinical interview and physical exam, your doctor will probably suggest one of the following:

A) you can go home and relax – what your child is experiencing is developmentally appropriate and will pass on its own.

B) Your child may be given medication, behavioural strategies, or both for managing the sleep problem.

C) Your child may be referred on to a sleep clinic, paediatrician or sleep specialist to get a deeper understanding of what’s going on.

Polysomnogram

Pediatric polysomnogram

In order to rule out any other conditions that might be causing your child’s difficulties, a sleep specialist may recommend a polysomnogram. This is an overnight sleep test that usually happens at a sleep clinic.

Your child will be hooked up to various sensors to measure their eye movement, breathing patterns, brain activity, muscular movements, blood-oxygen levels and other important biometrics.

While there are some home sleep tests that can be used in the comfort of your child’s own bed, these aren’t able to provide as much detailed information as a polysomnogram and are generally only used when screening for sleep apnoea.

Don’t worry, though: you’re allowed (in fact, required) to accompany your child for the sleep study and usually children manage the process without too much stress.

Multiple Sleep Latency Test (MSLT).

Another test that your sleep specialist may recommend is called the MSLT. Like the polysomnogram, this is performed at a sleep clinic and usually it will be done the day following a polysomnogram.

This is a full-day sleep study in which your child will be asked to take 5 short naps, spaced 2 hours apart. Again, they are hooked up to sensors which measure a) how long they take to fall asleep and b) what stage of sleep they are in during their naps.

The MSLT is often used when narcolepsy is suspected. If your child has this disorder, their night time sleep is severely disrupted. This means that when they take a day-time nap, their brain takes full advantage of the situation: the MSLT will likely show that your child falls asleep incredibly quickly and passes rapidly into REM sleep.

Remember that the REM stage is restorative and necessary for optimum functioning, so when you haven’t had enough of it your brain and body will work hard to get you back into that stage of sleep.

How can you prepare for a doctor’s visit?

When speaking to a health professional, they will need to gather as much information as they can in order to work out how best to help your child.

You’ll likely be asked a long list of questions about, for example, whether sleeping problems run in the family, whether there are factors in your child’s day-to-day routine that might be causing the problem, or whether your child has any other psychological or medical problems that could be affecting their sleep, and so on.

Of course, your doctor or sleep specialist will also want a detailed account of your child’s sleep patterns and any difficulties that they are having! You can assist in this regard by recording a sleep diary prior to the appointment.

This is a daily record of when your child goes to sleep, when they wake up, how well they sleep, whether they have any night-time awakenings, how they feel during the day and whether they’re engaging in any behaviours that impact on their sleep routine. You can access a free sleep diary template here.

What about overnight sleep studies? This can feel somewhat intimidating for both you and your child. If possible, try to make it into a fun occasion. Remind your child that they will be allowed to bring along any comfort items that they may desire – blankets, toys, pyjamas and books.

Furthermore, remember that you’ll be sleeping together and there will be no prescribed bed-time! Why not use this as a chance to catch up on some quality pizza and Netlflix time together?

What are some common sleep disorders?

Insomnia

Insomnia is the term given to someone who struggles to fall or stay asleep. This is an incredibly common problem, affecting up to 41% of children and 17% of adolescents [12]! Insomnia can exist as its own diagnosis (primary insomnia) or as a symptom of another medical or sleep disorder (secondary insomnia).

What are some of the symptoms of insomnia?

  • Taking a long time or being unable to fall asleep.
  • Struggling to sleep through the night without waking up.
  • Not wanting to sleep alone.
  • Excessive daytime sleepiness.
  • Irritability.
  • Memory problems.
  • Poor academic functioning.

How can I tell if my child or teen has insomnia?

Older children are more likely to speak up about this problem. In younger children, you can look out for signs such as tossing and turning during the night, distractibility and others listed above.

The challenge, however, is in identifying the cause of the insomnia. This condition has many possible causes, from psychiatric disorders (such as depression, ADHD, anxiety or everyday stress) to medical conditions (such as asthma or allergies); from noisy and uncomfortable bedrooms to excessive caffeine consumption or too much screen time before bed!

Ultimately, your doctor or sleep specialist will need to do some detective work to find out the cause and the best way of treating insomnia in your child or adolescent.

Narcolepsy

Narcolepsy is a sleep problem affecting the part of the brain that regulates our sleep patterns. This means that if you suffer from narcolepsy you’re likely to feel incredibly sleepy during the day and may unintentionally fall asleep at strange or inappropriate times, such as whilst working, talking or eating!

What are some of the symptoms of narcolepsy?

  • Excessive daytime sleepiness.
  • Falling asleep involuntarily during the day.
  • Sudden attacks of muscular weakness (called cataplexy) that may be triggered by stress and/or strong emotions.
  • Sleep paralysis: an experience of being temporarily paralyzed when falling asleep or waking up.
  • Vivid dreams or nightmares occurring just before falling asleep (called hypnagogic hallucinations).
  • Disturbed sleep at night.
  • Difficulties with learning, attention, memory and concentration because of sleepiness.

How do I tell if my child or teen has narcolepsy?

Children and teens with narcolepsy are often incorrectly thought to have ADHD, learning disorders or depression. Others are simply labelled as being lazy, all because of the sleepiness and distractibility that they experience during the day.

On the other hand, narcolepsy can be confused with other sleep disorders, such as periodic limb movement syndrome and sleep apnea, both of which have some similar symptoms.

When making a diagnosis of narcolepsy your sleep specialist will often need to perform a polysomnogram and a Multiple Sleep Latency Test (MSLT).

Obstructive Sleep Apnea (OSA)

Children and teens with OSA struggle to breathe properly whilst sleeping, which is evident due to gasping sounds or unusually loud snoring.

In such cases, the muscles in the back of the throat relax repeatedly, leading to a narrowing of the airway and making breathing difficult. This causes the person with OSA to wake up in order to take another breath; and this means that people with OSA struggle to achieve enough deep sleep.

OSA MAS

What are some of the symptoms of OSA?

  • Snoring and gasping sounds at night.
  • Pauses in breathing during sleep.
  • Bed-wetting.
  • Day time fatigue.
  • Irritability.
  • Morning headaches.

How do I know if my child or teen has OSA?

The biggest tell-tale sign of OSA is daytime sleepiness. There are, of course, many other conditions that could cause this, such as narcolepsy, nightmares, depression or simply not getting enough sleep.

Part of your doctor’s assessment will involve asking questions to determine whether any of these alternatives need to be considered instead of OSA.

On the other hand, your child’s symptoms might be caused by different problems, such as gastric reflux or other nose and throat blockages. Central sleep apnea is another similar condition which happens when the part of our brain that regulates breathing momentarily stops sending signals to the body.

All of these conditions cause similar symptoms to OSA and an assessment by a specialist – usually a neurologist or ear-nose-throat doctor – will help determine whether your child has OSA or a different condition altogether.

Restless Leg Syndrome (RLS)

RLS is a neurological condition and its main identifying feature is a sense of agitation and discomfort in your child’s legs, typically (though not always) occurring at night or during periods of rest.

Approximately 1.9% of all children (aged 8-12) and 2% of adolescents struggle with RLS [13]! Although scientists have yet to understand the exact cause of RLS, caffeine, chocolate and certain medications can make this condition worse.

What are some of the symptoms of RLS?

  • Discomfort in one’s legs: your child may feel tingling, pins-and-needles or creepy-crawly sensations.
  • They often describe an overpowering urge to move their legs, which temporarily relieves the discomfort.
  • Disturbed sleep.
  • Daytime sleepiness.
  • Difficulties with concentration and alertness during the day.
  • Irritability, moodiness and aggression.
  • Hyperactivity.

How do I know if my child or teen has RLS?

As many parents will know, growing pains – an ordinary and expected phenomenon – can lead to aches, pain and general discomfort in the limbs. When growing pains affect the legs, this can look a lot like RLS!

The big difference between the two, however, is that in the case of growing pains, moving one’s legs does not alleviate the discomfort as it does in the case of RLS.

ADHD and RLS look incredibly similar to one another. In particular, both involve an inability to sit still, irritability, reduced concentration and hyperactivity; and if your child experiences restless leg sensations during the day as well as during the night, this can make diagnosis very tricky.

Interestingly, RLS and ADHD often co-occur. In one study, for example, 44% of people with ADHD were found to also have RLS [14]!

Often, therefore, a careful screening interview along with an overnight sleep study (polysomnogram) may be needed to work out whether your child has RLS, ADHD or both.

Delayed Sleep-Wake Disorder (DSWD)

This problem is most common amongst adolescents. This disorder makes them seem like night owls: alert and active when it’s dark but struggling to wake up in time for school or work. On weekends, if your teen is not expected to wake up so early, they’re likely to sleep late and catch up on the sleep that they missed during the week.

DSWD is a type of circadian rhythm sleep disorder, which means that it is related to a problem with your teen’s internal biological clock – the mechanism responsible for telling him or her when to feel awake versus sleepy.

What are some of the symptoms of DSWD?

  • Excessive daytime sleepiness.
  • Difficulty falling asleep at an appropriate time.
  • Difficulty waking up at an appropriate time.
  • This sleep pattern often impacts on your child’s day-to-day functioning at work or school; and frequent absenteeism is often a concern.

How do I know if my child or teen has DSWD?

DSWD may be confused with a specific and highly prevalent condition: adolescence! It’s no secret that teens prefer sleeping in to waking up for school; and people with this disorder are often written off as being lazy or oppositional.

So how do we differentiate DSWD – a very real and challenging biological disorder – from common adolescent behavior?

The impact that DSWD has on a teen’s life goes far beyond a few missed classes and disgruntled parents. If daily lateness and frequent absenteeism due to oversleeping are getting them into serious trouble at school or impacting their grades, for example, you may be looking at DSWD rather than ordinary behavior.

Chronic insomnia is also frequently confused with DSWD, as it also involves a difficulty in falling asleep.

The difference between the two, however, is that an adolescent with DSWD will sleep the whole night through when they don’t have to wake up for school, whereas someone with insomnia is likely to struggle to maintain their sleep throughout the night.

On the other hand, the very real challenges of DSWD may be confused with other conditions that make it hard for your child to get to sleep, such as depression and anxiety; and in fact, these disorders often overlap and coexist.

In order to work out whether your teen is suffering from DSWD, a doctor or psychologist will need to do a careful clinical interview.

Periodic Limb Movement Disorder (PLMD)

People suffering from PLMD – a fairly rare condition amongst children and teens – experience uncontrollable muscular jerks, contractions or twitches in their feet or legs. All of this makes it harder for them to fall into a deep sleep.

Despite this, your child or teen will usually have no memory of these movements having happened during the night.

What are some of the symptoms of PLMD?

  • Repetitive muscular jerks in the limbs (most often the legs) during sleep. These usually happen during cluster periods of minutes or even hours, during which the jerks happen every 20 to 40 seconds
  • Night time pain and discomfort in the legs
  • Disturbed sleep and excessive daytime sleepiness
  • Hyperactivity, distractibility and academic difficulties

How do I know if my child or teen has PLMD?

To diagnose this disorder, your child will need to have a polysomnogram. This will help the sleep specialist to decide whether the pattern of muscular twitches look like PLMD or another similar disorder, such as Restless Leg Syndrome (RLS).

Apart from the differences in the pattern and frequency of twitches, RLS keeps a person awake, whereas someone with PLMD will sleep through the twitches; though they will struggle to fall into a deep sleep.

Although the two are different conditions, there is a lot of overlap between them and people with RLS are 80% more likely to also have PLMD [15]! There is also a fair amount of overlap between PLMD and ADHD, in that both are linked to hyperactivity and distractibility during the day-time.

Therefore, in order to work out whether your child has PLMD your doctor will need to check for symptoms of ADHD as well, to see whether this might be the underlying cause of your child’s daytime attentional problems.

Confusional Arousals

Imagine seeing your child confused and upset, but you’re unable to help. This is the struggle faced by parents whose infants – usually aged 5 and under – experience confusional arousals.

Children with this condition appear to wake up scared, disoriented and unable to communicate clearly – for this reason, the disorder is also known as ‘sleep drunkenness’.

These episodes happen when your child’s brain is, well, confused – namely about whether it is awake or asleep. More specifically, your child is asleep but the parts of their brain that control actions such as twitching and crying are still active.

Sleep experts believe that generally these episodes are a normal part of your child’s development, rather than reflecting a worrying underlying condition [16].

Nonetheless, confusional arousals can be incredibly distressing for the parents of the affected child. While it’s tempting to wake your child up and console them, often this can make them even more confused or scared; and it’s usually best to allow them to simply ride it out.

What are some of the symptoms of confusional arousals?

  • Moments of awakening where your child may mumble, cry, sit up or thrash about.
  • The episodes are usually over within a matter of minutes and they typically occur at least two hours into sleep.
  • During these awakenings, they are not able to respond appropriately to environmental stimuli, including your efforts at consoling them. So, while they may respond to your voice, their responses are usually incoherent or illogical.
  • While the episodes may involve twitching, scratching and picking at the sheets, they do not involve gross motor movements, such as walking or jumping out of bed.
  • Children with this disorder typically don’t remember anything unusual having happened during the night.

How do I know if my child or teen has confusional arousals?

This condition is easily confused with sleep terrors, which are often described as a rarer and more intense version of confusional arousals. Given that confusional arousals represent a milder form of the disorder, they often build up gradually rather than starting with a blood-curdling scream, as with sleep terrors (described below)!

Furthermore, when in a confusional arousal your child looks like they’re awake, whereas with sleep terrors it looks like they’re asleep, albeit having a vivid dream.

Confusional arousals can also exist alongside and be triggered by other sleep disorders, such restless leg syndrome or periodic limb movement disorder.

For this reason, it’s important that a sleep specialist does a thorough investigation to work out exactly what is causing the problem and how best to move forward from there.

Sleep Terrors

Also known as night terrors, this frightening disorder may look to you, the parent, like an extremely vivid and distressing nightmare. Your child may sit bolt upright and scream; and they often appear terrified, with eyes sparingly fixed on some unknown horror.

This disorder is most common in children between 3 and 12 years of age, although it may also happen amongst teens. The episodes themselves usually last between 1 and 3 minutes, but it may take half an hour for your child to calm down thereafter.

Sleep terrors are problematic in that they stop your child from getting a good night’s rest, making them sleepy, grumpy or unfocussed the following day. Furthermore, it’s important to monitor them during an episode in case they get out of bed and thrash around, which may place them or others at risk of injury.

Apart from these risks, however, most children grow out of sleep terrors without experiencing any long-term damage.

What are some of the symptoms of sleep terrors?

  • Recurrent episodes of extreme fear during the night, often starting with a scream.
  • Usually your child will not respond when you speak to them during a terror.
  • Sweating with increased heart rate and breathing.
  • Upon awakening, they will have no memory of the event or the dream content.

How do I know if my child or teen has sleep terrors?

Aren’t sleep terrors just intense nightmares? The answer is no: nightmares happen during REM (stage 5) sleep, whereas sleep terrors usually occur shortly after falling asleep, during sleep stages 3 and 4. During sleep terrors, your child is not really dreaming!

For this reason, it’s extremely difficult to wake your child up from a sleep terror, and they’re highly unlikely to remember any of what happened. On the other hand, children are often able to give you a blow-by-blow story of their nightmares; and if you see them having a nightmare, it’s easy enough to wake them up!

Sleep terrors are sometimes confused with seizures, which can cause a similar state of agitation along with sleep walking and bedwetting.

In order to make sure that your child or teen isn’t experiencing seizures, your doctor or sleep specialist may ask about your child’s symptoms, family history of epilepsy and perhaps even request a brain scan (EEG) for detecting seizures.

Sleep Walking

Sleep walking, also known as somnambulism, is a very common condition occurring in nearly one fifth of all children, particularly those aged 4 to 8 [17].

Don’t let the disorder’s name fool you, however: it involves behaviors beyond just walking. For example, sleep walkers may crawl, sit, talk, rub their eyes and even urinate in strange places (such as the wardrobe)!

In rarer cases, sleep walkers have even been known to leave the house, become violent or drive a car! For this reason, sleep walking can put your child at risk of being injured and it’s best to try to wake them from an episode (unlike with confusional arousals or sleep terrors).

Having said that, this condition doesn’t usually call for any sort of medical treatment and often sleep walking goes away by itself as your child ages.

What are some of the symptoms of sleep walking?

  • Performing complex behaviors during sleep, including walking, sitting or crawling.
  • Your child’s eyes may be open and glazed over. They may talk but are generally only slightly responsive during an episode.

How do I know if my child has this disorder?

So, you know that your child gets up and walks around during the night whilst clearly still asleep. Does that mean that they have this disorder? Not necessarily. Similar behavior can have other causes, for example, epileptic seizures.

If your doctor suspects that your child’s behavior might be caused by seizures, they may request a brain scan (EEG); or else a sleep study to see if sleep walking is being triggered by other sleep disorders, such as sleep apnea.

Sleep walking can also be caused by a psychiatric condition such as post-traumatic stress disorder (PTSD), so it’s important for a clinician to assess whether your child has experienced trauma or other symptoms of PTSD (such as frightening memories or periods of forgetfulness).

Sleep Paralysis

Imagine being trapped inside your own sleeping self, helplessly unable to control any part of your body. That’s what it’s like to suffer from sleep paralysis – a sleep disorder that is more common amongst adolescents than children.

These episodes, which normally last no longer than two minutes, usually occur shortly after falling asleep (hypnagogic form) or just before waking up (hypnopompic form).

How does sleep paralysis happen? During sleep, our bodies are offline and disconnected from our brains, which is why we’re able to dream without physically acting out what’s happening. During sleep paralysis, however, a part of our brain is awake, allowing us to be aware of our sleeping bodies!

Although these episodes can be unsettling, they’re not problematic in and of themselves.

What are some of the symptoms of sleep paralysis?

  • Becoming conscious during sleep.
  • An inability to move or control one’s body, often accompanied by feelings of terror.
  • Episodes may be distressing and may be accompanied by scary hallucinations – for example, your son or daughter might imagine a person or presence in the room that wants to harm them.

How do I know if my child or teen has sleep paralysis?

This condition can be confused with ordinary nightmares. The difference is that with nightmares, your son or daughter usually isn’t aware of the environment (usually their bedroom) or of being paralyzed.

Nonetheless, it is possible that they are simply dreaming of being semi-conscious whilst also paralyzed; but this sort of nightmare would be an unlikely coincidence!

People with Sleep Paralysis may also be thought to have post-traumatic stress disorder (PTSD), which can also change a person’s patterns of sleep and alertness. A person might experience scary flashbacks of the traumatic encounter, which at times can look a lot like sleep paralysis.

When deciding whether your teen is suffering from PTSD or sleep paralysis, a careful clinical interview should take place regarding other possible symptoms. Keep in mind that with PTSD, flashbacks can happen at any time during the day, not just during sleep-wake transitions.

Also, whilst people with PTSD often struggle with feelings of helplessness and powerlessness, this generally doesn’t involve physical paralysis as well.

Finally, sleep paralysis is also sometimes confused with sleep terrors, especially when the paralysis is accompanied by frightening hallucinations! The difference, however, is that you, as a parent, can often awaken someone from their sleep paralysis by comforting them, whereas this isn’t possible with sleep terrors.

Often, your doctor may ask you to keep a sleep dairy so that they can have clearer picture of your child’s pattern of sleep problems. If they suspect that a different disorder might be causing your child’s problems, they may write a referral for a polysomnogram or an assessment with a psychologist.

Sleep Talking

As you most likely know from the name, sleep talking (or somniloquy) involves your child speaking out, in a variety of ways whilst asleep. It’s a fairly common disorder, affecting as many as 50% of children under 13; and it is more likely in people who struggle with other sleep disorders [18].

Sleep studies show that somniloquy can happen during any stage of sleep, but that the speech becomes increasingly difficult to understand as the person passes into the deeper stages.

When sleep talking occurs during REM (stage 5) sleep, your child may be talking in relation to what’s going on in their dream!

Ultimately, sleep talking is completely harmless to a child – although it may annoy anyone who shares a room with them!

What are some of the symptoms of sleep talking?

  • Speaking out during sleep. This may take the form of anything from incoherent mumblings and mutterings to the shouting of rude words and even elaborate conversations.
  • The sleep talker is usually unaware of ever having spoken during the night.
  • The symptoms are often accompanied by other sleep disorders.

How do I know if my child or teen has this disorder?

It can be challenging to know whether your child is simply demonstrating harmless sleep talking behavior, or if this might be a part of another sleep disorder, such as sleep walking, sleep terrors, sleep related eating disorder or sleep apnea.

If you’re noticing other unusual behavior or if you feel that your child’s sleep talking may be making them tired during the day, then it’s definitely worth speaking to a doctor or sleep specialist who may conduct a sleep study to work out whether any of these other conditions may be causing your child’s sleep talking.

Sleep Related Eating Disorder (SRED)

Do you ever wake up the morning to find that your kitchen supplies – especially the tastier bits – have been heavily depleted? Is someone in your house a chronic midnight snacker? Or is it possible that they qualify for a diagnosis of sleep-related eating disorder?

With SRED – a disorder more common amongst adolescents than children – the person is able to prepare and eat a large meal whilst asleep. It may sound slightly comical, but this is a serious condition which brings with it a risk of developing obesity and Type 2 Diabetes.

Beyond that, the sleep-eater may put themselves at risk of hurting themselves whilst preparing food or perhaps even accidentally eating something inappropriate and harmful.

What are some of the symptoms of SRED?

  • Frequent episodes of uncontrolled eating whilst asleep.
  • Large volumes of food are typically eaten – usually foods that are high in fats or carbohydrates.
  • It is difficult to wake the person up during these episodes and they often won’t remember the episode the following day.

How do I know if my child or teen has this disorder?

While seeing a sleep specialist, your adolescent will need to be assessed for a similar condition called Night-Eating Syndrome. This is an eating disorder, closely associated with bulimia and binge-eating disorder.

Although SRED and night-eating syndrome both involve night-time binges, night-eating syndrome is not actually a sleep disorder because the person is conscious and aware during their episodes.

Furthermore, SRED is also closely linked to and may co-occur with other sleep disorders such as sleep walking, narcolepsy and obstructive sleep apnea.

Sleep eating episodes may also be triggered by depression and stress; or by the use of certain sedative medications (such as Zolpidem) and antidepressants (such as Zoloft).

To be diagnosed, your adolescent will likely undergo a physical exam and have detailed questions asked about their sleep patterns. Your doctor will use this information – and perhaps even data from a polysomnogram – to work out whether anything other than SRED might be causing this behavior.

Other medical and psychiatric conditions that are linked to sleep problems

If your child has been diagnosed with one of the following medical or psychiatric conditions, they are statistically more likely to have been diagnosed with a sleep disorder as well [19].

Often, a vicious cycle develops where children are at risk for sleep problems because of their medical condition; and their sleep problems then make it harder to cope with and recover from their pre-existing condition. This, in turn, makes it more likely that they will struggle to sleep!

For this reason, it’s very important that health professionals pay attention to these conditions which may be causing, caused by or contributing to your child’s sleep difficulties.

A lot of medical detective work may be required to work out which problem is causing which, so that your child’s difficulties can be treated effectively.

Now, let’s look at some medical and psychiatric conditions that are closely linked to sleep disorders.

Diabetes

Type 1 Diabetes is one of the most common chronic illnesses amongst children; and an increasing rate of children and adolescents are also developing Type 2 diabetes, both of which may put your child at risk of developing a sleep disorder.

When children with diabetes experience fluctuations in their blood sugar, this can be physiologically uncomfortable, and this has been linked to more frequent awakenings and overall sleep deprivation [20].

Asthma

Asthma is another common condition in kids and teens that is closely linked to sleep disorders, including night time arousals and reduced time spent in deep sleep [21].

Essentially, asthma is an inflammation of the airway; and it’s known that this naturally becomes worse at night, thereby making it harder to breathe comfortably enough to sleep properly.

Interestingly, kids with Asthma who have a poor night’s sleep are likely to have worse asthma symptoms the following day!

Allergic Rhinitis

Like asthma, allergic rhinitis is an inflammation of the airway. This is an allergic reaction to anything from dust mites to mold or pollen; and these allergens can lead to an itchy and irritated throat and nasal passage.

This sort of uncomfortable allergic reaction makes it harder to breathe comfortably and thus to sleep – and for this reason childhood allergic rhinitis is closely linked to obstructive sleep apnea along with sleep problems more generally [22].

Chronic Pain

In children and adolescents, chronic pain can exist as a result of another condition (such as cancer, arthritis or inflammatory bowel diseases), or it can exist in its own right, such as in the case of severe stomach aches and persistent headaches.

Needless to say, pain makes it hard to fall asleep, to stay asleep and to experience enough good quality sleep.

Epilepsy

Children with epilepsy experience seizures: a disruption of electrical signals in their brain. Epilepsy can be caused by a brain injury, by genetics or both

. Regardless, there is a strong link between epilepsy and sleep disorders: a seizure can increase the amount of time spent in Stage 1 sleep, whilst decreasing time spent in restorative REM sleep [23]. Furthermore, if your child hasn’t slept well this puts them at risk of having further seizures.

Gastroesophageal Reflux Disease (GERD)

If you have ever experienced a bad case of heartburn, you’ll know that this can easily be unpleasant enough to keep you from sleeping. GERD is a chronic condition affecting children who experience a reflux of gastric (stomach) fluids into their esophagus.

Evidence suggests that GERD is a risk factor for obstructive sleep apnea and may cause disturbed sleep due to general nighttime awakenings [24].

Depression (Major Depressive Disorder)

Depression and sleep disorders go hand-in-hand. Does this mean that depression causes sleep problems; or is it possible that sleep disorders lead to depression?

This riddle of the chicken or the egg has kept brains scientists busy for many years and at this point in time it seems entirely plausible that depression and sleep problems reinforce one another.

For example, if your child or adolescent struggles with depression, they are more likely to have insomnia. However, the fact that they’re not getting enough REM sleep each night can also cause brain chemical changes that make their depressive symptoms worse.

It’s not surprising, then, that research has shown people with depression and insomnia to take longer to recover, compared to those who lacked the insomnia [25]. It seems that insomnia made it harder for them to cope with their depressive symptoms!

One final thing to note, however, is that the link between depression and sleep problems is stronger for adolescents than for children [26], meaning that doctors and parents alike should be careful about interpreting sleep problems in younger children as signs of depression.

Anxiety Disorders

Anxiety disorders are one of the most common psychological conditions affecting children today. Examples include phobias, generalized anxiety, panic attacks and separation anxiety.

All of these disorders are closely linked with disturbed sleep: for example, one study of 128 children and adolescents showed that kids with anxiety disorders were 88% more likely to have a sleep problem [27]!

Again, researchers aren’t entirely sure whether anxiety causes sleep problems or vice versa, but if your child suffers from either one it’s important that the health professional treating them attends to both issues simultaneously.

Stress

Everyday stress is not a medical or psychiatric disorder in and of itself; but it’s something that’s worth talking about, given that 1 in 5 children experience it, according to a survey by the American Psychological Association [28].

It shouldn’t come as a surprise that stress and sleep are not exactly best friends: research has shown repeatedly that stress is closely linked to and may aggravate existing sleep problems.

This is because stress causes a release of hormones and changes in the nervous system that amounts to a triggering of the fight or flight response [29]. In other words, when your child or teen is stressed, their body is wired to jump into action – not to lie down and go to sleep!

Autism Spectrum Disorder (ASD)

Research shows that as many as 80% of youngsters with ASD also struggle with insomnia and other sleep disorders [30]. Why? There are several theories that can help us to make sense of this link.

For example, the brains of people with ASD may struggle to regulate their circadian rhythms, partly because melatonin – the hormone that helps to control one’s biological clock – is produced in irregular quantities. This means that people with ASD struggle on a biological level to regulate their sleep-wake cycles.

Furthermore, people with ASD are at risk of having other psychological disorders such as depression and anxiety, both of which are linked to sleep difficulties. Finally, certain medications that are used to help people with ASD may have sleep difficulties as a side effect.

Attention Deficit Hyperactivity Disorder (ADHD)

Kids with ADHD struggle to focus and concentrate; their behavior also tends to be hyperactive and impulsive. Interestingly, these problems are often caused by sleep deprivation in people who don’t have ADHD! For example, hyperactive behavior may represent an attempt at coping with daytime sleepiness!

It’s no surprise, then, that ADHD will put your child at increased risk of sleep disorders such as restless leg syndrome, periodic limb movement disorder, obstructive sleep apnea and circadian rhythm disorders [31].

Furthermore, children with ADHD are typically treated with stimulant medications (such as Ritalin and Concerta), which can keep them awake at night.

How are sleep disorders treated?

Once your doctor has determined which sleep disorder your youngster is dealing with – as well as the possible factors that are causing and maintaining this disorder – you will be ready to explore the best treatment options.

Fortunately, there are a wide variety of safe and effective possibilities for children and adolescents with sleep disorders.

  • Behavioral interventions

Behavior therapy – which involves working with a health professional to find creative ways of changing your child’s sleep patterns – is regarded as a first line approach for treating children’s sleep problems [32]. There are many different behavioral approaches that have been proven to be effective.

For example:

Relaxation training

Relaxation training is a popular strategy for teaching anxious and distractible children to soothe themselves at bed time. This might involve, for example, helping them to meditate, take deep diaphragmatic breaths or calm their bodies through a technique called progressive muscular relaxation.

Stimulus control

Stimulus control involves working out exactly what aspects of your child’s environment are contributing to their sleep disorder and finding ways to minimize these factors. Examples of problematic environmental stimuli include bright light, noises, extreme temperatures and even unhelpful thoughts that pop into your child’s head.

Cognitive Behavioral Therapy (CBT)

CBT trains a child to identify and change these sorts of problematic thoughts. Examples include: “I’m definitely not going to be able to sleep tonight” or “It’s 11pm and I’m still not asleep” and “I’m going to feel absolutely horrible tomorrow”.

These sorts of thoughts can increase feelings of anxiety, making it even harder to get to sleep. CBT is favorite amongst my own clients because it’s straight forward, practical and has a strong evidence base behind it.

Scheduled awakenings

For children who struggle with sleep terrors or confusional arousals, scheduled awakenings may be recommended [33]. Often, these sleep problems happen at more or less the same time.

The first intervention involves identifying the time at which these happen and waking your child about half an hour before they happen. This helps by altering your child’s sleep cycle, so that they avoid entering the problematic stage with which sleep terrors are associated.

Extinction

Extinction is a strategy often used in children who struggle to separate from their parents at bed time. They may cry out and ask for a parent to be with them. However, according to this intervention, going to your child simply reinforces the problem by stopping them from learning to self-soothe and fall asleep on their own.

In other words, extinction involves supporting and training parents to ignore their child’s cries when this happens at bed time. A similar, but slightly kinder approach is called graduated extinction (or the Ferber Method) and this involves checking-in on your child very briefly when they cry, instead of ignoring them completely.

Parents are encouraged to gradually increase the amount of time that they hold-off before checking in, until they’re able to stop doing so completely. Understandably, parents rarely opt for extinction-based approaches because it can be highly distressing for them to ignore their child!

Note: Can extinction techniques harm your child? It has been suggested that extinction or graduated extinction may affect your child’s emotional development negatively, but more research is needed in order to work out whether there are any long-term consequences.

  • Medication

Medication should be used sparingly amongst children and adolescents with sleep disorders. This is partly due to insufficient evidence for the usefulness of medication over other strategies, and partly due to avoid unpleasant side effects [34].

Nonetheless, there is a place for medication, especially when other treatments have been ineffective or when this is used in combination with other therapies. Let’s look at some medications that are commonly used:

Melatonin

Melatonin is used to treat general insomnia and circadian rhythm disorders, as well as more general sleep issues in children with ADHD or autism spectrum disorder. Melatonin is produced naturally in the brain and taking it helps to regulate a person’s biological sleep-wake cycles. This medication is generally thought to be a safe and effective option.

Antihistamines and Antidepressants

Certain antihistamines (e.g. Diphenhydramine) and antidepressants (e.g. Trazadone) have drowsiness as a side effect. For this reason, these medications may sometimes be used to help manage sleep problems.

Sedating Medications

Finally, sedating medications such as Clonazepam and Ambien may also be prescribed in the case of parasomnias: in particular sleep walking and sleep terrors. However, it’s important to keep in mind that these drugs are habit forming and may have problematic side [35].

  • Other strategies

Adenotonsillectomy

An adenotonsillectomy is a medical procedure which involves surgically removing your child’s tonsils and adenoids (glands located in the roof of the mouth). This is an effective way of treating obstructive sleep apnea, so that the airway does not become so easily blocked during sleep.

Continuous positive airway pressure (CPAP) device

Another highly effective way of managing obstructive sleep apnea is to use a CPAP device. This is a mask which fits over your child’s face and it helps by softly blowing air down the airway to make sure that they are breathing properly.

Light therapy

Light therapy is used to treat circadian rhythm problems such as delayed sleep-wake disorder. This involves repeatedly exposing your child’s eyes to a source of artificial light, which helps to reset their circadian rhythms, thereby bringing about a more regular sleep-wake schedule.

Light therapy may have the added benefit of improving your child’s mood and cognition; and it has been shown to be effective in the treatment of depression!

  • Education

Finally, education is a simple but effective strategy employed by most health practitioners to help you and your child to work together in managing a sleep condition.

This may be a simple matter of knowing that you shouldn’t try to wake your child up during a night terror (because this can lead to more confusion), but that you can console and control them during an episode of sleep walking.

This is also a matter of helping your child to identify what triggers and worsens their sleep problems, so that they can make changes to their lifestyle in order to take control of their disorder. Often, education involves learning about sleep hygiene.

What is sleep hygiene?

Sleep hygiene consists of the routines and habits that are put in place to help your child sleep better. Whilst this is an effective way of preventing and managing sleep disorders, sleep hygiene can be used by anyone – adults or children – to improve sleep quality more generally. Here are some sleep hygiene pointers:

  • Routine. Start a bedtime routine. The predictability of doing the same thing every night – eating dinner, followed by brushing teeth, followed by listening to a story, followed by a goodnight kiss (for the youngsters) – can help children and adolescents to fall asleep more easily.
  • Scheduled sleep and wake times. Try to go to sleep and wake up at the same time, every night. This helps your biological clock to set up an internal pattern.
  • Relax. Just before bed, relax by taking deep breaths or visualizing calming imagery.
  • De-caffeinate. Avoid caffeine after 3pm!
  • Exercise. Try to move your body at least once per day, preferable earlier rather than close to bed-time.
  • Digital detox. Avoid technology in the evenings. The bright light can trick our brains into thinking that it’s time to wake up; and more generally, we want our brain to be calming down rather than getting activated.
  • Small portions. Avoid large meals right before bedtime.
  • No stimulation in bed. Use the bed for sleeping – nothing else! If your child is reading, talking, or playing on their phone whilst in bed, their brain will start linking bedtime with an active mindset. Rather, we want being in bed to signal their brains to become sleepy!
  • Don’t toss and turn. If your child can’t sleep, encourage them to spend some time out of bed and to try again in twenty minutes. This helps to preserve the association between being in bed and being asleep.

For more pointers on sleep hygiene, take a look at this resource provided by the Harvard Medical School.

When should I seek professional help?

How can you, as a parent, know when your child’s sleep problems warrant a visit to a sleep specialist? If their sleep problem is happening more nights than not; and things are not improving despite you having implemented sleep hygiene practices, this is a cause for concern.

If your child is worried and distressed about their problem or about bedtime generally – and if their sleep difficulties are keeping you up at night as well – this is a sign that professional help might be needed.

Finally, are your child’s sleep problems are making it harder for them to be their normal selves during the day? Are their sleep patterns impacting on their mood, grades and social lives?

If any of these points describe your situation, it’s likely that you and your family will benefit from a visit to the GP, who can guide you further in taking control of the situation.

Outlook

Sleep DisorderIn summary, sleep problems are a common problem faced by children and adolescents all over the world. Disturbed sleep can cause a wide range of negative consequences for your child.

These range from mood disturbances to academic and social problems; from reduced cognitive abilities to weaker immune systems and behaviour problems. Beyond that, sleep problems very often co-exist with other medical and psychiatric conditions.

Often the sleep disorders make the other condition worse; and this in turn makes it even harder to sleep. It’s clear, then, that sleep disorders can seriously affect our children’s quality of life – not to mention our own sleep and wellbeing as concerned parents!

In this article, we have taken you through the basics of sleep: what’s normal and what’s not, what is to be expected for different age groups and what some of the more common sleep disorders look like. We have also discussed treatment options and ways that you can improve your child’s sleep hygiene.

Remember: if you are concerned that a sleep disorder is affecting your child’s quality of life, support and treatment if often simply a click or a call away! Thank you for reading and.. sweet dreams!

References

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The Ultimate Guide to Sleep Disorders and Sleep Problems in Children
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The Ultimate Guide to Sleep Disorders and Sleep Problems in Children
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About the Author Daniel Sher, M.A. Clinical Psychologist

Daniel Sher is a clinical psychologist at a private practice and a locum therapist at the Western Cape Health Department.

Sher completed his Masters in Clinical Psychology at the University of Cape Town (UCT). During this time, he was trained in various modalities of psychotherapy as well as psychological assessment at the UCT Child Guidance Clinic. Furthermore, he completed his master's thesis, titled, Cultural Discourse Among South African Clinical Psychologists, and presented his findings at the European Congress of Psychology in Stockholm, 2013.

In 2015 he worked at Valkenberg Psychiatric Hospital. More specifically, he worked at the Male Admissions Unit (acute psychosis), as well as Alexandra Hospital (Inpatient Unit and Outpatient Service for adults with comorbid Intellectual Disability and Mental Illness), J2 Psychiatry Unit at Groote Schuur Hospital and Hanover Park Community Health Clinic.

Under supervision of clinical psychologists and in collaboration with multi-disciplinary teams, he worked intersubjectively with clients suffering from psychiatric disorders using individual psychotherapy, psychoeducational groups and family interventions. He also completed psychometric and neuropsychological interventions, the latter of which involved case presentations to the Division of Neuropsychiatry at Groote Schuur Hospital.

As a Community Service Clinical Psychologist (2016), he was employed by the Western Cape Department of Health. he worked at a district level general hospital: Khayelitsha District Hospital, where he engaged in psychological interventions with clients dealing with various psychiatric disorders and comorbid medical conditions. He also provided outreach therapy services at two community health clinics and worked closely with a multi-disciplinary team consisting of psychiatrists, nurses, and family physicians.

His professional interests as a therapist include long-term psychodynamically informed therapeutic models, in addition to cognitive-behavioral and other short term solution-focused interventions.

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