Adam S. Weissman, Ph.D.
Sleep is essential to our physical and emotional health. While most of us have experienced trouble sleeping at one time or another due to stress, persistent sleep problems can compromise our mood, energy level, emotional balance, work and school performance, and our ability to handle stress. Research has shown a powerful link between childhood psychological problems and sleep disruptions including:
- Difficulty falling asleep or falling back to sleep after waking
- Waking up frequently during the night
- Sleepiness and low energy during the day
- Light, fragmented, or exhausted sleep
- Relying on sleeping pills in order to fall asleep
Studies also show that children with anxiety disorders are at particularly high risk for developing chronic sleep problems, and that chronic sleep problems, in turn, may lead to, or exacerbate an anxiety disorder. One recent study reported that insomnia appeared before the anxiety disorder in 18% of cases, whereas anxiety appeared before insomnia in 43.5% of cases (Ohayon & Roth, 2003). Research has consistently shown that anxiety and sleep problems co-occur at markedly high rates in children and exacerbate one another.
At the Child & Family Institute, a cognitive-behavioral therapy (CBT) center, anxiety and sleep problems are two of our most common referral problems. Take “John”, for example, a 14 year old high school freshman diagnosed at our clinic with generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and insomnia. When John and his family first came to see us he played X-Box until 1:00AM on weeknights because he was procrastinating from doing his schoolwork. He would then stay up for several more hours trying to complete his homework “perfectly”, erasing and re-writing his work. He would then have trouble falling asleep—worrying about school the next day, having to wake up early, and whether he completed all of his homework correctly. John reported feeling very tired throughout the day, which affected his performance on class work and exams, contributing to more nighttime worry about his grades and school performance. John was also a very talented tri-varsity athlete. Naturally his performance on the field was compromised by his fatigue. John was so wiped out by the end of the school day that when he finally got home from his games or after-school practice, he would take a 3-hour “power nap” and then wake up and turn on the Xbox, and the cycle continued.
John received a 6-month course of CBT for anxiety, OCD, insomnia, and significant parent-child conflict. Following treatment, John’s grades in school and his relationship with his parents, had all improved considerably. He was completing his homework promptly each day when he got home from school and he was back on track with a healthy, regular sleep schedule and evening routine. In addition, he was managing his anxiety and OCD effectively and had developed a coping plan for stress and worry.
John is one of many children diagnosed at our clinic with a combination of anxiety and insomnia, leading to significant exacerbation of both disorders, as well as impairments in daytime functioning and performance across multiple life domains. The good news is there are clear, effective strategies for improving the lives of these children, including the CBT tips below. With a supportive and collaborative CBT approach, children suffering from anxiety and sleep problems can regain control of their lives and begin to thrive.
Coping Tips for Kids:
1. It’s a scientifically proven fact that when we’re feeling stressed out, we tend to have anxious, exaggerated thoughts; we tend to overestimate the likelihood of something bad happening and underestimate our own abilities to cope. We especially have a tendency to feel more vulnerable and worry at night. That’s when the “worry bully” tends to rear its ugly head and disrupt our sleep. Coaching children to write down their worries can help relieve some of the stress caused by repetitive worry at night. Have them write down their worries and fears on a piece of paper and rate each anxiety-producing thought from 0-10, 10 being “extremely worried”, 0 being “not worried at all.” Having them crumple up the paper and shoot a basket across the room into the trash can make it fun. Alternatively, have them put the paper aside, and re-visit their list and re-rate each worry when they wake up. Chances are their anxiety-producing thoughts will not seem so bad in the morning. Younger children can also draw to express their fears and worries at night before bed.
2. Coach your kids to give themselves a “pep talk”. Help them identify their anxious thoughts (e.g., “I am going to fail the test” or “I’m scared and can’t be alone at night”) and come up with more positive, realistic coping thoughts (e.g., “I know my stuff and did well on the last test, I’m going to do just fine” and ” I can be brave alone in my bed at night; my room is a safe place, Mommy and Daddy are just down the hall”).
3. Teach your kids to practice deep breathing/mindful meditation before bed (e.g., “lie down in a comfortable position and concentrate on your breathing. Take long, slow deep breaths using your diaphragm (aka “belly breathing”), instead of using your chest. It is called belly breathing because your belly inflates like a balloon when you inhale and deflates when you exhale. Try inhaling slowly, and exhaling slowly. To enhance your mindful breathing, you can use a mantra, which is a word or a phrase that you say in your mind as you focus on your breath (e.g., “one… relax, two… relax” or “breathe in calm, breath out stress”).
4. Help your child create a relaxation image using a favorite place that your child can imagine. Have your child identify each sensory component of the image – what your child would see, hear, smell, feel, and taste. Perhaps make a special soothing playlist for your child’s iPod and have your child listen to relaxing music or a guided imagery relaxation recording before bed.
5. A healthy and consistent diet and exercise can provide more lasting energy throughout the day, reduce daytime fatigue, improve nighttime sleep quality, and help to regulate your child’s sleep-wake cycle.
How Parents Can Help:
1. Parents need to be a part of the solution. Set firm, consistent rewards and consequences. Tell your child that there is no computer or X-box until homework is completed, even if you need to use parental controls at first to help your child get back on track. Sometimes kids don’t want to ask for help and want to feel independent, but they still need our help, and it’s our job as parents to know the difference. Yes, it is easier to say, ”Sure honey, you can play one more game.” However, it may not be the healthiest decision for your child. It is important to help your child get into a healthy bedtime routine with good sleep hygiene, no naps, and electronics turned off at least two hours before bedtime.
2. Especially for younger children, it can be helpful to spend some 1-on-1 time with your child before bed free from electronics or distraction, talking about the day, any worries or concerns they might have, reading a book or drawing together, and cuddling. Spending just a few minutes of quality time consistently, every night before bed, can promote positive attention and predictability in the parent-child relationship, more secure attachment, and build confidence, self-esteem, and independence.
Additional Tips & Strategies:
- Set aside enough time for your child’s sleep. Most children need at least seven to nine hours of uninterrupted sleep each night in order to feel alert, focused, and productive.
- Keep your child on a regular sleep schedule. Make sure they go to sleep and wake up at a similar time each day, including on the weekends.
- Make sure your child’s bedroom is dark, cool, and quiet. Use heavy curtains or shades to block light from windows. Make sure your child’s mattress and pillows are comfortable and consider using a fan or noise machine to drown out excess noise.
- Encourage your child to use his/her bedroom as a bedroom, not for watching TV or doing work, if possible.
- Establish a regular, relaxing bedtime routine. Make sure your child avoids stimulants like chocolate and caffeine before going to sleep, and turn off all electronics a few hours before going to bed. Encourage your child to read a book, listen to soft music, or meditate instead.
- Turn the clock away from your child or remove it from the bedroom. Looking at the clock can make your child feel anxious in the middle of the night.
- Help your child keep a “Sleep Diary” to identify and track sleep patterns and pinpoint day and nighttime habits that may be contributing to your child’s sleep difficulties.
The good news is that many cases of childhood insomnia can be alleviated with lifestyle changes, better sleep habits and relaxation techniques. Contact a CBT specialist in your community if your child is experiencing more chronic or severe anxiety or sleep problems.
Ohayon M. M., & Roth T. (2003). Place of chronic insomnia in the course of depressive and anxiety disorders. Journal of Psychiatric Research, 37, 9–15.
Dr. Adam Weissman is founder and Executive Director of the Child & Family Institute. He is an adjunct clinical faculty member of Columbia University and is President-Elect of the clinical division of the Westchester County Psychological Association.
Dr. Weissman’s website is http://www.childfamilyinstitute.com/
To view Dr. Weissman’s referral listing, click here
Disclaimer: Although Dr. Weissman is a board member of the Westchester County Psychological Association (WCPA), the views in this article are his and not the views of WCPA.
Statements contained in the authored articles on the Westchester County Psychological Association (WCPA) website are the personal views of the authors and do not constitute WCPA policy unless so indicated. The information in the articles on the WCPA website is for educational purposes only. The information contained in the articles is not intended for diagnosis, psychological advice or medical advice. It is not intended to be treatment and is not a replacement for psychotherapy. If you are in need of psychological treatment, you can utilize our clinician database which can be accessed by clicking on the link, “Find a Psychologist.” WCPA and its directors and employees are not liable for any damages resulting from the utilization of information contained in articles posted on the WCPA website.