Good morning. My name is Jess Jatkin, and I am here to present to you on pediatric sleep disturbances and their management. I want to thank the APA for inviting me. I hope that what I have to share is useful for you. I'll spend 45 to 50 minutes talking. You have the slides or will have the slides, so there may be some material that, excuse me, I have to move through a little quickly so that we can have time for questions, but I'm happy to go back to anything and, of course, give you more detail at any point. All right, so let's get on with it. I'm at NYU, and there we go. Here are our learning objectives. Recognize the most common pediatric sleep concerns and their comorbidities, so we'll spend a few moments talking about that up front, and then we'll talk about some of the epidemiologic factors, risk, and likelihoods of things, and who's affected, particularly by age group amongst children and adolescents and young adults. We'll talk about some key components of a pediatric sleep history. We'll talk about identifying the primary behavioral and medication treatments, and I do have one slide on marijuana. I just wanted to add that in at the end to go over what we know about the sleep effects of marijuana because we're all seeing it so much in our practice. So a little bit of sleep education before we start. I just want to spend five minutes going over three pictures that I think will be very useful for you in every aspect of sleep, whether it's pediatric or adult. This is not pediatric specific, but it just is a reminder of things that perhaps you've learned before, perhaps not, that will be very helpful for our discussion today. So you've all seen the sleep hypnogram before somewhere, medical school, some sort of place where you learned about sleep, and this is a sort of idealized hypnogram, as we call it for an adult. Eight hours of sleep, going to bed. You can see my mouse moving here. 11 p.m. they go to bed and wake up at 7 a.m., and the phases we have are the awake phase, which comprises about three to five percent, ideally, of our night. So it's normal to be awake sometimes while you're sleeping. More on that soon. Then there's REM. Now, we should not have a REM period typically until about an hour and a half into our sleep cycle. If you go directly into REM, we call that narcolepsy. If you're very underslept and you take a nap or go to sleep and have a very quick REM period within the first 15 or 20 minutes of sleep, that usually indicates that you're quite a bit underslept, because that's called a REM rebound, where REM is pushing itself earlier in the cycle. But for most of us, we won't be having a lot of REM early. We'll have a little bit of stage one, again, about three to five percent of our night, just like the awake phase. And then stage two. Stage two is roughly 50 percent of our sleep period. So it's a period of time that we didn't know a lot about in the past. We used to think it was mostly important for keeping us asleep and limiting the impact of the digestion and other sort of body feelings and sounds and temperature changes in the environment so that our bodies could stay asleep. But in the last decade or so, with better tools, we've learned that we do a lot of memory encoding during stage two. Stage three, which we used to call stage three and four, that's a term we don't use anymore. So just stage three or deep sleep happens next. And depending on your age and your sleep, it's probably somewhere between 13 to 15 at the low end and 20 to 25 percent at the high end of your sleep in a full sleep period. Most deep sleep, this is when we're really out. Our bodies are very sort of parasympathetic at this point. Digestion is active. Gastro juices are flowing. Heart rate slows. Our respiratory rate tends to slow. We do a lot of memory encoding during this time, a lot of immune and cell repair during this time. And this tends to happen early in the first sort of few cycles more than later in sleep. So you can see that this first cycle is predominantly stage three. The person climbs back up just as they went into it through stage two, doesn't have any stage one, has their first REM period about an hour and a half after they went to bed. So the usual sleep cycle for most people, adults, after about one year of life, for most the first year of life, it's not so organized. But after about one years of age, the rest of our life, cycles are about 90 minutes, maybe as long as 120 minutes in length. And then it repeats. You go back down the same way you came to go back around. And you can see that at the end of the second cycle, this person wakes up. Like I said, waking up is normal. Here's another awakening. So one of the mantras that you want to remember to tell your adult patients in particular, also the kids, is that nobody sleeps through the night. It's just really valuable phrase. Nobody sleeps through the night because a lot of times people think I'm supposed to go into a coma or my child is supposed to and never awaken. And that's not normal. We actually do awaken. But we think that if you're not awake for three to five minutes, you don't tend to remember the awakening. When you remember the awakening, if you're anxious about your sleep or you've been struggling with insomnia, you then often think, oh my gosh, I'm a terrible sleeper. That gets you anxious. And then you have more trouble sleeping subsequently. So go back down a little bit of stage one in various places. Sometimes it's not there. Stage two becomes lessened throughout. I'm sorry. Stage three becomes lessened throughout the night. Stage two has a fair amount of stability. It's always there, almost always there because it is about half of our night, more towards later morning. And also you have more REM as the sleep cycles go on. So towards the morning, you have more REM. This is why if you slept like I did last night, I slept about five hours. I woke up, had most of my deep sleep. Then I went to the bathroom because I'm an older man. And so that's what happens to us. And then I went back to bed. And then I had a lot of dreams when I woke up at five in the morning or whatever time I woke up. I don't remember a lot in my head. Sometimes it's fuzzy thinking, sometimes a little vague thoughts or sleep mentation. But then as you move towards the morning, a lot more dreams. And when I woke up, my head was full of dreams. So this is a pretty typical experience. REM increases throughout the night, slow wave decreases throughout the night. And that's about the time we spend in our sleep stages. Now, this next view of sleep is theoretical, but it's very practical and very helpful. And I teach this to all the adults, at least in adolescence, who I help with sleep. This is called the two process model of sleep regulation. It's designed by a guy named Borbely. And the model he came up with was to say, again, this is 7am down here. This is 7am the next day. The shaded area is sleep. He said that when you wake up in the morning, you have very little sleep drive or sleep debt. We call that process S for sleep. And this is thought to be homeostatic, thought to be pretty consistent. For every two hours you're awake, you owe an hour back to the Sandman, 16 hours awake, eight hours of sleep, that's 24 hours in a day. And as the day goes on, your sleep debt or the burden you feel from being awake increases. And so this is drawn as a pressure pushing down on people that as you go throughout the day, your backpack of exhaustion gets bigger and bigger. Because when you wake up in the morning, you have very little of this since theoretically you slept the night before. And you can see the sleep debt burned off here during the sleep period, come back around the next day. And the person is tired when they wake up because they're groggy. But if they've slept reasonably well, then they should in short order not have too much sleep debt and feel like they're pretty alert. Now, as the day goes on, you need to oppose that sleep debt because that sleep debt keeps mounting and mounting. And we would all just sort of flatten and kind of walk downhill in exhaustion. Our bodies would just drop over the period of the day. So how do we stay awake and alert? Well, there's something called the circadian rhythm or process C, which is driven by cortisol, signaled by light, responded to by norepinephrine. And this essentially alerts us and keeps us awake and engaged. It mounts our heart rate. It mounts our body temperature. It does a number of things to keep us alert and engaged. And you can see that as the sleep debt mounts throughout the day and the day goes on, the circadian process gets more and more active, not too active in the early morning because we don't need too much alertness. We do have some certainly about two hours before our habitual wake time, our circadian rhythm starts to kick in. And that's one of the reasons we see a lot of heart attacks in the morning amongst elderly people, because as your heart is diseased, if it is diseased, then the circadian push can sometimes be difficult on a diseased heart. But for most of us, the circadian rhythm picks up. We just notice feeling more and more alert with time throughout the day. There's a dip around what we would consider siesta midday after lunch, about five to seven hours after you habitually wake up, you'll have a sleepiness that has nothing to do with the food you ate unless you had a hugely fat or sugary meal. In that case, you might get a little bit of sleepiness due to the cholecystokinin from the fat or the insulin secretion from the sugar. But for most of us, if our meals are even close to being somewhat balanced, we're not having an exhaustion from the food. And we're not tired because the meeting is boring, even though it might be. We're tired because melatonin secretion mounts around midday. And we think this is an evolutionary hangover from people who were on the Savannah in very hot middle of the day when the temperature is very high. And those who went off into the shade or found the cave or somewhere were able to survive. And so this melatonin burst that makes us feel groggy, we think persists and is particularly noticeable in hot areas like northern Africa, southern Europe. And so you see continually this kind of dip in the midday. And it's nice to remember this happens because this is a good time to do things that are less time intensive and I'm sorry, less energy intensive. So I'm giving a talk now at, you know, for me, it's about 11 in the morning right now, New York time where I am. I woke up at 830 this morning, had a nice lie in, as they would say. And so I'm probably around here, pretty good energy. But if I were to give this talk around three o'clock today, I might be at a low and maybe it would be harder to word find and harder to be direct. Maybe this isn't a good time. I tell my college students to ask their parents for more money or break up with their boyfriend or girlfriend. Maybe this is a good time to do your laundry or if you can muster the strengths to take a run. As the day goes on, your energy level or your circadian rhythm increases and increases and your alertness corresponds to that. So ironically, for most of us, we would imagine our alertness is best around here. But for most of us, our concentration and focus, even though our sleep debt is mounting, is best around here. Very helpful to think about. And we have lots of studies showing this to be the case behaviorally. You'll see athletes performing at their peak when they're here. West coast teams beat east coast teams, two to one, much better than Las Vegas odds. Because they're always playing the game when the east coast is starting their brain right about here, but then falls in here. And the west coast is starting about here, but then ends up here. So lots of interesting stuff, but this is the sleep regulation throughout the day. And it's very helpful when you're thinking about insomnia and sleep difficulties. The last picture for education is just a very complicated looking, but basic message I want to give you around neuroscience. On the left, you have a demonstration of the redundancy of the wake promoting neurons in our brain. It's very important we stay awake and we have a very easy time alerting ourselves and becoming awake in case there's a threat to us. So the redundancy of what's called the reticular, which means net, this network activating system, this reticular activating system is redundant. You've got acetylcholine, serotonin, norepinephrine, histamine, dopamine, all of these are activating neurochemicals. And so the body has a lot of places where activating neurochemicals can alert us and send their messages to the basal ganglia and to the frontal cortex and other areas. Correspondingly, in image B on the right side of your screen, we see and highlight the VLPO, the ventrolateral preoptic nucleus of the hypothalamus, which contains mostly GABA, which is our primary sort of sleep promoting neurotransmitter. And the point here is that our brains have a lot less devotion or space committed to putting us to sleep than to keeping us awake, which helps to explain why a lot of people have insomnia. It also helps us to think about how we've developed medications and treatments to target this area. All right. How common are pediatric sleep disorders? Really common. Lots of studies. I'll show you a few just now, but it's estimated on a ballpark about a quarter of kids will have some sleep trouble. When we train pediatricians, as we did at CHOP, to ask about sleep troubles, we find actually a lot more because at the initial study, without them being trained, only about 4% of sleep troubles were identified. So we believe that sleep troubles are under-identified in primary practice and that we won't know if we don't ask. If you look at, I've summarized some studies here for you from the past, 50% of preschool children, 30% of school-aged kids, 40% of adolescents report some difficulties. Here's another study showing a lot of kids, high percentages of kids in pediatric clinics when looked at have insomnia or parasomnias or excessive daytime sleepiness or sleep disorder breathing. Among normal school-aged kids, 6 to 13, parents report a lot of sleep difficulties. About a third of parents report that their kids have troubles initiating and staying asleep. Our best prevalence estimates today show that, you know, these are the numbers here, but about a third of preschool kids, about a fifth of school-aged kids, and about a quarter of adolescents have some difficulties with sleep, usually insomnia, but sometimes other things as well, which we'll talk about. In both adults and in kids, insomnia coalesces with and often predates the development of psychiatric conditions. So in kids, when we look at people who have insomnia, we will often see elevated psychiatric scores, even if they don't meet criteria, but we'll also see higher estimates of psychiatric diagnosis than we would otherwise find in a general population without insomnia. So there's a study I'll show you in a second about that. Snoring and obstructive sleep apnea, quite common in kids, snoring that is, less often apnea, but it's important for those of us who treat ADHD, and I treat a lot of it, to look in the throats of every child who I want to treat for ADHD, because if they've got big kissing tonsils, there's a good chance that they're snoring, and then I'll ask the parents to record on their phone or something the sounds of the child sleeping. We think that maybe as many as five percent of kids who get diagnosed with ADHD are actually suffering from apnea, which limits their ability to get into deep sleep and REM, makes them a little bit overactive during the day, sort of hyper and inattentive, and looks like ADHD. Snoring, we would say, is not normal, and it happens, so it's the repetition of it, the disruption of it in sleep, that we want to stop if we can. Apnea runs pretty high in adults. Bedwetting and uresis, pretty common in kids, 30 percent of four-year-olds, 10 percent of six-year-olds, so around five, we would say that we would like kids to be dry throughout the night, but some kids continue to have difficulties, even a percent of those kids over 15 or so. I have a couple of adolescents now who still struggle with enuresis. We have great treatments, both behavioral and medication, that can help. Even over five, some kids occasionally have a wetting episode, but if it's primary, that is, they've never been dry, we're a lot less concerned. Usually, they will grow out of it, and it's a question of how disruptive it is and how we want to treat it or how aggressively we want to treat it, but it's totally treatable. Parasomnias are difficulties that occur between sleep stages, so people who are moving either between wake and sleep or between stage two and three or three and two or one and two, these moments are when we tend to see parasomnias, which include the alert awakening with an enormous sympathetic discharge, which we call a sleep terror, which can happen any time of sleep, but happens typically during stage three or deep sleep. Sleep walking, which is a disruption usually also during stage three when kids actually will get up, or adults, and move around. It's got a high prevalence in that it does happen to a lot of people once, but it doesn't happen that much again, so some people have one experience or two and that's about it. These kind of things will continue, and the same is true with sleep terrors, by the way. A lot of kids get them, but very few kids hold on to them, and the confusional arousals are some version of a parasomnia where there's an awakening. Usually, it's a sleep walking episode that goes awry, where the person engages in some behavior, becomes agitated, and is potentially at harm, risks to harming themselves. Amongst kids with psychiatric diagnoses, we know that sleep problems are much more prevalent. ADHD, of course, in fact, through DSM-3, sleep problems were one of the core symptoms of ADHD. We don't have that anymore because it's not 95% of kids, which is our theoretical cutoff for a criterion for the DSM, but we do know that a lot of kids who have ADHD have difficulties falling asleep, have difficulties waking up in the morning because they're so exhausted from their very active sleep. They move around a lot. Even mothers who have kids who are later diagnosed as hyperactive will often say the child was very active even in the womb. A lot of kids and adults with autism spectrum disorders suffer sleep problems, and it's about 90% of adults and kids. We see very significant difficulties there, and we do everything we can to address that, and we'll talk about how. A lot of kids, of course, with depression and other mood disorders and anxiety report sleep problems. Here's a study by my friend Anna Ivanenko who found that just kids showing up at a sleep center, 50% of them had a pre-existing psychiatric diagnoses, and the remaining 50% had elevated psychiatric impairment scores. Again, we see insomnia as sometimes a precursor, sometimes a ride-along, a component of psychiatric disorder. We see the same sorts of things in adults with anxiety and depression and anxiety and heart illness and pain. I am a pretty athletic guy, and my left shoulder bothers me a lot, and when I start to have too much tennis or something else, I'll roll over, and I'll get pain, and it'll wake me up. That's pretty mild compared to what a lot of people suffer with. Pain is absolutely something that alerts and keeps people awake, causes disruption in their sleep, as does, of course, anxiety, mood, and other problems. During COVID, I'll just say a word about that. There were a lot of sleep problems, and if you Googled sleep or insomnia during the era of COVID, you had a lot more hits. There were many more Google searches for insomnia, for example, than there had been previously, and a big swath of people, 34 to 82 percent by one study, had some sleep difficulties all across the board. Insomnia was, of course, generally the big one. The largest meta-analysis of sleep during COVID, which was 500,000 people from almost 50 countries, found that there was a very high global prevalence of sleep disruption amongst both adults and kids, whether people were infected or not. Okay, so what are the most common sleep problems, and who is most vulnerable? So now a little more epidemiology and descriptions. So bedtime problems. This is one of the main difficulties we see in kids. They don't want to go to sleep. They refuse to go to bed. They have difficulty when limits are set, and we work with parents a lot on this. Nighttime fears. I'm scared of the monster under the bed. I'm scared of going to bed without you, Mommy or Daddy. I want you in the room. These sorts of concerns, and it does seem awfully unfair that a child has to go off on their own at a very young age and sleep in a bed by themselves while Mommy and Daddy get to be in a bed together and to enjoy the comfort of that association. Parasomnias, we've talked a little bit about already. Sleepwalking, sleep terrors, confusional arousals, occurrences that happen between transitions in sleep, and usually in and out of deep sleep, stage three. Aneurysis, we've mentioned. Bedwetting, which again is fairly common and expected, but can be persistent and a problem. Sleep disordered breathing, which we should always pay attention to because of the potential for apnea and not getting valuable stages of sleep and the strain it causes on the heart and other things that you know about. Delayed sleep phase disorder, my colleague and good friend Argelina Baroni is going to talk to you later today about delayed sleep phase disorder, but this is something that's typical amongst adolescents, again, for evolutionary reasons that she'll talk to you about. We do see a delayed phase for many or most adolescents that lasts into adulthood for some, and this can cause a lot of problems and disruption in how they function during the day. Insomnia, we'll talk about more. Less common difficulties, but things that happen are rhythmic disorders where kids rock in bed, may bang their head against the bed board or the bed itself. And it's almost like a self-soothing autistic-like stereotypy, but they will do this in bed and have trouble sleeping or do this a lot during sleep, which disrupts the sleep. Bruxism or grinding of the jaw. Restless legs or periodically movement disorders, which are affected minority of people, of course, but can be disruptive even in kids. And narcolepsy, the sudden dropping off to sleep in a cataplectic way. If we look at who isn't sleeping, we've known for decades now that to be poor, to be from a marginalized community, to be in a neighborhood that is violent or unsafe makes your sleep worse. And you can see that this is just the percent of short sleep which is people who are sleeping five hours or fewer. And you can see that it is elevated amongst people with less education, people who are from marginalized communities, people who have low income. And you can see some of the odds ratios here in terms of comparisons. And this comes out of a study in Oakland, California. And also if you smoke cigarettes or you drink or you're physically inactive or you're overweight, these things also affect your sleep. Amongst adults, we idealize about seven to nine hours of sleep at night. So fewer than seven is associated with all these things and more than nine is associated with all these things. And more sleep once in a while is good, but on a regular basis, it usually indicates depression, pain, or some other disability or a desire to stay in bed because people's quality of sleep is not good. BMI impacts sleep and you can see that here to have a healthy or BMI results in more healthy sleep. And when adults at least are not sleeping seven to nine hours, they will report more difficulties falling asleep as you would expect, awakening too early, feeling tired during the day and having a lot of wakes up at night. We've also looked at kids now as well as adults around issues of discrimination. And we find that kids who perceive low discrimination tend to sleep better. And that's what this study shows you. So we do have a recognition that a lot of the social factors again, not just poverty, not just marginalized communities, not just education, but how you perceive yourself to be received in your community also impacts your sleep. All right, how do I take a good sleep history and when should I refer? So what do you wanna know? You wanna know how somebody sleeps and what their 24 hour cycle is like. I'll help you with how to assess that in a moment, but that means when they sleep and when they're awake throughout the 24 hour period, when they're active, when they're not, when they take medication, when they drink caffeine, those sorts of things. You wanna know how they've slept in the past. Has it been different? If so, how? Medical history is hugely important for the kids that we see, of course, in neurodevelopmental history and particularly since 90% of kids with autism and a lot of kids with ADHD have sleep troubles. Those are things I'm keenly interested in, but of course, mood and anxiety as well. The psychosocial history, what the bed looks like. When I'm working with someone, we'll have them take pictures of their bedroom or what they see from the site in which they are in bed, what their house looks like, what the neighborhood they're in, all those factors I was just talking about that impact sleep from a sociologic perspective. Family sleep history, scales and inventories, and I'll go through a few with you now, but sleep diaries are immensely helpful. Certain questionnaires are also useful like the pediatric sleep questionnaire or the children's sleep health questionnaire. Sleep history, specific questions. How many hours do you sleep in a 24-hour period, including naps? When is bedtime, when is wait time? Because our circadian rhythm starts our alertness, it's actually when we're fixing people's sleep and you'll learn more about this when you hear about CBTI, I'm sure today, cognitive behavioral therapy for insomnia, it's more important that we set a wake time that's pretty regular and pretty steady. And for that, our circadian rhythm will then start to get more regular and then our sleepy time will follow. But ask, of course, when bedtime is and when wake time is and with whom the person sleeps, people, pets, who's in and out of the room? How long does it typically take to fall asleep? We call that the sleep latency. Are there any awakenings throughout the night? If so, how often do they occur? Now, again, nobody sleeps through the night, but you can ask them, do you remember any awakenings during the night? If so, how many, how long do they tend to last? Are there any rituals or typical steps used to fall asleep? Does someone read in bed, use a computer, use a TV? And that could be in bed or not in bed. We don't want people doing anything in the bed, as you know, other than sleep and sex. However, people often do. And I'm of the mind that if it ain't broke, don't fix it. So if you read in bed, like I do, and you fall asleep pretty well, like I do, you don't have too much to be concerned about. On the, in the events, and I've had them where I don't sleep that well for a while, then I will never read in bed. I will only go to the bed for sleep and I will not use the bed for anything other than sleep and sex. And I will do my reading on the couch in the other room under dim lighting, et cetera. So you really wanna be thoughtful about that. We know that over half of kids have electronic devices in their bedrooms. A lot of adults do as well. Phones, iPads, computers, televisions. And these things universally disrupt sleep for so many reasons. So knowing about them is important and asking about them. But we'll get to more about screens, me or somebody else, or we can talk about it more. But they interrupt sleep because of the fact that they release blue light, which blocks melatonin. They're also stimulating. They make you experience FOMO. If you're a kid, you know, I thought I was gonna hang out with my buddy at the park and then they said they couldn't tonight. And so I said, all right, I stayed home. I went to bed and then I decided to look at Snapchat and on the Snap Map, which tells me where my friends are, I can see my friend is in the park with other friends of ours and I wasn't invited and I feel terrible. That's the fear of missing out, the FOMO. And that causes me distress and keeps me awake. Or I get on Facebook or Instagram and I'm comparing myself to other people and what they're doing, living their best social media lives. And I'm feeling like mine isn't showing as well. These kinds of things make kids really upset and affect their sleep a great deal and for some adults as well. What position do they sleep in? This is telling often in terms of apnea. Is the room dark and quiet? Again, what's the presence of electronic devices and other things? Do they feel refreshed in the morning after they wake up? Is there any excessive daytime sleepiness or fatigues or are they pooped out during the day? And you can assess with a sleep diary. Here's one place to find one. And here's a really good one, which is where that website leads you to. There's actually a newer version than this, but it's basically the same exact thing. They just use a different way to write down the sleep. But this is a great sleep blog. It's found on the American Academy of Sleep Medicine's AASM.org's education's page. And this is two weeks of sleep information. And I have every single patient who I see for whatever reason, and I see children, adolescents, and adults fill out this form. It's really easy to do. And on one side of a page, you get two weeks of information. So the day of the week, work or school or weekend, it starts at noon and goes till noon the next day. And they put an E for where they exercise, an A for where they have alcohol. You can have them put an MJ for marijuana. This little hash mark is where they get in bed and desire to fall asleep. The shaded boxes are where they slept. C is caffeine, M is morning medication. And there you have it. So this person starting at noon on Monday, which was a work day, exercised for an hour just after lunch or around the lunch hour, had a drink maybe with friends. At 6 p.m. took a nap. They were tired. Then they were up for a few more hours. Around 10.30, they went to bed, took them an hour and a half of fall sleep. That's a long sleep latency. We don't like to see 90 minutes. We'd like to see fewer than 30, probably because they had a drink here, which made them drowsy in addition to their leftover drowsiness. And that burned off some of their sleep debt. So some of their process S went away. And they probably, if they slept for a full hour, burned off some stage three sleep. Stage three is the most driving factor that drives us to fall asleep. And so this burned off some of their deep sleep, which is why it took them an hour and a half to fall asleep at night. They slept for four hours, and then they woke up for an hour. Why? Well, it could be the alcohol even still had a residual effect, but more so probably that their sleep was fractured. And because they took some deep sleep here, the density of deep sleep didn't persist here. So they had an hour awake in the middle of the night. Then they got two more hours sleep, had coffee and medicine in the morning. So this person got enough sleep. That is, they got seven hours over a 24 hour period, but it was fractured. And they had some long sleep latency. And they had two and a half hours when they were in bed, trying to fall asleep and couldn't. And that makes the bed feel like a scary, unsafe place. So this is very helpful as you're thinking about behavioral strategies and working through sleep training with people. The BEARS is a very easy acronym that we use for assessing sleep difficulties in children. Are there B, bedtime problems? E, excessive daytime sleepiness? A, awakenings during the night? R, what's the regularity of evening and morning sleep and awakenings? And S, are there any sleep-related breathing problems or snoring? So that's BEARS. And when we use BEARS, we identify in one study, twice as many sleep problems as when we don't use BEARS. Here's a grid to help you think about the BEARS questions for toddlers, school-aged kids, and adolescents. C is for a question you would ask the child. P is for the parent. So there it's broken up a little bit here, but this is just a very simple tool if you're seeing kids to ask about sleep. Collateral history, of course, is helpful. Snoring, really important because of apnea and disruptions during sleep and things like ADHD, as I mentioned. So assessing snoring is useful and you can do it with a sleep study. You can also have parents, if they're aware that their child snores, you can have them just place their phone and record some noises or record a video for 20 minutes or 10 minutes. And if there are apnea pauses, you will hear them, so there you go. Breathing pauses during sleep, which is the thing to ask about, the apnea pauses. Are there unusual behaviors during sleep? Sleepwalking, headbanging, and so forth. What's the tendency to fall asleep unintentionally during the day? There's something called the Epworth, E-P-W-O-R-T-H, named by an Australian fellow who came up with this very simple scale to assess how likely you are to fall asleep. You can find it online. We use this with people all the time in sleep clinics all over the world, just to assess how likely they think they are to fall asleep if they were sitting and watching TV right now, sitting in a car in traffic right now, reading a book right now. And these things, it takes about a minute to fill this out, but it's very helpful to get a sense of how sleepy someone is during the day. Are they taking naps? When and how long are they? Any disturbances associated with insomnia or daytime sleepiness? Are they having trouble driving, trouble with accidents on the job? We know that doctors who work 16 hours straight without a break tend to have much more needle sticks and tend to have more surgical mistakes and more likely to have a sponge in a body and all these kinds of things. So we definitely see errors. And is there a family sleep history? These are some collateral points that are helpful. We can evaluate the sleep with an actigraph. These are the traditional type tools that would assess movement and they can be done at home. You can put this on someone's arm for a week or two and bring them back. And that's very easy. It doesn't tell us what stage of sleep the person was in, but it does tell us whether they were asleep or awake pretty reliably. Polysomnography is where we wire someone up with all sorts of other measures, including heart rate measures and EEG measures and EMG measures, potentially, and EOG measures. And we look at pulse oximetry and we get a lot of data, the respiratory rate, and that can be much more informative and necessary sometimes. Multi-sleep latency test is essentially a complicated test to look mostly at narcolepsy. It's interesting. It's time-consuming where somebody goes in and out of the sleep lab periodically throughout the day. It has a sleep opportunity and you can measure how tired essentially or how likely someone is to fall asleep at atypical times. And there's other things we can do to measure and look at sleep problems. Some labs can be helpful. We see iron askew often in people with sleep difficulties or restless legs. And so that may be something that needs to be corrected, but most of us are not doing that on a regular basis. Here's a child who's wired up for polysomnography. You can see it's fairly intrusive, but most people do tend to sleep fairly typically once they get to bed. We have a lot of wearables, consumer wearables these days. Amongst those that are open and available to the public, the Aura Ring is probably the best device at this point in terms of giving you information. It does measure things like pulse ox and body temperature that most of the others do not measure. But how good these things are is variable. I've worn the Aura for a year. I'm not wearing it any longer. I've worn Fitbits. I'm using a Garmin now for my sleep. I'm sorry, for my activity tracking. And when I use these things for sleep, I find variable results and they're getting better. Their algorithms are getting better. They profess to give you a lot of information about your sleep, much more than a typical actigraph, which would tell you, again, when you're awake and when you're asleep. These devices will try and tell you whether you were in REM, whether you were in deep sleep, whether you were in light sleep, how many awakenings you had, how many movements you had during a typical sleep period. And there is some level of accuracy, but we have, and the FDA has approved a few of these for certain purposes. I think they just last week approved, if I'm remembering correctly, a couple of these for measuring some aspect of sleep, but they're not highly reliable for sleep stages. So I wouldn't get too stuck on that. Treatment of insomnia in children and adolescents and young adults. Okay, so this is a little more where you probably come in. And armed with the knowledge I've given you now, let's spend about 15 minutes talking about how we help people with sleep. First, when it comes to training young children to sleep, whether they've got a coexisting psychiatric pathology or not, educate the parents. And I educate them on a lot of the stuff we just talked about. I talk about sleep cycles and stages. I talk about the two process model. I talk a little bit about the brain and body and what normal sleep looks like and that nobody sleeps through the night. And that is all part of the sleep training. And then I will get into a process of sleep training, which includes often these components. Graduated extinction. That is not falling asleep with your kids unless you want your kids to always have you in the room or always be in your bed. And if you do, that's okay. There's no rules against that, may not be good for your life. In the event that it isn't, and it isn't for most people, typically we use graduated extinction, a very quick but graduated process of having some presence in the room and then stepping out of the room. What we want, since nobody sleeps through the night, we want when our kids to wake up in the middle of the night to have the same environment in which they actually fell asleep. So it's important to not be there at the moment of actual falling asleep, because if you are there, then when they wake up four, three, five hours later, they will look around for you and come calling for you. This may involve sitting in a chair near the bed, moving it further away, further away, further away, until you're out of the room in three or four days and always leaving before they fall asleep. This may involve telling them that you're gonna give them a minute to fall asleep and then you'll come back and sit with them. And the first night it's one minute, the next night it's two minutes, the next night it's three minutes. But in fact, it's one minute the first night, five minutes the second night, 10 minutes the third night, because they don't really understand the concept of minutes at a young age and they will fall asleep on their own and then you'll be safe. That's a little technique I developed called minutes, which works really well. Positive bedtime routines is making sure that there is a routine that moves towards bed. The lights dim an hour or two before bedtime. There's no screens an hour or two before bedtime. Calming voices, family related activities that are not excitable. You're not, if you're playing a card game, it's not a jump up and down card game. It's a very calm card game. You're singing soft songs. You are reading enjoyable, relaxing, not scary books. For those kids who wake up in the middle of the night regularly, sometimes we will schedule an awakening. It's hard on the parents, but may ultimately be less hard. If the child wakes up at 4 a.m. every night and comes to the parents, the parent can start waking up at 3.45 in advance and then go in and literally wake up the child and say, hi honey, just checking in, seeing you're good, you're good, okay, and settling them back to bed. And that way the parent may stay awake less time than if they were to wait for the child to come to them, then have to walk the child back to bed or struggle with where they're gonna sleep. Bedtime fading is just like what we call sleep restriction. When you hear about CBTI, in this case, this would be a child who's typically not falling asleep at the expected time and or not sleeping through the night. So what we do is we make the bedtime later, which seems ironic, I know, but we give them less sleep. So we set a regular wake time. They have to wake up at seven every morning. That's the time for school. So that's typically the time we're gonna expect them to wake up. And if they've been going to bed at 8.30 and they've been having trouble falling asleep and not falling asleep till 9.30, then we make the bedtime 9.30. Yes, they're gonna get a little bit less sleep for a little while. That may be all they need, but they will feel more successful in falling asleep. They'll fall asleep quicker. They're more likely to sleep through the night. And once they're successful, mostly sleeping from 9.30 till seven, we can then make bedtime 9.15 and fade it back earlier, which may help them to sleep more solidly. We may not get back to 8.30 ever because they may not need that much sleep, but we'll bring them closer. A bedtime pass, excuse me, is for children who are up and down out of bed. They gotta give the dog one last hug. They gotta get another glass of water. For these kids, we will sometimes give them a bedtime pass. You can find these online. You can color it yourself. You can make it look nice and you can put it under the child's pillow. And you can say, you get one bedtime pass. And that means that you are able to leave the bed once for some sort of treat opportunity. So you can take a treat, nice thing, and visit the dog, get another hug, get a glass of water. And if you don't use the pass, you get a reward in the morning. So you're incentivized not to use the pass. But if you use the pass, you get it once and then I take it away. Then you gotta go back to bed. Kids love rules. So this can be helpful. Monster spray for kids who are afraid of a monster under the bed. You can go online. You can type in monster spray. You can find nice little designs. You can print them out and color them or you can make your own. You can make a label of some sort that you can get at the 99 cent store. You can add a nice smell that child likes, vanilla, lavender, chamomile. And they can spray under their bed and spray in the closet because this keeps away monsters. You will tell them, the label will say it. So it's true. And this is often very helpful. I just started seeing a kid because of a terrible incident at school. But I'd seen this kid about 10 years earlier when he was four and he was having trouble with monsters. And we did monster spray. I saw him two sessions. He slept beautifully until I saw him again. Now, 10 years later, they came back because of another terrible incident that happened at school with him. Nothing to do with sleep. His sleep has been great. And he would go downstairs in New York City and spray the doorman and do all sorts of things to keep the monsters away. It was terribly cute, but it worked for him. Reinforcements like rewards in the morning, as I mentioned with the bedtime pass or talking about the sleep fairy. The sleep fairy, parents can tell their kids about and the sleep fairy can leave a note for the child that they sleep through the night that says something nice to them about how they slept. So lots of ways to incentivize children to sleep. Our model of insomnia, chronic insomnia, is that everybody has predisposing biological, psychological, and social factors that may interfere with their sleep. There are various precipitating factors that might be the sort of things that ultimately are the straw that break the camel's back. So whether it's psychiatric illness, stressful life events, or medical illness, they stop sleeping well, that finally hits a big peak. And then there are perpetuating factors. And this is a lot of what CBTI, cognitive behavioral therapy for insomnia targets. It targets the maladaptive behaviors that people get into once they start experiencing insomnia. Well, I didn't sleep well last night, so maybe I'll watch TV in bed tonight. I didn't sleep well last night, so maybe I'll go to bed extra early tonight. I didn't sleep well last night, so maybe I'll take a Benadryl or have some alcohol. I didn't sleep well last night, so I'll take a nap today, a long nap. All of these things ultimately result in a perpetuation of the insomnia. So that's really what we're often addressing. And insomnia prescribing is common. If you look at, this is a study of about a thousand child psychiatrists from 15 years ago, finding that amongst child psychiatrists who were in the American Academy of Child Psychiatry, a third of their patients were having sleep difficulties, school age and adolescence, and medications were used in at least a quarter of these kids. And almost 100% of child psychiatrists had recommended a sleep medication for one of their patients or more that month, and almost 90% recommended an over-the-counter medicine. So, we're using sleep medicines and adults are as well. 8.5% of adults use a medication every night to help them fall asleep. Another 10% of adults occasionally use medicine, women a bit more than men. Overall, that tends to be true, particularly in middle age and beyond, but in childhood, not necessarily. White adults more likely than others. And use of sleep medications decreases as family income increases, which is another point talking about distress. The more stress you have in your life, and to some degree, income correlates with that, the more likely you are to want to use a medicine. And regarding kids, there's no FDA approved treatments for insomnia in children when it comes to medication. So, just be aware of that. We do find that in most studies, sleeping pills induce a little bit more sleep. If you ask yourself how much sleep, you might be inclined to think a couple of hours, but in most studies, it's only 15 to 45 minutes. And that's not nothing, but that's like Ambien, Sonata, Lunesta, whatever you like. These medicines only induce a little bit more sleep. They do decrease the sleep latency. So, it takes people less time to fall asleep, which is something they like and appreciate, but only usually by about 15 minutes. But people feel more rested. Why do they feel more rested? Because they have amnesia for the times that they woke up. It's the waking up that often drives people crazy when it comes to insomnia. Oh, I'm still awake. It's only been an hour. I'm still awake. What time is it? Oh my God, I'm a terrible sleeper. Oh, I'll never get to sleep. And they worry. And so, because they do wake up still, but they forget those awakenings, which are usually pretty brief if they don't get stuck on them, they tend to believe they slept a whole lot better. These memories don't get encoded because of the amnesia of the benzodiazepine-like effect of these medicines. Remember, nobody sleeps through the night. So, our CBT for insomnia, which you're going to hear about next, involves these various steps, but I'm not even going to mention them other than this slide, because you're going to get a whole section on that. But rest assured, this really works for adults. It works in terms of lessening the amount of time to fall asleep, reducing the number of awakenings, improving the quality of sleep, less sleepiness during the day. Most patients get a therapeutic response. Not everybody gets total remission, but a big chunk do. And here's the data, but the data is as good as sleep medicines. The good thing about the CBT-I is it's more empowering because these things are sustained over time because you don't have to keep taking a medicine. You just use these tools. So, we're very keen on CBT-I for sleep. It works as well in adolescents as it does in adults. And in kids, you don't really use the cognitive components so much, pre-pubertal kids, but the behavioral components work and they work just as well. These are the medications we have for insomnia across the board for adults and kids. I've starred those that are FDA-approved for adults. I've double-starred those where there's some pediatric data available. Remember that none is approved for the use in children. Here is the list of medicines, and again, they're all approved for over 18. In most cases, there's no data for those under 18. In some cases, like with Zolpidem, there's no benefit or Azopiclone. In some cases, like Benadryl, diphenhydramine, there's a little bit of benefit, but there's not strong enough benefit for any of these to have met FDA approval. And in the case of Azopiclone and Zolpidem, there have been double-blind randomized controlled trials. So, these things are not helpful for young people by and large. What do we do when we're thinking about medications for kids? We've done our CBTI. We've done our sleep education. We've done our parent education. What can we do next? We can consider drug-drug interactions as we move into medications. We can consider medications that first might be exacerbating their sleep problems. So, are they taking medicines like a stimulant or an antipsychotic or something else, an SSRI, that might be agitating their sleep already? It wouldn't be out of the question. We can think about medications they're taking like antihistamines that might be interfering with their sleep as well. We can screen for alcohol use and drug use and pregnancy, of course. We can screen for over-the-counter medicines, herbal meds, and dietary supplements. Really important to ask about all your patients, of course, because that can also have an impact on their sleep. When we're looking at assessing them for a sleep treatment, let's make sure there's not another sleep disorder besides insomnia or another psychiatric disorder that needs to be treated or another medical pain, something else that needs to be treated. If they have autism, there may be behavioral things and cognitive things that we can do, even medication things that we can do to help. And maybe we haven't picked up on the autism on this person, but addressing that will subsequently often make the sleep better. We can think again about all the medicines they're taking currently, review their current sleep practices, consider what the caregiver's role here, figure out whether it's a sleep onset problem, a maintenance problem, and then start with behavioral interventions always because they empower people, they are persistent and long-lasting, and you don't need to get people hooked on, I don't mean hooked like addicted, I just mean in a pattern of taking medicine. So we use all those tools I talked about before, scheduled awakening, sleep training, all that. Healthy practices, get the screens out of the bedroom, get the phone out of the bedroom. If you're having any trouble sleeping at all or any of the kids are, no phones in the bedroom, buy them an $8 clock on Amazon, get them an alarm clock, put the phone in the other room. That's why God created the fruit bowl to let it charge during the night, get it out of the room, even knowing it's there, even recognizing that when they have those periodic awakenings that their phone could be there and something could have happened on Snapchat, something could happen on Instagram, their parent could have called an emergency, you know, all that craziness, just get it out of the room and they're less likely to think about it. Likewise, if they're studying geometry in ninth or tenth grade and they're stressed out by it, have them not sleep with their geometry book, you know, get anything that's stressful out of view of the sleep environment. Limit caffeine, I'm not going to talk to you about caffeine much given the time we have, but a lot of kids are drinking caffeine and more than they need and so think about caffeine and where they're getting it and when they're stopping it during the day. Avoid screens at night, most recommendations would say not for the last hour, but melatonin starts to be secreted about four hours before the habitual bedtime, around the time of dusk for most adults, a little bit shifted later for adolescents, maybe a lot shifted later, so start to promote that by limiting screens at night. If you must use screens, use blue light blocking devices, all the different phone services can go to black and white or they can pull blue light out through various devices they have, there's something called Flux, f.lux, which is free, you can download on any laptop or computer or pad and it will take the blue light out of your screen about the time that it becomes dusk in your part of the country, so it will recognize that based on entering your zip code and then you'll start to get a more orangey-yellow hue to your screen, but you can still see everything at work and you're not going to get blue light blocking your melatonin. Also these white lights and fluorescent lights that we have in our houses, dim them because they too have blue light in them. We use CBTI and all those tools preferentially, if we must use medication, short-term, you know, think about again killing two birds with one stone, if there's something like they have ADHD and they're pretty disruptive and they're having rebound anyway, then you might want to use an alpha-2 agonist in the end of the day, but typically our first choice would be melatonin because the data is best with melatonin, but it's best with kids with neurodevelopmental disorders, it's best with kids who have autism or ADHD, it's not so great with other kids, the effect size is about 0.3, 0.35, it's not huge, it separates from placebo, but it's not great, so you know it helps and it helps in two ways, it helps first if you give a bolus dose of one to five milligrams and we have no data that more than five milligrams is helpful, so that's up to you, but there's no indication that much more is any more helpful than five milligrams, so we give one to five milligrams a half an hour before bed, that can make some kids groggy or help orient their circadian rhythm, but if a child that really has a delayed rhythm, you'd want to give about a milligram or a half milligram about four or five hours before the desired bedtime and expect that that could take a few weeks to start to help, but that will prime the pump and start to get that melatonin secreting on time. The alpha-2 agonist clonidine is more sedating than the alpha-2 agonist guanfacine, so we tend to use clonidine for kids with ADHD, for kids with disruptive agitation and difficulties falling asleep, we'll use up to 0.3 milligrams, which is a fairly high dose and kids might have rebound tachycardia in the morning, so you need to be prepared for that, but at low doses, it's only chart reviews that show us it's moderately helpful, not remarkably helpful, you could combine them, we sometimes do, and then what? You verify the diagnosis, you look at their sleep logs, you treat by diagnosis psychiatrically, if they're depressed, maybe you want to give them some trazodone, we do have some concern about trazodone too, though, yes, it can be helpful, trazodone also may increase the amount of MCPP, which is a, when someone has a antidepressant that uses the 2D6 pathway, like fluoxetine, this combination can increase MCPP as a metabolic offshoot, which can make people more agitated and anxious, so we don't always use it with antidepressants, it sometimes can make people feel worse, and we've seen that in the treatment of resistant depression in adolescence, the Tordia study, mirtazapine has some sedating qualities, also has some hunger-promoting qualities, so cautious use there, but sometimes, and sometimes for the right kids, ADHD, melatonin and clonidine sometimes, ASD, same thing, consider sedating antipsychotics, but they have their side effects and disadvantages, and we rarely will use those, but we do get very complicated patients, and sometimes we'll use those medications, same thing with people who have severe mood and psychotic disorders, sedating antipsychotics get used not infrequently, benzodiazepines with older kids, we don't have any good data for kids with ADHD that it's effective, but, you know, around 16 or 17, kids do get a full complement of GABA receptors and can often respond to these medications, it's not a given, but it may be helpful. So our summary is we prescribe a lot of medications, it's true, educate as best you can, because education and behavioral methods trump medications when it comes to pediatric insomnia, melatonin has the best data, followed by clonidine, and that's about all we've got, really, when it comes to good data, insufficient information for anything else for pediatric sleep, and so we tend to rely heavily on things like behavioral techniques, education, melatonin, clonidine, and then we treat expectantly. I want to say one word about marijuana, then I'm done. So this is the normal sleep hypnogram, we went over this this morning, so you've seen that already, the same thing I showed you before, with these sleep cycles, deep sleep, REM, awakenings. When someone uses marijuana on a short-term basis, and this is cannabis that has THC and CBD, so it's not clear exactly what constitution they're using, but it's the kind of thing that they would say would get them sleepy, or would maybe make them high and get them sleepy, you will see a short-term increase in deep sleep, you will see a short-term decrease in REM, and a short-term, often, increase in awakenings, not always. This is the reason that people often think they are sleeping better when they use marijuana, because early on when they use it, it makes them feel groggy, often if they use an indica species, which is the more sleepy, anxiety, sort of cutting type of marijuana, the other is sativa, which is more active or high-promoting, but there are many hybrids that use both. So using an indica type marijuana, somebody's strain of marijuana, someone would likely, on a few nights in a row, have more deep sleep, might feel groggy when they wake up, but might feel very well rested. So that is one of the reasons people start using it. What happens over time, however, is that it starts to fracture your sleep, and it does this by decreasing your REM overall, but mostly your deep sleep, and when you have less deep sleep, you feel far less rested, and you have more memory problems, which is why people don't remember as well, because we encode an awful lot of memory when we're sleeping, mostly in stage three sleep, and so if you're knocking out stage three sleep, you're not remembering as well, and you're having more awakenings, and REM can often get postponed, pushed around, or fractured. So this is when people are using regularly, and now their sleep is worse. Then they stop thinking, well, god, it's gotten worse with marijuana, not better, and then it gets even worse then. They have the same problems, but even more awakenings, more REM rebound, funny sorts of things are happening. So there is a process of sort of detox, essentially, when their sleep is fractured and broken, and we're trying to get them out of that. So we want to get them back here. You know, my sort of general theme around drug use is if it ain't broke, you don't have to fix it. So if they're sleeping fine, and they're smoking weed once on the weekend, and they're sleeping okay, I'm not really worried, but when they start to rely on marijuana for sleep, I get concerned, because it's not helpful. Thank you for your attention. I'm thrilled to answer questions for as long as we have, and I know your next talk is on CBT-I, which I'm sure is going to be great and very important for you. I'll stop there. I'm looking at the Q&A. Do you have a brand of melatonin that you recommend? Since nothing's regulated by the FDA, I agree, and I don't have a brand that I recommend. What I would tell families, and what I do tell them, is to look for a pharmaceutical grade product or a company that guarantees the purity, because every study that we've done on melatonin and other herbal meds and dietary supplements on the shelf shows that the amount in the bottle is very often not what is said on the label, and this can vary not only by lot or group, but also even by tablet in the same lot or group. So pharmaceutical grade or guaranteed purity, something like that, is more likely, since the company is probably charging a little more and telling you they're testing it, but the FDA doesn't test. Do I ever prescribe clonidine for adults with ASD and ADHD with insomnia? Yes, I do. Adults, usually young adults, but I would not be cautious. I would be comfortable using it with older adults as well. I would simply monitor their cardiac status, which I do with kids as well. I get their blood pressure, and if you're normotensive, you might see a few-point drop when you use these alpha-2 agonists, but not usually a profound drop in either heart rate or in blood pressure. But you might see a few points drop, and you might not even notice it in the office, depending on time of day when you see them and the frequency with which you see them. But generally, I ask about dizziness, syncope, exercise tolerance, shortness of breath, chest pain, all of those things that would indicate there's any kind of cardioactive effect from the medicine. But I would not hesitate to use these in adults with ASD and ADHD as an earlier treatment before I get into the prescription sleep medications. I'm always relying on CBT-EI, though. Just a reminder. How hard is it to get buy-in from families regarding behavioral changes for kids and families? Any tricks to get them to commit? Great question, because this is the work, and we all want our problems to go away quickly. So we very much would like to take a pill if it exists, or take a needle if it's ozempic. We're very anxious to not have to take the run or do the swim or do the sleep hygiene practices and all the rest. So it is a struggle. And I have to balance that like you do with each case. And I tell them that if I teach them these things, it's going to be helpful, undoubtedly. I tell them that they will have tools that they can use their whole life. I tell them that it won't only help the kids, it'll help the parents as well. And they are more likely to then have better sleep themselves. And then if the kid has a real psychiatric problem or the insomnia, even if it's existing alone, which I virtually never see, is causing huge amounts of problems in the family, I will treat with medication and insist on doing behavioral training as well. I'm reticent to just see a kid and put them on clonidine or recommend melatonin and keep them going on that and not see them. That's not my approach. So I usually, it's in the context of ASD or ADHD or mood disorder or anxiety. So this becomes part of our treatment. Do I provide CBT on myself or refer out to certified therapists? So I don't know, should I? I'm sorry, I'm not sure what that is. Maybe that's an online service. I'm not sure. I do CBT on myself. There's a really great book. I don't get any money for it. Let me see if I have it on the shelf here to show you. Yep, here it is. Let me grab it. And this is a good resource. I think I put this in the resources as well. This is a book by Perlis et al. This is cognitive behavioral therapy for the treatment of insomnia. It's not child-specific, but it's a very helpful book. I read the book. It goes through a session-by-session outline of what you might do in CBT-I. I attended some training programs, a couple of lectures, and I was off to the races. And I've been doing it for more than a decade now. And it's not rocket science. It's very straightforward. It's usually something you can deliver in four to six sessions. People may need more time. They may need boosters. They may need less time. I assess how they're doing early upfront. I teach it to all my trainees. I run the fellowship here at NYU. I find it very, very useful. The VA has a CBT-I coach. That program I know online. And it has all good information, and people can get that on their phone. But the information's there. You can find it online for free. You can buy the book. You can look at your cell phone. But it's just about using it. That's the issue. Okay, I'm getting the message. We can wrap up. So thank you very much. There's one last question. I'll just see if I have a moment to it. Can you talk about which meds affect different stages of a sleep cycle and if they know how long it takes those meds to reverse? So great question. We don't know a lot about how various medications affect the sleep cycle because they haven't been studied. So I can tell you in general that SSRIs tend to be activating. So SSRIs do tend to decrease REM overall, which is interesting because people will tell you that they have more dreams or remember their dreams more often when they're on SSRIs. We think that's because serotonin is an activating neurochemical. And just like it causes some insomnia for a lot of people or anxiety when they start it, eventually those factors tend to go away. But people have more sort of an alert, active brain during REM, which we think might be due to the increase in serotonin. So it may be that they tend to remember their dreams more but aren't necessarily dreaming more or having more REM. The medicine of the old antidepressants, and we don't use it anymore, Serozone, was a good medicine for sleep because that had been studied and it mirrored the normal sleep architecture. It didn't disrupt normal sleep architecture much. And it did often make people sedated, but it ultimately was found to cause liver impairment. And so we stopped using it. But it didn't have sexual side effects and it was a good medicine for sleep and anxiety and depression. So those days are gone, unfortunately. You can use it, but nobody really makes it or offers it. Somebody does, but you got to do blood tests all the time, like every two weeks. So the other medicines, though, we don't know much about how they impact the sleep cycle. And that's because they haven't been studied. No one's incentivized to do that because none of them make sleep that much better. All right, I better stop. Thank you so much for your attention. I hope it was helpful. And thanks to the APA for inviting me.

pediatric sleep disturbances

insomnia

parasomnias

CBT-I

melatonin

sleep cycle

behavioral interventions

ADHD

autism

circadian rhythm