Improving sleep in vulnerable children
It’s time to wake up to sleep!
‘We have two main epidemics among children. One is obesity and the other is mental health, and underpinning both of these is sleep…as a society we downplay the importance of sleep.’ Michael Farquhar, consultant in sleep medicine, Evelina Children’s Hospital (Marsh, 2018)
Why are we interested in sleep?
As a lead for evidence based parenting in Sheffield City Council, I have always been aware of the huge number of our families who struggle with sleep, or lack of it.
A couple of years ago I was lucky enough to meet Heather Elphick at Sheffield Children’s Hospital, a Paediatric Respiratory and Sleep Consultant, who leads the sleep clinic. Heather was clear that among the huge number of children referred to the hospital sleep clinic, only around half of these, and only around 5% sleep problems in the community, were due to a medical cause. She was also concerned about the rising number of children using melatonin, a drug to aid sleep onset. Together with The Children’s Sleep Charity and Sheffield City Council, Heather was successful in securing funding from The Health Foundation to conduct research into whether a behavioural intervention could work to reduce sleep problems in children in the care system, and children with attention deficit hyperactivity disorder (ADHD).
The Children’s Sleep Charity, which was established in 2012 following the founders own experience of sleep problems with her son, has devised comprehensive sleep practitioner training. A group of practitioners from parenting and senior learning mentor backgrounds in my service had been trained back in 2017. They had described the training as ‘inspirational’ and were persistent in championing the work.
As a parenting service, layering sleep practitioner training on top of evidence based parenting, opened up a whole new approach. Admitting to difficulties in sleep seems easier than saying you are struggling with parenting, so a whole new cohort of families were suddenly coming forward.
The research programme was delivered as a partnership between the three organisations (Sheffield Children’s Hospital, Children’s Sleep Charity and Sheffield City Council) over a twelve month period, and now culminates in a national conference to share the findings this March. For us in the local authority, the process has been transformational.
39 children completed the intervention and evaluation. 75% had ADHD and 25% were looked after or adopted children.
The intervention entailed basic education about sleep, a one-to-one session with a sleep practitioner to create an individual sleep programme, and telephone support to empower the parent to carry out the sleep programme at home. What was different about this was the intensely practical nature of the intervention and the partnership approach that benefited all of us.
Too often parents ‘bounce back’ into services with the same issues again and again, this approach sought to work alongside the parent whilst they implemented a customised plan on a daily basis. The stress and pressure that a lack of sleep can cause often results in parents giving up at the first hurdle when attempting to change the sleep routine. Our practitioners used daily phone calls to motivate and empower the parent or carer until they no longer needed the support. This was overwhelmingly sited by parents and carers as a key to success.
There is increasing research into the importance of sleep, but in busy Children’s Services do we always spot a sleep issue? Lack of sleep can result in behavioural difficulties, irritability, decreased attention, impact on ability to learn and concentrate at school, and on weight and emotional wellbeing. It is not surprising that services often respond to what they perceive to be the primary concern and hope that sleep will improve as a result.
The research evaluated the wider impact of the sleep intervention and found that parents and young people were reporting quite life changing outcomes. Parents and carers reporting feeling less isolated, less stressed and having improved relationships with the child and their partner. Overwhelmingly, the parents told us the intervention had given them more confidence in their parenting and more able to tackle other issues in their lives. There were also improvements noted at school for the young people, with children more able to regulate their emotions.
Children gained on average an extra 2.4 hours sleep a night. Over a week, that adds up to an extra two nights of sleep! The primary word used to describe the mood of the child on wakening changed from ‘grumpy’ to ‘happy’. The impact of sleep deprivation on the parents’ wellbeing improved for all measures. 100% said they would recommend the programme to others.
The cost of prescribing melatonin (Circadin® 2mg prolonged release tablets) for one year is £309.36 (derived from Sheffield prescribing costs 2017-18). Anecdotally, the majority of children with ADHD are currently prescribed melatonin for sleep difficulties and continue to take it until discharged to Adult Services. Previous surveys in Sheffield have indicated that 35% can be weaned off melatonin and 30% can avoid melatonin prescriptions after receiving the behavioural intervention.
This research did not set out to reduce prescriptions in melatonin but there is an obvious link and opportunity to explore this further. The average cost of the sleep intervention was £300-400 per family, which is around the same annual cost of prescribing melatonin but is a one-off cost rather than a year-on-year cost.
Following the research, we have continued to develop sleep interventions across services in Sheffield. Our strategy has been to work with The Children’s Sleep Charity to train practitioners in a variety of services and settings so that families receive sleep interventions as part of their journey. Professionals in early help, health visiting, school nursing, parenting, and children’s residential settings have all been trained in the basics with key staff in each service trained as sleep practitioners to deliver the sleep intervention directly to families.
About the author
Candi Lawson is a Strategic Commissioning Manager at Sheffield City Council.
To find out more about the programme, contact firstname.lastname@example.org.
27 March, Solihull
Health and local authority services are waking up to the importance of sleep for improving the physical, emotional and mental wellbeing of children and young people and their families.
The aim of the conference is to share research findings and insight with discussion around implementation, delivery and commissioning strategies for people interested in setting up a sleep support service in their region.
Marsh S (2018) Children's lack of sleep is 'hidden health crisis’, experts say. The Guardian. Available online: https://www.theguardian.com/lifeandstyle/2018/sep/30/childrens-lack-of-sleep-is-hidden-health-crisis-experts-say