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Oct 25 CAPHC Concurrent Symposium - Sleep Disorders - Dr. Penny Corkum and Dr. Shelly Weiss

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CAPHC Concurrent Symposium
Sleep Disorders in Canadian Children: What Can We Do to Ensure Better Nights and Better Days for Children and their Families?

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Oct 25 CAPHC Concurrent Symposium - Sleep Disorders - Dr. Penny Corkum and Dr. Shelly Weiss

  1. 1. 2016 CAPHC Annual Conference October 23-25, 2016 Halifax, NS Sleep Disorders in Canadian Children: What Can We Do to Ensure Better Nights and Better Days for Children and their Families? Penny Corkum, PhD, Registered Psychologist Professor, Department of Psychology & Neuroscience; Psychiatry Dalhousie University IWK Scientific Staff; CEH ADHD Clinic ShellyWeiss, MD FRCPC, Pediatric Neurologist Professor, Faculty of Medicine, Hospital for Sick Children, University of Toronto 1
  2. 2. Outline  Introductions & Objectives  Xavier’s story  Importance of sleep  Access to services in Canada  Barriers to care  Guidelines for pediatric sleep  Service delivery models  Introduction to Better Nights, Better Days  Discussion/Questions 2
  3. 3. Main Goal forWorkshop  Determine how we can all work together (as administrators, policy makers, researchers, clinicians, and families) to improve paediatric sleep assessment and treatment in Canada so that there is access to services for all in need, no matter where they live 3
  4. 4. Importance of Sleep
  5. 5. Causes of Sleep Disorders/Problems  Prevalence  25% of typically developing children  ≥ 80% of children with physical and mental health disorders  Causes  Sleep disorders  Lifestyle factors 5
  6. 6. Classification  DSM-5 (2013) / ICSD-3 (2013)  10 different sleep disorders/sleep disorder groupings 1) Insomnia Disorder 2) Hypersomnolence Disorder 3) Narcolepsy 4) Breathing-related sleep disorders 5) Circadian rhythm sleep-wake disorders 6) Non–rapid eye movement (NREM) sleep arousal disorders 7) Nightmare disorder 8) Rapid eye movement (REM) sleep behavior disorder 9) Restless legs syndrome 10) Substance/medication-induced sleep disorder 6
  7. 7. Insomnia  Most common sleep disorder in TD children and children with mental health and physical health disorders  Criteria  Reports of difficulties falling asleep, staying asleep, and/or early waking  Daytime consequences of sleep problem  Adequate opportunity for sleeping  Frequent (≥3x/wk) and chronic (≥3 mos)  Not explained by another sleep-wake disorder, medical condition or mental health disorder 7
  8. 8. Lifestyle Factors  People of all ages are sleeping less now than ever before  Sleeping about 1 hour less now than at the beginning of the century  Reasons…  Electronics  Sleep not seen as a priority  Extra-curricular activities  Social activity  School start times  Results in a Social Jet Lag & Sleep Debt 8
  9. 9. Factors Affecting Sleep in Children Sleep Genetics Sleep Environ- ment Family/ Parents Health Develop- ment Social – Emotional Social – Cultural Sleep Practices Slide courtesy of Jodi Mindell 9
  10. 10. Chronicity of Sleep Disorders  Transient and persistent sleep problems  Genetics may play the largest role in stability of sleep problems  Stability depends in part on the type of sleep problem and the treatment provided  Even when a sleep problem does not persist it predict later behavioral/mental health problems 10
  11. 11. Cognition/ Learning Mental Health Physical Health Quality of Life Consequences of Sleep Disorders 11
  12. 12. Consequences of Sleep Disorders Community School Family Child 12
  13. 13. Importance  Sleep problems could put individuals at risk for mental health or physical health disorders  Sleep problems could mimic mental health disorders and as such need to be considered as a differential diagnosis  Sleep problems could exacerbate mental health problems/increase symptoms severity and chronicity  Treatment of sleep problems may reduce impairment and may even act as an enhancement therapy (e.g. make other therapies more effective)  The treatment of mental health problems with medication may increase sleep problems 13
  14. 14. How could poor sleep in children affect your service? 14
  15. 15. Access to Services in Canada
  16. 16. Facts about the gaps in Canadian resources for sleep  Despite high prevalence of sleep disorders/problems, chronicity, and significant impact, they are often unrecognized and under treated by clinicians  Main Reasons  Limited awareness and knowledge of the importance of sleep  Limited skills in this area for health care providers  Limited access to services and resources/tools 16
  17. 17. Access to services to diagnose Obstructive Sleep Apnea in Canadian children  What is the gold standard for diagnosis?  Where are the sleep clinics?  Where are the pediatric sleep practitioners? 17
  18. 18. PSG is gold standard to diagnose OSA 18
  19. 19. Canadian Sleep Society Clinic Map www.css-scs.ca 19
  20. 20. Western Canada 20
  21. 21. Eastern Canada 21
  22. 22. 22
  23. 23. Pediatric sleep resources for OSA in Canada  Survey study of pediatric sleep practitioners and sleep laboratories Results  No sleep practitioners (for OSA) or PSG available in Yukon, NWT, Nunavut, Saskatchewan, Nova Scotia, New Brunswick, PEI, NFLD/Labrador  Wait time for PSG varied from < 1 months to 1.5-2 years  Lack of resources and services for pediatric sleep disordered breathing has great geographical disparity 23
  24. 24. 24
  25. 25. Service Providers  CSS listing for sleep clinics, insomnia treatment providers, dentists (searchable by province)  https://css-scs.ca/resources/types-of-providers  Diagnosis  Physicians  Psychologists  Treatment  Physicians  Psychologists and other allied health professionals  Dentists  Sleep Consultants  http://goodnightsleepsite.com/toronto/  Others (e.g., naturopath, chiropractor)  Main concern – Lack of regulation of field and some service providers! 25
  26. 26. Barriers to Care
  27. 27. Limited awareness and knowledge of the importance of sleep 27
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  30. 30. 30
  31. 31. Methods  124 Canadian health care providers were surveyed about barriers and facilitators  Included: physicians, nurse, psychologist, social workers 31
  32. 32. 32
  33. 33. 33
  34. 34. New RCPSC initiative in sleep education  Currently no route to certification for subspecialist physicians who practice sleep medicine in Canada  As of July 2016, there will be a AFC (Area of Focused Competence/Diploma) in sleep medicine  1 year – include ongoing maintenance of certification  Eligible for physicians who are specialists in : ENT, respirology, psychiatry, neurology, developmental pediatrics 34
  35. 35. Guidelines for Pediatric Sleep
  36. 36.  http://sleepfoundation.org/ho w-sleep-works/how-much- sleep-do-we-really-need  Suggestion: Monitor sleep amounts and mood over a few days during which time the child is allowed to sleep until he/she awakens spontaneously (during vacation is best)  Concern: Sleep duration recommendation for school- aged children previously was 10-11 hours but now 9-11 and even 7-12 36
  37. 37. Participation 2016 Report Card 37
  38. 38. 38
  39. 39. Recommended hours of sleep  Age 5-13 years: 9-11 hours  Age 14-17 years: 8-10 hours 39
  40. 40. • Healthy sleep is the goal for all infants, children and adolescents • Guidelines to evaluation and treatment of sleep disorders • Position statement endorsed by College of Family Physicians, Canadian Psychiatry Association and Canadian Sleep Society • Endorsement by Canadian Pediatric Society (pending)  Published Jn Can Acad Child and Adol Psychiatry,Vol 23 (3), 2014 40
  41. 41. 41
  42. 42. What do you see as the main barriers to sleep services in your communities? 42
  43. 43. Service Delivery Models
  44. 44. Current Service Delivery  Large differences between provinces and regions (urban/rural)  Focus on obstructive sleep apnea  Use of medications that do not have efficacy data to support their use in children  Limited access to behavioural treatments 44
  45. 45. Measurement of Sleep PSG Actigraphy Sleep Diary Questionn aires Interviews Objective Subjective 45
  46. 46. Best Practices – Assessment • PSG/MLST • Actigraphy/ Videography • Interviews/ Sleep Diaries • Screening/ Questionnaires 46
  47. 47. Best Practices – Assessment • PSG/MLST • Actigraphy/ Videography • Interviews/ Sleep Diaries • Screening/ Questionnaires 47
  48. 48. Best Practices – Treatment • Medication • Specific behavioural sleep interventions • Implement healthy sleep practices • Psycho- education 48
  49. 49. Best Practices – Treatment • Medication • Specific behavioural sleep interventions • Implement healthy sleep practices • Psycho-education 49
  50. 50. Suggested Model: Stepped Care Individualized intervention provided by sleep medicine specialist Individualized intervention by highly trained health professional (non-sleep specialist) Manualized in-person individual or group intervention provided by trained health professional (non-sleep specialist) Self (parent) administered interventions with human support (non-specialist) Self (parent) administered interventions (no direct human support) BNBD-TD / BNBD-NDD Public education/ prevention/ screening *adapted from Espie, C.A. (2009). “Stepped Care”: A health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep, 32(12), 1549-1558. 50
  51. 51. Introduction to Better Nights, Better Days
  52. 52. 52 http://betternightsbetterdays.ca/ http://ndd.betternightsbetterdays.ca/
  53. 53. Session 1: Sleep Information Session 2: Healthy Sleep Practices Session 3: Settling to Sleep Session 4: Going Back to Sleep Session 5: Looking Ahead Z ZZZ BNBD Intervention Program 53
  54. 54. Program Tools and Supports Daily online Sleep Diary allows participants to track their results and see patterns in their child’s sleep and behaviour Sleep Diary Weekly Activities and Reviews Track Your Progress Participants receive feedback on their progress Activities help participants make positive changes to their child’s sleep • Learn how to create sleep routines, a healthy sleep environment, and practice techniques to reduce stress 54
  55. 55. BNBD-TD Randomized Control Trial Goal: 500 participants 55
  56. 56. Who Can Participate http://betternightsbetterdays.ca/ 56
  57. 57. Steps to Study Participation Website Self-Screen Screening Eligibility Assessment Baseline Randomization Better Nights, Better Days Intervention Usual Care 4 Month Follow-Up 8 Month Follow-Up Study End 57
  58. 58. Recruitment and Enrollment Update • As of Oct 21, 2016, we have had: – 852 parents express interest in the study – 503 consent to screening – 293 consent to participate in the study – 204 deemed eligible – 196 start baseline • Recruiting 400 English-speaking parents/guardians from 4 Canadian regions (Atlantic, Central, Prairies, West Coast/Northern) – 100 parents per region – Atlantic Canada region has met quota and is not closed • Recruiting 100 French speaking parents across Canada (Winter 2017) 58
  59. 59. Discussion/ Questions
  60. 60. How to improve awareness and knowledge of the importance of sleep? How to train health care providers in sleep assessment and treatment? How to increase equitable accesses to services and resources? How to work together to to improve paediatric sleep assessment and treatment in Canada so that there is access to services for all in need, no matter where they live? What would you need to make a stepped care model for pediatric sleep work in your service? 60
  61. 61. Thank you Web Resources Canadian Sleep Society  http://www.css.to/ National Sleep Foundation  http://www.sleepfoundation .org Star Sleeper  http://www.professorgarfiel d.org/pgf_StarSleeper.html Insomnia Rounds  http://www.insomniarounds .ca 61 penny.corkum@dal.ca http://myweb.dal.ca/pvcorkum/

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