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

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. 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. 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. Importance of Sleep

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. 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. 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. 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. 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. 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. Cognition/
Learning
Mental
Health
Physical
Health
Quality
of Life
Consequences of Sleep Disorders 11

12. Consequences of Sleep Disorders
Community
School
Family
Child
12

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. How could poor sleep in
children affect your
service?
14

15. Access to Services
in Canada

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. 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. PSG is gold standard to
diagnose OSA
18

19. Canadian Sleep Society Clinic Map
www.css-scs.ca
19

20. Western Canada
20

21. Eastern Canada
21

22. 22

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

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. Barriers to Care

27. Limited awareness and
knowledge of the importance of
sleep
27

28. 28

29. 29

30. 30

31. Methods
 124 Canadian health care providers were surveyed
about barriers and facilitators
 Included: physicians, nurse, psychologist, social
workers
31

32. 32

33. 33

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. Guidelines for
Pediatric Sleep

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. Participation 2016 Report Card
37

38. 38

39. Recommended hours of sleep
 Age 5-13 years: 9-11 hours
 Age 14-17 years: 8-10 hours
39

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

42. What do you see as the
main barriers to sleep
services in your
communities?
42

43. Service Delivery Models

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. Measurement of Sleep
PSG Actigraphy
Sleep
Diary
Questionn
aires
Interviews
Objective Subjective
45

46. Best Practices – Assessment
• PSG/MLST
• Actigraphy/
Videography
• Interviews/
Sleep Diaries
• Screening/
Questionnaires
46

47. Best Practices – Assessment
• PSG/MLST
• Actigraphy/
Videography
• Interviews/
Sleep Diaries
• Screening/ Questionnaires
47

48. Best Practices – Treatment
• Medication
• Specific behavioural
sleep interventions
• Implement healthy
sleep practices
• Psycho-
education
48

49. Best Practices – Treatment
• Medication
• Specific behavioural
sleep interventions
• Implement healthy sleep
practices
• Psycho-education
49

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. Introduction to
Better Nights,
Better Days

52. 52
http://betternightsbetterdays.ca/
http://ndd.betternightsbetterdays.ca/

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. 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. BNBD-TD
Randomized Control Trial
Goal: 500 participants
55

56. Who Can
Participate
http://betternightsbetterdays.ca/
56

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. 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. Discussion/
Questions

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. 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
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penny.corkum@dal.ca
http://myweb.dal.ca/pvcorkum/