Dr. Henry Paul, MD

Psychiatrist, Author and Educator

SOME IDEAS FOR HELPING CHILDREN SLEEP

February 27th, 2014

Joannie has been a poor sleeper all of her life but when she turned seven last year it got even worse. She goes to sleep late, wakes up a lot, and is always tired. I work two jobs and its exhausting me too. What can I do?

Sleep Hygiene

Here are some things you can try that most likely will help to solve the problem.

First, make sure that a regular bed time (and wake time) is adhered to and that any bedtime rituals start thirty minutes before the desired sleep time. Bedtime rituals should include pleasant activities such as reading to your child, rubbing, and soothing. Sleep onset associations like being rocked or fed by you at the time of going to sleep should be minimized.  For example, try to put the child in bed before falling asleep when rocking. Make sure that daily schedules are adhered to in all areas of life. Limit napping. Make sure your child has a balanced diet with enough food, gets adequate amounts of exercise,  and is protected from excessive chaos in the house such as violence, shouting, emotional upheavals, and quarreling. Bedtime should be three to four hours after eating, and there should be no heavy exercise for at least two hours before going to bed. After dinner the atmosphere should be one of relaxation and quiet activities, and emotional issues should be avoided as should any rough play and caffeine. The room should be a normal temperature, and be dark and quiet without clocks or televisions. If needed, teach your child some relaxation techniques such as deep breathing.  The major thing to keep in mind is that as sleep time approaches the goal is to induce a relaxed drowsiness, not an emotional or active time.

If a parent abides by these sleep hygiene suggestions the great majority of children will sleep well consistently. Of course from time to time there will be awakenings, especially if a child is sick, disturbed, or scared, but these are episodic and usually respond to gentle and firm reassurances and do not require special interventions. Do remember that not all children sleep exactly the same and there will be variation from child to child, but knowing your child’s natural patterns and adjusting your ways to your child’s rhythms go a long way to pleasant night times.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

WHAT SHOULD WE EXPECT ABOUT SLEEP WITH CHILDREN?

February 25th, 2014

Our son Randy has always been a hyper-type but over the years he has received great school treatment and understanding. He was diagnosed as having ADD and has done well with tutoring and special programs. But he has never slept well and I read that his poor sleep can lead to all sorts of problems.

I want to focus my next few blogs on sleep disorders with children.  I’ll discuss the sleep problems, sleep hygiene, the four parasomnias, and the use of medication.   I want to start by making it clear that, in general, use of medication for common sleep problems for children and teenagers should be a last resort. While the use of sleeping pills (hypnotic medication) has grown astronomically in adults, this should not take place for our youth.   What is important is what we call “sleep hygiene”, and that should be your first course of action.

It is important and often tedious for parents to do what is necessary to ensure that their child sleeps well and enough. Nearly all common behavioral sleep problems, such as bed time refusal, bed time resistance, difficulty falling asleep, frequent awakenings, getting up too early, and the like can be overcome without the use of medication.

Let’s first identify the sleep problems.

In general some sleep knowledge is helpful. Children sleep less as they get older. Newborns and infants can spend half of their time sleeping. But by four months old, regularity of sleep starts with the establishment of regular circadian patterns. These regular biological patterns contribute to regularities in sleep and waking, activity levels, hormone secretion, and other biological phenomena.

Although four months marks the establishment of some regularity of sleep cycles it is not usually until one year old that the frequency of night awakenings significantly diminishes. By four years old most children do not need to nap but often do need eleven to twelve hours of sleep. By early to mid-adolescence sleep patterns are quite close to those of adults who require about seven to eight hours of sleep.

Sleep problems

It should be noted that so-called sleep problems have a lot to do with what particular parents find tolerable in their children which in turn is affected by their own sleep patterns, the subculture in which a child is raised, and the overall tolerance of the household to a child’s awakenings. It is also important for parents to know what to expect at various ages in order to know when a sleep problem exists.  It is important that a child gets enough sleep. A child who does not get enough sleep can be plagued by many problems which include:

  • Irritability
  • Impulsivity
  • Inattention
  • Moodiness
  • Aggressiveness
  • Fatigue
  • Learning problems
  • Child/parent interaction disturbances
  • Overweight
  • Having to be awakened regularly

In addition to the common causes of insomnia including stress, anxiety, stimulus overload, and caffeine, there are other causes which should be ruled out such as obstructive sleep apnea, restless leg syndrome, side effects of medication including ADHD and antidepressant medications, chronic illness, autism, developmental delays, ADHD itself, depression, and anxiety disorders. After these have been ruled out, common insomnia can be handled without the use of special sleep medications in almost all cases.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

WHAT TO DO IF YOU FEEL YOUR CHILD MIGHT BE SUICIDALLY DEPRESSED

February 18th, 2014

The most important thing you can do if you think your child is suicidal is to explore the situation openly.  If your child states that he has suicidal ideas or intentions or plans then an immediate mental health evaluation is necessary.

Unfortunately, things are not always that clear, so first ask yourself is my child or teenager depressed? If after a week or two, a sad mood does not budge or gets worse and signs of depression are present, be concerned.   Talk to your child openly about how he or she is feeling.  Include direct questions about suicide. Many parents mistakenly feel that by asking about suicide they will put it in a child’s mind.  This does not happen. It is important to know what your child is thinking and direct questioning is the best way to find out. You can ask directly about suicidal ideas, rehearsals, preparations, and the like. This can also be done by asking something like: Sometimes when we feel like this, thoughts of dying or wanting to take your own life can pop up. Has that ever happened to you? Further probing can include other questions like:

  •     Do you think about death?
  •     Do you feel like you want to disappear?
  •     Do you feel hopeless?
  •     Do you think about the afterlife?

It is also essential that you look for possible signs of preparation:  a note or other writing, a weapon, or hoarded medication.  Increased drug use is also a high risk sign

If, after open, kind, and compassionate questioning of your sad child, without lecturing or criticizing, you see no progress in the depression, and have little or no handle on understanding the situation, and see any signs of possible suicidal intent, then a mental health assessment is needed. No time should be wasted in getting professional attention.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

THE WARNING SIGNS OF SUICIDE

February 13th, 2014

Potentially suicidal young people frequently show warning signs. What follows is a list of some of the thoughts, feelings, and actions that could indicate that a young person is contemplating suicide. They range from internal, unexpressed thoughts, like wanting to die, to overt actions, like writing a note or collecting drugs or weapons.

  • Thoughts of death
  • Wanting to die
  • Prior suicide attempts/gestures
  • Feeling that the world would be better off if they were dead
  • Feeling useless and hopeless
  • Giving verbal hints about not being able to take it anymore
  • Writing about death
  • Getting absorbed in music, video sites, or activities stressing death or suicide
  • Talking of the afterlife
  • Dressing in black
  • Becoming absorbed in morbid subjects
  • Having an inappropriate burst of enthusiasm or cheerfulness after being depressed (this sometimes indicates that a person has decided to commit suicide)
  • Cleaning house and putting his/her things in order
  • Writing a suicide note
  • Buying books or researching modes of suicide
  • Idealizing celebrities who have committed suicide or died in other ways
  • Engaging in drunken driving
  • Accumulating weapons

If you see any of these signs you should be immediately concerned and contact a medical health professional right away.  In my next blog I will discuss having an open conversation with your sad/depressed child if you suspect that he or she might be contemplating suicide, but is not showing any clear signs like those listed above.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

THE STATISTICS OF SUICIDE

February 11th, 2014

Of course, suicide is always a worry when there is talk about depression.  While suicide is quite uncommon for younger children, we do see an increase starting at about nine years old.  By 13 to 14 years old, the rate of suicide increases and becomes the third highest cause of death for 10 to 24 year-olds. The rate of suicide under ten years old is about .8/100,000 children, it doubles in the 10 to 14 year old group but then increases to about 8/100,000 by 15 to 19 years old. Suicide attempts are often reported as accidents and are not reflected in the statistics — like the depressed teenager who crashes the car into a tree. About two thousand suicides in youngsters occur in the United States each year. There are about one hundred thousand world-wide. While depression is the main risk factor associated with youth suicide, other conditions also raise the risk:

·         Behavior disorders

·         Physical/sexual abuser

·         Severe anxiety

·         Eating disorders

·         Suicide in the family

·         Substance abuse

·         Being bullied

·         Family disruption

There are many triggers for suicide including being rejected socially or in a love relationship, school failure or expulsion, being caught by the police doing an antisocial act, feeling humiliated, being intoxicated, and experiencing family stress.  Hopelessness, often found in depressed youngsters, is one of the most indicative signs of a possible suicide attempt.

So where do antidepressants fit into adolescent/teen suicide? After some preliminary studies had come out from the FDA in 2003 and 2005 saying that there was an increased risk in suicidal thoughts in children, adolescents and young adults, parents became scared to have their child on any of these medications.  There was, and still is, a lot of information on the Internet to dissuade parents from using antidepressants, so I understand the fear.

Here’s how I see it.  When the studies came out, many psychiatrists, me included, spoke out nationally emphasizing that if, in fact, this was a risk, it was so rare that most of us had never seen it and that proper monitoring by the prescribing physician would, in all probability, be enough to ward off any tragedy.   Despite this, the new prescribing of antidepressants dropped markedly.  Tragically the suicide rate increased in teenagers.  No scientific correlation was made, but it seems that this was related to less use of the antidepressants which could have treated the depression and prevented the suicide.

The reality is that, if prescribed correctly under the guidance of an experienced psychiatrist, I do not think there is an increased risk of suicide.  Further studies about particular drugs with proper control groups will clarify this.   What I recommend is that parents do not withhold antidepressants on what we know so far, but parents should be cautious and make sure that their child is being monitored for every possible side effect.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

SIGNS OF DEPRESSION IN YOUNG PEOPLE

February 7th, 2014

Childhood depression is a great health challenge for our country.  Depressed children and teenagers often appear as if their personalities have changed.  Sadness is normal, but depression is more painful and deeper.   The symptoms of depression in a youngster may vary from child to child somewhat, but overall they are fairly easy to recognize if you know what to look for.

A depressed child is often sad, angry, irritable, cranky, whiny, and prone to rage at times, even violence.  Sleep and appetite patterns change, weight is lost, menstruation and normal bowel function are affected, personal appearance deteriorates, and serious fatigue could ensue as well.  Self-esteem is lowered and often the youngster feels like she is bad, a loser, worthless, unlikable and inferior.  Depressed young people often feel sick and have a host of pains – headaches, muscle stiffness, and stomach aches.  School functioning will decrease as concentration, attention and attendance drop off.  These kids will usually isolate from friends and family.  Communication is lessened and often irritation in short spurts is all that a parent sees.  Formerly fun activities give little pleasure and are sometimes replaced by risky pursuits and behavior.  Energy is low, and fatigue is high.  These depressed youngsters often look like they move in slow motion, heads down, slumped shoulders, with a sad and pained expression.  They appear to be apathetic.  Sometimes a depressed child will talk of running away or becomes angry at authority.

Suicide is a major concern with depression as the teen years approach.  Depressed young people often feel hopeless, a particularly worrisome sign that is associated with suicide.  Suicidal thoughts and even, tragically, successful attempts are not uncommon in teens.  There are warning sides to watch for with suicide.  I will address those in my next blog.

Fortunately, depression is a treatable condition if properly diagnosed.  If you suspect depression with your child you must act immediately.  Contact your pediatrician, the school counselor, your religious counselor, the local mental health association, or ask a friend who has been through this for a referral to a mental health professional. If you have further questions about the signs of depression, please email me.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

YOUNG PEOPLE DO GET DEPRESSED

February 4th, 2014

At first our eight-year-old Ivan’s teachers thought he had ADHD. He would stare off, seemed consumed with daydreams, and never paid attention to his work. But one day he told his gym teacher that he was just too sad to participate in basketball and that he was always sad and lonely. Now I feel that my wife and I misread his crying in his room as a reaction to poor grades but maybe he’s just been depressed all these years. After all, he never seems to really enjoy anything for more than a few minutes, drops new hobbies, and rarely gets excited.

Joanne seemed sad and withdrawn when she heard about her friend Sally’s leukemia. We figured, “Who wouldn’t be?”  After ten days she seemed worse. She stayed in her room listening to Gregorian chants, started reading the Bible, and didn’t eat or even come out. Last night she said she felt guilty that she didn’t get sick herself. She said we would be better off without her around and wrote a poem about the joy of death.

For many years the psychiatric establishment didn’t believe that children could experience depression. We saw depressed children every day, but because many of the theories that informed our work implied that children had not reached a developmental stage capable of getting depressed, we could not call them depressed.

This backward thinking stopped much research and development of treatments for childhood depression. We now know this was shortsighted. As the stories above, and hundreds of thousands like them, attest, children and teenagers of all ages experience depression. According to the American Academy of Child & Adolescent Psychiatry about 5 percent of children and adolescents in the general population suffer from depression at any given point in time.  Still, tragically, the great majority of these youngsters do not get proper evaluation or treatment due to limited availability of care and lack of compliance with treatment. This leads to high levels of family, educational, and social problems, as well as substance abuse and other psychiatric problems, and even suicide — one of the leading causes of death for adolescents in this country.

DISCLAIMER
Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.