Greatest Hits - Sweet Dreams: Down Syndrome and Sleep, Part 1

This summer, we're revisiting some of Hina and Marla's greatest hits from the first 11 seasons of The LowDOWN. On Season 2, Episode 3 of The LowDOWN: A Down Syndrome Podcast, Dr. Rafael Pelayo gives us the lowdown on sleep issues for people with Down syndrome. (part 1 of 2)

Transcript

The purpose of this episode is to explore common health and wellbeing, strengths and challenges for people with down syndrome. The content discussed here is not meant as a substitute for direct medical care with relevant professionals. Rather, we hope to share new and little known information so that families and supporters can be well informed when accessing medical care. Your child or student's medical or educational professionals may have recommended different practices or procedures that are specific to your child or student. Do not modify or change your child's treatment or therapy plan without consulting with your care provider first. Today on the Lowdown a Down Syndrome podcast, doctor Rafael Pelayo gives us the lowdown on sleeping issues for people with down syndrome. Over to you, Marla. Hannah. Thanks, Danielle. Hello everyone, and welcome to the lowdown podcast. My name is Hannah and I am the senior occupational therapist at the Down Syndrome Research Foundation. And I'm joined by my amazing co-host, Marla Folden, who is an SLP at the DSF. Hi, Marla. Hi, Hannah. How are you? Doing pretty well today. Are you good? I'm good. I'm very, very excited about our guests today. We do. Yeah. So today's we're very excited about today's episode because we will be discussing a topic that comes up in almost every conversation we have with our parents and caregivers of individuals with down syndrome, which is sleep. Huge, huge, huge issue. Um, children with down syndrome sleep poorly with more fragmented sleep and frequent awakenings compared to typically developing kids. And, you know, for many of us, a poor night's sleep can moderately impact our functioning throughout the day. But for our clients with down syndrome who experience prolonged sleep difficulties, the impact is far more severe, including challenges of behavior, poor emotional regulation, impaired attention, and an adverse impact of their overall physical health. So today, we are pleased to welcome Doctor Rafael Pelayo to the Low Down Podcast. Thank you. Welcome. We're glad to have you today. Um, I'm going to read a little bit about you so that our listeners get to know sort of your background and where you're coming from. So doctor Rafael Pelayo is a clinical professor at Stanford University School of Medicine in the Division of Sleep Medicine, which I think is Department of psychiatry if I'm not wrong. Um, he graduated with a degree in biology from the University of Puerto Rico. He his initial exposure to sleep medicine was as a med student in the Albert Einstein School of Medicine, and that experience led him to pursue a career in sleep medicine as a pathway into sleep medicine. He trained as a child neurologist. Oh, he's just the best person for us to interview. It's so great. Um, and he joined the Stanford Sleep Disorders Clinic in nineteen ninety three and never left. The focus of Doctor Pelayo's treatment of sleep disorders has been in patients of all ages. And he chairs the American Academy of Sleep Medicines Political Action Committee. In twenty nineteen, he was appointed to serve on the board of the National Sleep Foundation in the States, and he also serves as on the board of the Start School, and he has served as the chair of the Sleep Disorders Research Advisory Board on the National Center for Sleep Disorders Research at the National Heart, Lung, and Blood Institute at the NIH. That's a lot of things. And he also chaired the pediatric special interest sleep section of the American Academy of Sleep Medicine. So that was that was that was in the past. I don't do that anymore. Okay. Especially because they dissolve that. Um, and I have a book. I have a book coming out. Oh, fantastic. Yeah, you can look it up. How to sleep? Very straightforward. Yeah. So if you look up how to sleep. The publisher is a company called a New York City publisher named Workman. Okay. So it'll be out in the in the late fall, probably be in stores in December. But yeah, so it's already the cover and all that's already done. It's called how to sleep. Okay. Awesome. We will look for that. Absolutely. Um, Doctor Pelayo, usually when we interview somebody here we start with five secret questions is not a test. It's just for people to get to know you better. So do you mind if we start with that? Depends. I don't have to answer. That's true. That's true. So the first question is what are you currently listening to? Could be a podcast or an audiobook or some kind of music that you're enjoying a lot. Uh, last night I was listening to a CD of the band R.E.M.. Oh, yeah. Perfect. Yeah. I was actually very lucky to see them in concert before they broke up, so they're great. Very cool. Yeah, yeah, I saw them when they came. They did an outdoor concert in Burnaby. It was awesome. Oh, yeah. The summer series. Yeah. Okay. Yes. Yeah. And the second question would be what would be your favorite season and why? The fall. I love the fall. Just kind of a nice transition. Happens to be around time on my birthday. But I just I've always liked the time of the year, like the transition of seasons. I like the Indian summers when we get them. And I like the cool nights also sitting by the fire. So I love the fall. Love it, love it. Um, okay, I'm going to take over for a bit. If you could meet any historical figure alive or dead, who would it be? And I know this is a bit of a tough question to give you right off the bat, but I've thought of this. But I don't want to tell you who I thought when I was in college, I got in trouble for saying Hugh Hefner. Oh, so so that's the. So I always remember that that that issue. Um, I would love to meet Obama. I'd like to talk to President Obama if I could. Mhm. Yeah. Yeah. That's a really good one. Um, okay. Question number four. What is your ideal way to spend a weekend? Right now, with the social distancing, I started going just some like just drives around. Uh, Northern California is beautiful. So I've just been staying in my car, driving, listening to music, sometimes with my wife or one of my children. I really like doing that. Mhm. Fantastic. And the, the eucalyptus in Northern California is just so spectacular. I would just drive and go see all of those. We have those also have the big redwoods too. Yes. You got you got plenty of trees in Vancouver. You don't smell like eucalyptus. Yes. But that's what I've been doing lately. I've discovered a bunch of like, back roads that I've never been on. Mhm. Because I'm not trying to get anywhere. I'm just saying, what happens if I go down this road? Yeah. And I just start driving until the road ends. Then I find another road. Yeah, that's what I've been doing lately. That's nice, I love that. That's really great. Okay. And our last question, so Marla had mentioned that you did your undergraduate degree in Puerto Rico. For anyone traveling to Puerto Rico, hopefully post Covid, when everything can kind of go back to normal, what would you recommend they do? Like what would be the first thing that they should check out or do in Puerto Rico? I think if you arrived in Puerto Rico for the first time, you can be there for a few days. The first thing you want to do is just go to the beach and do nothing but stay at the beach. Just let it soak in. Yeah, just just get a sense of the island by being around the beach, being around local people. Later you can go do some sightseeing and things like that. But I would just go to the beach. Land, land that sand, maybe go to the beaches on the far eastern side of the island are really nice. Even off the coast of the mainland of the main island of Puerto Rico. There's some beautiful beaches, Vieques and Culebra, which the sand is like sugar, clear water. Oh, wow. Just just go there and do do go there and do nothing. Just go to that beach and do nothing. Yeah. Things. Food and drinks will come to you in that beach. Do that for a few days first, and then explore the rest of the island. Love it. I'm not even a beach person. But you've sold me now. I kind of want to check it out. Now, I'm not a beach vacation person, but I want to do it now. Um, thank you so much. That was really great. I appreciate you kind of playing along with that with us. And I think our listeners kind of got a good sense of, um, of what you like and not. So let's kind of dive into what we're here to talk about. Um, as Marlow was reading your biography, I noticed that your expertise fall into a few areas. So psychiatry, sleep medicine, child neurology, and behavioral science. How do all of these domains work together in your everyday interactions with your patients? One of the things I like about sleep medicine, if you look at the symbol for sleep medicine, the is actually a yin and yang, the black and white symbol. And that was meant to be represent the day and the night. But I've taken it to mean that in sleep medicine. We don't separate the mind from the brain. It goes together. And the work that I do works with that together. We don't need to separate the mind from the brain. So even though I trained as a neurologist, I mostly take care of adults in the Department of Psychiatry. And I like that because I get to work with all ages. And I've come to think about sleep not as how an individual sleeps, but I'd like to think about how a family sleeps. It's very important to think about how down syndrome works, because some things we can't change and some things we can. But if I can help that child's mother sleep better, it'll help her work with that child more. So I really like to think about the entire family and how they're sleeping. And so I like to integrating of the mind and the brain. And that's what I try to do in my work. Mhm. Very holistic approach for sure. Yeah. But but it has to be that way because we can't separate them from the brain. If you've had poor sleep for more than two or three months, it may be a physical reason. A child with down syndrome could have a large tongue and block their breathing. But once you've had poor sleep for more than two or three months, it will never be an entirely physical problem. Because sleeping is something that we learn how to do. Sleeping is a learned behavior. Mhm. We're taught how to sleep. Mhm. All babies will drink milk at birth, but what a five year old eats throughout the planet will be different. And when you visit other countries, the first thing you look at is what are the foods there? So the need to eat is biological, but what you eat is cultural. Sleep is the same way. The need for sleep is biological. But the way sleep is learned and we teach our kids how to sleep. Mhm. And that's something that I like to get into how the entire how the entire family sleeps. Yeah. Yeah. It's a great comparison. Yeah. Yeah. Makes it very clear. Yeah. That's great. And I'm so happy that you kind of touched on this, because my next question was asking you about in a previous presentation of yours that I heard you had referred to sleep as a learned behavior, and that we're often taught this behavior incorrectly. So could you expand on that a little bit more? I mean, maybe especially as it may relate to individuals with developmental disabilities or Down's syndrome. Sure. I think it's kind of you've been sleeping longer than you been doing pretty much any other activity. You've been sleeping longer than you've been eating food or breathing oxygen. Because you sleep in the womb, you sleep in utero before you have your first breath of air, or you have your first taste of food, you've already been sleeping. So considering the fact that we've been sleeping for so long and a third of our life sleeping, we don't spend a third of our life eating right. It's amazing to think that you would have to learn how to sleep, but you have to learn how to sleep because there's an inherent paradox of sleeping, sleeping, sleeping animals can be attacked at any point. Mhm. So all animals seem to have defense mechanisms that occur while they're sleeping. And humans are no exception. We're very successful animals, but there are a lot of misconceptions about sleep. In fact, sleep for a long, long time, for hundreds and hundreds of years was thought to be a death like state. Mhm. And you hear it on the way people talk. People say things and you may have heard people say this, I'm sure saying, well, I can't see because I can't turn off my brain. Mhm. Uh, well that's crazy. You're not supposed to turn off your brain. Your brain is active. In fact, your brain is protecting you while you're sleeping. In some parts of our brain are more active while we're sleeping than when we're awake. For you to hear my voice, I basically, the sound waves are banging off your ear, the eardrums and being represented for you. If you were to have a dream of somebody saying something to you, you have to create that image. It requires more energy to dream about something than to just see it in real life, get it physically. So some parts of the brain are more metabolically active when we're sleeping than when we're awake. In fact, if you have a sedentary lifestyle, your peak heart rate is when you're dreaming. So, so sleep is an active state. That's one of the main discoveries of the nineteen fifties and early on is carry forward that sleep is not a passive state, but people still think of it that way. Yeah. And they also equate sleeping with being tired, Which is another common mistake. Being tired of being sleepy may converge or may diverge. Anybody's been jet lagged. Knows there's a difference between being sleepy and being tired. And if the listeners were to get up now and do one hundred jumping jacks, you might feel tired. You're not going to be sleepy. This idea of needing to be tired to sleep or turning off your brain, these are misconceptions, and people are trapped in these misconceptions. That's what drives the sleep problems. When people have sleep issues, they talk a certain way. Nobody else really talks the way they do, and they'll catch your ear if you pay attention to what they're saying. For example, people with sleep problems say things like, I try to sleep. I try to go to sleep. Nobody else does that. Everybody else says, I go to sleep. You're not trying to get hungry. You're not trying to breathe. So when somebody's trying to do this, okay, now you know something is wrong. And then when you talk about children or adults, um, you got to get a sense of what, of what's the motivation of that person to go to sleep. I think of sleep in four dimensions. Whenever I talk to anybody about their sleep, I break it down to four dimensions. I think about the amount of sleep, the amount of sleep, the quality of their sleep, the timing of their sleep, and their state of mind. You got to get a sense from the individual when they talk about bedtimes. Who's picked this bedtime? Is it convenient for the parents or for the child? Who? What else? It's not just falling asleep. It's waking up. Right? Do you sleep to live or live? To sleep? It's a different thing, right? So? So we have to think about what is your incentive to get out of bed? Waking up is biological. Getting out of bed is volitional. What if that person has no desire to get out of bed or doesn't matter to them? If they get out of bed. Right. What are you getting up for? Are you looking forward to tomorrow? Are you eating tomorrow? So I really think of sleep in that context. What I think about how one individual sleeps, and I want to think about the entire families and all those four domains, how the families interact with each other in this arena also. Mhm. Did I answer your question? I just went off and talked about random stuff. No, no, no, you answered our question, but you gave us so much more to think about because I think we have to really understand the what sleep is and the on the function of sleep and how what our conceptions are about sleep. In order to really help figure out how to solve the problems that we are having with sleep. So I think that was super helpful. What are your thoughts, Marla? Yeah. Yeah, I agree. I'm going to focus us in a little bit on down syndrome here because as I'm sure you know, fifty to ninety percent of kids with down syndrome have obstructive sleep apnea. I from, from my perspective, that margin is super wide. And I think it speaks to the inconsistent testing and the changes that they go through as they grow older. Certainly the dually diagnosed group of kids with down syndrome and autism have more impaired sleeping. And in our clinic, Hannah and I both have about fifty percent of our students that have a dual diagnosis. So we see that a lot. And those families are extremely stressed out. Um, and some of our students actually also have a central sleep apnea diagnosis. So there's a lot of things in the mix. Um, could you maybe talk a little bit about the types of sleep apnea? For our listeners to make that piece of it really clear? Sure. The term apnea means without air and the. So sleep apnea, somebody who is not breathing while they're asleep. And I want you to just take a moment and think about how important sleeping is that the brain decides the brain's hierarchical decision. The way the brain is designed, created, evolved how everyone think of it, that it decides I'd rather sleep than breathe. That's important. Sleeping is so the brain continues to sleep despite the person stopping breathing. Eventually you have to breathe and your sleep will be interrupted in order for you to breathe. But for a window of time, the brain says, I prefer to sleep and to breathe. So, uh. And the term is obstructive sleep apnea means that there's a blockage of your breathing, an obstruction or blockage. And then, as you mentioned, the central sleep apnea where the brain is not sending the signal to the diaphragm to inflate the lungs. There are you can have both. You can have mixed conditions. You can have obstructive and central apnea. By far down syndrome is going to be obstructive sleep apnea. The American Academy of Pediatrics guidelines is. My understanding is that all children with down syndrome by the age of four should be tested for sleep apnea, because the condition is so prevalent and a lot of them aren't getting tested, I'm sure it may not be available. There may be other issues with it having now something to be aware of is that central sleep apnea on a sleep study may actually be obstructive, and it may be a wrong diagnosis in some of some of the kids. Central sleep apnea is silent, obstructive is snores. So if I see somebody who snores as obstructive and maybe central sleep apnea, the central apnea may actually be an artifact of the recording technique because what we measure it, we put these bands around their chest and the abdomen, and we have a microphone for snoring and an air flow signal usually on the upper lip. And what can occur is that if the if the airflow signal on the upper lip is flat or diminished. We say that's an apnoea. Then we look down at the chest and say, well, is the chest moving up and down? That means you're trying to breathe and air is not coming out. That's called obstructive. And if no effort is being made to breathe, then we say it's central. And that's a very simple way of thinking about this. But what happens sometimes is these are all night recordings. These are multiple hours, nine ten hour recordings. And the bands can slide or slip and we lose the signal. Okay, so when the technologist is acquiring the data, they have to decide, do I go in and fix these belts, wake the kids and wake and risk waking up the kid who may not want to go back to sleep later? Or do I keep collecting data? So what can happen is if something is obstructive, it really is obstructive. If something is central, it might be central, it might be obstructive, and it just looks that way briefly. So sometimes what we do, depending on the clinical situation, especially if the child snores, is treat the central sleep apnea as if it's obstructive first and see if the central then goes away. Okay, other. Now things get even more complicated because sometimes the kid only has obstructive sleep apnea when they diagnose a sleep apnea. But then if they use one of these breathing machines called Cpap machine, which we can talk about in more detail later. Continuous positive airway pressure Cpap when you when you blow the air down the child's throat or an adult. Also, sometimes you stretch out the throat and the brain's reaction is to stop breathing because things are getting too much air. So sometimes the central apnea is an artifact of the treatment that we're offering the child or the adult. They call that complex sleep apnea sometimes. So the central sleep apnea that we're seeing in the kids may really be central. Could be, but it could also be an artifact of the recording technique or an iatrogenic being induced by the treatment that we've given them. Okay. So you always keep that in mind a little bit when we see these people. And the main thing is obstructive sleep apnoea will snore in central sleep apnea typically doesn't. Okay. And those are really good things to know. I think we have a lot of families that come to us that insist that their child sleeps well. And we know from research that parents are actually not a good and valid reporting measure on their child's sleep quality. But certainly, I think the children that are diagnosed with central sleep apnea also tend to have a dual diagnosis. AM I right, Hanna? If you think of your people. Yeah. I mean, if I think anecdotally, yes, I have a lot going on. Well, they may also have something. They may have a third diagnosis. You can get central sleep apnea. Let's say you have, um an arnold-chiari malformation of the cerebellum which coming down you can get one of those, some of the medications that people are given to help them sleep better if they're sedating can induce central sleep apnea. Right. Um, you can get central sleep apnea for um congenitally. What I tell my patients is you can break your right arm and your left leg. There's no reason to only look for one diagnosis for these things. Sometimes if something's complicated we're trying to pigeonhole them into a single diagnosis when there's actually more than one thing going on. So you can have central apnea. It should be. If it doesn't go away, it should be explored. It should not be accepted. It's just bad luck. Yeah. Um, an unrelated condition. But some parents would know this as Praderwilli syndrome. Yeah. And Praderwilli can have both obstructive and central apnea as part of the syndrome in of itself. Okay, that's good to know. So I guess for our parents listening, then we would recommend pursuing it a little bit further. I would first, I would first not freak out if they say your kid is central sleep apnea. Um, because, because because because that tends to be incurable, right? Um, it's likely obstructive. Okay. So I would take obstructive sleep apnea seriously and central. I would just put, hey, maybe it is obstructive and it just appears that way. Okay. Um, so let's treat it as obstructive first and then see what we get. Mhm. If obstructive sleep apnea is corrected or not present at all, then definitely in the sleep central sleep apnea remains. Mhm. And it's not a first night effect, by the way. The only reason we get central events I should have mentioned is the control of breathing is different awake than asleep. When you're awake. You can hold your breath. You can sing, you can laugh, you can sing, you can sing. Right? So the control of breathing is different. Awake and asleep. And we transition from the awake world to the to the sleep world. And when we do that transition, sometimes we have a central apnea, which is thought to be completely normal. Okay. And so, so some of these central events, if they're very short and self-limited events, they just may be physiological transitions. You have a child sleeping in a room that he's never slept in before, wires on their head, they're uncomfortable. There may be a little scared or freaked out. They may have very choppy sleep. And those central events are actually just, again, an artifact of being in an unfamiliar environment. Mhm. So so yes, central apnea is real. I don't I'm not trying to downplay it if it's really there, but more likely than not, it's obstructive with the central not being maybe an artifactual finding. Yeah. Okay. That's that's excellent information. Thank you for that. I'd like to talk about two more sleep conditions that affect our population regularly. The first of these is restless leg syndrome. Can you talk a little bit about that? Restless leg syndrome is described as being used to be described as the most common disorder you've never heard of. Mhm. And first, um, and people would have it and thought it wasn't real. The um first described over six hundred years ago and it was given a name by um sir, I forgot his first name, but last name is Willis, sir. Something. Willis, I apologize, I'm not remembering his first name, but Willis is important. Uh, name to know because it's at our brains. We have a traffic circle of arteries and blood called the circle of Willis. The circle of Willis? Yeah. Same guy. Okay, you guys know it? Same guy? Yeah, well, he was observing, right? He was observing, right? Yeah. Yeah. So, um, so the same guy who coined who's, who found the circle of Willis or named after him also was the first person to describe restless legs as a medical condition. Before then, people thought it was a curse because it sounds like a curse. Over six hundred years ago, you can imagine how this would be viewed as a curse, because it's the perfect kind of curse to have. When you talk to people with restless legs, they'll often say it feels like a curse because it's a condition that doesn't bother you when you're working and going about walking around. But when you want to want to get your rest, then it comes up. It's a diabolic condition to have if you think of it right, because it's, it's fine as long as you keep walking. And the newsletter for the Restless Leg Foundation was. And I think it still is, it's called the Night Walkers because they get up and walk. Now, I must say, I did not know that restless legs had a higher prevalence than average in downs population until you mentioned it just now. I will talk to you more about it. Um, I'm not sure why, but I have a suspicion why it may be happening. Um, but I'm just speculating now. Hearing it from you for the first time. A restless legs is a very common condition. It runs in families. Strongly runs in families. Um, in fact, it's unusual to have somebody, only one person who has it in the family. And the youngest person I had was a little girl that came from China. She was two or three years old, and she didn't speak English, but we couldn't figure out what. She wasn't sleeping well. And, um, the parents would try to adopt her sleep her, and she would just sleep. Even worse, if somebody has a sleep issue and you think it's behavioral. If you let them sleep with you, they tend to get better. And if you sleep with them and they still sleeping poorly, it's more likely to be physical. And of course, it can be a combination. So this little girl sleeping horribly and we couldn't figure out why and we couldn't see what was happening. And I said, maybe she's low in iron because, um, restless legs is a condition related to iron metabolism. She could have been malnourished, and sure enough, she was low in iron. We gave her some supplementation. She slept better when she learned to speak English more clearly. One of the first words she ever said was itchy to describe the feelings in the legs. So Restless Legs is described as an unpleasant feeling that's hard to describe. Just as uncomfortable feeling the legs. It's not necessarily painful, but it's unpleasant. Children may often describe it as growing pains. Their parents describe it as growing pains, but in fact, it's not supposed to hurt us to grow. Mhm. So. But you'll see. Oh, I had growing pains. Growing pains, runs in our family. It's probably restless legs, but there's a wide variation in how it shows up. And some people have it so mild they don't even really notice it unless they're low on iron. So women, when they go through pregnancy, people who donate blood on a regular basis, adults with occult cancers like colon cancer may have a flare up of restless legs. And so the restless legs acts like a canary in the coal mine. Mhm. Anybody with a genetic tendency towards restless legs if they're low in iron or show up more. So it's possible. It's possible. So I'm not I'm not sure if down's by itself makes you more more prone to have restless legs Symptoms versus having the actual condition. Yeah, maybe a little maybe distinction there going on there. Yeah. And I think it's the reason we kind of wanted to talk to you about the restless leg part was because it's always something that doctors look into first when there's sleep difficulties with our with our population and majority of them are very low in iron. So it's always like that first step to figuring out a sleep issue. Like, okay, let's check the iron first. Let's see if that's what's causing, you know, the and that's the easiest fix. And that's the easiest thing to look at and the easiest fix for. So that's kind of where we were coming from with that as well. Just trying to understand. And I think with our population too, it's hard for them to communicate what that would feel like. And if that is a cause of, you know, and we're going to Marlo's going to talk to you about this in a second. But their frequent nighttime awakenings is a huge problem with our population. So so that's kind of where we were thinking of the restless legs flare up. Also, when they do something that's boring to them. So it may go away after watching a video game that they like or playing a video game. But if you have to go on a drive that they're bored or go visit somebody, then they'll really have a hard time sitting still and be uncomfortable when they have that. Yeah. Um, and sometimes all you need is to give them some structured activities at night. Let's go for a walk. Um, let's say you have a family dog. Let's walk the dog in the evening. Strenuous exercise can make it worse at night. So exercise aerobics class or something at night or something like that may not be the right move, but something that's a mild to moderate exercise. They may like give us a little chance to get that energy out their legs. And also you want to know it before they get on any airplanes. Assuming we can travel again someday. Yeah. You want to give them a little chance to get some energy out before before they get on the plane? Absolutely. Yeah. And sometimes, sometimes we can use medication just as a spot check dopamine type medications. You can give them just before they like an hour before they get on the plane or something to calm their legs down. So things you can do. Yeah. Low doses will work if you give them too high a dose. It makes it worse. Mhm. So sometimes you're not sure if it's restless legs or not. And you give the medication and the parents say, oh he's worse now. Well, that's actually good news. That means that if you come across a diagnosis now because you made it worse, now you got to find the right medication for them. But but inadvertently making it worse temporarily can be therapeutic. Uh, it could be, excuse me, a diagnostic signal that that you're on the right track. Mhm. Okay. Um, the last sort of sleep issue that I wanted to start with in this intro section is insomnia or frequent nighttime wakings. And with your four domains of speech, speech, speech, sleep, sleep, um, could you speak about how insomnia or frequent night wakings fits in with that? Because it's probably all four areas. Sure. And I think you said insomnia is with an S. I think you said it in plural. Did you say it that way, Marla? I did, yeah. I'm glad most people don't say it that way. Yeah, but. But I think that's the right way of saying it. Okay. Because they're different. They're different. There are a lot of variations on insomnia. Types of insomnia. Insomnia is a symptom that can become a syndrome. Insomnia is a complaint of poor quality sleep, either trouble falling asleep or trouble staying asleep to a point that bothers the next day. If there's no daytime impairment, then there's no insomnia. So if you're up all night and seem to enjoy it and it doesn't bother you, there's no insomnia. Now, with a child, it may be different because the child may stay up all night and like it and the parents are complaining. So sometimes you got to say where is the subjective issue for them. So insomnia is this complaint of trouble falling asleep or staying asleep. But this next time daytime impairment. And that's a symptom. But when it goes on for more than three months, it takes on a life of its own and becomes a syndrome. Just like you can have pain symptoms and pain syndromes. Yeah. So we can correct somebody's insomnia syndrome doesn't mean they're going to get insomnia again someday, because at some point in our lives, we're just going to lose sleep. I, for example, have trouble sleeping if I have to catch an early morning flight and I'm staying at a hotel. I don't want to miss my flight, and I tend to wake up before the alarm clock. But I don't typically set an alarm clock so we can have situational insomnia. It does not mean that you never have insomnia again because insomnia is actually a defense mechanism. It's a way of protecting ourselves. Sometimes we have to avoid sleeping. How can a mother have a baby that sleeps eight hours if the baby has to eat every two to four hours? Mhm. That there has to be a biological mechanism to interrupt your sleep. Take care of something and go back to sleep. So waking up at night is biologically hard wired into our brains. And all humans wake up about every hour and a half. That's one of the main early discoveries of sleep in the fifties, was that nobody really sleeps eight hours in a row. The issue is not whether your child wakes up at night. The real issue is that you're falling back asleep on their own, or they need your help to do this. If the child learns to fall asleep a certain way, let's say being rocked or told stories, or the lights on, if you fall asleep with the lights on, the TV on or some music on, and then when you find yourself an hour or two hours later and the lights are off, everything's dark, you should be surprised. Just like if you fall asleep in your bedroom an hour and a half later, you're in the kitchen. You should be alarmed. How'd you get there? So. The thing I really focus on is not the waking up. It's. Why are you having trouble going back to sleep? Yeah. So, insomnia. We can think of sleep onset, insomnia, little kids. It's something that they learn to do. And the term that's used is sleep, sleep onset association disorder child that learns to sleep a certain way, being rocked, held or whatever like that. And then we have the situation of trouble staying asleep. So your adults will tell you they have trouble staying asleep. Your kids will tell you have trouble falling asleep. But if you really question the adults who say they have trouble staying asleep, if you ask them, how do they fall asleep, you'll see that they have trouble falling asleep, that they're masking. So they're doing things at the last second. Okay. Yeah. And we can talk about rituals and why they're important in a moment, because there's something there's some things to point out about that, but they'll have something that they do. They may read until the book falls out of their hand and their partner turns off the lights for them, or they do something else. But it's usually trouble falling asleep first and then later trouble staying asleep. Some some people later in life, like women, some of the moms and they're listening in. And women have more insomnia than men. Men, of course, have insomnia, too, but statistically it's more common in women, particularly more common in women after menopause. And you'll have some older moms who'll have trouble staying asleep. And it's frequently part of the the transition as they're going through menopause, it changes hormones. Progesterone is a hormone that helps people sleep. And when those numbers start getting down, people have trouble staying asleep. Um, I was going to make a point about the, uh, about the kids. One of the things that you'll see a lot if you accept the idea that sleep is a learned behavior, something you taught how to do A lot of the kids will will talk about being scared of the dark and. But they won't admit it because they're not supposed to say that kids with Down's are not as guarded. Sometimes with the nice things about talking with them, they're just more honest when you speak with them. Um, but, uh, kids in general, they talk about things, but some people, when they have trouble sleeping, there's a degree of shame. A lot of people with sleep problems kind of blame themselves for their sleep problems and don't mask it. So somebody parents say things, well, um, he's falling asleep. Okay. But when you talk with them, they if you get into the details, which I'd be a fly on the wall. Some of the things I'll describe to you is like leaving a nightlight on or leaving the bedroom door slightly open and the light in the hallway or the bathroom light on. And I say, well, what's that for? What's that light for? Well, he likes it that way. She likes it that way. What is it that what is it that they want about this? Why is that important to them? Why do they want this light for? And I think what happens is that children are taught That they usually start sleeping with the parents or parents are near them. They get tucked in and then at night they're not there. And then they get scared like, well, what's going on? And the light, the darkness represents them being left alone. And they learn to associate darkness with being left alone. So they want the light on to check things out. But the light is not really necessary. They don't need it. So a fifteen year old girl one time who. Was in the habit of walking to the parents room a lot. And a lot of the parents, like these kids, walk into their rooms and it's actually kind of a rude thing. If, you know, if you talk with them, you'll see that they always go to only one of the parents. They don't go to both parents, they know which parent to go to, they know which side of the bed to go to. And if you ask the child or they ask the parents, how come they don't go to the other person? He says, well, that other person won't do anything. So it falls on the parent to do that to the one, the parent that's been designated to do this. So this fifteen year old kid coming into the room, what happened was she was raised single mom. Um, they used to share the same bed. And then when she was when the mother remarried, they had the child sleep separately from them. And she kept coming into the room at night. And when we talk about her routine, she always left the light on in the hallway, on the bathroom light on. And I asked her what's going on? And she finally said, I'm scared of monsters. And I told her, if I was a monster, it's easy to find you. Lights on. Lights are off. It's easy to find. Your lights are on. And what we try to do with with the children, the adults and the children, especially the children, is you can be creative because they have magical thinking. So you want to reframe things for them. And the concept of cognitive behavior therapy is to realize, think about things differently. So you want to tell them that darkness is how you're safe. You don't fear the dark. Dark is good news. You're safer in the dark. We like the dark. The brain likes being in the dark. We don't like sleep with the lights on, it's not good. Plus, you can reframe it that you're wasting energy and things like that also. So there's other ways of teaching them this, but you can do this. The reason you mentioned, I think, Marla, you mentioned the word rituals. And people often say, well, hey, we need routines. But routines is not really the issue because you can have routines that are unpleasant. I had a child I took care of whose father was a stickler about how he would have to brush his teeth. So that was like a thing. So as in that approach, the tension built in the household because he's going to have his tooth brushing inspection going on, his teeth inspected. So there's a routine to brush his teeth, but it wasn't pleasant. Mhm. The reason we want one of the the misconceptions that people have about sleep is that we fall asleep when we're bored. And boredom does not make people sleepy. That's a misconception. What happens is when you are bored, it means you're safe to the brain. The most dangerous thing we can do is sleeping. If you're in a boring situation, if you're in a monotonous situation, it must mean you're safe. When you're in danger, you don't feel bored. Mhm. So if most people are sleep deprived, end of the day, you are sleep deprived. The body, the biological drive to sleep is building by providing you with a monotonous, predictable environment that's pleasant. What you're doing is signaling to the brain you're in a safe environment. So the monotony, the routine equates with safety. When a little kid gets a full night's sleep in the morning and they're bored, they don't go take a nap. They misbehave. Look for something to do right. Teenagers fall asleep at their desks when they're bored in school, not because they're bored. They fall asleep because they are sleep deprived. And boredom means I can catch my sleep now. Mhm. So that's what we want the routines to be, is that we're all about conditioning this environment of feeling safe in a state of serenity and predictable. That's what that's about. It's not about the routine per se. It's what the environment that the routine creates predictability. And when a predictable environment and your sleep deprived That that wonderful sleepy feeling will come on. Right. That that sense of it's okay. It's coming. Right? You don't have to force somebody to sleep. Sleep. You leave it alone. It's going to come just like breathing. And it says, I'm going to hold my breath. Go ahead. You start breathing. Eventually. Sleep will always come. You can't stop somebody from sleeping. What you want to do is get them in a situation where they find sleeping something they look forward to. You get to go to sleep. You got to stop saying you have to go to sleep. It's you get to go to sleep. It's a great privilege to have a safe, comfortable place to sleep. Not everybody has that. And we're providing that to these kids, I hope. Yeah, that's kind of that connection to earlier, what you were saying about how sleep is a learned behavior. Like it's an all encompassing in terms of the environment that you set up, the routine that you set up. It's all part of, you know, like a whole, a whole ritual of sleep. And it needs to be viewed in a positive way that it's going to lend itself to good outcomes. Not. And I really like how you said not to say you have to go to sleep, but that you get to go to sleep. I think it's just reframing. All of that is really important. People. People treat sleep. I'm sorry. I'm sorry. People treat sleep like it's a chore with the kid, you know, like you like you have to take the garbage out. You gotta put the kid to sleep. It's like a chore you can only break. A parent gets to not be a parent. Yeah. Is when the kid is sleeping. And when you tell children that they don't, they can't imagine their parents not being parents because whenever they are around their parents, their parent mode. But we're different people when we're not around our kids to some degree, right? We behave and act a little bit differently. And the only break a parent gets is when they get this kid to sleep. And you have situations where you may have a mother that sleeps biologically more hours of sleep than the child does, and that may be an issue there. And I keep saying mothers, but it could be dads too. There's all kinds of families, all kinds of combinations. I'm just using your mother as a general caretaker term. I'm sorry I interrupted you, Marla. You want to say something? No, no, I think it's it's fascinating and interesting. And I think what happens in a lot of cases is if it's, you know, historically gone badly. Then it's very hard for the parents to feel calm enough to make the safe and comfortable routine, because how can you not be stressed if the last one hundred days have been a battle and something horrible, and you can feel that tension mounting and it's a fight to get your kid to lay down or whatever. So it's a lot of work for the parents to reframe it for themselves first before they can do that for the children. I think that's that's very true. And I've seen this many, many times now, things like restless legs we talked about earlier, or just the child that needs a little less sleep than average, where the sleeping schedule has been imposed by the parents based on what the parents want for themselves. And now the kid has a situation where they're in bed and they're trying to be good because they've been told to be a good child, they've been offered a reward or something, but biologically they can't sleep yet. They're not at the right time to sleep. And now they feel pressure on themselves to sleep and they're not good at it. They have a sibling who's better at it. They feel bad about themselves. People with sleep problems often blame themselves, and you can see the seed planted for sleep problems in adults that I take care of. That began in childhood because they were never considered good sleepers, something they weren't good at. There was something they were bad at their entire lives. Mhm. Um, or they're told, well, you got that from your dad's side that they've been cursed. It's you're from your uncle's side right now, you know? Uh, and they're like, okay, what can I do? And a phrase that I sometimes use with people is that your tendencies are not your destiny. Right. So, so just because you have a destiny doesn't have to be that way. But we really, really want the parents to sleep better first. That's what you want to do. Sometimes when your kid is crying and upset that they can't sleep, all the parent can do is pretend they're sleeping themselves and the kid is like, okay, well, they're asleep. I might as well sleep too. Well, you know, there's nothing else to do here, but eventually that will happen. Um, an analogy that I've used many times, um, you may have come across this, if I may, is you on any plane you go on any airplane, um, when you get on a plane. Right. And especially in the old days before there was, uh, traveling was not as crowded if you got on a plane. And then and when you sit down and there's an empty seat next to you, what are you thinking? I hope that seat stays empty. Right. Best case scenario, seat remains empty. You feel like you've got a first class ticket. If the seat next to you is empty, you got all the space of first class at a coach price, let's say. So if the seat next to you is empty, all you want is for it to remain empty as the plane is boarding, right? Best case scenario. Empty seat. What's worst case scenario? Crying baby? Nobody wants to sleep next to a crying. Nobody wants to sit next to a crying baby on a plane. So just imagine again. You're the mom. It could be the dad, but let's say you're the mom walking down the aisle. You missed the pre-boarding. So now you're stressed. Yeah, carrying the aisle. You have this baby you know, you're thinking of, uh. I hope whoever I sit next to is good with kids is not sick themselves. You got the diaper bag? You put the stroller up. It's stressful things. Yeah, right. Right. You're stressful. You come in on the aisle and as you come down the aisle, everybody with an empty seat next to them sees you coming. They look away. Yeah. They won't make eye contact with you. They're hoping to. They look away, hoping that they think that magically, the seat assignment is going to change. And as the person gets further, further on the aisle, the number of empty seats dwindles. So the tension builds on the plane, and, well, you'll see what'll happen is at some point that baby starts to cry. When the baby starts to cry, it echoes in the cabin and all eyes will dart on the mother. Right. What are you gonna do about it? The baby. The mother is shaking the baby like it's a maraca, right? She's shaking that baby. And what happens is the kid starts crying. If you watch this play out, usually a complete stranger offers to help the baby. For example, the flight attendant and the flight attendant holds the baby. The baby stops crying and the question is always the same what is the stranger? Console the baby faster than its own mother because the mother is stressed and that's feeding on the baby. So if you have a child who is healthy otherwise and is now crying and upset, you got to calm yourself down first. You're shouting, shushing the baby, feeling the pressure because you got to get this kid to sleep because the other parent has to go to work in the morning. Is that pressure is not going to help anybody sleep better. So you really just got to take a step down and be very it's hard to do, but you can practice this. Calm yourself down. Know that you're you're lucky to have a healthy, beautiful, beautiful child. The kid will sleep eventually. And again, that gets to this whole issue of the frame of mind that people have around sleeping. You can't be sleeping as something you're dreading or a chore. I'm sorry to go off on that, but I thought it might be helpful. Yeah. That's great. And it also describes my flying experience. Yeah. Marla being a mom of a of a toddler too. Yeah. She can relate, I'm sure. So, Marla. Super quick. I've heard that story many, many times. And one time I told it at a community event and one of my neighbors was in the audience. I did not know my neighbor was there. She was a mother of a young child and she said she was on a flight to Oklahoma, and the kid kept crying the whole time and took off. The baby kept crying and the pilot came out of the cabin. It was a female pilot, and she says, where's that baby? And the pilot held the baby. The baby stopped crying. People on the plane started clapping. Wake the baby up. Well, no. The babies will fall asleep to noise. Actually fall asleep to noise. But the people in the plane start clapping. The mother gets really embarrassed and the pilot hands the baby back to the mother and the mother starts. Baby starts crying again. So so so you see how this plays out. So it was a horrible flight. Yeah, I bet, I bet, I bet. Um, you know, why don't you go next I think. Sure. Yeah. Um, so is there any truth to this notion that many individuals with developmental disabilities may not? And I think you had mentioned this briefly earlier, that may not need a full eight hours of sleep or that they can actually make do throughout their day with a shorter amount. Sure, on any one of us will tell you when you ask about your sleep amount, sleep needs or desires will give you two numbers. Your own mind if I say how many hours sleep you need? You may say things like, I'd like to get nine, but can get by with six. I need, I know I need, I like eight, but if I, if I get at least five and a half, I'll be okay. And human sleep is probably seasonal to some degree. If you've got friends and further north in Alaska, for example, they'll tell you that they sleep more in the winter, less in the summer. So it makes sense if our human sleep cycle is dependent on degree in light, the seasonality of sleep is kind of built into it. So you have an ideal amount of sleep and you have an amount that seem to get by. Yeah. And what happens is some people just get happier just getting by little sleep as possible. So there's part of that range is in there also with insomnia. We don't normally see a one to eight hours of sleep. So how many hours do you typically sleep? six, I see five and a half. We may get a half hour or an extra forty five minutes of sleep, but it's a predictable time. We don't get. They don't get eight, but now they no longer have that tension about sleeping. It becomes less of a concern to them. Yeah, they'll be there. That's why sometimes you hear the phrase, which is not a fair phrase, that sleep begets sleep, that the more you sleep, the more comfortable you are sleeping, the more you do. I don't that's not a perfect term, but I think that kind of implies that to some degree. So yes, there are going to be some kids that are going to need less sleep than others. The twenty seventeen Nobel Prize in Medicine was for this thing called the clock genes, the circadian system, and the sleep mechanism. The timing mechanism is actually been worked out. It's located right behind our eyes. And those genes are similar to the same genes in flies. It's a very well preserved system because animals must predict sun up and sun down in order to survive. The world is very different daylight than night time, and you have to have a system that adapts to the change of seasons. We just had our summer solstice, right? So we have long days. We should be behaving differently than we should on the winter solstice. It's a biologically different environment, so our brain must adapt to this. So you need a system in your head to adapt to this change of seasons. And I think that plays a role in it. That's why we talk so much about light and the kids. So yeah, some of the kids may need less sleep, but they also may have a situation where you have one parent needs less sleep than the other parent, and the child may take after the parent who sleeps a little bit less than average. But the main caretakers, the parent that needs more sleep, there's going to be a conflict there too. Yeah, yeah, yeah. No, that's a really good point. And I, I think, I mean, I had a consultation with a parent a while ago where they were saying that their little kiddo with down syndrome would have no problem falling asleep, would wake up in the middle of the night. And then, like you said, from a learned behavior perspective, dad would come help him go back to sleep, would stay with him in the bed. And then the mom was at the end of the day, she was shocked that despite that disturbance in sleep, he could still function throughout the day. I mean, he was only five years old. He's only five. But so that's kind of what got me thinking like, do did that five year old really need a full eight hours of sleep? Or, you know, like, there's so many factors involved in trying to figure out how was he able to manage throughout the whole day when he had like this nighttime awakening for two hours and then went back to sleep and then got up and was ready to go? Well, he can get by, but I bet that child, if they got more sleep, they could do better yet. There was a study done on healthy adults and they just had them take a nap. And these are adults who were getting all the sleep they needed, but still managed, were given opportunity to take a nap. And they found that I think there was a jump of twenty three percent, over twenty percent improvement in their, in their ability to remember a list of words. Mhm. So there's a range of functionality. We're not fragile creatures. You can hold your breath on the water, something as important as sleeping. You must be able to do without temporarily. We can skip a night of sleep that five year old can get by and do okay with that sleep, but they might do better yet. And what you're going to see with mild sleep deprivation is being a little bit moody, a little bit inattentive. Mhm. So. Yeah. So. Oh, yeah. So little in a little inattentive. You give him a stimulant. Of course you're gonna behave better. And you go, oh, they have Add. Well, yeah, maybe, but maybe they just need a little bit more sleep. Yeah. Um, the five year that you're describing this apparent said he sleeps okay, but wakes up and he's the father there with him. That kid probably needs the father or one parent with him to fall asleep also in the beginning of the night. Yes, probably you're right. Yeah. So so that's what's really happening there. They're masking. See, the parents don't mind. Help them fall asleep by doing that. Yeah. But it's later in the night that it becomes exactly that it comes back to. Yeah, exactly. And one of the things I talked, one things you can tell a child and a child with Down's will understand this. Uh, but you can see the look in their eyes when you frame this to the child. Just talk with them about this. It goes, you know, when you come to our room at night. Mommy, daddy, you know we love you, but it bothers us. Why? Well, it's very simple. The store doesn't sell any three people beds. It only sells two people beds. Right? You just. You don't fit, right? Just use logic, right? Yeah. Right. Yeah. You know, if one child, if the parents are parallel to each other and the child makes the letter H with his body. Whoever gets the feed is not going to be happy. Yeah. So you can explain to say, you know. Yeah, it's you still we love you, but you're interrupting our sleep. And then you tell the child, you know that mommy and daddy sometimes wake up at night to, you know, when we wake up at night, do we go in into your room and tell you that we're awake? No. Why not? Because it's rude. And kids learn about being polite. Mhm. The fact that you woke up is one thing. The fact that you came into a room to let us know that you woke up is rude. Okay. You don't need to do that. You can tell me in the morning that you woke up. I'll be here. I'll talk. I'd love to talk to you. I want to know about how your night went. Just tell me in the morning. You don't have to tell me in the middle of the night that you. That you were awake. Mhm. Okay. Waking up in the night should not be viewed as a problem to be fixed at that moment. Sleep will come later. You can tell me about it later on. Stay in your room. We'll talk about it later. Yeah. If you drive the home that point over and over again. Very. Just matter of fact, mom and dad wake up at night and we don't go tell you, right? You know, do you want me to wake you up to tell you that I woke up? You know, do it that way. Just just very matter of fact that that we're not rejecting you. It's just, you know, the bed doesn't fit that way. You're growing and they know that your shoes have changed, right? You know, you don't fit. Your old shoes don't fit you anymore. There's no space in the bed for you. Nobody put their kids in separate caves thirty thousand years ago, right? Put them in a separate room is a cultural phenomenon. Which is fine. You can afford a room. That's wonderful. But don't expect a child. The child has to learn to do that. It's not innate to them to sleep separate from a parent. Mhm, mhm. Do you have any suggestions? The other thing that we see a lot is, you know, the little kid, sometimes not so little will wake up and three in the morning. Yeah. And start playing by themselves. Very content. But they might play, they might color, they might help themselves to whatever. And until it wakes the parents up because they're playing trucks or they're playing things, making a ruckus, and they either two things will happen. Either they're up for the day from three a m onward, it's a bad situation, or they then maybe might fall back asleep an hour to two hours later, but then they don't want to get up when, you know, school comes. Yeah. It's yeah. So they're not getting mom and dad up per se, but they're, they're up there being disruptive. Mhm. Right. Or unsafe sometimes nighttime wandering, you know, like, let's go on a walk. Let's take that dog out right now. Grab a snack in the kitchen. Yeah, right. First off, we never want to lock kids into bedrooms because it could be a fire. It could be a hazard. You don't want to tie anybody down. You don't want to lock them in. Um, so that's not something you want to do. That's not safe. It's better for you as a parent to close your door than to lock your kid in their room. Right? Mhm. That's not a safe thing to do. The child that's waking up that way. I think about the word breakfast, right? When you wake up in the morning, you want to have breakfast? Did you did your stomach magically become empty when you woke up? No, it's been empty for hours. You could have eaten at any point, right? And in fact, it's kind of a fun thing to do. Sometimes if you've been out, is to have an early breakfast before you get home because your stomach has been empty. Um, but you know that food is going to come in the morning, so there's no need to sleep now to make sleep a priority because I'm going to get my food later and I can go without food enough hours without going to hypoglycemic shock. The child that's waking up probably has no motivation to make get get up at a certain time on their own. Parents want their kid to be in their day program or go to school, but they have no incentive to do that. There's no sense of like, if I wake up now and play, I'm going to be late for what I have to do exactly later. They don't have. So you got to drill home that point that. So we always. No matter what we do, you can force people to wake up. You can't force people to fall asleep. Mhm. Right. If if um, so I know this is an audio podcast, but listen, I mean, I know we're on Zoom, right? We're seeing each other. So, so I'm seeing you, uh, Hannah, uh, let's make believe that I'm watching you breathe and you're breathing twelve breaths a minute. Mhm. I say, please take twelve breaths. In a minute. I'll time you. You'll screw it up, right? If you leave it alone, you'll just breathe rhythmically at twelve breaths a minute. But if I tell you to do it, you're going to screw it up. Sleep is the same way. Telling somebody to sleep is is is very hard. It's easier to force somebody to wake up. It's easy to force somebody to wake up, to force somebody to fall asleep. I can wake you up no matter how sleepy you are. If I yell fire, if I, if I, if I, if I do something to you, you'll wake up. Because sleep is rapidly reversible by definition. So we must rapidly wake up when we need to, but we don't rapidly fall asleep in crash. We drift into sleep. Mhm. So that child that you're describing, first of all, decide what is that you want to change? Right. Is it that they're waking up and playing and making noise that's bothering the parents, or is it waking up and not going back to sleep and not making it to there? So I try to be very focused on what is the actual problem itself. Because waking up is normal. Mhm. Wanting to play is normal. It's a question of what are the routine and the and the rhythm that we want to impose on the child. And it may be a rhythm that that we're imposing on them that they have no motivation to follow. Mhm. So if we're going to try to force somebody to do things, the way we force it is through their wake up time. So yeah, you want to be up, go ahead, kid, but you got to get up at the same time no matter what. Mhm. And if you lock in the wake up time, parents say, oh, but it's a horrible day. It'll be a very horrible day. It'll be horrible day for one, two, three days, four days. It won't go past a week or two of doing this if you keep locking in the wake up time. Okay. Because the sleep will consolidate and one of the concepts to get squeezed out middle of the night, awakenings, uh, prolonged awakenings, middle of the night. It's called sleep restriction. Sleep deprivation is different. That's a form of torture. Sleep restriction is saying, hey, we know that you typically do well on seven and a half hours of sleep or nine hours of sleep. You're nine hours sleep, you got nine hours to sleep. And we lock in the wake up time, the bedtimes there, if you keep that bedtime, if you keep that wake up time locked in, they will eventually fall asleep. They always will lock in that wake up time as long as they feel safe, comfortable, and loved. If they feel stressed out, if there's something not good at, they're in pain. Of course, it's a different scenario, but if the child is feeling in a state of serenity, that's going to happen. An easy example that that is a real experiment that anybody can do. Um, and I'll describe this very briefly to you if I can, if you take a wild rat, a rodent genetically set up to be nocturnal, always active at night, All this family is is nocturnal. If you take that wild rat and simply do an experiment, you put it in a cage and only give it food. And the lights are on. And at night you take away the food. What's going to happen? Initially, the rat is going to go hungry because genetically it's a nocturnal animal and it's scared to eat in the daytime because it could be attacked by hawks. So the rat will go hungry, but eventually the need for food will drive that rat to become active in the daytime. So you can make you can make a genetic nocturnal animal behave like a diurnal animal. Simply change the timing of its meals. Mhm. So if the things that that child wants to get to the toys or the snack are only available at certain times, they'll sleep. Now, you may have a child whose parents are putting them to bed too early, and the kid is already sleep satiated. And they got and they're awake because there's time for them to be awake. So. So what you really want to do is figure out what is the total sleep you want the child to have. Lock in a wake up time, go backwards, and that's the bedtime. So the bedtime may be much later than And you're used to. But you lock in that wake up time and that over a few weeks will will then get into a proper cycle, assuming the sleep is of normal quality. Yeah. Yeah. Um, before we take a break, I just wanted to ask you one more question. I'll hand it back over to Mala. Do sleep issues get worse during certain periods of of our lifespan? Like I'm having some conversations with parents where their kids are kind of at that level of puberty. And she's, and this kiddo has a dual diagnosis. So she's definitely mom is noticing hormonal changes and she's trying to figure out a pattern. Um, and then on the other side of the coin, you know, some parents have said, oh, they used to be really bad sleepers, but now they've kind of it's just been a phase. So is there any truth to how sleep patterns change over the course of a lifetime? Sure. A misconception is to think that sleep problems will go away on their own. Mhm. And they don't. But because it's a learned behavior, child can learn on their own how to sleep better. They can figure it out on their own and it will be better. But there's a couple of things happen with the onset of puberty. You get two things occur in kids. One, a biological tendency to be stay up more late at night. There's a shifting of our time points to stay up later. So you may have a child who now is refusing bedtime or having trouble falling asleep. If you keep that same bedtime as they go into puberty, they may not show up as having sleep onset insomnia because they're dwelling more to be a night person. That's also, you know, a kid that age wants some privacy sometimes, and they want to stay up past their parents. So they may have behaviors, but it's not just behavioral thing. Biologically, biologically, we shift our sleep in puberty. And other animals seem to do this where they shift their sleep into the night. And this plays a role in the movement to delay school start times, which is a separate conversation, but it's coming up. And along with that tendency to shift into a later point of night. If you think about a tribe of people, humans past the age of fifty, to have a harder time staying up late at night, they start to go to bed earlier. And if and if the listeners are in the fifties and 60s some of them, they'll say, oh yeah, I can stay up later. When I was younger. Now I tend to go to bed earlier. But again, it makes sense for the for a tribe, for somebody to be awake at different times. So we have this surge of energy at night. All humans get a surge of energy at night. You sleep is not about being tired. We actually more alert at night than we are at any other point, because in the evening we could be attacked by our predators. So we get this surge of energy, and that shifting of that surge will be later with teenagers. Now, this is in general, there's going to be, of course, a variations within this because there are genetic variations to this. So that's the circadian part of adolescence that's shifting to sleeping, staying up late at night. And it'll come across as insomnia because the kid is keeping the same bedtime. The other point is that especially with the boys, but the girls too, with the onset of puberty, they get a deeper voice. Thicker neck and sleep apnea will kick in. So you have kids with mild sleep apnea, uh, that all of a sudden is getting worse because they develop into puberty. Now they have more upper body issues. They get thicker necks with the testosterone, your tongue gets thicker, things get bigger. So that's may be happening. On the flip side, you may have a kid with mild sleep apnea, five or six years old and they have trouble sleeping. The sleep is not restorative for them. So they so they wake up tired. Parents think they need more sleep because of the issue they're thinking is the hours of sleep. But it's not the hours, it's the quality because they have sleep apnea problems, but they try to correct a quality issue with quantity correction. And that can help a little bit if it's mild, but it won't work if it's severe. So what's going to occur is if they decide not to take out the kid's tonsils, which is a whole separate conversation. And this this special group of group of people, the, um, the tonsils will shrivel up on their own. Um, and behavioral issues tend to also improve because kids learn. So you tend to hit a sweet spot with kids around the age of have nine or ten where see problems seem to get better. Mhm. Because the tonsils are shriveled up now, they're more used to what's going on. They haven't had the pubertal shifts that I described earlier. So you have the sweet spot around nine or ten and then they'll come back later sometimes. Yeah. I think that's the fluctuation that you tend to see. And as I mentioned, people say, oh, if you just do careful, you know, a watchful observation or, or conservative treatment of their sleep apnea, it's going to go away. That's because they're looking at maybe nine and ten year olds. But if you check them out with the fifteen or sixteen, you'll see that it's come back with a vengeance. I think a lot of these, a lot of people. Yeah, that's what it seems like. Yeah. Yes. We'll be back for more in depth discussion of sleep quantity and quality with Doctor Rafael Pelayo. We will be discussing treatment options from testing to routines and supplements. Don't miss it next week on the lowdown Podcast. Next week on the Lowdown a Down Syndrome podcast. People with sleep apnea tend to be very restless sleepers. People say things to me like, well, I can't use Cpap because I can't sleep on my back. Yeah. The reason you can't sleep on your back is because you have sleep apnea and the tongue slides backwards. But if I get you in the right pressure, in the right position, the tongue will move forward. Then there won't be an issue. Yeah, yeah. Have you had so so that so so that that will correct itself once you get into that position. And on Cpap people will sleep better on their back. Having said that, new Cpap masks have been designed to let them sleep on their side. The Lowdown the Down Syndrome podcast is a production of Down Syndrome Research Foundation. For more at ds dot org and join the conversation at t s o f Canada on Twitter, Facebook and Instagram. The lowdown is hosted by Marla Folden and Hannah Mahmood and is produced by Glenn Hughes. The lowdown theme music and Josh do was written and recorded by Rick Scott.