Want to Ace That Test? Get the Right Kind of Sleep

Photo

Jillian Dos Santos studies at her home in Columbia, Mo. In 2013, she <a href="http://well.blogs.nytimes.com/2014/03/13/to-keep-teenagers-alert-schools-let-them-sleep-in/">successfully advocated for a later start times at her high school</a>.
Jillian Dos Santos studies at her home in Columbia, Mo. In 2013, she successfully advocated for a later start times at her high school.Credit Dan Gill for The New York Times

Sleep. Parents crave it, but children and especially teenagers, need it. When educators and policymakers debate the relationship between sleep schedules and school performance and — given the constraints of buses, sports and everything else that seem so much more important — what they should do about it, they miss an intimate biological fact: Sleep is learning, of a very specific kind. Scientists now argue that a primary purpose of sleep is learning consolidation, separating the signal from the noise and flagging what is most valuable.

School schedules change slowly, if at all, and the burden of helping teenagers get the sleep they need is squarely on parents. Can we help our children learn to exploit sleep as a learning tool (while getting enough of it)?

Absolutely. There is research suggesting that different kinds of sleep can aid different kinds of learning, and by teaching “sleep study skills,” we can let our teenagers enjoy the sense that they’re gaming the system.

Start with the basics.

Sleep isn’t merely rest or downtime; the brain comes out to play when head meets pillow. A full night’s sleep includes a large dose of several distinct brain states, including REM sleep – when the brain flares with activity and dreams – and the netherworld of deep sleep, when it whispers to itself in a language that is barely audible. Each of these states developed to handle one kind of job, so getting sleep isn’t just something you “should do” or need. It’s far more: It’s your best friend when you want to get really good at something you’ve been working on.

So you want to remember your Spanish vocabulary (or “How I Met Your Mother” trivia or Red Sox batting averages)?

Easy. Hit the hay at your regular time; don’t stay up late checking Instagram. Studies have found that the first half of the night contains the richest dose of so-called deep sleep — the knocked-out-cold variety — and this is when the brain consolidates facts and figures and new words. This is retention territory, and without it (if we stay up too late), we’re foggier the next day on those basic facts. I explained this to my daughter, Flora, who was up until 2 a.m. or later on many school nights, starting in high school. She ignored it, or seemed to. Learning Arabic is what turned her around, I think. She wants to be good at it, and having to learn not only a new vocabulary but also a completely different writing system is, in the beginning, all retention.

“I started going to bed earlier before the day of Arabic tests, partly for that reason,” Flora said (when reached by text). “But also, of course, I didn’t want to be tired.”

And you want to rip on the guitar, or on the court, right?

Just as the first half of a night’s sleep is rich with deep slumber, the second half is brimming with so-called Stage 2 sleep, the kind that consolidates motor memory, the stuff that aspiring musicians and athletes need. This is not an excuse to sleep through Period 1. Rather, it’s a reason not to roll out of bed too early and miss the body’s chance to refine all those skills learned while kicking a soccer ball off the garage or practicing dance moves.

For an older, teenage student, these two learning stages of sleep offer something more: a means of being tactical about sleep, before an important test or performance. If it’s a French test, then turn off the lights at your normal time, and get up early to study. If it’s a music recital, do the opposite: stay up a little later preparing, and sleep in to your normal time in the morning. If you’re going to burn the candle, it’s good to know which end to burn it on.

What about math tests? I hate those.

Math tests strain both memory (retention) and understanding (comprehension). This is where REM sleep, the dreaming kind, comes in. Studies find that REM is exceptionally good for deciphering hidden patterns, comprehension, and seeing a solution to a hard problem. If the test is mostly a memory challenge (multiplication tables, formulas), then go to sleep at the usual time and get up early for prep. But if it’s hard problems, then it’s REM you want. Stay up a little later and get the full dose of dream-rich sleep, which helps the brain see hidden patterns.

“Mom, I’m tired of studying – I’m going to have a nap.”

By all means. Napping is sleep too, and it’s a miniature version of a full night’s slumber. An hourlong nap typically contains deep sleep, REM and some Stage 2. One caution: napping can interfere with some children’s sleep schedule, and it’s important to make sure day sleep doesn’t scramble the full serving at night. But the central point is that a sensation of exhaustion during a period of work is the brain’s way of saying, “O.K., I’ve studied (or practiced), now it’s time to digest this material and finish the job.”

If a child can nap without losing a handle on his or her natural sleep rhythm, then let it happen.

The upshot is that, for any young student who wants to do better — in school, in sports, in music or even in the social whirl (yes, that’s learning too) — knowing the science of sleep will help them respect slumber for what it is: learning consolidation. Of the best and most natural kind.

Read more about sleep on Motherlode: On Sleep Research, My Children Didn’t Get the Memo; We Tell Kids to ‘Go to Sleep!’ We Need to Teach Them Why.; and ‘What Do Students Need Most? More Sleep.

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ADHD – Diagnosing the Wrong Deficit

An opinion piece from The New York Times

Shannon Freshwater

IN the spring of 2010, a new patient came to see me to find out if he had attention-deficit hyperactivity disorder. He had all the classic symptoms: procrastination, forgetfulness, a propensity to lose things and, of course, the inability to pay attention consistently. But one thing was unusual. His symptoms had started only two years earlier, when he was 31.

Though I treat a lot of adults for attention-deficit hyperactivity disorder, the presentation of this case was a violation of an important diagnostic criterion: symptoms must date back to childhood. It turned out he first started having these problems the month he began his most recent job, one that required him to rise at 5 a.m., despite the fact that he was a night owl.

The patient didn’t have A.D.H.D., I realized, but a chronic sleep deficit. I suggested some techniques to help him fall asleep at night, like relaxing for 90 minutes before getting in bed at 10 p.m. If necessary, he could take a small amount of melatonin. When he returned to see me two weeks later, his symptoms were almost gone. I suggested he call if they recurred. I never heard from him again.

Many theories are thrown around to explain the rise in the diagnosis and treatment of A.D.H.D. in children and adults. According to the Centers for Disease Control and Prevention, 11 percent of school-age children have now received a diagnosis of the condition. I don’t doubt that many people do, in fact, have A.D.H.D.; I regularly diagnose and treat it in adults. But what if a substantial proportion of cases are really sleep disorders in disguise?

For some people — especially children — sleep deprivation does not necessarily cause lethargy; instead they become hyperactive and unfocused. Researchers and reporters are increasingly seeing connections between dysfunctional sleep and what looks like A.D.H.D., but those links are taking a long time to be understood by parents and doctors.

We all get less sleep than we used to. The number of adults who reported sleeping fewer than seven hours each night went from some 2 percent in 1960 to more than 35 percent in 2011. Sleep is even more crucial for children, who need delta sleep — the deep, rejuvenating, slow-wave kind — for proper growth and development. Yet today’s youngsters sleep more than an hour less than they did a hundred years ago. And for all ages, contemporary daytime activities — marked by nonstop 14-hour schedules and inescapable melatonin-inhibiting iDevices — often impair sleep. It might just be a coincidence, but this sleep-restricting lifestyle began getting more extreme in the 1990s, the decade with the explosion in A.D.H.D. diagnoses.

A number of studies have shown that a huge proportion of children with an A.D.H.D. diagnosis also have sleep-disordered breathing like apnea or snoring, restless leg syndrome or non-restorative sleep, in which delta sleep is frequently interrupted.

One study, published in 2004 in the journal Sleep, looked at 34 children with A.D.H.D. Every one of them showed a deficit of delta sleep, compared with only a handful of the 32 control subjects.

A 2006 study in the journal Pediatrics showed something similar, from the perspective of a surgery clinic. This study included 105 children between ages 5 and 12. Seventy-eight of them were scheduled to have their tonsils removed because they had problems breathing in their sleep, while 27 children scheduled for other operations served as a control group. Researchers measured the participants’ sleep patterns and tested for hyperactivity and inattentiveness, consistent with standard protocols for validating an A.D.H.D. diagnosis.

Of the 78 children getting the tonsillectomies, 28 percent were found to have A.D.H.D., compared with only 7 percent of the control group.

Even more stunning was what the study’s authors found a year after the surgeries, when they followed up with the children. A full half of the original A.D.H.D. group who received tonsillectomies — 11 of 22 children — no longer met the criteria for the condition. In other words, what had appeared to be A.D.H.D. had been resolved by treating a sleeping problem.

But it’s also possible that A.D.H.D.-like symptoms can persist even after a sleeping problem is resolved. Consider a long-term study of more than 11,000 children in Britain published last year, also in Pediatrics. Mothers were asked about symptoms of sleep-disordered breathing in their infants when they were 6 months old. Then, when the children were 4 and 7 years old, the mothers completed a behavioral questionnaire to gauge their children’s levels of inattention, hyperactivity, anxiety, depression and problems with peers, conduct and social skills.

The study found that children who suffered from sleep-disordered breathing in infancy were more likely to have behavioral difficulties later in life — they were 20 to 60 percent more likely to have behavioral problems at age 4, and 40 to 100 percent more likely to have such problems at age 7. Interestingly, these problems occurred even if the disordered breathing had abated, implying that an infant breathing problem might cause some kind of potentially irreversible neurological injury.

CLEARLY there is more going on in the nocturnal lives of our children than any of us have realized. Typically, we see and diagnose only their downstream, daytime symptoms.

There has been less research into sleep and A.D.H.D. outside of childhood. But a team from Massachusetts General Hospital found, in one of the only studies of its kind, that sleep dysfunction in adults with A.D.H.D. closely mimics the sleep dysfunction in children with A.D.H.D.

There is also some promising research being done on sleep in adults, relating to focus, memory and cognitive performance. A study published in February in the journal Nature Neuroscience found that the amount of delta sleep in seniors correlates with performance on memory tests. And a study published three years ago in Sleep found that while subjects who were deprived of sleep didn’t necessarily report feeling sleepier, their cognitive performance declined in proportion to their sleep deprivation and continued to worsen over five nights of sleep restriction.

As it happens, “moves about excessively during sleep” was once listed as a symptom of attention-deficit disorder in the Diagnostic and Statistical Manual of Mental Disorders. That version of the manual, published in 1980, was the first to name the disorder. When the term A.D.H.D., reflecting the addition of hyperactivity, appeared in 1987, the diagnostic criteria no longer included trouble sleeping. The authors said there was not enough evidence to support keeping it in.

But what if doctors, before diagnosing A.D.H.D. in their patients, did have to find evidence of a sleep disorder? Psychiatric researchers typically don’t have access to the equipment or expertise needed to evaluate sleep issues. It’s tricky to ask patients to keep sleep logs or to send them for expensive overnight sleep studies, which can involve complicated equipment like surface electrodes to measure brain and muscle activity; abdominal belts to record breathing; “pulse oximeters” to measure blood oxygen levels; even snore microphones. (And getting a sleep study approved by an insurance company is by no means guaranteed.) As it stands, A.D.H.D. can be diagnosed with only an office interview.

Sometimes my patients have resisted my referrals for sleep testing, since everything they have read (often through direct-to-consumer marketing by drug companies) identifies A.D.H.D. as the culprit. People don’t like to hear that they may have a different, stranger-sounding problem that can’t be fixed with a pill — though this often changes once patients see the results of their sleep studies.

Beyond my day job, I have a personal interest in A.D.H.D. and sleep disorders. Beginning in college and for nearly a decade, I struggled with profound cognitive lethargy and difficulty focusing, a daily nap habit and weekend sleep addiction. I got through my medical school exams only by the grace of good memorization skills and the fact that ephedra was still a legal supplement.

I was misdiagnosed with various maladies, including A.D.H.D. Then I underwent two sleep studies and, finally, was found to have an atypical form of narcolepsy. This was a shock to me, because I had never fallen asleep while eating or talking. But, it turned out, over 40 percent of my night was spent in REM sleep — or “dreaming sleep,” which normally occurs only intermittently throughout the night — while just 5 percent was spent in delta sleep, the rejuvenating kind. I was sleeping 8 to 10 hours a night, but I still had a profound delta sleep deficit.

It took some trial and error, but with the proper treatment, my cognitive problems came to an end. Today I eat well and respect my unique sleep needs instead of trying to suppress them. I also take two medications: a stimulant for narcolepsy and, at bedtime, an S.N.R.I. (or serotonin-norepinephrine reuptake inhibitor) antidepressant — an off-label treatment that curtails REM sleep and helps increase delta sleep. Now I wake up without an alarm, and my daytime focus is remarkably improved. My recovery has been amazing (though my wife would argue that weekend mornings are still tough — she picks up the slack with our two kids).

Attention-deficit problems are far from the only reasons to take our lack of quality sleep seriously. Laboratory animals die when they are deprived of delta sleep. Chronic delta sleep deficits in humans are implicated in many diseases, including depression, heart disease, hypertension, obesity, chronic pain, diabetes and cancer, not to mention thousands of fatigue-related car accidents each year.

Sleep disorders are so prevalent that every internist, pediatrician and psychiatrist should routinely screen for them. And we need far more research into this issue. Every year billions of dollars are poured into researching cancer, depression and heart disease, but how much money goes into sleep?

The National Institutes of Health will spend only $240 million on sleep research this year. One of the problems is that the research establishment exists as mini-fiefdoms — money given to one sector, like cardiology or psychiatry, rarely makes it into another, like sleep medicine, even if they are intimately connected.

But we can’t wait any longer to pay attention to the connection between delta sleep and A.D.H.D. If you’re not already convinced, consider the drug clonidine. It started life as a hypertension treatment, but has been approved by the Food and Drug Administration to treat A.D.H.D. Studies show that when it is taken only at bedtime, symptoms improve during the day. For psychiatrists, it is one of these “oh-we-don’t-know-how-it-works” drugs. But here is a little-known fact about clonidine: it can be a potent delta sleep enhancer.

Vatsal G. Thakkar is a clinical assistant professor of psychiatry at the N.Y.U. School of Medicine.

A version of this op-ed appeared in print on April 28, 2013, on page SR1 of the New York edition with the headline: Diagnosing The Wrong Deficit.

Helping Your Child Adjust to Daylight Savings

From Yourteenmag

By Diana Simeon

It’s that time of year again: daylight savings, when we turn the clocks forward and, ugh, lose an hour of sleep.

Already wondering how it’s going to go on Monday morning when your teenager’s alarm goes off? Probably not so great, says Sasha Carr, Ph.D., a certified sleep consultant with the Family Sleep Institute and founder of Off to Dreamland.

“If you have a teenager, you should be concerned,” explains Carr. “It’s going to be rough on them on Monday morning to get up for school.”

Carr has some suggestions for making the transition easier. These include:

  • Turn your clocks forward early on Friday evening, not late Saturday when you’re headed to bed. Yep, you read that correctly. By changing your household routine two days early, your teenager will have time to adjust to daylight savings over the weekend, making Monday morning all the easier. “Start daylight savings as of dinner on Friday. That gives that cushion of the weekend. It also helps that on Saturday and Sunday morning, your teenager doesn’t have to get up for school.”

Or, if you’d rather ease into it, you can move your clocks forward a half hour on Friday and then another half hour on Saturday, adds Carr.

  • Don’t let your teenager sleep in. Teenagers are biologically designed to want to go to bed later at night and sleep later in the morning than children and adults. But this weekend in particular, says Carr, parents should get their teenagers up at a reasonable hour. “When a teenager sleeps super late on Saturday or Sunday morning and then has trouble getting up on Monday morning, that’s called weekend jetlag,” explains Carr. “I would suggest, especially this weekend, trying to get them up around 8 a.m.”
  • Turn off computers, phones and any other devices, even the television, for 30 minutes before bedtime. “Staring at a screen does a number on melatonin, which is the most important sleep hormone we have,” explains Carr. “It’s been shown that just looking at a screen for even 10 seconds in the half hour before you’re trying to go to sleep will affect the secretion of melatonin in the brain … it’s like turning all the lights on in your house.”

The good news, says Carr, is that within a few days, your teenager should have made up for whatever sleep deficit daylight savings causes.

But in the meantime, anticipate some grumpiness.

“Unfortunately, I would put teenagers in the group that has the hardest time with daylight savings,” says Carr. “But they eventually make up for it because they’ll start to go to bed earlier once they make the adjustment.”

Daylight savings starts at 2 a.m. on Sunday, March 10.

Sacrificing Sleep for Study Time Doesn’t Make the Grade

Sacrificing Sleep for Study Time Doesn’t Make the Grade

Posted: 10/09/2012 8:06 am

 

Kids are back in school. Students (and parents) said goodbye to the freewheeling days of summer and returned to the structure of the academic year. The school routine typically includes early mornings and, often, late nights of homework and studying.

For students, there is increasing pressure to perform well academically, especially as they enter high school and college is on the horizon. Academic workloads increase, and so do time commitments to other extracurricular activities, including sports. It can be a real challenge to find enough time for all of this activity, and it’s not hard to see how bedtime gets pushed back later and later to make room for studying.

It might seem like a reasonable sacrifice to give up a little sleep to hit the books late into the night, but research says this strategy doesn’t work. This study found that students who stay up late doing homework are more likely to have academic problems the next day. This is true regardless of how much overall studying the student does, according to the study results.

Researchers at UCLA examined the daily sleep and study habits of 535 students in grades 9, 10, and 12. All the students were enrolled in Los Angeles schools and represented a range of socioeconomic and ethnic groups. For two weeks, students kept diaries recording their daily study amounts and sleep amounts. They also kept track of two different types of academic problems:

• Having trouble understanding material being taught in class
• Doing poorly on tests, quizzes, or homework assignments

Researchers found that opting to delay bedtime in favor of studying was linked to an increased risk of both types of academic difficulty. And this was true regardless of the total amount of students’ study time.

The remedy to this problem is not to study less, but rather to create a schedule that allows for sufficient study time and sufficient sleep time. Is that easier said than done? Probably. But as these results indicate, extra study time at the expense of sleep is likely to create academic problems, not solve them. And students who regularly stay up late are exposed to other risks of low sleep. Here’s some of what we know about how insufficient sleep can negatively affect teens:

• Teens who don’t get enough sleep are more likely to engage in risky and unhealthful behaviors. This study found low sleep was linked to increased likelihood of smoking, drinking, drug use, and fighting, among other risky behaviors.

• Teens who sleep less are more likely to gain weight. We know that low sleep is associated with weight gain, in children as well as adults. This study found that teens who sleep less are more likely to consume more total calories in a day, as well as to eat higher fat foods and more snack foods than teens who get enough sleep.

• Teens who are short on sleep are more likely to feel depressed and anxious. There’s substantial evidence that teens with sleep problems are at higher risk for mental health and behavioral problems. This National Sleep Foundation survey found that teens short on sleep were significantly more likely to experience depression, stress, excessive worrying, and anxiety.

Teenagers, as any parent knows, are predisposed to staying up late and sleeping late, which complicates things even further. This is a biological reality, not just a teenage preference! It’s not always easy to manage a teenager’s sleep schedule. Here are some strategies that can help:

• Keep technology out of the bedroom. Electronic and digital devices have no place in the bedroom. Exposure to the light emitted by these devices is disruptive to sleep, and their presence at bedtime can keep teens awake — or even keep them engaged in activity while they are asleep!

• Work backward to find the right bedtime. Teens need more sleep than adults, about nine hours per night. To find the appropriate bedtime, start by identifying what time your teen needs to be rising from bed. From there, work backward to set the bedtime that will ensure your teenager gets enough rest.

• Let them sleep in a little on the weekends — just not a lot. With biological and hormonal changes making teens inclined to sleep later, after a week of school your teenager may want to spend most of Saturday in bed. This much sleep isn’t healthy and will actually make your teen feel more tired, not less. Such a variation from the weekday routine will throw your teen’s schedule off course. This doesn’t mean a little sleeping in isn’t okay. Letting your teenager sleep for an extra hour or two on weekend mornings is fine.

We all want our kids to study hard and achieve academic success. It’s important to remember that sleep is a critical part of the equation.

Sweet Dreams,
Michael J. Breus, PhD
The Sleep Doctor™
www.thesleepdoctor.com

“Attention Problems May Be Sleep-Related”

 A New York Times Article

By KATE MURPHY

April 16, 2012

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Diagnoses of attention hyperactivity disorder among children have increased dramatically in recent years, rising 22 percent from 2003 to 2007, according to the Centers for Disease Control and Prevention. But many experts believe that this may not be the epidemic it appears to be.

Many children are given a diagnosis of A.D.H.D., researchers say, when in fact they have another problem: a sleep disorder, like sleep apnea. The confusion may account for a significant number of A.D.H.D. cases in children, and the drugs used to treat them may only be exacerbating the problem.

“No one is saying A.D.H.D. does not exist, but there’s a strong feeling now that we need to rule out sleep issues first,” said Dr. Merrill Wise, a pediatric neurologist and sleep medicine specialist at the Methodist Healthcare Sleep Disorders Center in Memphis.

The symptoms of sleep deprivation in children resemble those of A.D.H.D. While adults experience sleep deprivation as drowsiness and sluggishness, sleepless children often become wired, moody and obstinate; they may have trouble focusing, sitting still and getting along with peers.

The latest study suggesting a link between inadequate sleep and A.D.H.D. symptoms appeared last month in the journal Pediatrics. Researchers followed 11,000 British children for six years, starting when they were 6 months old. The children whose sleep was affected by breathing problems like snoring, mouth breathing or apnea were 40 percent to 100 percent more likely than normal breathers to develop behavioral problems resembling A.D.H.D.

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