Exploring Sensory Processing

Approaches to Address Sleep in

Children
Jason Browning, Ph.D., OTR/L
April, 20, 2023
Where did it all begin?

(Stock Photos used under common licenses)

 Objectives

1. Identify behavioral insomnia symptoms in children

2. Describe sensory performance patterns as they relate to
sleep across pediatric populations
3. Create evidence-based occupational therapy
interventions to enhance sleep hygiene and sleep
participation

(Pictures used throughout this presentation were used with parental

permission, and copying or usage beyond this presentation is not permitted)
 Important Sleep Facts
• National Academy of Medicine (Institute of Medicine)
declared sleep deprivation a public health issue in 2006.
• CDC stated that children and adults in the US are not
getting enough sleep (2015)
• Health People 2030 Objective EMC-03: Increase the
proportion of children who get enough sleep (Target 70.6)
Findings 65.6% 2018-2019
• Up to 40% of children have sleep issues

(Office of Disease Prevention and Health Promotion, 2023; Sleep Health Objectives, 2011)
 Why is sleep so important to the
occupational participation of children?
• Sleep affects immunity, repair of bone, muscle and
neurological structures
• Sleep enhances restoration of neurotransmitters
which allow the body to regulate mood, behavior, and
metabolism
• Sleep increases the ability for cognitive functioning
and executive functioning
• Adequate sleep improves overall quality of life

(Byars et al., 2001; Knutson et al., 2017; Mindell et al., 2009; Vriend et al., 2013)
 What are the recommendations?
Age Recommended hours of sleep

Infants (0-3 mo) 14-17 hours Including naps

Infant (4-11 mo) 12-16 hours Including naps
Toddlers (1-2 yrs) 11-14 hours Including naps
Preschoolers (3-5 yrs) 10-13 hours Including naps
School-aged (5-13 yrs) 9-11 hours
*These recommendations include naps
Adolescents (14-17 yrs) 8-10 hours
(Chaput, 2019; Tremblay et al., 2016, 2017)
 Sleep Medicine History

Pre-1900 Early1900 1950s 1960s 1970s 2000s 2010s

• Sleep is • Electrical • REM • First sleep • NREM sleep
observed
• Sleep
Deprivation
• 4 stage sleep
cycle
activity Discovered center
Passive • 5 stage established • AASM Declared proposed
observed founded public health • Continued
in the sleep cycle • 1st Sleep issue lack of sleep
proposed Journal • Lack of sleep professionals.
brain • 1st professionals
Certification in to treat the
sleep need
medicine
awarded
Neurology of Sleep

(Harvard Health Publishing, 2022)

 Sleep Assessments
• Adolescent Sleep Wake Scale
• BEARS
• Bedtimes Routines Questionnaire (BRQ)
• Brief Infant Sleep Questionnaire
• Children’s Sleep Habits Questionnaire (CSHQ)
https://depts.washington.edu/dbpeds/Screening%20Tools/CSHQ.doc
• Children’s Sleep Hygiene Scale (CSHS)
• Children’s Sleep Wake Scale
• Daytime Functioning Scale
 Sleep Assessments
• Cleveland Adolescent Sleep Questionnaire
• Pediatric Sleep Questionnaire
• Family Inventory of Sleep Habits
https://www.childrensal.org/Workfiles/Clinical_Services/Med_Autism_Clinic/
Sleep_Habits.pdf
• Infant Sleep Questionnaire
• Pediatric Sleep Questionnaire
http://www.bayclinicpediatrics.net/getattachment/27a261cc-b54b-413e-b22c-
e3f36a37aa2f/Pediatric-Sleep-Questionnaire.aspx
• Sleep and Settle Questionnaire
• Sleep Disturbance Scale for Children
 Behavioral Sleep Disorder Categories
Inadequate Sleep Hygiene
Adjustment Sleep Disorder
Insufficient Sleep Syndrome
Limit-Setting Sleep Disorder*
Sleep-Onset Association Disorder
Due to performance of ADLs that are
inconsistent with maintenance of good quality
sleep and full daytime alertness
Temporarily related to acute stress, conflict,
environmental change causing emotional
arousal
Persistently fails to obtain sufficient nocturnal
sleep required to support normally alert
wakefulness
Inadequate enforcement of bedtimes by a
caretaker, with child then stalling or refusing
to go to bed at an appropriate time (curtain
calls)
Occurs when sleep onset is impaired by
absence of a certain object or set of
circumstances
(Blunden, 2012)
Sleep in Occupational Therapy
Debate in OT literature
regarding sleep as an
occupation.
2013 Fung et al.
recommended that
What are you doing to address
sleep become part of the occupation of sleep?
every OT evaluation

1980-
1990s 2012 2023

1922 2008 2015

Adolf Meyer Discussed OTPF-2 Upgraded sleep First published book on

the importance of from an ADL to an Sleep in Occupational
Sleep as part of a Occupation. Upheld in Therapy and clinical
balanced life. OTPF 3 and 4 publications applications
Occupational Therapy Practice
Framework-4 Edition
th
Current Research
Regarding Sensory
Processing and
Sleep
Year Authors Age Range Findings
2009 Shochat et al. 6 years -10 years Significant correlations were found with tactile
sensitivity, sensory seeking, and movement
sensitivity. Sensory sensitivity predictor of 25%
of variance.
2012 Reynolds et al. 6-12 years Significant correlations were found between all
quadrants and sleep in the typical group. The
ASD group had significant correlations with the
sensation-avoiding quadrant only.
2012 Engle-Yeger 12-60 years Sensory sensitivity, and sensory avoiding
(specifically related to vision, tactile, and
auditory) were significantly correlated with
insomnia scores
2015 Vasak et al. 0-36 months Increased sensory sensitivity required more time
to settle
2017 Tauman et al. 7-36 months Oral Processing had the most effect on sleep
performance. Sensory Avoiding and sensory
sensitivity was significantly correlated with
insomnia scores.
Year Authors Age Range Findings
2018 Foitzek et al. 8-12 yrs Low but significant positive correlations were found
between insomnia symptoms and tactile, oral, and
planning/ideation scores
2020 Rajeai, S. et al. 7-12 yrs Moderate Correlations with sensory processing
patterns and sleep habits. Significant differences in
sleep performance between those with sensory
processing differences and those without sensory
processing challenges.
2020 (ProQuest- Browning 3-10 yrs All quadrants correlated with sleep performance.
dissertations) Sensory Avoiding had a moderate correlation.
Sensory systems review: Oral (no correlation);
Vision, movement and position (low correlation);
Auditory and touch (moderate correlations).
2021 Spira, G 6-11 yrs Tactile, taste/smell sensitivity correlated with
increased daytime sleepiness. High scores on visual
and auditory sensitivity correlated with higher sleep
anxiety.
 Synthesis of Findings
• Individuals with lower neurological threshold sensory processing
behaviors (Sensory Avoiding and Sensory Sensitivity) have
more difficulty with insomnia overall. Specifically settling to
sleep and sleep anxiety.

• The sensory systems showed more variation. Sensitivity in

vision, tactile and auditory systems are most prominent to affect
sleep duration in the data. Smell and planning are also
correlated with insomnia symptoms and daytime sleepiness.

• The strongest predictor of insomnia symptoms was sensory

sensitivity (25% of variance)
 Sensory Aspects of Sleep
• Vestibular
• Vision
• Tactile
• Proprioception
• Auditory
• Smell
• Taste
• Interoception

(Stock Photos used under creative common licenses)

 What to keep in mind when addressing sleep
• Make sleep a priority (ensure there is time for
recommended sleep times)
• Be Consistent (including weekends)
• Encourage a dark, quiet, temperate (68-72F) sleep
environment
• Keep the bedroom only for sleep
• No electronics in the bedroom
• Avoid large meals/caffeine before bed
What to keep in mind when addressing
sleep
• Encourage daily activity; exercise has been proven to help
sleep (Tse et al, 2022)
• If anxiety is an issue, write in a journal, create a worry
discussion prior to bed time
• Provide a drink near the bed to reduce “curtain calls”
• Encourage parents to seek medical advice if you observe
excessive sleepiness or abnormal breathing
Addressing Sensory Needs of the Child
• Ensure the comfort of clothing and bedding
• Make sure the child is regulated to allow calming to
sleep
• Ensure proper temperature and lighting in the room
• Remove excessive auditory or visual clutter
• Encourage the child to go to sleep when they are
visibly sleepy
 Case-Study
James is a 5 yr old child in foster care. He was diagnosed with global
developmental delay and demonstrates sensory-related behavior. The foster
mother indicated occupational deficits with sleep. She reports he only
sleeps 2 hours per night. He is very hyperactive in the evenings and it takes
him a very long time to settle.
Assessment findings: He was very low arousal in the morning, but
increased arousal throughout the day. He is demonstrating defensiveness in
the tactile, auditory, and vision systems. His new foster parents live in an
urban area across from a major highway. His favorite activities are jumping
on the trampoline and he loves a bath. She has difficulty getting him out of
the bath before bed. He has no sleep hygiene routine. His foster mother also
reports she often wakes up to him asking to join them in bed.
 Your Turn…

Do you have a child

in mind?

What is your next

step?
 Sleep Resources
Occupational Therapy’s Role in Sleep (AOTA)

Establishing Bedtime Routines for Children

8 Steps To Great Sleep for Children

Do your children get enough sleep CDC

Sleep Strategies for Kids

Night Terrors
 References
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Blunden, S.L. (2012). Behavioral sleep disorders across the developmental age span: An overview of causes, consequences, and treatment
modalities. Psychology, 3(3), 249-256
Browning, J. (2020). Pediatric Insomnia and Sensory Processing: Exploring the Role of Occupational Therapy Practitioners in Sleep Medicine
(Doctoral dissertation, Nova Southeastern University).
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Office of Disease Prevention and Health Promotion. (n.d.). Sleep. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-
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Thank you!
Jason Browning, Ph.D., OTR/L
Assistant Professor
Radford University
jtbrowning@radford.edu