Sleep Hygiene Recommendations to Improve Sleep – Dale Mortimer, M.D.

Sleep Hygiene Recommendations to Improve Sleep

Based on a review of relevant literature – plus my own 31+ years of clinical experience treating children, adolescents and adults with sleep problems – below is a summary of experts' recommendations for good sleep habits.

First, some background information. The types and frequencies of sleep problems vary with age, with epidemiological samples estimating sleep problems at 25–43% in otherwise healthy children. Sleep problems tend to become more frequent beginning in adolescence. Types of sleep complaints include: difficulty falling asleep, difficulty staying asleep, early morning awakening, difficulty waking refreshed in the morning, excessive daytime sleepiness/ daytime sleep attacks, restless legs especially in the evening, sleepwalking, sleep–talking, nightmares, rhythmic movement disorders, snoring, apnea, bed-wetting, and teeth–grinding. Depending on the chronicity and severity of sleep deprivation, resulting daytime symptoms may include: morning headaches, irritability, difficulty concentrating, reduced vigilance, distractibility, reduced motivation, depression, fatigue, physical restlessness, incoordination, malaise, loss of appetite, gastrointestinal disturbances, and muscle pains.

Good sleep habits are important skills for children and adolescents to learn. For children, bedtime should neither be a reward (i.e., “You can stay up later if you’re good!”) nor a punishment (i.e, “You have to go to bed early if you don’t behave!”), but part of appropriate health care. While some families have a “children's’ bedtime” that applies to all kids regardless of age (i.e., a 10–year old may be expected to go to sleep at the same time as a 4–year old, despite the older child having a shorter sleep requirement), it is no more correct to give all the children the same bedtime as it would be to give them the same medicine.

Significant daytime sleepiness despite adequate nighttime sleep in children is not common and should be taken as a serious complaint. Children need an average of 9 hours of sleep, and the need for sleep increases during adolescence, with 15–year–olds needing more sleep than 13–year–olds. Unfortunately, with the pubertal increase in daytime sleepiness, the restriction of nocturnal sleep to meet societal expectations or obligations, the additive impact of chronic sleep restriction, and less parental influence over the adolescent’s sleeping hours, an adolescent with a 10-to 11-hour sleep requirement will have great difficulty getting that much sleep in our society – especially given the very early time that the school day begins for those in high school. To clarify: being awake by 6AM and getting 10-11 hours of sleep would mean a 7-8PM bedtime – which is completely unrealistic in most social environments and especial with high school homework demands. It is rare for an adolescent to retire before 10PM and even this results in only 8 hours of sleep at night. Thus, in one study, 25% of 13–year–olds, and 33% of 15–year–olds were identified with sleep problems. It appears to me that in our culture, the "typical" adolescent and the “typical” adult are chronically sleep–deprived.

For best results, my sleep hygiene suggestions include the following: minimize the chance of associating your bed with unpleasant thoughts or feelings. Avoid minimize the likelihood of making your bed a place for worry and frustration rather than for rest. Stimulus–Control Behavioral Modification involves eliminating the conditioned association with arousal and lying in bed. If you are unable to fall asleep within a few minutes, then get out of bed and go to another room. After a spontaneous awakening, you should also get out of bed if unable to fall asleep within 10-15 minutes. With a little luck – and commitment – then over time, the association with lying in bed and being awake will be extinguished.

An alternative approach to achieving the same desired result is Sleep Restriction Therapy. Many people with chronic insomnia underestimate their actual time asleep and have poor sleep efficiency. Estimate your average sleep time with a 2–week sleep diary. After that, restrict your time in bed to fit that estimated sleep time. Initially, you will have your usual difficulties with sleep continuity. The resulting mild sleep deprivation will hasten the onset of sleep, and over time, your sleep efficiency will improve as the association between arousal and lying in bed is extinguished.

The following are recommendations for improving sleep habits that I have found most helpful for my patients. Of course, one does not need to necessarily follow all of the suggestions to obtain a satisfactory result.

Sleep as much as needed to feel alert during the day, but not more. Curtailing the time in bed solidifies sleep; excessive time spent in bed fragments sleep. Waking up early is associated with improved mood (i.e., partial, late–night sleep deprivation has an antidepressant effect), and “sleeping in” or sleeping until late in the morning is associated with worsening mood (i.e., sleeping late in the morning causes or worsens depressed mood).
Go to bed when you are tired, go to bed about the same time each evening, and arise at about the same time each morning – even on weekends and vacations! A regular awake time in the morning leads to regular times of sleep onset.
Avoid long periods of wakefulness in bed. If you do not fall asleep within 30-45 minutes after lying down, get up, go to another room, and do something minimally stimulating (and mildly punishing) until you become sleepy (e.g., read a boring book, fold clothes, iron clothes, wash dishes); then return to bed. Repeat as needed if you do not fall asleep within 30-45 minutes.
If you feel angry and frustrated because you cannot fall asleep, don’t try harder to fall asleep. Instead, leave the bedroom and do something which is not very stimulating (– but certainly do not play video games, surf the Internet, or watch TV!).
Do not do anything in bed except sleep (– and engage in sexual intimacy for those mature enough for this). Do not watch television, read, eat, or fight in bed. Reminders, or discussions of finances and schedules should be banished to another room.
Exercise is the only known way for healthy adults to boost the amount of deep sleep (restorative, restful sleep) they receive. Regular exercise is encouraged (at least 30 minutes daily; at least three or four times a week) – but not in the evening if this interferes with sleep. Exercise performed regularly and not too close to bedtime deepens sleep.
Excessive noise may disturb sleep. Insulate the bedroom against loud noises: consider installing carpeting, using opaque curtains, and closing the door. Removing the television, telephone, and office paraphernalia from the bedroom is a good way to reinforce the message that the bedroom is meant for sleeping.
Excessive warmth disturbs sleep. Keep the room temperature at a comfortable level.
All the experts concur: Don’t take naps!
Hunger may interfere with sleep. A light snack before bedtime may improve sleep, although a large meal and excessive fluids close to bedtime may have the opposite effect.
Avoid excessive liquids in the evening, in order to minimize the need for nighttime trips to the bathroom. Do not drink fluids or eat after 7:00 PM, especially beverages containing caffeine or alcohol.
Caffeinated beverages disturb sleep, even though you may not be aware of their effect. Caffeine can remain in the bloodstream for up to 20 hours after ingestion, and for some people a single cup of coffee in the morning can result in a sleepless night. Caffeine can also interrupt sleep by increasing the need to urinate during the night. Although consumed for the opposite effect, too much caffeine can cause daytime sleepiness because it depletes one’s neurons’ supply of norepinephrine and dopamine (– which are believed to be the principle neurotransmitters needed to stimulate wakefulness). In fact, people with insomnia would do best to avoid caffeine completely.
Abstain from all alcohol!! Alcohol depresses the central nervous system and, thus, alcohol helps people fall asleep more easily. However, the net effect of alcohol is sleep fragmentation: alcohol suppresses rapid eye movement ("REM" sleep or “dream” sleep), and then when the alcohol is metabolized several hours later, drinkers then experience more frequent awakenings, and sometimes with terribly frightening dreams (– probably from "dream rebound" which is caused by alcohol's suppression of REM sleep). Sleep fragmentation is also the result of alcohol–induced snoring and sleep apnea. Do also remember that alcohol is a neurotoxin. Those whose priority is restful and restorative sleep, and clear thinking should avoid all alcohol (– and, of course, a well–functioning brain is a prerequisite for success in academics, employment, and parenting!).
Don't use nicotine! The chronic use of nicotine disturbs sleep (– after all, nicotine when used as an insecticide is effective because it is a central nervous system stimulant, making it impossible for the critters to breathe.) Nicotine interferes with falling asleep because it increases the heart rate, increases blood pressure, and stimulates fast brain wave activity associated with wakefulness. In addition, nicotine withdrawal occurs every night after the last cigarette (or chew), and withdrawal symptoms worsen as the night goes on. So, if you want to sleep well, then don't use nicotine!

Dr. Mortimer is a physician licensed to practice medicine in the State of Washington. He is a diplomate of (i.e., “Board certified” by) the American Board of Psychiatry and Neurology. He is also a fully–trained child & adolescent psychiatrist. Among other things, Dr. Mortimer has been on the clinical teaching faculty for Oregon Health Science University’s Department of Psychiatry, and for the Family Practice Training Program at Eastmoreland Osteopathic Hospital in Milwaukie, Oregon. Dr. Mortimer has served as a principle investigator and as a clinical investigator for phase III clinical drug trials, several of which investigated specific stimulants proposed for the treatment of ADHD. Dr. Mortimer has also seen some of his clinical writings published in peer–reviewed international medical journals. Dr. Mortimer currently enjoys maintaining a full–time, solo private practice in child, adolescent, and general adult psychiatry in the non–incorporated Hazel Dell neighborhood of Vancouver, Washington.

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