By the age of two, most children have spent more time asleep than awake. And overall, a child will spend around 40% of their childhood asleep. It is during this time that developing bodies are able to grow and repair, as well as consolidating memories formed throughout the day.
“We talk about the first 1000 days of life—but often forget that 500 of those are spent asleep!” says Dr Michael Farquhar, a consultant in children's sleep medicine at Evelina London Children's Hospital. “Children and young people’s main job is to grow and develop. And for that, good sleep is paramount.
“It’s difficult for paediatricians to encourage good sleep habits for children when they themselves may not have had much training about sleep. Medical training has a lot to pack in and, historically, paediatricians have had relatively little teaching or training about normal sleep and common sleep problems in childhood. Like most things to do with children, there is a huge range of ‘normal’!”
Michael says that although sleep is known as a bedrock of overall health, when it comes to training doctors, the medical curriculum is lagging. This, in turn, has downstream consequences for educating parents and carers, who are often left without the best advice on how to manage sleep in children.
Maggie Fisher is a sleep specialist at the Institute of Health Visiting, which aims to educate families on sleep during their home visits: “Proper sleep cues are really important. Although rocking and feeding are effective cues, children can quickly become dependent—the evidence suggests that encouraging children to self-settle aids sleep and prevents dependent sleep associations.”
Maggie says that suboptimal sleep cues can have far-reaching consequences. If a child is relying on feeding to fall sleep, for instance, the extra milk can lead to accelerated tooth decay. Breastfeeding or offering a bottle during the night can also be an unsustainable routine for parents and carers.
“Good sleep cues include putting children to rest when they are drowsy, and having a consistent routine,” says Maggie. “Parents and carers want to do their best and are receptive to this message—the main challenge is making sure that it forms a part of the conversation when we speak with them.”
We don’t need no medication: behavioural approaches to improving sleep
Lisa Artis is deputy CEO at the Sleep Charity, a recent merger between the Children’s Sleep Charity and the Sleep Council. The Sleep Charity offers training for health professionals and support for families to help ensure that people prioritise good sleep.
“Medical training focuses more on sleep disorders than healthy sleep, so it’s understandable that doctors have historically been quick to prescribe medications like melatonin,” says Lisa. “But we’ve shown that behavioural approaches can give better results for children and their families.”
The Sleep Charity’s pilot scheme focused on vulnerable children, including those from troubled backgrounds or with challenging behaviour. The programme replaced medications with workshops that led to improvements in sleep patterns for the child—and better wellbeing for the family.
The workshops led to increases in sleep of up to 2.4 hours per night, and many young people reported a shift in mental state from “grumpy” to “happy”. The study illustrates effective social prescribing, part of the NHS Long Term Plan that aims to solve health issues using non-clinical interventions.
“There’s a postcode lottery, though,” says Lisa. “Underserved communities are more likely to have suboptimal sleep settings, like sharing bedrooms and noises outside the home. They’re also less likely to have access to support—which is why we need full, consistent sleep services across the UK.”
Jenny Fox is a senior subject specialist at the PSHE (Personal, Social, Health and Economic) Association, which is supporting widespread sleep education in schools: “This year, the Department for Education introduced statutory education on health and wellbeing, including lessons on the importance of good sleep.
“Our resources provide teachers with tools to engage the classroom. We use a story-driven approach that presents hypothetical scenarios, rather than putting kids on the spot by asking them questions about their own lives. This removes some of the pressure they might feel to give a ‘right’ answer.”
The PSHE Association’s curriculum includes three lesson plans at Key Stages 2-4, with a new lesson soon launching for Key Stage 1. The earlier lessons provide simple sleep tips and spark discussion among families—shifting gears when children grow into young people and gain more autonomy.
Fluorescent adolescence: late night screens and poor routines
Daniel Holmes has recently completed his A-Levels in England. After sitting through months of uncertainty in the wake of cancelled exams, he received an offer from his firm choice to begin a degree in computer science.
“Sleep is probably one of the most important things for people my age. Without it, you can’t properly function,” says Daniel. “But we didn’t have any teaching on sleep, at all. And when we did have workshops on other health topics, they were always brief and never went into much detail.”
Daniel says that many of his friends have issues with sleep, partly due to using phones around bedtime. He says that while they are told not to use phones, they are not offered practical advice on how to avoid them. Instead, they are often outwitted by the design choices of application developers.
While some design choices may be unconscious, they can incentivise behaviours that prioritise screen time above young people’s health. In a recent podcast interview, Jenny Fox noted that the most popular time for uploading a photo to Instagram is between eight and ten o’clock on a Sunday evening.
“I can look at my insights and see the exact time that I get the most likes, and I’d rather post at a peak time than a non-peak time,” says Daniel. “Quite a few of my friends sell vintage clothes, too, and a lot of people ‘late buy’ at ten or eleven o’clock, so that’s a good time to post things to sell.”
In later Key Stages, the PSHE Association’s curriculum focuses on changes in puberty and looming GCSE exams. The lessons encourage young people to make healthy choices, like avoiding phones late at night, by showing how good sleep can contribute to mental wellbeing and academic success.
Jenny notes that tackling phone use around bedtime is a challenging task, and one that is likely to involve input from the tech companies themselves. As the impact of social media on young people’s mental health becomes a prominent conversation, developers may be forced to rethink some of the design choices encouraging unhealthy sleep behaviours.
“Adolescence can be difficult, so it’s understandable that many young people seek CAMHS [Child and Adolescent Mental Health Services],” says Maggie. “I’ve seen cases where the person seeking CAMHS no longer needs support once an underlying sleep issue is resolved. That’s how important sleep is.”
Resolving sleep issues has, however, become more difficult during the pandemic. In addition to extra screen time, elevated anxiety, disruption to routine, and isolation are all leading to poorer quality sleep across the population. For some young people, however, COVID-19 has been an unexpected boon.
“The school routine can cause sleep deprivation, particularly for teenagers who naturally sleep in a little later,” says Michael. “Sleep has actually improved for 25% of young people during lockdown, as their cycles are now in sync with the world. This is something we should keep in mind going forward.”
Living the dream: rethinking sleep beyond the pandemic
In its recent sleep manifesto, The Wake Up Call, the Sleep Charity urged the UK government to prioritise good sleep. They estimate that 40% of the UK population has a sleep issue, and cite Public Health England data showing that one million people used drugs for insomnia in 2017-18.
As well as emphasising the physical and mental health that good sleep provides, the paper presents the benefits for wider society and public bodies like the NHS. This includes lower rates of obesity and driver fatigue, higher rates of productivity, and less money spent on sleep prescriptions.
“We typically see a surge in sleep-related referrals after summer, which is why we picked September for our #Sleeptember campaign,” says Lisa. “As the days get shorter and kids return to school, we’ll be offering support to help parents and kids get back into a proper routine.”
#Sleeptember will challenge parents and carers to maintain a consistent sleep pattern for one week and report any changes in mood, as well as providing tips for children and young people. Leading mental health charities, meanwhile, are set to release their own research on sleep and wellbeing.
“Experiences under lockdown have been wildly different,” says Jenny. “To re-establish lost sleep routines, we’ve put together a back to school pack for teachers. This will allow them to conduct a needs assessment in order to understand how to best tailor their lesson plans to students’ needs.”
Young people are already thinking about how to deal with sleep issues for themselves. YoungMinds has shared a number of tips from its community of bloggers and activists, including pragmatic advice to download a blue light filter if avoiding phones at bedtime is unrealistic.
Dr Michael Farquhar, meanwhile, has published advice for NHS staff on sleep in the time of COVID-19. Like the Sleep Charity’s study, Michael says that medication is not an alternative to healthy habits. His guidance includes suggestions to help health professionals wind down, rest, and build good routines.
"The way that many of us are feeling and responding to the pandemic is normal—it’s an extraordinary situation," says Michael. "But we need to get sleep right. Only then can we go out into the world and be the best possible versions of ourselves."