Back To The Basics When Looking At Maladaptive Behavior

Editor's note: This text-based course is a transcript of the webinar, Back To The Basics When Looking At Maladaptive Behavior, presented by Tere Bowen-Irish, OTR/L.

Learning Outcomes

• After this course, participants will be able to:
  • identify sleep irregularities and patterns that may affect behavior.
  • examine proper nutritional needs, inclusive of water, and learn the effects of deprivation.
  • analyze an individual's daily schedule and recognize any areas of concern regarding safety, care, and activity level.

Etiology of Behaviors

• What’s the etiology of behaviors? Big question…sometimes the answer is right in front of us!
  • As we learn more and more about the brain and body, certain basic needs affect self-regulation. They are common and exist for every human being.

What do I now do as an OT when I am on a team looking at a particular kid? I want to know right away what is going on with the child's sleep, nutrition, and safety, and if they have their basic needs. I heard a couple of therapists speak many years ago at a Massachusetts conference that talked about basic needs to be met and what can happen if they are not met.

We are seeing many behaviors in school, and this is a great area to start with in our clinical treatment planning.

Maslow's Hierarchy of Needs

Today, we are going to focus on the bottom two tiers of Maslow's Hierarchy of Needs (Figure 1), including food, warmth, water, sufficient rest, and security and safety needs.

Figure 1. Maslow's Hierarchy of Needs.

Think of yourself at this moment. How well did you sleep last night? Are you feeling well physically? Did you eat good food today? Or did you go to a drive-through, shove it in, and go to another school? Are you hydrated? These basic needs affect self-regulation and the ability to focus, attend, and do your work.

It is not just about clients but about all of us. I have a Fitbit, as do many people. It tells me when I have not gotten eight hours of sleep, or if I have been restless or have had deep REM sleep, as these are very important. Feel free to pursue these topics because there is so much information out there on the topic of sleep hygiene. Sleep hygiene is one of the areas that we, as OTs, understand well, as we have a 24/7 focus on whoever we are treating.

Things to Consider With Our Clients

• Sufficient sleep
• Sufficient nutrition
• Sufficient hydration
• Life in the 6 hours in school
• Life in the 18 hours away from school
• Check out the 24-hour chart in the handouts

Here are things to consider. First, are they getting sufficient sleep? We are going to talk today a little bit about what those numbers are. Are they getting sufficient nutrition, and are they hydrated? We are also going to look at their school life and home life.

I remember consulting at a school where a teacher did not allow water bottles because she felt like they played with them. I asked, "How do they get hydrated?" They were coming in at 8:15 am and eating lunch at noon. We also do not know what happened prior to school. Perhaps, they are not drinking before school.

Additionally, what are they doing when they leave at three o'clock? I have given you a 24-hour handout. I believe we need to look at what is going on in those other hours because it may be related to the behaviors.

They may be hyperactive, impulsive, irritable, or have a difficult time staying alert and need to give themselves input to their faces if they have not had adequate rest. In high school, I often see students' heads on desks. "I played video games until two in the morning."

Again, we need to talk to our clients or their caregivers about the other 18 hours to see how that affects their six hours in school or at work. You can start by asking yourself what sleep routines you have.

Sleep

• Loss of sleep can and does affect self-regulation, focus, task accomplishment, concentration, and even coordination.

A loss of sleep can affect self-regulation, task accomplishment, focus, coordination, and concentration. This is often very visible. For example, I was quite ill over the Christmas break. I could not sleep or eat because of pain and nausea. I noticed a dullness where I could not focus on something or start and finish a task. I did not feel refreshed after a night's sleep.

Our brain is pruned during deep REM sleep to remove things we do not need anymore. And, the older we get, the pruning starts later in our sleep. If we do not get a good night's sleep, we will wake up feeling more chaotic and groggy. This happens with our kids.

I worked with the parent of a 2nd-grade child with a diagnosis of ADHD. The family moved away and came back when he was in fifth grade. The parent called me and said their biggest problem was that he had now another diagnosis, which was a benign brain tumor, and he could not be on ADHD medication. They were a very supportive family and knew he needed proper nutrition, good sleep, and the ability to be able to attend and focus. They made him go to bed at 9 o'clock at night, but his reticular activating system was not allowing him to settle. He took apart his bed (undid the bolts), played basketball, and listened to music. He also never slept through the night.

I started talking to them about the brain tumor and the contraindications. When I went to the house to interview this child, he had a medium build and was thin. His mom was sitting at one end of the sectional, I was on the other, and he was at the corner. During the interview, he was doing non-stop forward rolls. She said, "See what I'm dealing with?" I thought it was interesting and asked the child, "What are you doing?" He said, "I love doing this because it helps me listen to what you are saying." I said, "I'm going to ask you to do something while your mom and I continue to talk. Sit between us, get comfy, and cover yourself with this blanket." She and I were droning on like Charlie Brown's mother, and he was asleep within 10 minutes. I said, "With the rolling, he was trying to keep himself alert. He is in desperate need of sleep."

We began working together to help him sleep. We talked about how taking a bath before bed releases melatonin and doing some sensory input with deep pressure are ways to help sleep. He liked having his sleeping bag in his bed and listening to calming online stories. The electronics went away. I will never forget the phone ringing one morning at 6:30 am. It was his mother saying that he slept through the night.

They started the ritual at 7:30 at night and did it for two weeks. After this, the school called her and said, "What's going on with Clyde? Things are very different. Do you have him on medication?" It was proof in the pudding for me to keep looking at these types of interventions.

Deficiency in Childhood Sleep

• Deficiency in childhood sleep has become a major problem.
• Sleepfoundation.org states: “15-25 percent of kids and teens struggle to fall asleep and stay asleep…”
• There has been a shift in thoughts about sleep being a predictor of overall health
• The authors cite ecological and social variables.
• More research sampling is needed to improve strategies for behavioral intervention.

Adults have been the primary group on which studies have been done for sleep, but deficiencies in childhood sleep are starting to become a major problem in the United States. The Sleep Foundation says that 15 to 25% of kids are struggling not only to fall asleep but to stay asleep.

When we think about whether a person gets a good night's sleep, it is now a factor in whether they are truly healthy. This is something to think about because we always have access to screen time and things to keep us alert and awake. Where are the rituals and routines similar to what you might have done if you were trying to get a baby to sleep, like a bed, bath, and book? 

• “History taking of the child’s habits regarding sleep patterns is a low-cost, measurable way of establishing a plan. The plan would be based on the individual’s needs based on family life, physical health, and educational status.”
• This is one of your handouts. Whether you interview the parent, student, or caregiver, the information is essential for ruling out sleep deprivation.

There also needs to be more research to improve strategies for behavioral interventions. History taking fits nicely with a 24-hour schedule in a low-cost measurable way. It is based on individual needs because everybody is not neurologically the same. Neurodiversity also affects how you sleep and what your habits are.

When you interview the parent, the student, and the caregiver, you want to rule out sleep deprivation. With this, you are getting bonus information. When I interview, I ask more questions other than what time do you get up? I also ask, "Do you have breakfast, or do you wait to get to school?" I am going to tell you a story about a couple of students. In the first example, the parent and I discussed her 3rd-grade child's 24-hour schedule because she was sleeping at her desk. Eve was very irritable, and she would come in the morning and give you that look like she was going to jump on you. She came into school at 8:30 am and was snoring when they returned to their desk to do independent work. I did a 24-hour clock with the parent and noticed some snoring when she fell asleep, and it increased at night. It was so loud that it kept the family awake, and the dog would no longer sleep with her. I said, "Have you talked about this with your pediatrician? I believe that sleep apnea can occur at any age, and it may be well worth looking into it." About a month later, the decision was to remove her adenoids, and she had to have a CPAP machine. Talk about a child's demeanor changing after a good night's sleep. It was night and day. We need to be a detective to try to figure things out.

This next case study is sad. As I said, the 24-hour clock can give you a lot of information. This kid was in high school and was falling asleep in class. He was also seen as unmotivated. I asked him, "What are you doing when you get home from school?" He replied, "I pick up my cigarettes and walk the town." He is up since six o'clock in the morning and in school by 7:15. He ate a snack at high school at ten, did not eat lunch, and then walked to town. I asked, "What time is supper?" He said, "There's no supper." He said, "I sometimes get a sub from a 7-Eleven, or a friend will invite me over." I then asked, "What time do you get home?" He goes, "Around 11 or midnight." He was not even getting eight hours of sleep, not even close. It turned out that this kid's mother was turning tricks from four o'clock in the afternoon until 11:00 PM and did not want him in the apartment. He confessed it was the only way to pay the rent.

Sleep Facts

Here are some more facts on sleep.

• We spend 1/3 of our lives sleeping…
• Sleep helps us with muscle repair, memory consolidation, and the release of hormones regulating growth and appetite.
• If the home environment is chaotic, regular sleep patterns can be unbalanced.
• If we are dealing with anxious kids…their sleep rituals can be dysregulated.
• Teen's rhythms of sleep and time awake shift, and school hours often don’t fit optimally into the teenage brain.

One-third of our lives we spend sleeping. It helps us with the regulation of our hormones, muscle repair, growth, and appetite. We can gain weight if we have chaotic sleep hours because we are not getting the restorative sleep we need. And if the home environment is chaotic, those patterns can be very unbalanced. If we are dealing with anxious children, their rituals can be dysregulated, and that is when they need more accountability for what rituals and routines will work.

Sensory preferences differ among individuals. The reality is what comes naturally to you. Someone may like a bath versus a shower. A shower can be stimulating or relaxing. We can also think about the bedding. Would a weighted blanket be necessary? What is going to connect with them before they sleep?

When teaching mindfulness and talking about stressors, one five-year-old said her stressor was going to sleep. Her mom works the second shift, so her dad puts her dad down to bed early. However, she is so anxious about her mom that she does not fall asleep until she comes home. The teacher and I started talking and thought maybe the mother could record her reading some stories so the child could listen to them before going to sleep.

Teens are a different group of folks. Their sleep time, wake time, and circadian rhythms are different. We expect them to be in class by 7:15, which might not fit well with the teenage brain. 

• These authors have found that if adolescents are not getting enough sleep, problems arise that interfere with large-scale, intrinsic brain networks.
• When sleep is disrupted, the adolescent may engage in repetitive negative thoughts, which is a risk factor for internalizing disorders.
  • Sleep to Internalizing Pathway in Young Adolescents (SIPYA): A Proposed Neurodevelopmental Model

Here is another article about adolescence and lack of sleep. Intrinsic brain networks are affected on a larger scale. I do not know about the adolescents you treat, but with mine, I hear a lot about late nights spending time on the internet, playing games, and falling asleep where they may.

The lack of sleep combined with screen time, which we are going to talk about a little more, can create repetitive negative thoughts. It is also a risk factor for mental health issues and internalizing disorders.

If you have a teenager acting up, use the 24-hour clock to rule out issues. You may find that they have a diagnosis like oppositional defiant, anxiety, or depression, but you may also find that some of their basic core needs are neglected.

Suggestions for Kids and Parents

• In order to be at your optimum level, make sure to rise and retire at the same time.
• Limiting screen time prior to bedtime
• Avoiding scary content (including both video games, books, and movies)
• Bringing back rituals no matter the age
• Creating individualized, co-active ideas with family to create new habits
• Later start time for adolescents
• Limiting caffeinated beverages or food
• Regular exercise, about 1 hour per day for kids.
• Unwinding activities prior to bed, e.g., reading, music, bath, or cultural rituals such as prayers
• Make sure the room temperature is around 65 degrees to allow the body and brain to cool down.
• Use of a fan or white noise to drown out unpredictable noises in the environment
• Dimming of lights about an hour prior to sleep and sleeping in a dark room (promotes melatonin release and the rhythm of the biological clock)
• Smells such as lavender and other essential oils via a diffuser may have a calming effect.
• Awareness of medication regime and its effect on sleep

Based on the parents' routines, styles, and what will work for the family, you can recommend rising and retiring at the same time. I had one family that liked some of the stuff I was saying. The father reported working on the computer after the kids went to bed and not being able to fall asleep. They decided to institute what they called downtime, which was a couple of hours after they ate. They turned the TV and computers off and just hung out. They sometimes did individual stuff or played a family game. It was a self-imposed ritual, and all of the family members changed their sleep patterns. They fell asleep better, and it lasted longer. They also avoided scary content prior to sleep.

How can you create sleep hygiene patterns? I listen to a Calm app every night for a sleep story or a meditation. Another one of my families started using a corn husk blanket or weighted blanket because of the cold weather in the Northeast. Everyone went to bed with their own bed warmer. When helping clients figure out a routine, you want it to be coactive and individualized.

A later school starts for adolescents is a more global idea. Our local high school decided to start at nine o'clock for the high schoolers, and the elementary would go earlier. As a result, they found that if exams were given at 10 o'clock versus that earlier, the grades went up.

Some other ideas include limiting caffeinated beverages, getting adequate exercise, and unwinding before bed. The room temperature should be around 65 degrees to cool down the body and brain. We also find that white noise and dimming the lights are helpful. Smells like lavender or other essential oils have a calming effect instead of an alerting one.

Lastly, we want to look at the medication regime and its effect on sleep. For example, is it better to take certain meds at night or first thing in the morning? I just learned that they are coming out with a new ADHD medication that will promote sleep but also allows awareness and alertness in the morning because it is often hard to get them launched.

Self-regulation From the Bottom Up

• Sleep-From www.kidshealth.org “The average 5-12-year-old needs 10-11 hours of sleep every night. Inadequate sleep can affect growth and having a robust immune system. Some scientists believe that our dreams affect how we organize memory and emotion.”
• www.webmd.com asserts that “nearly 2/3 of kids in the US have sleep problems. In fact, several studies suggest specific academic deficits, including poor school performance. Children with snoring issues that were treated demonstrated improved performance in school”.

Here are a couple more facts that might blow your mind. The average five to 12-year-old needs 10 to 11 hours of sleep at night. We also need to think about immune systems. Many kids are getting run down from sports activities, stress at school, or intense school tasks and group activities. With little sleep, we do not dream as much, and dreaming helps organize our memories and emotions.

Two-thirds of the kids in the United States have sleep problems, and as a result, we are seeing more academic deficits, poor school performance, and snoring, as we discussed before. 

Screen Time

• Another consideration: From BioMed Central Limited (2013, July 25). Kids' sleep patterns are affected by electronic media time and media presence in the bedroom.
• Sleep-deprived students: "Children need extra sleep as they go through puberty, but our study finds that TV and computer use affect the sleep of children. This is especially true during the week and may be impacting their schoolwork as well as their development. Media viewing habits should be considered for kids who are tired and struggling to concentrate or who have behavior problems caused by lack of sleep."

When we think about sleep-deprived students, we start to think about what is happening to the brain and the body as they go through puberty. TV and computer use affects the sleep of children, especially during the week. Media viewing habits could be something to be looked at by families as a way of altering and adjusting sleep patterns.

• Studies indicate that screen time before bed can increase the amount of time it takes to fall asleep, reduce sleep quality, and affect attentiveness the following day. In the long term, nightly exposure to light in the evening may increase the risk of certain sleep disorders and cancers.”
  • https://thesleepdoctor.com/technology/

Screen time before bed can increase the amount of time it takes to fall asleep. The average human being takes around 20 minutes to fall asleep. If they do not fall asleep within that time, what is going to happen is that they are going to pull a phone or an iPad out to entertain themselves. Many kids and adults are falling asleep to the television in their room.

• Affects circadian rhythm, and the blue light decreases melatonin output which helps sleep come along
• Brightness in areas where we sleep that emit blue light can affect our settling down. Dimming of lights prior to sleep aids in sleep hygiene. 
• Is tech reducing overall sleep time? Using the bed only for sleep may be a solution.
  • Fact: Passive use of media, e.g., watching TV, versus active use is more detrimental.
  • Fact: Reading an actual book, prior to bedtime, versus reading a book via a tablet is a better choice for quality sleep and am alertness.

Screen time affects the circadian rhythm, and blue light decreases melatonin. Brightness in the area where we sleep is not optimal. Dimming the lights or sleeping with your eyes totally resting in darkness is a good way to focus on sleep. Lastly, the bed should only be for sleep.

Fun Facts for Sleep Hygiene

• Here are some fun facts for kids to get the conversation started about sleep hygiene. (zzzquil.com)
  • Human infants need 16 hours of sleep, which is the same amount an adult tiger needs.
  • Fatal heart attack risk is higher when we “spring forward “ for daylight savings.
  • Humans dream about 6 dreams a night to help process daily events
  • We can’t catch up on lost sleep…prolonged catch-up sleep results in decreased reaction times and affects focusing skills
  • Fun fact: Elephants sleep less than any other animal, averaging 3 hours a day.
  • Putting phones away 30 minutes prior to sleep helps you drift away within 10-20 minutes
  • Koalas spend 18-22 hours sleeping!

When we start to look at the facts below, I thought these were interesting. Watching TV is better than playing a game on your phone or pad. Reading an actual book versus reading via tablet is better for sleep.

I had a sleep discussion with a few of my kids at school because we were talking about a 24/7 routine. I came up with a bunch of sleep facts. Human infants need 16 hours of sleep, the same amount an adult tiger needs a day. Fatal heart attack risk is higher when we spring forward for daylight savings. Humans dream about six dreams a night to help process whatever happened the day before. We cannot catch up on lost sleep; prolonged catch-ups decrease reaction times and affect skills. Fun fact, elephants sleep less than any other animal averaging only three hours a day. And koalas spend 18 to 22 hours sleeping. Putting phones away 30 minutes prior to bed helps you drift away within 10 to 20 minutes. 

Movement

Lack of Movement Research

• Lack of Movement: Exercise beefs up the brain. Exercise improves memory. When the body is inactive for 20 minutes or longer, there is a decline in neural communication (Kinoshita, 1997).
• Just knowing this fact immediately gives us the ability to act on it and see if a few movement interventions can help reboot focus, attention, and self-regulatory behaviors…
• Let’s have a taste right now!  Time to move after sitting for 30 minutes!

One thing that is not in Maslow's Hierarchy of Needs is exercise. However, movement can help us alert and keep us focused. The movement will not make up for the sleep, but it may help in short increments for task accomplishment.

Demonstration Video

If your body is inactive for 20 minutes or longer, there is a decline in neuronal communication. Let's all stand up right now and do a couple of movement activities.

This is one I actually use for a calm-down alerting activity to increase focus. And it's from my "Drive Thru Menus." It's called tie it in a bow. Your arm's going to come up, your fingers are going to come down, your fingers come up. You turn, flip, pull. Other arm comes up, fingers down, fingers up. Turn and pull. Both arms up, fingers down, fingers up, turn and pull. Nice.

Okay, another one we're going to do, I'm going to take my glasses off. So one thing that they're noticing is that tactile input, whether it's by another person or of ourselves, can really help calm the body. And so we're going to do some gentle massaging of the forehead right now. You've all had a long day at work, so you'll probably enjoy this. You can do it with two fingers, you can do it with all four, pulling down from the top of your forehead, down. And this is from calming and stress-busting; it's called "It's All In Your Head." And then you're going to take two fingers and just make circles around your temples. Notice how hard or soft that feels if you want them in sync. And what I often add to it is the idea of now coming down across the bridge of the nose over the cheekbones, about three or four times, giving yourself some pressure. And then your jawbone. I tense up in my jaw a lot. Just giving it... you can tap on it. Then take a deep breath in and out.

I'm not seeing you vote, but I hope it's a thumbs up that it can make a difference in how you're feeling. Just those little movement breaks after 30 minutes can rejuvenate for the next block of time.

If a child is not getting enough movement, it can affect sleep. Exercise for a typical elementary kid should be one to two hours a day. If that is not naturally occurring, then it is going to affect the body's need to sleep and downtime. It is quite a bit to think about.

Nutrition

• Our bodies are not unlike machines. Food and water are the fuel we need to function optimally. Nutritional habits affect productivity, focus, and attention.
• There is a relationship between sugar and the brain. Our bodies depend on glucose, and our body's demand is higher when we concentrate.
• According to Angela Ruth (Business Tips, Productivity 1/23/19
  • “Our brains are responsible for roughly half of all glucose consumption in the body.”
• Eat a balanced diet 3 times a day…breakfast really does help with focus and attention.

We are now going to move into nutrition. Our bodies need the right fuel of food and water, and there is definitely a relationship between sugar and our brains. Our bodies depend on glucose, and our body's demand is higher when we concentrate. Eating a balanced diet three times a day and breakfast helps with focus and attention. 

Maladaptive Eating Habits

• Education for all; parents, students, and caregivers
• Carbs play an important part… in boosting energy…but aren’t addressing the long haul.
• Nuts, eggs, meat, fish, and beans fuel the body and brain…
  • Think about the child that has daycare prior to school
  • Can we influence dining and snacks within our school system?

In that 24-hour schedule, what are you going to see? You may hear, "They have a granola bar on the way to the sitters. I drop him off at six." You have the aha moment because the teacher's first complaint to you is he walks in at 8:30 saying he is hungry. This child ate at 5:30 on the way to the sitter's and now has not had anything for three and a half hours. There is a lack of fuel to get going.

Proteins, nuts, eggs, meat, fish, and beans fuel the body. Many of us eat processed food that does not provide us with adequate fuel. How can we influence that? If you are consulting with a family about what would be good for snack time or daily eating, you can share this information. In school, I work very closely with teachers, especially younger kids (preschool to second grade). We have a theme for the month, like sleep, nutrition, and snacks. We have noticed some changes. One teacher and I suggested to the parents that instead of packing a snack every day for their child, they could bring in a snack for the whole class once a month. We then provide a list of healthy snacks. It might be apples and peanut butter, celery with cream cheese and raisins, or granola. Parents love it. The kids were eating and serving one another, learning some social conventions, and asking for more. The parents liked not having to worry about a snack, so they ate much better food.

I also consulted at a nursery school where three-year-olds were in one room and four and five-year-olds in the other. The school provided the snack, but the four and five-year-olds set tables, took out utensils, poured the milk, and set out the snack. They also went around and asked kids if they wanted more blueberries, apple juice, or what have you. It was a lovely social and emotional way of getting to know each other through good nutrition.

One high school also worked on making its own granola. Every two weeks, this group of kids would go down to the cafeteria, and they would use all these bits and pieces to make their own granola and have the bags ready to sell for snack time in the classrooms.

Nutrition and Effects on the Body

• Protein allows our body to make the chemicals (dopamine, serotonin, adrenalin, etc.) that help us stay regulated.
• When we eat food that awakens the brain in am and early afternoon, it increases the neurotransmitters that promote sleep.
• Dr. Russell Barkley says: “The amount of blood sugar fuels the systems…a little sugar in your bloodstream. Sports drink, juice, sugary drink…not a lot but just sips.”

Proteins make the chemicals of dopamine and serotonin. Eating food awakens the brain in the morning and in the early afternoon, it is going to promote sleep at night. What you have eaten today is going to lay the foundation to promote a good night's sleep. I am not trying to make anyone feel guilty, but it helped me wrap my head around what I am doing. I can talk the talk, but am I walking the walk with my nutrition? 

Dr. Russell Barkley, who is a guru for ADHD, says the right amount of blood sugar can fuel the system. A little sugar in your bloodstream, such as sipping a sports drink, juice, or a sugary drink, will help with focus and concentration. This goes against everything that we think, but what do we witness? We see kids trying to alert themselves by drinking three or four Red Bulls, which is dangerous. However, we can educate kids and parents about their own bodies, nutrition, and sleep. These are great conversation starters.

When I talk to parents and kids about ways of adapting, many of them talk about certain rituals, like their mom serving them a cup of camomile tea and some salty crackers before bed. Another kid said his mother insisted that he have a banana before going to bed each night because, supposedly, potassium helps you sleep. You may see much more motivation as they begin to recognize their actions affect their attention and focus.

Food Insecurity

• When we think of food insecurity…from an article from UVA Today
  Brain Food: Exploring the Connections Between Nutrition and Learning by Laura Hoxworth 1/4/2018
  • Rarely does our mind think about the links to school performance and self-regulation.
  • Hoxworth cites a study from the Journal of Child Development “The study found children who experience food insecurity in early childhood are more likely to start K less ready than children from homes that are food secure.”
  • School food programs are essential for improving behavior and fueling the brain and body.

Food insecurity can affect school performance and self-regulation. I work closely with a public health nurse. We were talking about the basics of behavior, and she enlightened me that in addition to food insecurity, there is clothing insecurity. She said that if you are a teenager and do not have cool shoes that fit or the right clothing for the weather, you are going to feel unsafe and insecure around your peers. You are going to avoid going to school. I thought that was worth bringing up as we talked about nutrition because I had never heard of it.

This study from the Journal of Child Development says that children who experience food insecurity in early childhood are more likely to start kindergarten less ready than children from food-secure homes. There have also been studies linking sleep that say if kids have a normal routine with eight hours of sleep from an early age, they are more apt to have better academic performance because they have started this routine earlier in their lives.

School food programs are essential for improving behavior and fueling the brain and body. I have worked in many schools over my 40 years, and I do not think food is as thought out as I wish it were. I know they have to feed a lot of kids, but when you start to look at financially what it is costing and what is being served, I think we have to do more. This is whether we are sitting on boards for schools or part of a PTO to help schools understand proper nutrition and its effects.

The other thing that hit us all when Covid appeared is that schools are a source of breakfast and lunch for many kids that were not getting dinner when they got home. breakfast foods are essential. There are also therapy opportunities during this breakfast time. "Can you cut that pancake instead of eating it off the end of your fork?" "How do we pour the maple syrup?" or "How can we make a sandwich out of that egg?" There are plenty of therapy options with dining.

• From www.bigoven.com, “Kids who have proper nutrition generally receive higher grades because it creates a sense of well-being and increases mental clarity.”
• Concerns about certain dyes and glucose levels that may affect hyperactivity
• Obesity rising in our youth as well as inactivity
• High blood pressure due to sodium intake
• Reading labels can help us all know what we are eating, inclusive of additives, fillers, etc.

Research is showing that with proper nutrition, there are higher grades, mental clarity, and a sense of well-being.

This is an interesting fact about label reading. About ten years ago, I learned that Europe, France, Italy, England, and I think Germany decided to get rid of the different foods with chemical dyes due to an overload of attentional issues in kids. For example, their version of Nutri-Grain Bars has beet juice instead of red dye. They have seen changes in behavior based on the lack of dyes in food.

I got curious and have a few everyday things to review with you. Listen to the ingredients of Kraft Catalina dressing. In addition to sugar and tomatoes, there is dried onion, Xanthan gum, Guar gum, dried garlic, red dye number 40, and blue number one. Let's now look at bread and butter pickles. There are fresh cucumbers, high fructose corn syrup, 2% salt, and yellow dye number five. When we begin to start reading labels, the other thing to consider is the amount of salt in products. We also need to think about glucose. Considering all of this (dyes, salt, etc.), we also want to look at the rising obesity rates in our youth and adult populations. We can also think about high blood pressure due to sodium intake. Even though those Lunchables look convenient and easy, the amount of sodium in them for the long term is not so great.

Food Dyes

• “The US food industry has been adding FDA-approved synthetic chemical dyes to our food supply since 1963. These dyes include known and suspected carcinogens and other substances that have been found to cause medical issues like attention and anxiety disorders* in children.”
• “Laboratory-designed artificial chemical compounds do no more than improve the visual acceptability of processed edible material. The dyes are derived from fossil fuels, formerly coal tar, and now from crude oil.”
• “Approximately seventy percent of the food we eat is processed food. The bulk of it is colored with more than 15,000,000 pounds of approved dyes for buyer appeal.”
• The Concerning Effects of Synthetic Chemical Dyes In Our Food – stack By Nicholas Hill Published On: 2020-12-03

The FDA has approved synthetic chemical dyes since 1963. My 67-year-old body has been consuming them now for close to 59 years, and include known and suspected carcinogens and other substances that have been found to cause medical issues like attention and anxiety disorders. We are also seeing genetically engineered food. We have to be curious about laboratory-designed artificial chemical compounds that do more than improve the visual acceptability of edible material. Dyes come from fossil fuels, like coal tar and crude oil, and 70% of the food we eat is processed. The bulk of it is colored with more than 15 million pounds of approved dyes for buyer appeal. Consumers and therapists beware, especially those with kids acting out. You may need to unzip their lunchboxes and take a peek.

School Snack Suggestions

• Protein (eggs, peanut butter, yogurt)
• Whole grain carbs (fruit, beans, pasta, cereals)
• Calcium (yogurt, cottage cheese, string cheese)
• Vitamin D (get outside),
• Zinc (pumpkin, trail mix, sunflower seeds)
• Potassium (bananas, kiwi, citrus fruit, peaches)
• Vitamin C (fruits to help the immune system)

Here are some suggestions for school snacks that make great sense. How do we promote these? Again, when we sent home that monthly paragraph, which we did for ten months, we talked about movement at home, doing chores, nutrition, and sleep. We said for the parents to mark down these items on a weekly chart. For example, if they had yogurt for breakfast, then they checked that on the form. They could bring this form back at the end of the week and count it for one of their center activities. They counted how many things had calcium in them, how many things had zinc in them, etc. I think it was like an aha moment for the parents as well.

Hydration

Signs of Dehydration

• There are many signs of dehydration in kids, today’s focus is on behavior, so the top of the list is:
  • Sleepy
  • Irritable
  • Somatic complaints such as headache, cramping in the abdomen, feeling lightheaded, either excessively hot or cold
  • Other symptoms might be a sticky mouth, dryness around the lips
    • How Much Water Should Kids Drink? - Children's Health Orange County (choc.org)

The kids do not often monitor their own intake, and when they do, they often say they are thirsty. Immediately, they have a drink. Preventative hydration is important. They may be sleepy and irritable without being hydrated and have more somatic complaints like headaches, stomachaches, and lightheadedness. They talk about wanting to lick their lips because their mouth feels sticky. We can work on educating school nurses, cafeteria workers, or the child.

How Much?

• “The Institute of Medicine says children and teenagers should consume about two to three quarts of water a day (1.7 to 3.3 liters, the IOM says), depending on age, size, and sex. Adolescent boys generally need to drink more water than girls do, research suggests.”
  • Got Water? Most Kids, Teens Don't Drink Enough

The Institute of Medicine says they should consume about two to three quarts of water a day depending on their age, size, and sex. Adolescent boys need to drink much more water than girls. When we think about access to water, I remember the days of "bubblers." In some schools, you can fill a water bottle.

We have to assess how this is integrated into the system. retired this past June from a school where I worked for 12 years. One of my teachers had a morning ritual of seven tasks written on the board. They had to look at the board and find those tasks. Kids that had IEPs often had them on index cards. One of the tasks was to fill up your water bottle. There was also remove your chair from the top of the table, hang up your backpack, and put your lunch in the refrigerator. She felt that the hydration made a world of difference. They were not going to the nurse as often or going out in the hallway to the bathroom. She is also the same one that would go to BJ's and buy huge containers of these nugget pretzels. She them gnaw on those while they were writing.

What Can We Do?

• Stay hydrated! Our bodies are 2/3 water. A 5% drop in hydration can cause 25-30% loss of energy. University of Connecticut’s Human Performance Laboratory found that even a 1.5% water loss led to reduced cognitive function, headaches, and fatigue in 25 women and 26 men.

When we think about our bodies being two-thirds water, a 5% drop in hydration can cause a 25 to 30% loss of energy. This is huge. Even a 1.5% water loss can lead to reduced cognitive function, headache, and fatigue.

Conclusion

• As therapists in any setting, consideration of the basic needs contributes to overall functional performance.
• We are unique in our perspective, based on our knowledge and training.
• Let’s use those skills to educate others who work with these kids to start with basic needs before labeling kids with emotional disorders.
• Thanks for your time and attention.

In conclusion, I hope I have ignited a curiosity in you. It has been an eye-opener for me in my work with kids. I see many behaviors like irritability, negativity, and impulse issues. I often see sleepiness, but I want to find out what's going on with their basic needs. As therapists, we look at the whole body and occupational performance. We can educate teachers, kids, and parents about the potential causes of the behaviors. I would rather do that than label kids with emotional disorders if other things have not been ruled out.

I appreciate your time and attention, and thank you so much for coming today.

References

Akbar, S. A., Mattfeld, A. T., Laird, A. R., & McMakin, D. L. (2022). Sleep to internalizing pathway in young adolescents (SIPYA): A proposed neurodevelopmental model. Neuroscience and biobehavioral reviews, 140, 104780. https://doi.org/10.1016/j.neubiorev.2022.104780

BioMed Central Limited. (2013, July 25). Kids' sleep patterns affected by electronic media time and media presence in the bedroom. ScienceDaily. Retrieved January 5, 2023 from www.sciencedaily.com/releases/2013/07/130725202325.htm

Bodden, C., Hannan, A. J., & Reichelt, A. C. (2021). Of 'junk food' and 'brain food': How parental diet influences offspring neurobiology and behaviour. Trends in endocrinology and metabolism: TEM, 32(8), 566–578. https://doi.org/10.1016/j.tem.2021.04.001

Choc. (n.d.). How much water should kids drink? https://www.choc.org/programs-services/urology/how-much-water-should-my-child-drink/

Hill, N. (12/3/2020). The concerning effects of synthetic chemical dyes on our food. Retrieved from https://www.stack.com/a/the-concerning-effects-of-synthetic-chemical-dyes-in-our-food/

Hoxworth, L. (2018, Jan. 4). Brain food: Exploring the connections between nutrition and learning. UVAToday. https://news.virginia.edu/content/brain-food-exploring-connections-between-nutrition-and-learning

Kinoshita, S., & Mitsuoka, T. (1997). Effect of standing on ventricular parasystole: shortening of the parasystolic cycle length. Heart (British Cardiac Society), 77(2), 133–137. https://doi.org/10.1136/hrt.77.2.133

Meltzer, L. J., Williamson, A. A., & Mindell, J. A. (2021). Pediatric sleep health: It matters, and so does how we define it. Sleep medicine reviews, 57, 101425. https://doi.org/10.1016/j.smrv.2021.101425

Ordway, M. R., Logan, S., & Sutton, E. H. (2022). Sleep Deficiency in Young Children. Clinics in chest medicine, 43(2), 229–237. https://doi.org/10.1016/j.ccm.2022.02.007

Questions and Answers

What about clocks?

I think alarm clocks are good, especially developmentally. We want kids to lean towards that independence around first or second grade. My daughter bought me an alarm clock that projected light on the ceiling for Christmas one year. If I woke up in the night, it would tell me what time it was. It felt like I was being monitored, and so this would not be a good choice.

It sounds like a silly question, but I find that lights bother me, and I know others who say the same thing.

You are absolutely right. There are many people that hear light sounds, especially fluorescent lights. Cup your hands around your eyes and look at your computer. Do you see a difference? Lights may bother some people as part of neurodiversity.

What would you recommend for a client who has racing thoughts and parents report that they have noticed the child can't get to sleep without background noise? They've tried white noise machines and calming music with no success. The only thing that works is the television being on at low volume.

That is a tough one. A muted television with blah, blah, blah, blah, blah, blah, blah, blah, blah in the background may be similar to rhythmic sound. I would explore rhythmic music with them at 60 beats a minute or less. I would also explore what the child likes. I would also try to get them into a routine where it feels like they are not being left on their own to go to sleep. Leaving the TV on suggests there may need to be more caregiver involvement.

Can you talk more about how we can't catch up? I have heard about sleep debt and assumed that meant we could eventually catch up.

I am not a sleep expert, but from what I have read, you cannot. For example, I can look at my own sleep patterns. Over the weekend, I easily got eight hours, but this week has been crazy with five hours and 39 minutes, six hours and 45 minutes, et cetera. I know that I have to get more sleep, but it is not going to make up for my behavior that occurred this week.

What do you think about movement breaks in between fine motor activities?

I am the creator of the Drive Thru Menu, which is movement breaks. You get more brain oxygenation and alertness. We can use movement to reboot our neurons to wire and fire.

How do early afternoon snacks help one fall asleep?

From what my reading of the research shows is that if we have a good protein in the morning and even mid-afternoon, it sets the body up to be able to disconnect and prepare for sleep. It is like priming the pump for sleep if that makes any sense.

I'm interested in the comment that high blood pressure is linked to increased sodium. I'm a licensed natural path and an OT, and the studies I have seen suggest that the main driver of high blood pressure is red meat. Can you comment on your sources for sodium?

I do not have another source than what was posted, but if you search, you will see that sodium is tied to that. I happen to know many people that have cardiac issues based on my age, and sodium is one of the first things they have to start cutting. Does the FDA ever retest, review, and edit the science? If you find that out, please let me know. I do not know. I think it is too big of an animal. I think specific companies will have to look at the best practices for food.

What if a child is afraid of the dark? Is colored light okay?

I think if a child is afraid of the dark, a small nightlight is fine. I used nightlights with my own kids. My ophthalmologist said that if we sleep in complete darkness, the eye can totally rest, but the nightlight to send them off is a grand idea. The reality is that if you turn it off when you go to bed, it is going to make a huge difference. The article is from the American Academy of Optometry. They say that since 1971, the incidence of nearsightedness has doubled to 42% of the population, and in the Asian population, it is 90%. Some of it is due to too much light that we are taking in and not being in outside natural light.

Do you notice a difference with diets like keto?

That child that I spoke about with the brain tumor was on this diet, and his tumor shrunk, but I do not know. I would suggest talking to people about it. I just have that qualitative experience to share.

Can you speak to the context of Dr. Barclay's comment on sports and sugary drinks?

He's talking about small sips. That little bit of glucose will alert the nervous system to focus and attend.

For those young kiddos aged two to four who have sleep disturbance, how much time should they be allotted during the day for napping based on your research?

Wow, I do not know. I think you have to look at them as a whole. I certainly think napping is necessary, but we must look at whether we're expecting an infant to sleep 16 hours a day. If the child is between two and four, we are most likely looking at 12 hours a day. When the child shows restlessness, irritability, sleepiness, or lack of focus, you may have to titrate that nap time according to the family schedule and what is going on in school. I do think that we cannot expect a hundred percent attention a hundred percent of the time. And unfortunately, our schools and our lives are expecting that. 

How do you deal with teachers, like PE teachers, that do not allow kids to drink water during the school day?

Go do more research for yourself on what the paucity of water means. Kids need to be hydrated.

What are your thoughts on Seltzer water versus regular water?

There's no difference other than fizzy. Fizzy waters may cause acid reflux.

What about difficulties with waking children? Does that mean they're not getting enough sleep even after nine or 10 hours?

If they wake up during the nine to 10 hours, their sleep is disrupted, or they are not going into that deep pruning sleep. They do sleep studies on kids now, and it is important to know if you have a kid that looks like they're having sleep challenges.

Is white noise helpful?

It can be for some. My husband loves the fan on all night.

If five to 12-year-olds should have 10 to 12 hours of sleep, how many hours of sleep should 13 to 16-year-olds get? I think it's around eight to 10.