Psychology, Sleep, and Treatment – Michelle Mullaley, PhD, Child Psychology Expert – Modern Psychology, and Why We Sometimes Suffer from Sleep Problems

Richard Jacobs: Hello, this is Richard Jacobs with the Finding Genius podcast. This is the health, medicine and bio-science edition. I have Dr. Michelle Mullaley. She has a doctorate in clinical psychology with an emphasis in child and family psychology at the Catholic University of America in Washington, D.C. She is working in the mental health field since 1991 again with children’s mental health. So we’re going to talk about that. So Dr. Michelle thanks for coming. How are you doing?

Michelle Mullaley: I’m great. Thanks so much for having me.

Richard Jacobs: Okay. What got you interested in working in the field you’re in and then what’s your recent focus and what have you learnt in past 20, 30 years?

Michelle Mullaley: Right. So I became interested long ago and working with children and I’ve kind of navigated through adolescence and now also work with adults. But one of the things I see a lot is I do a lot of psychological testing in addition to therapy with children and families. And one of the things that I see a lot with the individuals that we do testing with are history of some sleep issues, which got me curious to dig a little bit deeper into what that could be about. There’s been a lot of research in the last 10, 15 years that might explain that connection. So that’s one area I do some education around in the community as well as with the clients that we’re working with. Both in testing and in therapy.

Richard Jacobs: Let’s focus on children have sleep issues. What do you see commonly today? What kind of issues does  parents say that kids have?

Michelle Mullaley: Well in particular, kind of from a general perspective. Kids struggle with falling asleep, well especially kids who have sleep disorders or who have ADHD, which is a tension deficit hyperactivity disorder. And then there’s some societal aspects to that too. I think school and sleep do not always go well together because as kids are aging through puberty and teen years, their circadian rhythms shifts a bit to where they’re not tired until later. Which is normal and natural and why they don’t want to go to sleep until sometimes 10 or 11:00 PM. But then their bodies want to sleep that full nine hours that they really do need. But schools start at 6:30 AM, seven, 7:30 AM, eight o’clock in the morning, so they’re aren’t able to get enough sleep. So there’s kind of that cultural or societal piece. So we often have really sleep deprived kids, especially the really high achieving teens who are pushing themselves a lot and get all that work done and perform well. So they don’t want to leave something undone and they stay up late then to get that done. Which kind of further messes with their circadian rhythms, which is what regulates their sleep wake cycles. And there’s a lot.

Richard Jacobs: It’s not good.

Michelle Mullaley: Yeah, it’s not good. And unfortunately there’s not a whole lot they can do about that part. But what we know is that having sleep deprivation at all ages has some different impacts on mental health, on cognitive processing, on behavior regulation. And so it is kind of a bi-directional impact that if someone’s struggling with anxiety, stress, depression, ADHD, they’re going to have more difficulty with sleep. And if they’re having more difficulty with sleep, they’re going to struggle more with anxiety, stress, mood and attention and hyperactivity.

Richard Jacobs: Yeah. I’ve heard kids react the opposite way. Adults do too. None of them sleep. Adults maybe tired or grumpy. Even kids does, maybe get hyperactive. They act out. What have you seen when a child’s not sleepy? Right? What are some of the possibilities in their behavior?

Michelle Mullaley: That’s exactly right. So we as adults, we get sluggish, we get a little bit forgetful, but kids tend to ramp up. They tend to get more hyper, more fidgety, more irritable and cranky. Their concentration is poor, although that’s true for us as well. Memory and learning is not exactly something that their brain is ready to do. And so it can look like something different. And in fact, there are some studies that say that children who have sleep disorders like delayed sleep onset, disordered breathing, like you might get with adenoids that are swollen or tonsillitis, they tend to have ADHD like symptoms in all of those ways. So they are in attentive and fidgety or hyper or reactive. And for a subset of those kids resolving the sleep issue makes them no longer meet criteria for having ADHD.

Richard Jacobs: So do you do mostly clinical work or is it more research? What you do nowadays?

Michelle Mullaley: Yeah, I myself do mostly clinical work. I run a group practice in Fairfax, Virginia and also educate a lot in the community. So I’ll give talks, you know, schools or other organizations in the community that want to know more about these topics. And so that’s one of the ways I try to reach a little broader than just those I can see individually. But some of the ways that we do that as we work on this term called sleep hygiene, which is a little bit of a cheesy term, but what it basically means is having good sleep practices and sleep routines that set your body up to be ready to go to sleep in a timely way and then be able to stay asleep so that you can get that out, the sleep that is needed.

Richard Jacobs: In the clinic who comes in, moms or dads more, do they have their kid in tow and you know, what’s a common story you get from them?

Michelle Mullaley: Usually some combination thereof. Usually when the concern has to do with the child, they usually are bringing their child or their teen in. And they may not be bringing them particularly for sleep, but it is often one of the concerns that we want to try to address. And so, yep, the child is there too. And they’ll often report that they have a hard time falling asleep. Unfortunately, children are not the greatest reporters in terms of being accurate. Sometimes children will say, yes, it takes me two hours to fall asleep and parents will say really, because I went back in 10 minutes and you were out like a light. But having said that, we do often have kids who’ve really struggled to fall asleep in particular and then kids with anxiety may also have a harder time staying asleep or early wakening and kind of seek out some support at that time if they’re younger children.

Richard Jacobs: Do you notice a big difference in early wakening versus onset insomnia. Do they tend to correlate differently with behavior or mood or other things?

Michelle Mullaley: That’s a great question. I would say actually I think that correlates more with age. That younger children tend to have more likely hood of waking up early in the morning, four or five, six o’clock in the morning before they need to be up. And before their parents need to be up or as children are more older, teens are more likely to have difficulty falling asleep. And again, a part of that is the national shift in circadian rhythms at different ages developmentally. And part of that is anxiety can play a big role in sleep, difficulties to fall asleep. So separation issues, self-soothing kinds of issues that kids don’t have that ability to quiet their minds or calm their worries or fears well are more likely to struggle to fall asleep.

Richard Jacobs: But are there any differentiators on boys versus girls that they have sleep issues, again, age-related, early teen versus late teen, and other things that jump out at you?

Michelle Mullaley: Yeah, I don’t know so much about any research on gender differences. I would again say that age difference and even the older the teen gets, the more likely they are to have difficulty falling asleep. And again, if they have anxiety or ADHD, that’s going to be even more so the case many times. And then, so that’s one of the things that we try to teach young people too, is how to have good patterns. As teens, they have to start regulating that themselves more. Maybe not having their phone by their bed or having a break from electronics. Nutrition can play a role, exercise can play a role. And then there are things they can do environmentally, like having dimmed lights, quiet sounds, sense that are calming. There’s different things people can do to try to kind of enhance their ability to fall asleep.

Richard Jacobs: Well, what about snoring and apnea or large tonsils or narrow airways, that kind of stuff. The physiological stuff, you address that very much?

Michelle Mullaley: Absolutely and that’s so important. Sometimes parents will kind of mention those things anecdotally, like not really quite realizing how important those are. So they might mention, yeah, they really snore and they’ll just kind of think it’s funny. But really that’s for us a red flag that there is something like you’re talking about enlarged adenoids and large tonsils. Maybe I actually recently worked with a youngster who have a REM sleep disorder to where they’re really don’t enter REM sleep in the evenings at all, which is problematic because that’s when we have our most restorative sleep. That’s when our memory, our processing, our learning, our immune system are all most building us up to be able to kind of cope the next day. And so that person was diagnosed with ADHD, including to the test results. But really my question is I want that child to have a sleep study and intervention on that sleep. So any of those sleep disorders that interfere with sleep in general, the number of hours that are slept, but most importantly, their REM sleep is absolutely going to affect their mental health and their physical health as well. And so I’ll direct them there to a sleep professional. I’m in the medical field for evaluation and treatment.

Richard Jacobs: So what kind of interventions? The environment has to be right. It’s hard to do that. Like my kids every night I had to go in there and then say, turn this off. I’ll do that. Don’t do this. Is there any cognitive behavioral therapy you do or what kind of interventions would help kids?

Michelle Mullaley: Yeah, great question. So part of it is the environmental pieces, which are, keeping those lights down and the electronics away. But as you say, kids don’t always want to comply with those. Both from a cognitive and behavioral perspective. So from a behavioral perspective you know, with younger kids you can kind of do some reinforcements for those types of behaviors by doing the thing we want them to do. Maybe there’s, you get an extra book the next morning instead of that night, if you’ve gone to sleep and you’ve kind of closed your eyes and, and you kept your light dim and kept all the electronics away. Those kinds of behavioral reinforcements. As they get older though, we want kids to start to have their own ability to recognize what they need. So sometimes I’ll have kids keep a log even of how they felt on a given day and track their sleep and see if they can begin to notice some patterns because if they begin to notice it, then it’s much more meaningful than us as adults just telling them that will make them feel better. Another piece cognitively is that many kids have a hard time quieting their mind in the evening. And that can be because they’re stressed or anxious or worried about what test they have the next day or that conversation that they’re afraid their friend is mad at them from the day. And so both identifying this is what’s keeping me up and then giving them some strategies and maybe that’s being able to put it in a container type of thing where they imagined that they would put those worries in a container, maybe to have a journal near their bed where they write down the things that they’re afraid they’ll forget so that they don’t have to continue to loop it through in their mind. And then cognitive challenging is one way that people use cognitive behavior strategies to kind of challenge what they’re thinking that they might be worried about for the next day. You know, I’m worried I’m gonna fail my test, but the reality is I really don’t usually fail my tests. I’ve studied, I’m probably going to be fine helping them to kind of talk themselves off the ledge as well as more kind of self-soothing types of things. So I often teach kids calming strategies. You may have heard the term mindfulness, which refers to just kind of getting your mind in the here and now and letting go of all the other things that will take us into the past or take us into the future, but not in that. Just let’s get in the moment. So it might be really focusing on the sounds focusing on their sense of touch. Doing some deep belly breathing. We know that slow paced breathing releases oxytocin in the brain, which calms and settles the brain. It washes away the stress hormones and it allows our body to kind of physiologically relax. Doing some yoga poses can be helpful. Other imagery techniques. So those are all kinds of cognitive strategies or physical strategies. And then there’s even some great calming apps that some kids really like because it walks them through some of those calming visualizations or breathing. Then you have the challenge that the phone is then in the room or the iPad or whatever that device is. But it can be used for good as well as distraction.

Richard Jacobs: So I mean there’s all these possibilities, but what do you see actually works or it just depends on the kid? How much should the parents intervene and how much can they help?

Michelle Mullaley: Yeah, I mean it’s very individualized, right? So there are some kids who really want their parents to be an active part of helping them through like sleep routines or using good strategies that we might talk about. And that can be great. The other times we want to either pull the parent away a little bit and have the child have some more independence, or the child is the one saying, Nope, I’m going to do this my way. And then the trick is, yeah, to try several different things and see what works. See what felt good to them. And because this is true for all of us, right? We’re going to do what we think works, what we feel better with. And if kids can own it more, they’re going to buy into it more. So depending on the age, obviously that there’s some factors there. We don’t need 17 year olds whose parents are still helping them sleep. But it’s reasonable that a seven year olds parents may still be helping them do some of these strategies.

Richard Jacobs: Well because you know, teenage girls start having menstrual cycle, do you see before and after that they changed at all. And then sleep habits or they’re not really, they’ve been showing anything.

Michelle Mullaley: Well, I think for both boys and girls, once they go through puberty, that’s kind of the time when their circadian rhythm shifts and they don’t get tired for about an hour to two later than they had earlier on. And so that’s true for both boys and for girls. And again, if in an ideal world when they can sleep in and still go to bed at 11 but get up at eight or nine 10 o’clock in the morning, then that’s great. But our society doesn’t allow for that. Sometimes what we’ll see then is the infamous teacher did a teenager who’s sleeping in on the weekend until 11, 12, one o’clock and parents feel frustrated. Like they really should be getting up and having a more productive day. The reality is they’re probably often just trying to kind of make up for their sleep deficit through the week and sometimes they need that if there isn’t a need to get up. But it does suggest that if there are ways, if your teen is constantly sleeping till 12, 1, two o’clock on the weekend, it may be worth looking at their week and see if there’s ways to get them to be able to go to sleep or fall asleep a little bit earlier changing I don’t know if their sports practices or if they can do their homework earlier in the night. If they can sleep in a little bit later before they have to get up for school. But sometimes the reality is they just need to catch up on some of that sleep.

Richard Jacobs: So how much intervention makes a difference? Is it you find that the family would use and some food things and then everything’s great or do they need like a whole bunch of different factors to help the kids sleep better?

Michelle Mullaley: Gosh, again, I wish there was an easy answer on that, but most of the time there’s a couple of small tweaks that can be made and that’s sufficient. Most people don’t have to put a whole lot. Once they figure out what works. Most people don’t need to do lots of different kind of tricks to make sleep happen. But it’s matter of trying things and not giving up the first time or to something doesn’t work. Any new habit takes some time to settle in. So I’ll often kind of let people know this isn’t going to work the first time you want to try it five or 10 times till we see if maybe it’s going to work. Some say really as many as 20 to 25 times before you try and you have it. So it’s sticking with it until you figure out what works. And if you’re not getting success with kind of typical ways to increase sleep, then I do recommend touching base with a doctor too, to make sure that anything medical isn’t happening. Allergies, asthma, adenoids, a sleep disorder because then all the behavioral tricks in the world, all the cognitive ships in the world aren’t going to help if there’s something underlying that’s not getting addressed.

Richard Jacobs: Yeah. Then you find that more often than not, it’s cognitive or is it more physical issues? You know when someone has physical issues I guess the cognitive come right along with it or not?

Michelle Mullaley: Oh, that’s a great point. Yeah. Certainly if there’s physical issues, cognitive stuff’s going to come along too, because they’ll start to worry sometimes if you’ve ever had insomnia, something that’s often people talk about is as soon as you lay down in bed, you begin to have that worry of, Oh gosh, I wonder how long it’s going to take me to fall asleep tonight. Oh my gosh. I have such a busy day tomorrow, I really need my sleep. I wonder if it’s going to take a long time. Oh, I’m never going to fall asleep. And that cognitive self-talk just works us up and gets our cortisol flown in brain and it’s absolutely counter to falling asleep. So definitely if there’s a physical reason for that, you’re going to start to see some of the cognitive pieces. But I would say more often sometimes it’s not even worry, it’s just thoughts just moving through the head and it’s hard to quiet those down. And again, there are certain times when we are trying to go to bed before our body wants us to go to bed so we can’t fall asleep because our melatonin hasn’t been released in our body, which is what regulates our circadian rhythms and our sleep wake cycle. So that’s a harder one when we have to try to go to bed at nine, 9:30, even though the body isn’t ready to go to bed till 10:30 or 11.

Richard Jacobs: Yeah. I remember when my kids were little and I would lay with them and I’d turn off the lights and they’d go, I can’t see you and I say you’re not supposed to see. But now it’s different. Now I go in and catch them on their phones and say, stop that. I mean to be able to sleep. So it’s just the struggles but different struggles.

Michelle Mullaley: It is, it changes with age, but it can remain a struggle. And so sometimes it’s a fun, let’s do an experiment. Let’s try plugging in our phones downstairs in the living room. Mom and dad will do it too because really what we model for them is what they’re going to do. We can’t take our phones into the bedroom and expect them not to do the same. I mean we can, it’s going to be less successful. So I was encouraged all families, unless you have a job where you need to be on call as a parent, we also don’t need our phones in the room. We don’t need notifications going off, even if it’s on silent, that buzzing the light. All of that is activating. And so I just think everyone heads upstairs or back to where the bedrooms are, we just all plug in. And then it becomes not a punishment. It becomes just part of a healthy habit.

Richard Jacobs: That’s a good point. How often do you have to recruit the parents and say like, we need you also simultaneous in a model what we’re trying to do for your child?

Michelle Mullaley: Absolutely. Very often I would say. And one of the things I’ll say is how is it that we’re asking your child to do something that you’re not willing or able to do? So you have a fully developed brain and they don’t yet, right? Their frontal lobe is still working. And so that’s where the decision making problem, solving logic, delayed gratification, all lives in the frontal lobe of the brain. That doesn’t finish growing until the mid-twenties. So I’ll kind of use that biology to help parents see that you have that biology to make different decisions and to have good habits and routines to model for your child. They don’t have all that yet. So they really need you to be doing what we’re asking them to do to obviously in age appropriate ways. It doesn’t mean as a parent you go to bed at 8:00 PM, but it does, you know, if your child needs to go to bed 8:00 PM but it does mean maybe turning off electronics for a while before that, dimming the lights, doing some exercise, but earlier in the day to get the body tired but not in that last hour where it’s going to get your adrenaline pumping and talking to them about why you choose that, why that works for you.

Richard Jacobs: That makes sense. Any breakthroughs and understanding or therapies that you see on the horizon or that maybe you are experimenting with?

Michelle Mullaley: I would say that I’ve done some training in this. I’m not necessarily an expert in this, but there is a type of cognitive behavior therapy that actually is specific to insomnia that really helps people break down because it’s different for everybody. What causes their difficulty falling asleep? And it helps them break down what is the thought that you’re having. What is the behavior that you’re having and how to very like kind of slowly and methodically shift those, the ones that are getting in the way and leave the ones that aren’t alone. And so maybe you can go to bed at different times and it doesn’t seem to matter because it’s the cognitive issues that are getting in the way and the worries or the beliefs about sleep, but maybe it is not the worries and the beliefs about sleep and it’s the fact that you’re just flat out getting into bed two hours after your body was tired and now it’s over tired and amped up and can’t fall asleep. So then you slowly shift the sleep onset expectation. And so it’s called CBTI cognitive behavior therapy for insomnia. And so definitely there’s been more and more practitioners trained in CBTI in the last few years and sometimes our insomnia clinics actually that really do focus on that.

Richard Jacobs: Well, very good. What’s the best way for people to get in touch and find out more?

Michelle Mullaley: Well, gosh, there’s tons of resources about sleep in particular and about sleep and ADHD, which is one of the areas that I speak about. But certainly I’m happy to share resources if anyone wanted to contact me. And my practice is Bridges therapy and Wellness Center, which is a website of the same name, www.bridgestherapyandwellness.com all spelled out. And I’m happy to share some resources at that point.

Richard Jacobs: That’s great. Well Dr. Mullaley thank you for coming on. I appreciate it.

Michelle Mullaley: Absolutely. It was great to talk. Thank you.