1 00:00:01,040 --> 00:00:03,640 Clear goal. You must have a clear goal. 2 00:00:03,800 --> 00:00:08,039 You must have a written SOP so that everybody has something to 3 00:00:08,039 --> 00:00:11,560 refer to, because otherwise it's very hard. 4 00:00:11,720 --> 00:00:14,880 The consistency is the most challenging thing. 5 00:00:15,120 --> 00:00:25,560 The consistency. This podcast shares personal 6 00:00:25,560 --> 00:00:27,560 stories and professional insights, but it's not a 7 00:00:27,560 --> 00:00:29,760 substitute for medical advice or therapy. 8 00:00:30,320 --> 00:00:33,040 If you're looking for support, do speak to someone qualified 9 00:00:33,040 --> 00:00:35,600 and trained in child development or special needs care. 10 00:00:36,120 --> 00:00:38,600 You'll find the full disclaimer on the screen and in the show 11 00:00:38,600 --> 00:00:41,880 note. Welcome back to another episode 12 00:00:41,880 --> 00:00:45,400 of Adapting Together. We are a podcast to empower, 13 00:00:45,400 --> 00:00:50,600 support and inspire parents and caregivers of neurodivergent 14 00:00:50,600 --> 00:00:52,560 children. My name is Sydney. 15 00:00:52,560 --> 00:00:55,960 I'll be the host for today's episode and together with me we 16 00:00:55,960 --> 00:00:58,800 have two amazing Co hosts, Kevin and Carmen. 17 00:00:58,880 --> 00:01:01,720 Hello. Today we're going to talk about 18 00:01:01,720 --> 00:01:05,840 a topic that maybe not many people really talk about, which 19 00:01:05,840 --> 00:01:09,560 is sleep and Constipation. OK. 20 00:01:09,880 --> 00:01:13,720 So I believe at the end of the day, actually all parents, every 21 00:01:13,720 --> 00:01:18,800 parents want their child to be comfortable, safe and happy. 22 00:01:19,160 --> 00:01:24,920 So, but if a child cannot sleep or if a child has struggles with 23 00:01:24,920 --> 00:01:29,800 Constipation, then comfortable will disappears and maybe the 24 00:01:29,800 --> 00:01:33,360 family will feel stuck. And parents will be very worried 25 00:01:33,440 --> 00:01:34,960 and parents cannot sleep well also. 26 00:01:35,960 --> 00:01:37,840 Correct. So just now why I feel like 27 00:01:37,840 --> 00:01:41,800 behind a closed door, maybe people don't talk about like the 28 00:01:41,800 --> 00:01:46,120 struggles like 3:00 in the morning or like maybe the sudden 29 00:01:46,120 --> 00:01:50,520 waking up and leave the whole family feel exhausted after the 30 00:01:50,520 --> 00:01:53,880 next day. Yeah, so that's the whole reason 31 00:01:53,880 --> 00:01:58,840 why today we have Doctor Cindy from Sunway Medical Center here 32 00:01:59,040 --> 00:02:04,800 with us to discover and talk about problems related to sleep 33 00:02:04,800 --> 00:02:09,080 and Constipation, OK? Welcome, Doctor Cindy, and thank 34 00:02:09,080 --> 00:02:09,919 you so much. Thank. 35 00:02:10,520 --> 00:02:12,400 You for having me, it's such an honor. 36 00:02:13,200 --> 00:02:14,320 OK. Right. 37 00:02:15,280 --> 00:02:19,560 Doctor Cindy, could you start with sharing a little bit about 38 00:02:19,560 --> 00:02:24,800 your professional professional journey in both government and 39 00:02:24,800 --> 00:02:27,640 private sector not. Many people ask me that 40 00:02:27,720 --> 00:02:32,160 question. Yeah, well, I have. 41 00:02:32,840 --> 00:02:37,240 I am a dual trained pediatrician, trained as a 42 00:02:37,240 --> 00:02:42,320 general pediatrician for some years and then I pursued such 43 00:02:42,320 --> 00:02:45,240 specialty training in developmental Pediatrics, 44 00:02:45,240 --> 00:02:49,520 developmental behavioural Pediatrics and neuro disability. 45 00:02:49,880 --> 00:02:54,520 So my journey started in the Ministry of Health. 46 00:02:54,600 --> 00:02:58,800 I've been through various hospitals and over a career of 47 00:02:58,800 --> 00:03:04,920 20 years in KKM and so I've worked in general hospitals, 48 00:03:05,560 --> 00:03:11,720 district hospitals, rural areas and also as part of my specialty 49 00:03:11,720 --> 00:03:16,000 training, specialty training, I also spent some time in 50 00:03:16,000 --> 00:03:20,440 Australia. So I think I, it was a long 51 00:03:20,440 --> 00:03:23,160 journey. My first love is Pediatrics, of 52 00:03:23,160 --> 00:03:25,160 course. But then and over time, I 53 00:03:25,160 --> 00:03:28,800 realized that there's a very big group of kids that are really 54 00:03:28,800 --> 00:03:32,400 underserved. They are not really the minority 55 00:03:32,400 --> 00:03:35,880 actually, because you do see children with neuro disability, 56 00:03:35,880 --> 00:03:39,840 disabilities of all kinds, some not obvious, some with hidden 57 00:03:39,840 --> 00:03:42,000 disabilities. And as a young doctor, I always 58 00:03:42,000 --> 00:03:44,800 wondered like, where do I go to for this information? 59 00:03:44,800 --> 00:03:49,840 Where do I go to for advice? And and so that was how so I had 60 00:03:49,840 --> 00:03:51,560 a lot of good mentors along the way. 61 00:03:51,560 --> 00:03:55,160 Dr. Kutik Bang, he is a pediatric neurologist. 62 00:03:55,160 --> 00:04:01,600 Actually back then there weren't any developmental pits, none. 63 00:04:01,840 --> 00:04:06,360 So it was only those few senior neurologists who were interested 64 00:04:06,360 --> 00:04:08,240 in this. And then we along the way, I 65 00:04:08,680 --> 00:04:13,080 Doctor Ranjini Sid Sivanism, the first developmental pediatrician 66 00:04:13,080 --> 00:04:15,240 in KKR, she was an excellent mentor. 67 00:04:15,600 --> 00:04:18,640 So along the way, with the support of my mentors and the 68 00:04:18,680 --> 00:04:22,920 families that I worked with, even in low resource places like 69 00:04:22,920 --> 00:04:27,280 rural hospitals, you find a need, you you step up. 70 00:04:27,520 --> 00:04:30,240 Yeah. So then I think I was about the 71 00:04:30,240 --> 00:04:34,520 third one in the country in in the Ministry of Health to do 72 00:04:34,520 --> 00:04:36,920 this field. It's been a very rewarding 73 00:04:37,400 --> 00:04:41,480 journey, but I would say that at the end of the day, the more I 74 00:04:41,480 --> 00:04:44,560 learn about it, the more I realized that the best teachers, 75 00:04:44,560 --> 00:04:50,240 actually the kids whom I work with and and the caregivers, 76 00:04:50,400 --> 00:04:52,240 actually, they taught me the most. 77 00:04:53,000 --> 00:04:58,520 And so as a developmental pediatrician, after so long, I 78 00:04:58,520 --> 00:05:01,720 know I'm middle-aged. Really, I I sometimes just 79 00:05:01,720 --> 00:05:07,400 realize that the best way to evaluate a child's needs and to 80 00:05:07,520 --> 00:05:12,400 address the family's concerns, everybody just take a step back 81 00:05:12,400 --> 00:05:16,120 and observe this child. Everybody just take a step back 82 00:05:16,120 --> 00:05:19,600 and understand how your day-to-day activities are like, 83 00:05:19,920 --> 00:05:24,120 how it this concern impacts your functioning as a family. 84 00:05:24,440 --> 00:05:27,600 And then the answers will usually reveal itself. 85 00:05:27,920 --> 00:05:32,680 And then as a medical doctor, I may have the advantage of some 86 00:05:33,960 --> 00:05:40,240 medical input, but generally the medical input in terms of 87 00:05:40,240 --> 00:05:44,560 medication especially, is a very small part of what I do. 88 00:05:45,160 --> 00:05:49,480 It's about upskilling the child. It's about giving skills to the 89 00:05:49,480 --> 00:05:53,440 families and the parents. That's really what we do most of 90 00:05:53,440 --> 00:05:56,080 the time. Therefore, sharing your 91 00:05:56,080 --> 00:06:00,160 experience and I think we chose the right person to share with 92 00:06:00,160 --> 00:06:03,800 us on this specific topic about sleep and cultivation. 93 00:06:04,040 --> 00:06:08,240 So maybe we can hear from doctor about what are some common sleep 94 00:06:08,240 --> 00:06:11,720 difficulty faced by children on the spectrum. 95 00:06:12,680 --> 00:06:17,160 Sleep is a big problem. Often is ignored because, you 96 00:06:17,160 --> 00:06:22,120 know, culturally there are so much of differences between 97 00:06:22,120 --> 00:06:25,600 countries, between families, what is acceptable, what is 98 00:06:25,600 --> 00:06:31,520 socially acceptable. But often it is neglected until 99 00:06:31,520 --> 00:06:35,080 the parents can't get enough sleep, they can't function in 100 00:06:35,080 --> 00:06:39,200 the next, in the next morning, the difficulty in getting up 101 00:06:39,920 --> 00:06:42,440 fresh. And then of course, it begins to 102 00:06:42,440 --> 00:06:44,960 impact the child. But the impact on the child is 103 00:06:44,960 --> 00:06:49,840 actually not so obvious initially sometimes when the 104 00:06:49,840 --> 00:06:53,320 child presents with other problems like other challenging 105 00:06:53,320 --> 00:06:59,120 behaviours, hyperactivity, ADHD type of symptoms, mood problems 106 00:06:59,120 --> 00:07:02,840 and more frequent tantrums or school refusal. 107 00:07:03,120 --> 00:07:06,080 I mean, one of the very first questions we were asked, the 108 00:07:06,080 --> 00:07:09,320 parents are how's the sleep? How's the sleep? 109 00:07:09,320 --> 00:07:14,120 And parents would say, dear Tito, OK then, but we need to 110 00:07:14,160 --> 00:07:18,520 break it down like so that's the main thing that I mentioned some 111 00:07:18,520 --> 00:07:22,000 sometimes if sleep is we think it's a big problem, right? 112 00:07:22,240 --> 00:07:25,320 We have to break it down for families because they are really 113 00:07:25,320 --> 00:07:27,600 bogged down by day-to-day things. 114 00:07:27,600 --> 00:07:31,760 And if the child looks healthy, most families don't address 115 00:07:31,760 --> 00:07:34,560 sleep as an issue until it's very late. 116 00:07:34,880 --> 00:07:37,960 So some things are ingrained and some things are like a habit 117 00:07:37,960 --> 00:07:40,880 already, so they don't realize how big the problem is. 118 00:07:41,200 --> 00:07:44,000 So children with autism they can present with sleep problems in 119 00:07:44,200 --> 00:07:47,040 the most common one is difficulty falling asleep, 120 00:07:47,280 --> 00:07:50,640 getting to sleep. They have problems just getting 121 00:07:50,640 --> 00:07:55,160 to sleep, often very delayed on set, as in they take a long 122 00:07:55,160 --> 00:08:00,000 time, more than 1/2 hours to fall asleep and are very late by 123 00:08:00,000 --> 00:08:01,560 the time they finally fall asleep. 124 00:08:02,240 --> 00:08:05,960 These are things like past midnight, 1:00 AM, still hyper, 125 00:08:05,960 --> 00:08:10,760 still talking, still, you know, playing with the parents 126 00:08:10,760 --> 00:08:13,520 already, you know, falling asleep already. 127 00:08:13,680 --> 00:08:17,400 So that's a common issue. Then the second common issue is 128 00:08:17,640 --> 00:08:21,920 falling asleep already late on top of that very fragmented 129 00:08:21,920 --> 00:08:24,680 sleep. They keep waking up and then the 130 00:08:24,680 --> 00:08:28,080 family or the caregiver has to wake up to make sure the child 131 00:08:28,080 --> 00:08:33,080 is safe or no, just check whether the child needs a diaper 132 00:08:33,080 --> 00:08:37,720 change, milk feed, and then try to put the child back to sleep 133 00:08:37,720 --> 00:08:39,760 again. Sometimes it can go on 2/3 times 134 00:08:39,760 --> 00:08:42,440 in a night like that. And then of course, there's 135 00:08:42,440 --> 00:08:47,760 another group of kids with problems with reversal of sleep 136 00:08:47,760 --> 00:08:50,360 pattern. They may catch up on sleep and 137 00:08:50,360 --> 00:08:53,400 sleep a lot during the daytime and then the whole night they 138 00:08:53,400 --> 00:08:58,000 are up, you know, but that is less common because number one, 139 00:08:58,000 --> 00:09:01,560 they present earlier, you know, those those issues don't get 140 00:09:01,560 --> 00:09:05,280 swept under the cupboard so much, you know, But I do have 141 00:09:05,280 --> 00:09:07,800 kids like like that. And those kids tend to be those 142 00:09:07,800 --> 00:09:09,640 who are already in the teenage years. 143 00:09:10,400 --> 00:09:13,160 When they are in the adolescent years, they tend to have this, 144 00:09:14,160 --> 00:09:17,160 yeah, this reversal in their sleep wake cycle. 145 00:09:17,280 --> 00:09:19,520 Yeah. So those are the common issues. 146 00:09:20,520 --> 00:09:24,360 Afternoon naps, they the smaller issues are like they always fall 147 00:09:24,360 --> 00:09:27,880 asleep in the car. And then that really, like, you 148 00:09:27,880 --> 00:09:31,200 know, disturbs their nighttime sleep. 149 00:09:31,200 --> 00:09:32,800 Like, yeah, perfect. Here right? 150 00:09:33,280 --> 00:09:34,800 Yeah, yeah, Pick them up from DK. 151 00:09:35,440 --> 00:09:38,960 Yeah, from school. So because of that there, it's 152 00:09:38,960 --> 00:09:42,640 not uncommon, you hear families of children with autism, They 153 00:09:42,920 --> 00:09:47,520 they, they put the child in the car just to help them sleep at 154 00:09:47,520 --> 00:09:51,160 night, drive around and then quickly carry the child back to 155 00:09:51,160 --> 00:09:52,560 bed. This that's what we did. 156 00:09:53,920 --> 00:09:55,960 Yeah. The plastic drives around the 157 00:09:56,320 --> 00:09:57,840 city. It's a it's a rite of passage. 158 00:09:58,680 --> 00:10:00,760 When we see traffic jam, you feel oh good, good. 159 00:10:01,960 --> 00:10:04,720 Yeah, yeah, yeah. So, so these are things that we 160 00:10:04,720 --> 00:10:10,320 help the families to be aware of because some of these things are 161 00:10:10,320 --> 00:10:12,960 things that are self reinforcing. 162 00:10:12,960 --> 00:10:17,680 You know, it's actually an unintentional reinforcement of 163 00:10:17,720 --> 00:10:22,800 the negative sleep behaviours. So we start with those things 164 00:10:22,800 --> 00:10:26,640 first often. Doctor, I was just curious, is 165 00:10:26,640 --> 00:10:30,800 this only children on the spectrum, they have difficulty 166 00:10:30,800 --> 00:10:35,000 sleeping or actually typically all kids at this age of 16? 167 00:10:35,480 --> 00:10:40,200 All kids, especially when they are infants, the most difficult, 168 00:10:40,480 --> 00:10:44,160 then toddlers and then preschoolers they tend to settle 169 00:10:44,160 --> 00:10:45,920 and primary school they tend to settle. 170 00:10:45,920 --> 00:10:49,320 There are many factors why this tends to be the normal pattern. 171 00:10:50,160 --> 00:10:54,920 When children are more commutative, their cognitive 172 00:10:54,920 --> 00:11:02,680 development really helps them to understand societal or social 173 00:11:02,880 --> 00:11:04,360 expectations. Yeah. 174 00:11:04,360 --> 00:11:07,280 And then they want to emulate what the family routines are 175 00:11:07,280 --> 00:11:09,840 like. But a very big factor is that 176 00:11:09,840 --> 00:11:14,000 these kids locomotor skills have improved so much that they can 177 00:11:14,000 --> 00:11:17,960 get a lot of physical activity in and then they get more time 178 00:11:17,960 --> 00:11:21,760 in the outside sunlight. So all this helps to regulate 179 00:11:21,760 --> 00:11:26,440 their natural sleep wake cycle, which we call like the Sicardian 180 00:11:26,560 --> 00:11:30,680 rhythm. It regulates how melatonin our 181 00:11:30,680 --> 00:11:32,840 naturally produce hormone in our brains. 182 00:11:33,240 --> 00:11:36,160 It helps to regulate the melatonin production. 183 00:11:36,360 --> 00:11:40,680 So as kids grow older, they have more physical vigorous activity, 184 00:11:40,680 --> 00:11:42,800 they have more daylight hours exposure. 185 00:11:43,120 --> 00:11:46,040 All this helps to regulate and of course the social 186 00:11:46,040 --> 00:11:49,280 expectations help them to regulate their behavioral 187 00:11:50,040 --> 00:11:54,360 responses to sleep. So then by the time they go, you 188 00:11:54,360 --> 00:11:58,280 know, from as a toddler right up to, to adults, they, they start 189 00:11:58,280 --> 00:12:01,360 to reduce the number of sleep hours they need as well. 190 00:12:01,720 --> 00:12:06,160 So from 12:11 to 12 hours of sleep as an infant and a toddler 191 00:12:06,480 --> 00:12:09,120 preschooler, maybe 10 to 11 hours. 192 00:12:09,360 --> 00:12:12,320 And then as an adolescent, you know, anything between 9:00 to 193 00:12:12,320 --> 00:12:15,640 10 hours and then as an adult 8 hours, 7 hours. 194 00:12:16,040 --> 00:12:20,920 So all this is a natural pattern. 195 00:12:21,720 --> 00:12:25,480 But then there are children, although typically developing 196 00:12:25,480 --> 00:12:30,240 with no significant disability, they do have other factors like 197 00:12:30,440 --> 00:12:33,120 family factors. If the family sleeps late, if 198 00:12:33,120 --> 00:12:38,440 they all sleep in the hall, it's culturally very common for our 199 00:12:38,440 --> 00:12:42,680 Asian, our Malaysian families, they, they sometimes sleep in 200 00:12:42,680 --> 00:12:47,000 the hall, especially when their homes are very small, like if 201 00:12:47,000 --> 00:12:50,120 they live in a flat and they have extended family living with 202 00:12:50,120 --> 00:12:52,520 them. So it's not surprising they all 203 00:12:52,520 --> 00:12:54,760 sleep in the hall. The TV is on. 204 00:12:54,880 --> 00:12:57,680 And then they all learn to fall asleep with the white noise of 205 00:12:57,680 --> 00:13:00,960 the TV in the background with the lights on, just something 206 00:13:00,960 --> 00:13:06,240 covering their eyes maybe. So there's a very big variation. 207 00:13:06,480 --> 00:13:10,200 So we start with what the family's expectations are, what 208 00:13:10,400 --> 00:13:14,120 are culturally acceptable to them, and then we work with that 209 00:13:14,120 --> 00:13:16,760 law. And then does it mean that for 210 00:13:16,760 --> 00:13:19,440 children who are on the spectrum, there are certain more 211 00:13:19,440 --> 00:13:22,320 factors that cause them to have more? 212 00:13:22,400 --> 00:13:25,000 Yeah. So as you know, like anything 213 00:13:25,000 --> 00:13:28,920 between 15 to 30% or typically developing kids might have sleep 214 00:13:28,920 --> 00:13:33,400 problems at significant sleep problems at one point or another 215 00:13:33,400 --> 00:13:36,600 in their childhood. But when you talk about the, the 216 00:13:36,600 --> 00:13:43,080 autistic kids, the this right, this rates can rise to even 50 217 00:13:43,080 --> 00:13:47,040 to 70% of children with autism will have a significant sleep 218 00:13:47,040 --> 00:13:50,240 problem at one point or many points of their lives. 219 00:13:50,240 --> 00:13:53,120 And sometimes they it goes on and on for years. 220 00:13:53,600 --> 00:13:57,840 So it definitely a higher incidence and then the factors 221 00:13:58,120 --> 00:14:01,400 when you talk about child with autism, you know, they have 222 00:14:01,400 --> 00:14:06,000 communication problems and so they may not be able to express 223 00:14:06,200 --> 00:14:08,600 a lot of things like why do I have to go to sleep? 224 00:14:08,600 --> 00:14:12,720 They may want something and they may show it in their behavior 225 00:14:12,720 --> 00:14:16,760 and get very frustrated at big time or when you kill them or 226 00:14:16,760 --> 00:14:20,320 when you signal, because that signals the end of fun time, you 227 00:14:20,320 --> 00:14:23,080 know, and they can't express it. They can't negotiate. 228 00:14:23,920 --> 00:14:27,720 And then they, and if you explain to them, we tend to 229 00:14:27,720 --> 00:14:30,600 explain using language. That's how humans tend to 230 00:14:30,920 --> 00:14:34,320 develop, you know, and then so they may not be able to 231 00:14:34,320 --> 00:14:37,680 understand why. And then of course, the autistic 232 00:14:37,680 --> 00:14:44,280 mind now mind my way, my interests, my needs, my SOP, my 233 00:14:44,280 --> 00:14:47,000 play. And so when you ask me to stop, 234 00:14:47,040 --> 00:14:52,200 I don't see why I have to stop. So that inflexible mind really 235 00:14:52,200 --> 00:14:57,800 gets into the way they would correct. 236 00:14:58,520 --> 00:15:02,480 So it takes a long while for them to develop the social 237 00:15:02,680 --> 00:15:05,320 reciprocity to want to do it for you. 238 00:15:05,320 --> 00:15:09,400 Yeah, they may not want to do it for other people's sake. 239 00:15:09,480 --> 00:15:13,920 Like that's what I mean by the the, the social expectations as 240 00:15:13,920 --> 00:15:16,240 a typically developing child grows up, they kind of 241 00:15:16,440 --> 00:15:19,880 understand this, but the child with autism is really late to 242 00:15:19,880 --> 00:15:22,760 the game. They do not understand why they 243 00:15:22,760 --> 00:15:25,560 have to do it for you or for the rest of the family. 244 00:15:26,080 --> 00:15:30,240 So then another big issue is a sensory processing differences 245 00:15:30,960 --> 00:15:34,720 where when you turn off the lights, and I know some families 246 00:15:34,720 --> 00:15:39,200 will not turn on the acorn until night time and then change in 247 00:15:39,200 --> 00:15:42,160 environment. So a lot of sensory issues, 248 00:15:42,800 --> 00:15:45,480 hunger. They may have eaten dinner at 249 00:15:45,480 --> 00:15:48,880 the normal time with the family, but then if they go to bed, if 250 00:15:48,880 --> 00:15:51,840 they have dinner at 8:00 and they go back to bed only at 12 251 00:15:51,840 --> 00:15:55,120 and they finally fall asleep at 1, you know, the gastric 252 00:15:55,120 --> 00:15:57,960 emptying has happened and they're hungry again, but they 253 00:15:57,960 --> 00:16:00,440 have no way to understand that they're hungry. 254 00:16:00,640 --> 00:16:04,640 Some children with more significant difficulties in 255 00:16:04,640 --> 00:16:07,960 communication or introception, they may not pick up their 256 00:16:07,960 --> 00:16:11,840 sensory signals internally. They don't know they are hungry, 257 00:16:11,840 --> 00:16:16,320 they just get upset and they cling on to what makes them 258 00:16:16,320 --> 00:16:18,400 comfortable, which is their routine. 259 00:16:18,960 --> 00:16:21,680 So then some of them have repetitive, very inflexible 260 00:16:21,680 --> 00:16:25,120 thing like they need to have all their cars in a row around them, 261 00:16:25,320 --> 00:16:28,560 which makes it really difficult for them to fall asleep because 262 00:16:28,800 --> 00:16:32,000 everything has to be just right, you know, and they want to play 263 00:16:32,000 --> 00:16:33,960 with that kind of repetitive play. 264 00:16:34,240 --> 00:16:36,880 And it also is uncomfortable when they fall asleep and the 265 00:16:36,880 --> 00:16:39,800 cars get under them and then they and then it wakes them up. 266 00:16:40,040 --> 00:16:42,880 So a lot of sensory issues come into play as well. 267 00:16:43,200 --> 00:16:48,400 But the bigger issue is the overriding issue is anxiety at 268 00:16:48,520 --> 00:16:50,920 both ends. If you have child, a child with 269 00:16:50,920 --> 00:16:55,720 profound autism who's minimally verbal, you also have a child 270 00:16:55,720 --> 00:16:58,960 with very Asperger type of difficulties, highly 271 00:16:58,960 --> 00:17:03,280 intelligent, highly verbal, very rigid, both ends. 272 00:17:04,280 --> 00:17:07,760 These kids are very prone to anxiety. 273 00:17:08,680 --> 00:17:11,160 It's part of their lives, part of their daily life. 274 00:17:11,520 --> 00:17:14,920 And of course, the anxiety by the parents, like they offload 275 00:17:14,920 --> 00:17:19,440 to each other. So the anxiety in their lives 276 00:17:19,440 --> 00:17:22,960 play a major role in why they have difficulty falling asleep, 277 00:17:23,240 --> 00:17:26,040 staying asleep and having good quality sleep. 278 00:17:26,480 --> 00:17:31,000 All the issues, the rigidity, the reparative play and, and 279 00:17:31,000 --> 00:17:34,840 they're in a higher ability kids on the spectrum, their 280 00:17:34,840 --> 00:17:39,840 reparative play plays out here. They ruminate about their day, 281 00:17:40,120 --> 00:17:43,240 what they should have done, what they didn't do well, and they 282 00:17:43,240 --> 00:17:47,120 just get stuck on the loop. So these are very anxiety 283 00:17:47,320 --> 00:17:50,080 provoking factors that affect sleep. 284 00:17:51,320 --> 00:17:54,200 So that's why children at autism, you have a much, much 285 00:17:54,200 --> 00:17:58,600 higher incidence of sleep problems, 50 to 80% at any time. 286 00:17:59,040 --> 00:18:01,800 And sometimes it's like an old friend, you very annoying 287 00:18:01,800 --> 00:18:03,800 friend. You get take care of the sleep. 288 00:18:03,800 --> 00:18:05,720 Probably it goes away. And then next year, jumper 289 00:18:05,720 --> 00:18:08,080 Ballet. Yeah. 290 00:18:10,440 --> 00:18:16,080 My son is from the moment he was born until now still have this 291 00:18:16,080 --> 00:18:20,720 issue, just that this year reduced a lot but recently old 292 00:18:20,720 --> 00:18:25,080 Frank came back already. So that's why the, the skills 293 00:18:25,080 --> 00:18:27,960 need to evolve as the child grow older. 294 00:18:28,120 --> 00:18:32,920 The the, the, the family's skills in handling it and the 295 00:18:32,920 --> 00:18:38,280 child's skills, you know? Recently, maybe it's still not 296 00:18:38,280 --> 00:18:42,880 true, but what I observe is that when I sleep next to him it was 297 00:18:42,920 --> 00:18:45,040 a lot easier for him to sleep through the night. 298 00:18:45,520 --> 00:18:49,840 Maybe he need the comfort of knowing I'm around or maybe I 299 00:18:49,840 --> 00:18:52,440 sleep too deep already. I didn't know he wake. 300 00:18:53,920 --> 00:18:58,560 Up. So, yeah. 301 00:18:58,640 --> 00:19:02,920 So you are his. You are his his comfort. 302 00:19:03,200 --> 00:19:08,040 You are his security item. And like many families are 303 00:19:08,040 --> 00:19:12,240 children with autism. Without autism, having a parent 304 00:19:12,240 --> 00:19:17,760 to fall asleep with easily becomes a habit and the parent 305 00:19:17,760 --> 00:19:22,000 becomes the security item, like the pillow or the blanket. 306 00:19:22,000 --> 00:19:25,000 Right? But with children with autism, 307 00:19:25,320 --> 00:19:31,360 they have difficulty once you remove the security item. 308 00:19:31,360 --> 00:19:34,960 They have difficulty adjusting and adapting because it's a 309 00:19:34,960 --> 00:19:37,840 change. It's a big change for them. 310 00:19:38,120 --> 00:19:41,640 And you fulfill a lot of his sensory needs as well. 311 00:19:42,440 --> 00:19:46,400 Because when I slip away from him which my wife in between 312 00:19:46,400 --> 00:19:50,200 right I will get kicked by my wife midnight say I snore and 313 00:19:50,200 --> 00:19:53,440 woke him up. But when I am alone with him 314 00:19:53,480 --> 00:20:10,120 that feel like right no problem. Because mothers, right? 315 00:20:10,120 --> 00:20:13,320 I always say that the umbilical cord never really gets shot. 316 00:20:15,520 --> 00:20:20,240 Daddy is like very easy. Yeah, but but for mothers, 317 00:20:20,240 --> 00:20:22,320 right? They were already the mother 318 00:20:22,320 --> 00:20:25,400 senses connection across the world. 319 00:20:26,440 --> 00:20:30,160 Yes, yeah, yeah. And then I, I think also 320 00:20:30,440 --> 00:20:36,200 biologically mums tend to carry a lot of the emotional burden to 321 00:20:36,200 --> 00:20:40,160 sleep with us. We never really get put away. 322 00:20:40,160 --> 00:20:42,760 So we overreact to the slightest move. 323 00:20:43,240 --> 00:20:45,400 We are worried is, is this ingrained? 324 00:20:45,400 --> 00:20:48,960 I think mothers more, but fathers do have it as well. 325 00:20:49,160 --> 00:20:54,120 It's just that also fathers tend to be the more chill, chill 326 00:20:54,480 --> 00:20:56,200 factor. Yeah, yeah. 327 00:20:56,360 --> 00:21:02,920 So if some parents depend on Co sleeping, right, without Co 328 00:21:02,920 --> 00:21:04,920 sleeping, they can't function, right. 329 00:21:04,920 --> 00:21:09,000 And so I always tell parents like you decide what you need to 330 00:21:09,000 --> 00:21:12,520 survive. Survival is important, Your 331 00:21:12,520 --> 00:21:16,320 sanity is important. Whatever you need to do, you do 332 00:21:16,320 --> 00:21:19,240 it fast. And then when you're ready to 333 00:21:19,840 --> 00:21:23,200 address the Co sleeping issues, then we take the steps. 334 00:21:23,440 --> 00:21:27,600 But I don't want families to feel bad if they actually 335 00:21:27,600 --> 00:21:30,480 doctors separate, but I really need my sleep. 336 00:21:30,760 --> 00:21:33,560 So. So we we find something that is 337 00:21:33,560 --> 00:21:36,440 workable. Yeah, if the families don't mind 338 00:21:36,440 --> 00:21:40,960 Co sleeping, go ahead. You know, whatever works for 339 00:21:40,960 --> 00:21:42,920 you. But then we can work on other 340 00:21:42,920 --> 00:21:46,920 things like what happens, how the child goes to sleep, what 341 00:21:46,920 --> 00:21:49,440 time the child falls asleep. We can work on that. 342 00:21:51,080 --> 00:21:54,480 We can share some practical strategies that parents can 343 00:21:54,560 --> 00:21:55,960 practice. You know, some do and. 344 00:21:55,960 --> 00:21:58,000 Don't maybe. OK, so prove. 345 00:21:58,160 --> 00:22:01,080 Their sleeping pattern. The first things I I asked the 346 00:22:01,080 --> 00:22:04,560 parents is tell me what happened. 347 00:22:04,560 --> 00:22:08,800 What's your child's daily routine like where he goes, what 348 00:22:08,800 --> 00:22:13,960 he does, How long does he, you know, does he have a nap in the 349 00:22:13,960 --> 00:22:17,160 car on the way back from the early intervention center at 350 00:22:17,160 --> 00:22:21,320 4:30, you know, and does he have a nap in the evening? 351 00:22:21,680 --> 00:22:25,520 You know, things like that. Tell me what happens after 352 00:22:25,520 --> 00:22:28,120 you'll get back in the evening as a family. 353 00:22:28,240 --> 00:22:30,080 No. Like, tell me what time to what 354 00:22:30,080 --> 00:22:31,160 time. OK. 355 00:22:31,160 --> 00:22:32,760 At this time, what are you doing? 356 00:22:32,760 --> 00:22:35,200 What's the child doing when you are cooking dinner? 357 00:22:35,280 --> 00:22:38,520 What's the child doing? How much TV time? 358 00:22:38,640 --> 00:22:41,480 What type of shows? What type of screen? 359 00:22:41,560 --> 00:22:43,920 Is it YouTube? Is it a game? 360 00:22:44,080 --> 00:22:48,400 You know, is it a good quality educational child, child child 361 00:22:48,400 --> 00:22:51,040 program? And then what time do y'all go 362 00:22:51,040 --> 00:22:52,840 to bed? What's your bedtime? 363 00:22:53,160 --> 00:22:55,400 Family bedtime? What time, father's bedtime, 364 00:22:55,400 --> 00:22:57,480 mother's bedtime, Who goes to bed with the child? 365 00:22:57,680 --> 00:23:01,520 Where your sleep? How's the lighting? 366 00:23:02,400 --> 00:23:07,520 I can't because when when you take, it's like I can't be in 367 00:23:07,520 --> 00:23:10,520 your home. But if you can tell me what goes 368 00:23:10,520 --> 00:23:14,840 on, I can imagine the situation. I can visualize it. 369 00:23:14,960 --> 00:23:20,280 And that that imagery helps not just me, but everybody realize, 370 00:23:20,280 --> 00:23:24,480 OK, we can't take care of 10 problems, but maybe we can 371 00:23:24,520 --> 00:23:28,160 improve just two or three steps that can help. 372 00:23:28,400 --> 00:23:32,240 If you can even get to sleep half an hour earlier, big gains. 373 00:23:32,440 --> 00:23:35,480 And then everybody is more motivated to say, what else can 374 00:23:35,480 --> 00:23:39,440 I do like that? And so if then we then when we 375 00:23:39,440 --> 00:23:43,120 draw out like that, then we can visualize, OK, which step can we 376 00:23:43,120 --> 00:23:48,200 tackle first? Let's go for achievable, 377 00:23:48,480 --> 00:23:52,640 achievable goals, low lying fruits, which one can do first? 378 00:23:52,640 --> 00:23:57,600 We do first, like many parents, we try not to give medication 379 00:23:57,600 --> 00:24:01,440 for slime. Many families in Malaysia, 380 00:24:01,600 --> 00:24:04,240 whether it's for autism or not, was a total. 381 00:24:04,680 --> 00:24:10,920 And as a parent myself, I also try to avoid giving medicine of 382 00:24:10,960 --> 00:24:15,800 all kinds unless especially potent ones, very potent ones. 383 00:24:16,400 --> 00:24:20,040 OK, Having said that, right when the family is at crisis point, 384 00:24:20,040 --> 00:24:24,880 everybody comes in circles under the eyes and, you know, and then 385 00:24:24,880 --> 00:24:29,960 the child looks very unhappy, you know, very grumpy in the 386 00:24:29,960 --> 00:24:32,520 morning and then very hyperactive. 387 00:24:32,520 --> 00:24:36,720 And obviously, you know, not having enough sleep growth or so 388 00:24:36,720 --> 00:24:40,720 it's affected. I would say if behavior takes 389 00:24:40,720 --> 00:24:46,360 time to change, so sometimes medication is a circuit breaker. 390 00:24:47,160 --> 00:24:49,280 Wow, we go hand in hand first once. 391 00:24:49,280 --> 00:24:52,400 It takes time for everybody, everybody, not just the child to 392 00:24:52,400 --> 00:24:55,800 change the child's behavior. The caregivers around the child, 393 00:24:56,000 --> 00:24:58,880 those are the change makers. The makers of change are 394 00:24:58,880 --> 00:25:01,560 actually the caregivers. And which one you think is 395 00:25:01,560 --> 00:25:05,880 harder to change? It's always the adults. 396 00:25:06,160 --> 00:25:09,080 The adults find it hard to change their behaviors first, 397 00:25:09,200 --> 00:25:13,040 you know, so it takes time. So with medication hand in hand 398 00:25:13,040 --> 00:25:16,920 with behavioral intervention as a circuit breaker 1st and then 399 00:25:16,920 --> 00:25:22,160 once behavioral intervention has had time to effect change, then 400 00:25:22,160 --> 00:25:24,840 we win off. We withdraw with stops, 401 00:25:24,840 --> 00:25:27,880 gradually cut down and then we stop now. 402 00:25:29,440 --> 00:25:33,640 Yeah, but the behavioural change starts with understanding what 403 00:25:33,640 --> 00:25:36,480 happens throughout the day because everything has a 404 00:25:37,000 --> 00:25:39,640 everything has an effect. How much? 405 00:25:40,040 --> 00:25:44,920 OK, as a typical example I may give parents is a comparing 2 406 00:25:44,920 --> 00:25:50,280 kids are one older child, one younger child with no autism and 407 00:25:50,280 --> 00:25:53,720 the other child with autism. Tell me about the typically 408 00:25:53,720 --> 00:25:55,880 developing child going to kindergarten. 409 00:25:56,440 --> 00:26:00,560 How many hours of activity, vigorous are jumping, running, 410 00:26:00,640 --> 00:26:03,960 outdoor activities? How many hours does the kid have 411 00:26:04,440 --> 00:26:07,720 outdoors? Not even one hour. 412 00:26:07,720 --> 00:26:10,840 Yeah, not even one hour. Yeah. 413 00:26:11,160 --> 00:26:14,120 So when you compare that, and that's what young kids need, the 414 00:26:14,120 --> 00:26:18,240 younger they are, even teenagers are, the younger they are, the 415 00:26:18,240 --> 00:26:22,400 more outdoor activities in the sunlight, the more vigorous 416 00:26:22,400 --> 00:26:26,600 activity they need in one day to regulate not just their sleep, 417 00:26:26,880 --> 00:26:31,800 but their food intake and their focus and attention and their 418 00:26:31,800 --> 00:26:35,000 mood. So then if you understand the 419 00:26:35,000 --> 00:26:41,080 typical 5 year old child in kindergarten doesn't have even 420 00:26:41,080 --> 00:26:45,840 half an hour of outdoor vigorous climbing, jumping, playground 421 00:26:45,960 --> 00:26:50,840 playing, catching, When you understand your five year old 422 00:26:50,840 --> 00:26:55,240 child with autism, they have if they have to go outdoors, they 423 00:26:55,240 --> 00:27:00,920 need 1 to 1 supervision #1 and they already cannot go to like a 424 00:27:00,920 --> 00:27:04,880 playground with other kids. And so they tend to get bored 425 00:27:05,400 --> 00:27:09,080 and they want to stay indoors with their comfort items as 426 00:27:09,320 --> 00:27:12,600 repetitive play. And so there are things that you 427 00:27:12,600 --> 00:27:16,840 can do that you need to address that medication cannot take care 428 00:27:16,840 --> 00:27:19,800 of. Medication helps to certain 429 00:27:20,440 --> 00:27:26,080 maybe 20 to 30% of help. But somebody, something's else 430 00:27:26,080 --> 00:27:27,880 has got to change. Yeah. 431 00:27:27,880 --> 00:27:32,480 So parents are working, right? And if both parents are working, 432 00:27:32,480 --> 00:27:34,760 then that flexibility is not there. 433 00:27:35,000 --> 00:27:36,840 So can you work with the childcare? 434 00:27:37,520 --> 00:27:40,080 Can you work with the childcare that this child is having sleep 435 00:27:40,080 --> 00:27:42,640 problems? Can you just please I will 436 00:27:42,640 --> 00:27:46,680 prescribe half an hour of outdoor activity. 437 00:27:46,800 --> 00:27:48,920 Let's start with that first. Just that one need a 438 00:27:48,920 --> 00:27:51,560 prescription. You know, sometimes, yeah. 439 00:27:51,760 --> 00:27:56,360 So sometimes I will, I will eat. I find it writing letters very 440 00:27:56,360 --> 00:27:58,800 time consuming. So after the cleaning, I might 441 00:27:58,800 --> 00:28:02,440 write an e-mail to the parents. So with the parents consent, 442 00:28:02,440 --> 00:28:07,720 they share it with the the childcare or the kindergarten or 443 00:28:07,720 --> 00:28:13,400 their early intervention like prescribe half an hour vigorous 444 00:28:13,400 --> 00:28:18,480 play, outdoor activity helps with the melatonin regulation. 445 00:28:19,280 --> 00:28:24,240 And then then working with the parents out, which is the 446 00:28:24,240 --> 00:28:29,400 bedtime routine. What time to turn off the TV and 447 00:28:29,440 --> 00:28:33,360 make sure you give good quality protein at dinner time so that 448 00:28:33,400 --> 00:28:36,280 it lasts longer, releases the energy slower. 449 00:28:36,960 --> 00:28:41,160 Maybe offer proteins before you offer the carbohydrates at 450 00:28:41,160 --> 00:28:43,160 dinner time. So these are little tips. 451 00:28:43,640 --> 00:28:46,400 And then after that the bedtime routine. 452 00:28:46,400 --> 00:28:51,320 So let's say if the child is going to bed, bedtime is 10:00, 453 00:28:51,720 --> 00:28:54,640 but the child is only falling asleep at 12 midnight. 454 00:28:55,160 --> 00:29:00,000 So to reset the bedtime, I will tell the parents, aim for if the 455 00:29:00,000 --> 00:29:03,880 child is going to bed at 12 midnight on average, aim to 456 00:29:03,880 --> 00:29:09,760 start the bedtime routine at 11:00 and then bathe and then 457 00:29:09,760 --> 00:29:13,280 maybe meal. Brush this, take another wheel 458 00:29:13,280 --> 00:29:15,400 at the toilet, quiet play in the room. 459 00:29:16,040 --> 00:29:21,040 And then if the child is able to fall asleep within half an hour 460 00:29:21,120 --> 00:29:25,000 after that bedtime routine for about 3 days or so, then you 461 00:29:25,000 --> 00:29:28,080 move it back by 15 minutes. Now instead of starting at 462 00:29:28,080 --> 00:29:32,760 11:00, you start at 10:45. So this is how you set back bit 463 00:29:32,760 --> 00:29:37,080 by bit, like teaching a child with autism, any other complex 464 00:29:37,080 --> 00:29:40,200 skill that depends a lot on social interaction. 465 00:29:40,480 --> 00:29:43,560 It's about breaking it down to very small steps, right? 466 00:29:44,040 --> 00:29:46,320 And then also using a lot of visual cues. 467 00:29:46,360 --> 00:29:51,240 They will send pictures, like social stories, visual one to 468 00:29:51,240 --> 00:29:54,280 the parents and I'll tell them in bullet points. 469 00:29:54,640 --> 00:29:57,760 These are the main steps. Just stick with that first. 470 00:29:57,760 --> 00:30:00,360 And then later on we refine it and we tweak it. 471 00:30:00,600 --> 00:30:03,360 So, but most parents, you know, will aim. 472 00:30:03,360 --> 00:30:06,720 But I want my child to say at 10 o'clock 8:00 we go to see. 473 00:30:06,920 --> 00:30:09,680 It will never work. It will never work. 474 00:30:09,680 --> 00:30:14,280 Small steps, small steps, but behaviorally you change it as in 475 00:30:14,280 --> 00:30:17,520 the bedtime routine, the sleep routine, the sleep hygiene. 476 00:30:17,760 --> 00:30:20,520 You already got it. The parents will understand this 477 00:30:20,520 --> 00:30:23,680 is a sleep hygiene, the routine, everything is perfect. 478 00:30:23,960 --> 00:30:26,840 But the timing is also very important. 479 00:30:27,200 --> 00:30:30,960 Aim for within half an hour of the child's usual bedtime first. 480 00:30:31,360 --> 00:30:34,720 Now, with the routine in place, right, The SOP, very SOP. 481 00:30:34,720 --> 00:30:38,640 Yeah, if the SOP is in place and then the child can sleep within 482 00:30:38,640 --> 00:30:41,880 half an hour, then three days time you move back 15 minutes, 483 00:30:41,880 --> 00:30:45,040 15 minutes and 15 minutes. So it's more important for 484 00:30:45,040 --> 00:30:50,000 parents and caregiver to adapt our expectation to the child 485 00:30:50,000 --> 00:30:53,000 first, then slowly move. Yes, yeah. 486 00:30:53,240 --> 00:30:56,360 But you have a clear goal. Yeah, you must have a clear 487 00:30:56,360 --> 00:30:59,440 goal. You must have a written SOP so 488 00:30:59,440 --> 00:31:04,400 that everybody has something to refer to, because otherwise very 489 00:31:04,400 --> 00:31:06,800 hard. The consistency is the most 490 00:31:06,800 --> 00:31:09,360 challenging. The consistency we. 491 00:31:09,720 --> 00:31:14,640 Should make the wallpaper that has all these visual cue for 492 00:31:15,040 --> 00:31:18,600 sleep routine so that family with autism children can 493 00:31:18,600 --> 00:31:21,680 actually renovate their room with this wallpaper that's a 494 00:31:21,680 --> 00:31:24,200 good. Business idea. 495 00:31:27,000 --> 00:31:29,640 And I think this is where like, you know, behavioral 496 00:31:29,640 --> 00:31:32,360 intervention like ABA. Yeah. 497 00:31:33,400 --> 00:31:37,560 People like you expert you come into will be parents on how to 498 00:31:37,840 --> 00:31:40,080 implement the step that doctor yeah. 499 00:31:40,480 --> 00:31:43,760 Yeah, I like how just now doctor was like talking both about 500 00:31:43,760 --> 00:31:47,040 meditation and also behavioral interaction because I think hand 501 00:31:47,040 --> 00:31:47,600 in hand. People. 502 00:31:47,720 --> 00:31:51,800 Yeah, yeah, yeah. And melatonin, which is the one 503 00:31:51,800 --> 00:31:55,920 that we use the most, melatonin will be my first line. 504 00:31:55,920 --> 00:32:01,960 If the child is not on any other moods, what do you call that? 505 00:32:02,000 --> 00:32:05,400 Yeah, if a child is on respirator, which is 506 00:32:05,760 --> 00:32:10,000 antipsychotic, then that itself has got a sedative effect. 507 00:32:10,160 --> 00:32:14,560 So sometimes if the child is already on respirator, this it 508 00:32:14,680 --> 00:32:17,320 really helps you sleep. In fact, respirator side effect 509 00:32:17,360 --> 00:32:19,320 is sedation. So it helps you sleep. 510 00:32:19,560 --> 00:32:23,200 But the timing of the medication, you might tweak it a 511 00:32:23,200 --> 00:32:26,600 bit to help the sleep, but if the child is not on respirator 512 00:32:26,600 --> 00:32:33,080 and you just want to tackle the sleep, the Cicadian regulation, 513 00:32:33,280 --> 00:32:39,360 we give this medication called melatonin, it's medication, but 514 00:32:39,360 --> 00:32:43,480 it's actually something that is synthetically similar to what we 515 00:32:43,480 --> 00:32:46,640 produce, OK. And in fact, a lot of us when we 516 00:32:46,640 --> 00:32:50,840 take long haul flights, we reach say from Malaysia to New York, 517 00:32:50,840 --> 00:32:53,000 right? We take melatonin to reset our 518 00:32:53,000 --> 00:32:56,640 cicadine rhythm as well. So in many countries, you can 519 00:32:56,640 --> 00:33:00,280 buy it over the counter in any retail pharmacies, but not in 520 00:33:00,280 --> 00:33:03,480 Malaysia, not in Malaysia, you need a prescription from a 521 00:33:03,480 --> 00:33:07,000 doctor. So, So melatonin in children can 522 00:33:07,000 --> 00:33:12,240 be used very safely, even in children as young as 2-3 years 523 00:33:12,240 --> 00:33:16,800 old if the child has autism, because children with autism is 524 00:33:17,120 --> 00:33:19,760 is in a way an injured brain, right? 525 00:33:20,400 --> 00:33:25,080 Structurally of, you know, when we do an MRI, I would say almost 526 00:33:25,080 --> 00:33:28,880 always a child with autism but doesn't have any other genetic 527 00:33:28,880 --> 00:33:32,640 syndrome. They structurally normal, but 528 00:33:32,640 --> 00:33:37,480 the software there are injuries there along the way and so that 529 00:33:37,840 --> 00:33:43,200 overlap between that software in thing with the communication 530 00:33:43,200 --> 00:33:47,320 problem and the sensory issues melatonin is a lifesaver and it 531 00:33:47,320 --> 00:33:51,360 can be used very safely for very long time many months at a time 532 00:33:51,360 --> 00:33:55,840 non-stop OK, as long as you can adjust the dose. 533 00:33:56,000 --> 00:33:59,320 So for a very young child, even let's say three years old with 534 00:33:59,360 --> 00:34:04,160 autism and it's persistent and the behavioral interventions, 535 00:34:04,160 --> 00:34:08,040 the sleep hygiene, trying to all that the family is really on 536 00:34:08,040 --> 00:34:10,560 board has been really great. Not working. 537 00:34:11,360 --> 00:34:14,800 You need to give some help. So we might start at something 538 00:34:14,800 --> 00:34:19,280 very low dose, you know, like it can be compounded, it can be 539 00:34:20,760 --> 00:34:25,760 crushed and we can mix it with a sweet kind of a syrup and we can 540 00:34:25,880 --> 00:34:28,280 titrate it. We can really start at baby 541 00:34:28,280 --> 00:34:33,320 doses and go up. So it's and it's very helpful, 542 00:34:34,719 --> 00:34:38,120 it helps the child to fall asleep sooner. 543 00:34:38,560 --> 00:34:41,719 And although it doesn't maintain sleep through the night because 544 00:34:41,719 --> 00:34:45,760 in Malaysia we only have the short acting melatonin, in some 545 00:34:45,760 --> 00:34:48,520 countries we have the long acting melatonin. 546 00:34:48,760 --> 00:34:51,960 The long acting melatonin is useful for children who wake up 547 00:34:51,960 --> 00:34:55,120 frequently through the night when their sleep is fragmented. 548 00:34:55,239 --> 00:34:59,280 But in Malaysia, those that are readily available is the short 549 00:34:59,280 --> 00:35:01,120 acting. So that helps the child to fall 550 00:35:01,120 --> 00:35:05,040 asleep sooner. But it also helps certain faces, 551 00:35:05,040 --> 00:35:09,120 certain stages of the sleep. It helps to prolong each stage. 552 00:35:09,120 --> 00:35:12,320 So the the quality of sleep is in those stages are actually 553 00:35:12,400 --> 00:35:16,680 better certain stages of sleep. Melatonin has been found to help 554 00:35:16,760 --> 00:35:19,640 improve the quality of sleep, so the child gets deeper sleep, 555 00:35:19,640 --> 00:35:23,440 longer sleep, and so the sleep cycle is less disruptive. 556 00:35:24,040 --> 00:35:26,960 And so even though the child might wake up a few more times 557 00:35:26,960 --> 00:35:30,120 through the night, overall sleep quality is better. 558 00:35:30,800 --> 00:35:33,240 Yeah. Can you stop? 559 00:35:34,200 --> 00:35:37,240 Doctor, you mentioned that we cannot buy this in Malaysia. 560 00:35:37,360 --> 00:35:40,120 Do you mean that with a prescription we can still buy in 561 00:35:40,120 --> 00:35:42,240 Malaysia? With a doctor's prescription, 562 00:35:42,240 --> 00:35:45,640 yes you can, but then you have to ask the pharmacies. 563 00:35:46,040 --> 00:35:51,080 Not all retail pharmacies have it yeah Oh and and a word of 564 00:35:51,080 --> 00:35:55,640 caution to be honest, there are families because it's readily 565 00:35:55,640 --> 00:35:59,120 available overseas. So they may go yes. 566 00:35:59,280 --> 00:36:04,040 So they may go overseas and and tap out barley a lot or they 567 00:36:04,040 --> 00:36:07,840 might buy it from online pharmacy like those. 568 00:36:08,360 --> 00:36:12,440 I heard you're right and but the but the problem with this 569 00:36:13,760 --> 00:36:19,800 commercially available supplementary kind of melatonin 570 00:36:20,120 --> 00:36:23,720 formulation, they can come in syrup gummies, they can be 571 00:36:23,720 --> 00:36:26,760 together with other medication like multivitamins also. 572 00:36:27,280 --> 00:36:31,760 But the issue with that is there are emerging evidence and recent 573 00:36:32,520 --> 00:36:36,760 studies that really look into the concentration and is very 574 00:36:36,760 --> 00:36:39,200 variable. So if the gummies say 1 575 00:36:39,200 --> 00:36:42,640 milligram when they test, it can be much less than 1 milligram, 576 00:36:42,840 --> 00:36:44,800 it can be as high as 6 milligram. 577 00:36:45,720 --> 00:36:48,400 Yeah, correct. So they are less regulated. 578 00:36:48,400 --> 00:36:52,360 They are far less regulated than medication that are in the 579 00:36:52,360 --> 00:36:57,200 tablet form that hospitals will order because those come from 580 00:36:57,440 --> 00:37:00,200 highly regulated pharmaceuticals. 581 00:37:01,360 --> 00:37:04,560 So be careful what you buy from online for. 582 00:37:05,080 --> 00:37:08,720 The for the listener and audience, I think it's also 583 00:37:08,720 --> 00:37:12,720 important you consult your child's doctor before you order 584 00:37:12,720 --> 00:37:16,680 or buy anything because Doctor Cindy does not know our children 585 00:37:16,680 --> 00:37:18,880 individually. So it's very important we be 586 00:37:18,880 --> 00:37:22,360 more cautious on that doctor. Just another sub question 587 00:37:22,360 --> 00:37:24,760 related to that. Other than pills and medicine, 588 00:37:24,760 --> 00:37:28,840 is there any natural way like from food we can get melatonin? 589 00:37:29,880 --> 00:37:33,600 Not that we can medically advise on. 590 00:37:33,600 --> 00:37:36,800 Yeah, not that we can medically advise on the the things that 591 00:37:37,040 --> 00:37:42,320 work are things that are like the last meal of the day before 592 00:37:42,320 --> 00:37:45,400 the child goes to bed. If it's a milk feed or if it's 593 00:37:45,400 --> 00:37:47,800 something more substantial like dinner time. 594 00:37:47,960 --> 00:37:51,320 I always say prioritize the proteins because that releases 595 00:37:51,320 --> 00:37:54,560 the energy through the night. If you give the child, you know, 596 00:37:54,560 --> 00:37:58,120 some of our kids with autism are very picky and so they only eat 597 00:37:58,120 --> 00:38:01,920 carbs a lot or snacks, you know, or this proper only. 598 00:38:02,120 --> 00:38:04,960 So if that then you're in trouble because the child will 599 00:38:04,960 --> 00:38:07,600 be very hungry. I mean, anyone would be hungry 600 00:38:07,600 --> 00:38:10,120 after your gastric is emptied after a meal, which is about 601 00:38:10,400 --> 00:38:12,080 three to four hours for a young child. 602 00:38:13,320 --> 00:38:16,840 So then you you end up having to give a lot of milk feeds through 603 00:38:16,840 --> 00:38:17,960 the night. Yeah. 604 00:38:18,240 --> 00:38:22,280 Another thing about melatonin is the timing. 605 00:38:23,240 --> 00:38:27,600 So if the child goes to bed at midnight, readily falls to sit 606 00:38:27,600 --> 00:38:30,320 at midnight, I will ask the parents to serve the melatonin 607 00:38:30,320 --> 00:38:34,440 at around 11:00 to 11:30, half an hour, half an hour to 45 608 00:38:34,440 --> 00:38:38,760 minutes before the the child is actually falling asleep now. 609 00:38:39,120 --> 00:38:41,840 So if you don't tell the families that and they give it 610 00:38:41,840 --> 00:38:47,280 after dinner, it's just wasting because the melatonin helps to 611 00:38:47,800 --> 00:38:50,960 when when it released, when the medicine releases the melatonin 612 00:38:50,960 --> 00:38:54,680 or the child must already be in bed. 613 00:38:55,160 --> 00:39:00,440 Routines are done and the child is mentally ready to shut off, 614 00:39:00,640 --> 00:39:02,800 you know? So then the melatonin is the 615 00:39:02,800 --> 00:39:06,360 final cherry on the top. Yeah, but if you give it too 616 00:39:06,360 --> 00:39:10,680 early, it doesn't work. OK, Thanks, Doctor. 617 00:39:10,680 --> 00:39:13,640 We can hear a few strategies that doctor mentioned, like 618 00:39:13,920 --> 00:39:17,160 exercise is important. Sunlight, yeah, to that is the 619 00:39:17,280 --> 00:39:20,800 very natural way to promote melatonin in the child's body. 620 00:39:20,960 --> 00:39:25,680 Another tip is anxiety. A lot of kids are anxious at 621 00:39:25,680 --> 00:39:30,440 bedtime, right? So how to give them so, so if, 622 00:39:30,480 --> 00:39:35,880 if your child is more able and more verbally able, that's when 623 00:39:35,880 --> 00:39:39,600 they do their emotional dumping at bedtime, right? 624 00:39:39,760 --> 00:39:43,520 So if you have a child who, who's able to articulate his 625 00:39:43,520 --> 00:39:46,080 feelings, that's the time they want your audience. 626 00:39:46,520 --> 00:39:51,040 But what I I would discourage that gently and I will try and 627 00:39:51,040 --> 00:39:56,280 set away quality time or special time earlier in the day. 628 00:39:57,000 --> 00:40:00,320 Get it out of the way. Because if that's the last thing 629 00:40:00,560 --> 00:40:04,640 the child thinks about before the child goes to bed, you bet 630 00:40:04,640 --> 00:40:07,160 that's what the child is going to be dreaming about and 631 00:40:07,160 --> 00:40:09,440 worrying about in the middle of the night when he can't say he's 632 00:40:09,440 --> 00:40:13,280 going to the the last thing that the child is doing or thinking 633 00:40:13,280 --> 00:40:17,200 about. Let it be a calm positive. 634 00:40:20,000 --> 00:40:24,120 Very pleasurable in terms of the sensory needs of the child 635 00:40:24,280 --> 00:40:28,560 before the child goes to bed. Then another thing about sleep 636 00:40:28,560 --> 00:40:31,680 routine that I will remind parents is how the child falls 637 00:40:31,680 --> 00:40:37,920 asleep at bedtime is how the child is going to be able to 638 00:40:37,920 --> 00:40:40,640 fall asleep again if he or she wakes up in the middle of the 639 00:40:40,640 --> 00:40:44,680 night. So if if your child falls asleep 640 00:40:44,680 --> 00:40:48,560 with daddy next to him, turn on my alarm when he wakes up and 641 00:40:48,560 --> 00:40:54,200 daddy is no idea, that's it. So then another one is carrying 642 00:40:54,200 --> 00:40:55,840 the child, rocking the child, right. 643 00:40:56,440 --> 00:41:02,080 If the if the mom or daddy rocks the child for two hours to put 644 00:41:02,080 --> 00:41:04,720 the child to sleep, what do you think will happen when the child 645 00:41:04,720 --> 00:41:06,200 wakes up? You need to rock. 646 00:41:07,320 --> 00:41:10,600 If the child goes to bed with a bottle of milk, that's what's 647 00:41:10,600 --> 00:41:11,520 going to happen. So. 648 00:41:11,760 --> 00:41:15,880 So remove that association, whatever it was that the child 649 00:41:16,000 --> 00:41:19,680 went to bed with or whatever the child needs to go to bed, look 650 00:41:19,680 --> 00:41:24,040 carefully at that association and then change that also 651 00:41:24,040 --> 00:41:25,560 slowly. Correct. 652 00:41:25,760 --> 00:41:27,880 So there are many changes, right. 653 00:41:27,920 --> 00:41:30,760 So the extinction method helps. Yeah. 654 00:41:30,760 --> 00:41:33,960 Some parents are so frustrated because they are already tired, 655 00:41:34,200 --> 00:41:35,880 so they let the child cry it out. 656 00:41:36,600 --> 00:41:41,880 That is very anxiety provoking. Yeah, I think for a child with 657 00:41:41,880 --> 00:41:44,680 autism, that's not what I would advise. 658 00:41:44,680 --> 00:41:48,960 I but there are other things that we need to look into. 659 00:41:49,120 --> 00:41:50,560 Yeah. Yeah, we have a lot of 660 00:41:50,560 --> 00:41:53,520 information, but just one last question that I actually have is 661 00:41:53,520 --> 00:41:56,640 actually which I think a lot our audience also would like to know 662 00:41:56,680 --> 00:42:00,360 is a lot of parents will come to us asking how long should our 663 00:42:00,360 --> 00:42:03,120 kids snack? Like I also know that this 664 00:42:03,120 --> 00:42:06,160 depends on, you know, the age and all these things, but also 665 00:42:06,160 --> 00:42:09,600 what anything that you know that we can tell 8 these kids doesn't 666 00:42:09,600 --> 00:42:12,960 need nap. I think when the child is 667 00:42:13,520 --> 00:42:16,760 preschool age already getting ready to go to standard 1, 668 00:42:16,760 --> 00:42:19,320 correct? So around 5:00 to six years old, 669 00:42:20,240 --> 00:42:23,560 usually the child does not need to nap anymore because seven 670 00:42:23,560 --> 00:42:27,560 years old, most kids are ready, physically ready to go through 671 00:42:27,560 --> 00:42:31,520 the day without sleeping. So by 5 or 6 is practice time. 672 00:42:31,840 --> 00:42:34,400 So those naps need to get shorter and fewer. 673 00:42:35,120 --> 00:42:38,560 But if the child really needs to nap, right, if the child is, you 674 00:42:38,560 --> 00:42:42,000 know, constantly on the go and expending a lot of energy and 675 00:42:42,000 --> 00:42:45,080 then the battery run out ready, I will try to advise parents. 676 00:42:45,120 --> 00:42:48,960 Give the nap early afternoon, like after lunch or something, 677 00:42:49,800 --> 00:42:51,840 but wake up by three or three, 30. 678 00:42:52,480 --> 00:42:54,240 Yeah. And then try to keep the nap 679 00:42:54,240 --> 00:42:57,280 initially less than about one hour. 680 00:42:57,560 --> 00:43:00,040 And then after that, move towards half an hour. 681 00:43:00,880 --> 00:43:03,160 Move towards half, half an hour. Yeah. 682 00:43:03,360 --> 00:43:07,920 So for then this is how you sleep train in the daytime so 683 00:43:07,920 --> 00:43:10,560 that the child moves towards no need anymore naps. 684 00:43:10,960 --> 00:43:13,600 Yeah. Sometimes I also will tell the 685 00:43:13,600 --> 00:43:18,160 parents if they nap already at night they don't sleep until 1. 686 00:43:18,360 --> 00:43:20,160 O'clock, yeah. That also something that we 687 00:43:20,160 --> 00:43:21,240 need. Of course. 688 00:43:21,480 --> 00:43:24,600 Yeah, it it, it seems very logical to most of us. 689 00:43:24,840 --> 00:43:27,520 But when you're in the thick of things, right, and you yourself 690 00:43:27,520 --> 00:43:30,720 are like half sane because you don't have enough sleep as the 691 00:43:30,720 --> 00:43:32,800 parent, it's very hard to move straight. 692 00:43:33,240 --> 00:43:35,920 Yeah. So we we help to have that 693 00:43:35,920 --> 00:43:40,040 discussion, but write it down so that it's really very concrete. 694 00:43:40,520 --> 00:43:43,600 You know that some grandparents, they say, oh, kids need to 695 00:43:43,720 --> 00:43:45,640 sleep, you know, nap. Yes. 696 00:43:45,640 --> 00:43:47,440 And so if the child. Yeah, correct. 697 00:43:47,440 --> 00:43:50,480 So if the child has a neurodevelopmental issue with 698 00:43:50,480 --> 00:43:54,000 significant delays, the, the family's view is that the child 699 00:43:54,000 --> 00:43:56,520 is still very small, very immature. 700 00:43:56,680 --> 00:43:58,440 Yeah. So, but that's OK. 701 00:43:58,480 --> 00:44:01,920 We, we have, we work towards a goal we don't need to achieve, 702 00:44:02,160 --> 00:44:06,040 you know, good sleep times and all that immediately. 703 00:44:06,040 --> 00:44:11,080 This is a work in progress and sometimes things can regress, 704 00:44:11,600 --> 00:44:15,240 like after an illness or if there's been a change after 705 00:44:15,240 --> 00:44:19,400 holidays things were regressed. So don't worry, you've got the 706 00:44:19,400 --> 00:44:21,280 skills. So just have to go through the 707 00:44:21,280 --> 00:44:25,600 paces again, the SOP again. Yeah, so thank you, Doctor 708 00:44:25,600 --> 00:44:29,480 Cindy, for all the sharing. I think sleep, it's really 709 00:44:29,480 --> 00:44:32,320 important, not just for the children because it affects the 710 00:44:32,320 --> 00:44:38,680 whole family and when the parents have sleep deficit, it 711 00:44:38,680 --> 00:44:41,280 carries through the day and. It is grumpy. 712 00:44:42,520 --> 00:44:46,440 So emotionally when we are lack of sleep right, we are not going 713 00:44:46,440 --> 00:44:50,400 to be the best mood, you know throughout the day we get easily 714 00:44:50,400 --> 00:44:54,840 triggered or agitated and then for some work maybe even can 715 00:44:54,840 --> 00:44:59,760 cause negligence or effects of productivity which may effects 716 00:44:59,760 --> 00:45:03,000 our ability to continuously provide for the therapies and 717 00:45:03,160 --> 00:45:08,520 ongoing support for the child. So helping our children to sleep 718 00:45:08,520 --> 00:45:11,880 well, it's crucial because like I say, it affects the whole 719 00:45:11,880 --> 00:45:14,720 family. And I hope by listening to this 720 00:45:14,720 --> 00:45:19,240 episode you actually learn a lot more practical ways and tips. 721 00:45:19,520 --> 00:45:21,440 Yeah. And I know we said that in the 722 00:45:21,440 --> 00:45:24,800 beginning of the episode. We will talk about sleep and 723 00:45:24,880 --> 00:45:27,040 Constipation slash digestion, right? 724 00:45:27,800 --> 00:45:31,240 But we are going to make this episode just fully for sleep. 725 00:45:31,480 --> 00:45:34,760 And you will see the next episode, which we will be in the 726 00:45:34,760 --> 00:45:38,000 same room recording the same topic, but it's going to be on 727 00:45:38,240 --> 00:45:41,480 Constipation topic. So do come back for the next 728 00:45:41,520 --> 00:45:45,400 episode at the same time. But for now, after you listen, 729 00:45:45,400 --> 00:45:48,240 if you learn a few things about how to help or support your 730 00:45:48,240 --> 00:45:52,480 children to sleep, do remember to also help yourself to put 731 00:45:52,480 --> 00:45:55,120 aside your phone as early as possible as a caregiver, 732 00:45:55,160 --> 00:45:57,720 parents, and before you put the phone away. 733 00:45:58,160 --> 00:46:02,000 Share the podcast to be perfect. OK. 734 00:46:02,160 --> 00:46:02,640 Thank you. Bye. 735 00:46:02,640 --> 00:46:03,120 Bye.