A Pioneer in Pediatric Sleep Medicine

The genesis and development of the field of pediatric sleep medicine in the United States owe much to the work of Richard Ferber, MD ’70. As a co-founder and former director of the Center for Pediatric Sleep Disorders at Boston Children’s Hospital, Ferber was instrumental in introducing clinicians to the ways of identifying and treating children’s sleep problems, from general sleeplessness to more complex medical conditions such as sleep apnea.

Ferber served on the American Board of Sleep Medicine, where he advocated for incorporating pediatric sleep medicine competencies into certification exams, and on the board of the American Academy of Sleep Medicine, where he was involved in crafting standards related to research, education, and care in the field. He received the AASM’s Nathaniel Kleitman Distinguished Service Award as well as the organization’s Excellence in Education Award and held positions on three notable journals: an editor of Sleep, an associate editor of Sleep Medicine, and the editor-in-chief of Frontiers in Sleep Medicine. Now retired, Ferber is a corresponding member of the Faculty of Neurology at Boston Children’s and a founding and continuing member of the HMS Division of Sleep Medicine and its faculty executive committee.

In addition to these professional accomplishments, Ferber is widely known for his book Solve Your Child’s Sleep Problems, first published in 1985 and revised and expanded in 2006. Comprehensive in content and approachable in style, the book includes discussions of the neurology of sleep, normal sleep rhythms for children and strategies for supporting them, and biological conditions that might prevent children from getting a good night’s rest.

Harvard Medicine magazine talked with Ferber about his career. What follows is an edited version of that conversation.

Harvard Medicine magazine: You dedicated Solve Your Child’s Sleep Problems to your two sons, noting that they taught you how to be a parent and reminded you of how important it is to remember being a child. Did the spirit in that dedication express itself in your clinical work?

Richard Ferber: It must have. One of my favorite parts of working in the Center for Pediatric Sleep Disorders at Children’s was working directly with children. When parents would come in with their child, especially if it was a young child, they really didn’t expect me to talk very much to their child or try to solve the problem directly with the child. But I found this direct conversation approach was the most fun and often the most productive, especially when working with a child who had problems going to bed or sleeping through the night. What did the child think they could do to help with their own problem, what steps could they take, and what changes were they not ready to accept?

In these situations, I would try to work out a plan directly with the child. Then we would go over it. This repetition would help them remember it, their parents understand it, and the child feel empowered as a planner. The kids were surprised and often really excited about helping to form the plans and pleased that it was not just someone telling them what was going to be done and how. I found this process to be effective.

I obviously couldn’t take this approach in every situation, say, when the child was an infant or when the underlying cause could not be addressed behaviorally, but when I could, and I got the youngster to share in the decision, there was a good chance that things would go well quickly.

HMM: So the treatment became a family effort.

RF: Absolutely. It had to be. The child wasn’t complaining that they were waking up. It was the parents who were concerned and, even more than their child, not getting the rest they needed. I always felt that a sleep-deprived parent could not be as good a parent as one who was well rested. Being able to, in effect, give parents their sleep back while also giving the child their sleep was a goal in most sleeplessness situations.

Sometimes, of course, the problem that parents were observing was something that required more extensive treatment than a change in schedule or bedtime sleep practices — disorders like sleep apnea or narcolepsy. But regardless of the specifics of the problem, we would work to identify the root or roots of the problem and devise appropriate treatments or treatment options.

HMM: You mention that helping a family learn what behavior or schedule is normal could lead to a resolution of a child’s sleeplessness. What would you tell parents?

RF: Often the conversation started with clarifying some misunderstandings about children’s sleep behavior. Many people do not realize that all children wake up occasionally throughout the night — just as adults do. Sleeping through the night is something of a myth; we all wake up at night, turn over or move around, get comfortable, and then fall back asleep.

A child’s nighttime rousing can resolve itself if the child is allowed to complete the cycle and simply fall back to sleep, especially if the child always seems well when checked. But many times, parents intervene and the child becomes accustomed to the intervention, so instead of following the normal course of semi-rousing then falling back asleep, they would seem to require a parent’s intervention. This leads to poor sleep for both child and adult.

Another frequent misunderstanding is what a child’s sleep needs actually are. This can lead to parents’ concerns their child is not getting enough sleep and thus to mistaken concepts of when their child should go to bed at night, how late they should sleep in the morning, and how long they should nap during the day.

As a result, parents may put their child to sleep too early — during the end-of-the-day period of increased wakefulness — or try to get them to sleep too late in the morning or allow them to nap too much during the day. For these children, the night is simply ‘too long.’ Helping parents learn just what normal amounts of sleep are and correcting the schedule could often readily resolve the perceived problem.

The reasonable amount of time that one can expect a child to sleep day plus night varies considerably by age. And bedtime should ideally coincide with when the child feels sleepy: We all have an internal clock that tells our body when it’s time to gear down and rest. Expecting a child to sleep from 7 p.m. to 7 a.m. when they have a ten-hour nighttime sleep requirement can mean it takes them two hours to fall asleep or they wake two hours too early in the morning — or that they are awake for two hours during the night.

The good thing is that the body is built to adapt to a regular and age-appropriate schedule, and children can adapt even more quickly than adults, so once a proper schedule is instituted, a related sleeplessness problem can be resolved.

HMM: The Center for Pediatric Sleep Disorders was the first full-service sleep center in the world devoted to the treatment of sleep problems in children, wasn’t it?

RF: It was. We started it at Children’s in 1978. Sleep medicine as a clinical discipline was relatively new at that time. There might have been around fifteen sleep centers in the country, but all of them were focused on adults. I had done a pediatric internship and residency at Children’s and a fellowship there in psychiatric research that focused on the development of sleep and motor rhythms in infants. I also spent a year at the hospital as the pediatrician to the psychosomatic unit. I learned a great deal there about how to interact with patients and their families.

It was during the year on the psychosomatic unit that Myron Belfer, then the acting head of the Department of Psychiatry at Children’s; Patricia Boyle, a senior psychologist at the hospital; and I established the sleep clinic. The sleep laboratory was set up at the same time in the Department of Neurophysiology, where Cesare Lombroso took me on to develop and supervise its operation. Their interests stemmed from the number of sleep problems they were seeing among patients in their psychiatry program and the frequency with which seizures occurred at night during sleep.

My own interest derived from my work with Peter Wolff, director of psychiatry research and my mentor. It was from him that I gained my interest in all aspects of sleep and sleep rhythms. From him and my studies there, I learned a great deal about sleep in infants and children. I decided that I wanted to focus my career in those areas.

Initially the center’s clinic was in the psychiatry department and the sleep laboratory was in the neurophysiology department. But we were able to combine the program and, later, to greatly expand it.

For a long time, we were basically the only operating sleep laboratory in Boston, and we were referred patients of all ages for study — we might study a newborn one night and a 90-year-old the next. It was an extraordinary opportunity to see the development of sleep across the life span. Eventually, as we built a larger referral base for children, and when Beth Israel Hospital set up its own sleep laboratory for adults, we were able to shift our studies to just children.

Operating a sleep program seemed to bring together all my interests: working with children and their families, learning how to develop a specialized history aimed at determining causes, developing new treatment approaches, and using modern technology to better understand many of the problems we faced.

HMM: What findings came out of work done at the sleep center that you think helped advance the field of pediatric sleep medicine?

RF: First, and very fundamentally, the work helped us understand the various causes of sleeplessness in children. Clarifying what was normal sleep, what were normal nighttime wakings, and what habits influenced sleeplessness — overfeeding, needing to be rocked, inappropriate napping, incorrect schedule — turned out to be huge. We also conducted a good deal of research on the disorders of circadian timing for sleep in children.

We found that obstructive sleep apnea was much more common in children than originally thought. Usually, when a physician would see a child in their office and the child looked fine and breathed normally, the doctor would have no idea that the child was having difficulty breathing while sleeping. But our studies, including videos we produced of such children during sleep, helped show other practitioners that obstructive apnea was common. The children had difficulty breathing in sleep just as adults who have obstructive apnea do.

It had long been known that children diagnosed with pediatric obesity-hypoventilation syndrome, also known as Pickwickian syndrome, can suffer from obstructive apnea. We helped show that obstructive apnea was more commonly present in children because of large tonsils and adenoids, not weight. In our hospital we also saw many children whose obstructive apnea was due to congenital facial abnormalities.

We described and named the disorder of “confusional arousals,” which joined sleepwalking and sleep terrors as a category of so-called arousal disorders. Children who experience these would wake up in the middle of the night, confused and screaming inconsolably. And in younger children, their behavior more closely resembled confusion or temper tantrums than the terror seen in teenagers and adults. Parents often assumed their children were having nightmares. But a researcher in Canada had already shown that sleepwalking and sleep terrors were incomplete arousals from the deepest stage of nondreaming, or non-REM, sleep and that they had nothing to do with dreaming. The children acted as they did because their arousal systems were being activated but their sleep systems were only slowly giving way to full waking.

Learn more about sleep

Although arousal disorders could be treated with medication, we found that for young children, confusional arousals often had behavioral triggers and could be treated behaviorally. We found that explaining to parents what was happening and reassuring them that it was nothing bad helped them let events run their course with minimal intervention. This helped the child complete the arousal process more quickly and kept the parents from worry.

HMM: I was hoping we could take some time to talk about your days as a medical student at Harvard. What do you recall from that time?

RF: I still remember some of the advice we were given. In particular I remember a talk that the late Judah Folkman, MD ’57, gave a group of us at Children’s, long before he became chief of the Department of Surgery at the hospital.

During the talk, he told us the story of a young child on a cancer ward at Children’s who had just died. The child’s father arrived at the hospital, picked up the child, and began walking the halls with the child in his arms. He had walked back and forth but would not relinquish the baby. The staff tried to reason with him to allow them to take the child, but nothing worked. They decided to call another physician at the hospital, one they knew was skilled in such situations. The doctor came and just started walking up and down the hall next to the man who kept holding his child. The doctor talked to the father about the child. He mentioned how beautiful the baby was and generally talked about the child as if the baby were still alive. Then he asked the father if he could hold the baby for a while. The father handed the baby to the doctor and then sat down and wept.

That story was very striking to me. It told me you have to understand where the parents are cognitively and emotionally before you can help them and their child.

Ann Marie Menting is the editor of Harvard Medicine magazine.

Image: Mark Finkenstaedt