Why Sleep Hygiene Doesn’t Always Work, featuring Professor Dagmara Dimitriou

PROFESSOR PHILIP SCHOFIELD (INTRO)

Hello, and welcome to series two of The Greatest Good, a UCL Press podcast. 

Jeremy Bentham, the late 18^th and early 19^th century philosopher, was the intellectual inspiration for the founding of University College London and is credited with the maxim that actions should be judged by the amount of happiness that each produces.

I’m your host, Professor Philip Schofield, Director of the Bentham Project here at UCL. Join me as I explore the ways in which Bentham’s thought is still relevant in the 21^st century.

In this series, we focus on the intersection of Bentham’s ideas with current research into how we understand the human mind, in conversation with leading UCL academics.

PROFESSOR PHILIP SCHOFIELD 

Hello Dagmara, and thank you for coming to tell us about your research, which concerns sleep and neurodiversity. 

PROFESSOR DAGMARA DIMITRIOU 

Thank you for inviting me. I’m Professor Dagmara Dimitriou. I work at the University College London Institute of Education, and I am directing sleep laboratory, which is called Sleep Learning and Education Research. The research I’ve been carrying out, probably for about 20 years now, started with parents coming to us in terms of the questions, ‘what can I do about sleep of my child?’ They are exhausted and children are exhausted.  So, the research I’m doing with my team is for individuals with autism, so neurodivergent, autistic children, autistic adults, ADHD, also individuals who have eating disorders – so it’s a wide range. Anybody can actually come and tell us about their sleep problems. And then we would, if we can, investigate that further and see whether we can provide any benefits for individuals, recommendations for healthcare as well, and education. So, we know that in terms of neurodiversity, they would be people with autism, ADHD, dyslexia, anybody with neurodiverse conditions. And in terms of sleep, we know that they do have different sleep problems. And this is how my research links to neurodiversity. We go further into examining these sleep problems. 

PROFESSOR PHILIP SCHOFIELD 

Are you sort of like a specialism within a unit that looks at sleep problems generally? 

PROFESSOR DAGMARA DIMITRIOU 

So, absolutely. So, we also examine sleep or explore sleep in general population. It could be typically developing mainstream children, but our focus is on neurodiverse individuals.  So the bottom line is if we can find what sleep problems they have and whether they are very specific to different neurodiverse conditions, neurodiverse people, then we are able to map out and actually help them to benefit individuals and to provide them with different recommendations as well.

PROFESSOR PHILIP SCHOFIELD 

Do you find that what you do is very much tailored to a particular individual or are there more general conclusions you reach about the relationship between sleep and neurodiversity? 

PROFESSOR DAGMARA DIMITRIOU 

It’s a really interesting question – whether that is for individual or general condition. There’s no clear answer to it.  So, we would, for example, provide certain recommendations for autistic children that, well, do not follow the basic sleep hygiene that is for general population. So, for example, going to bed, quiet music, quiet place and etc. Their brains are neurodiverse brains and all of them, they will have different needs and different environments. So, this is where individuality comes into it. We would say to parents, your neurodiverse child will probably need slightly different tailored sleep hygiene. So, for example, where we tend to say ‘do not use iPads, gaming and etc. before bedtime’, here we would be more gentle and say ‘if that calms down your child, do allow them for a few minutes to actually get rid of their anxieties and try to modify that area.’ But it is also individual environment. We are all living in individual families. People have different needs and also different housing, different environments. So central London is very, very busy, so we would ask them to tailor that into their sleep as well. 

PROFESSOR PHILIP SCHOFIELD 

I’m just wondering why you were in the Institute of Education, but is that because you’re mainly dealing with children? I’m just wondering about your relationship with the medical side of things. 

PROFESSOR DAGMARA DIMITRIOU 

So we are very much multidisciplinary at Institute of Education and sleep, although it’s probably unique and we all have different relationships with sleep, it is extremely important for learning. So it’s not only about children, adults also are coming to learn in our institutes and we have students who also struggle sometimes with sleep and when I am giving a lecture I always say to our students you are coming from international backgrounds, different environments, you do need your sleep.  How you tailor your sleep is really important for learning and this is where Institute of Education comes into play. We are there to also provide recommendations for teachers. Children are not naughty children, very often they are children who are lacking sleep.

PROFESSOR PHILIP SCHOFIELD 

Hmm, yeah. 

PROFESSOR DAGMARA DIMITRIOU 

So this is very much raising awareness through sleep and our outcomes to educational settings, to healthcare settings as well. 

PROFESSOR PHILIP SCHOFIELD 

And do you think patterns of sleep are, to use a crude word, cultural or natural? I’m thinking of, you know, the countries where you have the siesta in the middle of the day. 

PROFESSOR DAGMARA DIMITRIOU 

The answer is yes to both. Sleep is very much like diet: we need to eat; we need to sleep. But, similar to diet, we are very much prone to different interactions with our environments.

So for instance, recently we’ve collected some data in India, and children in many states in India, they will sleep with their parents in the same room till the age of 12-13. This is very much a cultural setting, and the parents find it absolutely fine, and children also. In the UK and some of the western countries, this is not the case. And, as you mentioned, we have also countries where children are sleeping during the day. In some parts of China, our students also collected, at the Institute, data where children would be sleeping after their lunch at school. So, the facilities are there for them to sleep. So, the cultural also settings and recommendations within different countries.

PROFESSOR PHILIP SCHOFIELD 

And is there any difference between the general population and the neurodiverse population in terms of sleep patterns within those different cultures? 

PROFESSOR DAGMARA DIMITRIOU 

Yes, there are. So most neurodiverse people will have very much neurodiverse, I would say, sleep. Many individuals who are autistic, they will be waking up at night. I would call it ‘chunking’ their sleep. So, they will sleep a few hours, then they will be awake and etc.  Individuals with ADHD, similarly, they will be having problems with settling to fall asleep. And so there are certain specific things which usually you do not see that in general population unless it’s triggered by anxieties, mental health problems, so individuals will have sleep problems. In terms of neurodiverse people, I think it’s so important that we understand that their sleep, their relationship with sleep, is very different, and triggers such as anxieties at school, anxieties at university, will have negative impacts on their sleep as well. 

PROFESSOR PHILIP SCHOFIELD 

Does the condition generally change with age, and if so, does that make a difference to, again, what you recommend in terms of sleep?

PROFESSOR DAGMARA DIMITRIOU

I don’t think the neurodiversity changes. We are changing as we grow older, and our experiences change as well. Sleep will change and fluctuate throughout our lifespans. But I’ll give you an example. When during the COVID, we had lockdowns, there was something interesting where most populations were saying across the world that sleep was really badly affected. But there was one difference here. When we collected our survey data from autistic individuals in the UK, and that was a large number of individuals, there were some very positive things there. So, for example, their waking at night were diminished. They slept much better. They felt that fresh during the day.  And part of that was due to the fact that they were not facing everyday challenges with environments. So this is what the difference was. So we can see. So, for example, these events were changing our sleep – so throughout the lifespan, that will change.

PROFESSOR PHILIP SCHOFIELD 

So it was like a calmer experience during the daytime meant a calmer night?

PROFESSOR DAGMARA DIMITRIOU

Absolutely. They didn’t need to think that they need to come for transportation, they don’t need to have face-to-face talks with their employers – so all of those things that often they’re socially impacting in a negative way, they didn’t need to face that; they could work in this sort of calm, safe environment. 

PROFESSOR PHILIP SCHOFIELD 

I’m just going to change the subject slightly, because one thing I’ve been dying to ask you is about Jeremy Bentham and his sleep. Bentham had this fear of ghosts, which he’d had from his childhood, and he said this is completely irrational but it shows the power of the imagination over the reason, and he used to have a small boy sleep in the same bedroom with him because he said that if no one slept in the same room as him, he used to have dreams about ghosts – nightmares. 

PROFESSOR DAGMARA DIMITRIOU

Okay.

PROFESSOR PHILIP SCHOFIELD

Have you heard of anything like that?

PROFESSOR DAGMARA DIMITRIOU

So, it’s difficult to say but maybe he had lucid dreams, and about 50% of the population will have, at certain times, lucid dreams – or maybe he was a very anxious person as well. 

PROFESSOR PHILIP SCHOFIELD

I mean, there’s a theory, I mean I’m not totally convinced by it myself, that he had Asperger’s Syndrome. 

PROFESSOR DAGMARA DIMITRIOU

It could be as well, but then when we are talking about nightmares, they tend to diminish with age, although some individuals, autistic individuals, adults, they would say they do still continue to have nightmares throughout their lifespan. But it also could be lucid dreams. 

PROFESSOR PHILIP SCHOFIELD

Yeah. I mean, this is talking about Bentham in his 70s and early 80s, he still had a boy sleeping in his room. I should add that nobody ever suggested there was any impropriety – but that’s interesting. And what do you mean by lucid dreaming?

PROFESSOR DAGMARA DIMITRIOU

So it’s very interesting area of work in terms of sleep work. We are trying to create international network looking at lucid dreams. We know that prefrontal cortex is involved. We know that many people have lucid dreams and there are very much several studies that they are not very concrete studies that are saying that maybe people who have lucid dreams very much that they’re conscious about their dreams. And can you prompt also having lucid dreams? This is the interesting part as well, whether you can trigger them yourself and some studies say that you can. So how does it relate to creativity as well and your working memory and prefrontal cortex as well. So all of those questions are really, really interesting.  And as I said, we are just at the start of some of the research, which is really exciting. Unfortunately for quite a few years, dream stages and rapid eye movement has been moved on side from research. And we started to sort of re-look at it and re-evaluate what is happening. So we looked also at dreaming of children who have foetal alcohol syndrome, how they are dreaming as well. The stages of sleep have been really beautifully mapped out. We are all dreaming. We all have different stages. And dream stages, rapid eye movement stages, are longer in the morning. But there are people who do not have this sort of longer sleep stages or they have very, very long. So what happens to them? And what I always ask a question, and I don’t think we are nowhere near answering that, why babies have very, very massive chunks of rapid eye movement. They dream a lot. So in the first two years, rapid eye movement takes loads of space from the time of a new development. Yet in those two years of age, think about how much they learn. They learn to walk, they learn to smile, recognise all our emotions, language, huge amounts. So why we are not looking at dreaming. So I know it may be difficult, but we should be looking how that actually impacts the development. 

PROFESSOR PHILIP SCHOFIELD

Would there be any difference between neurodiverse people and the general population in terms of the stages of dreaming, the sorts of dreams they have?

PROFESSOR DAGMARA DIMITRIOU

I think you could ask me this question in a few years’ time. We don’t have the answer to it, we definitely don’t. 

PROFESSOR PHILIP SCHOFIELD

And do animals dream?

PROFESSOR DAGMARA DIMITRIOU

Oh, I don’t know! I’m sure they do.

PROFESSOR PHILIP SCHOFIELD

I know our cat sleeps a lot.

PROFESSOR DAGMARA DIMITRIOU

I’m sure you’ve seen dogs as well, they dream that they are running and eating, so I’m sure they do, yes. 

PROFESSOR PHILIP SCHOFIELD

Yeah. I mean, when I do remember dreams, I think one of the extraordinary things is the detail. 

PROFESSOR DAGMARA DIMITRIOU

Well, we do rehearse a lot of information at night – so this is why I call sleep our tutor, that is for free. So when children go to schools, very often they have personal tutors after school, and they are told to study and etc. I tend to say, ‘your free tutor is your sleep. If you gain your good quality of sleep, you will learn so much’. So if you read a bit before bedtime, or, let’s say, play a bit of piano or something like that, you are able to rehearse that at night – this is what our brains beautifully are doing at night. They are rehearsing all the information, they are putting that in beautiful storage places. 

PROFESSOR PHILIP SCHOFIELD

That makes absolute sense, because if I read a novel at night, I’m sure I then dream about it. 

PROFESSOR DAGMARA DIMITRIOU

Yeah.

PROFESSOR PHILIP SCHOFIELD

I mean, I do have sort of vague memories of it when I wake up 

PROFESSOR DAGMARA DIMITRIOU

So, the new generation of students say ‘I don’t read anymore’, and that’s fine – but if you can take an audiobook, you can do anything as long as it’s there. Nowadays, I don’t, I wouldn’t, ask people to take a book and read. We are in this new generation, which is so hard, but as long as they can have an audiobook, as long as they can listen to it, I am personally very, very happy if that happens and if it is before bedtime, at least ten minutes; that will make a huge difference to them. 

So, what happens with our new generation and children? We often ask parents, ‘how is your child sleeping?’ I can ask this question, from my experience nowadays, I can ask this question when the child is five, six. After that, after the age of about eight, they have autonomy over their sleep, and we are not able to actually say whether they’re asleep or not. And sometimes when we ask children, they say, ‘I struggle; I cannot fall asleep; I cannot sleep, and our iPads are taken,’ and et cetera, et cetera. And we talk to many neurodivergent people, and especially adults, and they were saying that if they – and adolescents – if they have their iPhone or whatever digital media it is, if they can finish off what they were doing, it calms them down. So, for example, we had these beautiful stories from our neurodivergent adolescents who are saying, I have to finish on my iPad Route 72, for example, when it is finishing that bus stop. He was following the bus stop for that particular route. If that person could finish that, he could fall asleep. If that is taken away, when we give them this sleep hygiene, which is very much, I would say nowadays for a small number of individuals nowadays, they are not going to get good night’s sleep. They have to get rid of all their thinking. What happened during the school day? What happened during interactions with peers? Sometimes it can be really bad. Let them finish that. And I think this is where individualised sleep is. We need to listen to them. We need to adjust it. And also they need to be aware that sleep is ever, ever so important for them. 

PROFESSOR PHILIP SCHOFIELD

Right, so what you’re doing is finding out what strategies are best for each particular individual, and they might differ? I was coming back to the point I made earlier, about what’s general, what’s particular. I mean, is that sort of coming to the end of a mental process, is that much different from the average person?

PROFESSOR DAGMARA DIMITRIOU

Hmm. So, I often call, for example, individuals who have ADHD, those beautiful brains – that they are ticking everywhere. Many of the individuals will have 110 different things that they want to talk about, that they want to do, and they need a closure before bed time. And the closure for them, they’re often not the same as for others, because they need to think that they haven’t finished that task, they haven’t managed to do something else.  And at the same time, we mustn’t forget about also our mental health. And mental health of individuals who are neurodivergent very often is different. They will have anxieties, they will have also depression. And that fluctuates, it’s not constant. Sleep is not constant for us anyway, but so is everyday sort of takings of social lives as well. So when we are talking about the anxieties in ADHD, this is why I think it is quite different for them. The time management can be very different. Many individuals, for example, with ADHD, they don’t feel time. And I hear it so often from our students, I don’t feel the time, that’s absolutely fine. We can adjust for that, but adjust also your life to get your sleep.

PROFESSOR PHILIP SCHOFIELD

And do neurodiverse people need the same amount of sleep as everyone else?

PROFESSOR DAGMARA DIMITRIOU

I would come back with a question: how much sleep do we need? It varies. It varies across ages. It varies from individual to individual.  We do have international recommendations. So, the international recommendations are driven by age, but also whether they need the same duration of sleep, probably. But the quality of sleep is more important as well. So, if we have individual, for example, autistic individual who has also sensory problems, and this is where we haven’t talked about, sensory problems can be ever, ever so huge. Far more, I would say, bigger barrier than anything else. 

PROFESSOR PHILIP SCHOFIELD

So what do you mean by sensory problems?

PROFESSOR DAGMARA DIMITRIOU

So if an individual has, for example, problems with texture and doesn’t like bed linen that whoever it is in the house gave them, they don’t like the bed. They don’t like the smell within the environment. Or they are, for example, I had an individual once saying to me, I can hear the toothbrush being charged. Now if you can hear that, you do need to block those senses.  So this is where I said, I’m coming back all the time to individualized environment. If the environment is that, for example, you live in Soho, it’s so busy. And it’s not only a pollution that we have nowadays, but it’s also the environmental pollution such as noises, the bars opening and closing. That will have triggers for people to actually wake up because there are sudden awakings, sudden noises that are coming through. And they need to block them off. And how they block them off, how they actually make the environment sensory for them, it’s very individualized. We can suggest certain things, but doesn’t mean that I am going to get that 100% right. So some individuals say, I have to have my TV on. And in the old days, many, many years ago, I said, no, no, no, you cannot have your TV on because it’s bad for your sleep. And I’ve taken that back. I would never say that that is wrong nowadays. If that makes you fall asleep, that’s absolutely fine because it’s just a noise for you to block all the environmental problems. 

PROFESSOR PHILIP SCHOFIELD

So there’s a certain pragmatism there, looking at what works?

PROFESSOR DAGMARA DIMITRIOU

Yeah, absolutely.

PROFESSOR PHILIP SCHOFIELD

Yeah, yeah, interesting.

PROFESSOR DAGMARA DIMITRIOU

We have international student who are coming from different countries and we have students who are coming from different environments, not only from different countries but within the UK. They would be coming from very, very quiet areas. Suddenly they are ending up in busy, busy London and they find it so challenging to sleep. So this is where I’m talking about different sensory problems. 

PROFESSOR PHILIP SCHOFIELD

And in noisy halls of residence, perhaps.

PROFESSOR DAGMARA DIMITRIOU

Exactly, but also the taxis and all the cars in central London, they find that so difficult. Imagine you’re coming from this very quiet farmland and suddenly you’re faced with all this busy life – it is so difficult. This is where they need different sleep aids. This is where we need to make them aware that, actually, this is problematic and you need to get rid of that sort of problem and to fall asleep. But we also have international students that we mustn’t forget, that we are not accommodating them very often. Our international students often say that, ‘look, in my country I am actually having a siesta in the afternoon’ or ‘we are having quiet time at lunch’, and this is not accommodated. Some of the banks in the city, they’re accommodating their employees and they are having the napping facilities. So it could be just a quick power nap that we could provide for our students and that would definitely benefit them. 

PROFESSOR PHILIP SCHOFIELD

Yeah, yeah, and what about soundproofing of student rooms?

PROFESSOR DAGMARA DIMITRIOU

That would be a wonderful idea, yes definitely! But even very simple things such as blinds, blackout blinds – that would help them immensely and they often don’t have that. 

PROFESSOR PHILIP SCHOFIELD

Mm-hmm.