So please don't fear when your child cries in protest at night, because he is being allowed to “practice” falling asleep, that this crying will later cause emotional or psychological problems. By itself, it will not.
Let me be very clear about this. I am talking only about children over the age of four months and only during normal day and night sleep times. During these periods, emotional problems do not develop if parents ignore protest crying.
Drs. Thomas and Chess were sensitive to irregular sleep patterns in the infants in their study. Many of those infants also had frequent and prolonged bouts of loud crying. When I asked Dr. Thomas what advice he had given to the parents of those crying babies who did not sleep at night, he responded, “Close the door and walk away.” Did this create or produce any problems? He said, “No. None at all.”
Always going to your crying child at night interferes with this natural learning and growth. Such behavior produces sleep fragmentation, destroys sleep continuity, and creates insomnia in your child.
One study examined infant crying at one year of age. It compared children over six months of age whose parents indiscriminately responded to every cry, day or night, to those children whose parents were trained to respond promptly to every intense, stressed, or demanding cry but to delay their response to quiet vocalizations or weak cries. The children in the first group, whose parents indiscriminately responded, cried much more than children in the second group. This suggests that crying for attention can be learned or taught by at least six months.
Mothers who in general do not feel loving or empathetic toward their children, who are insensitive or emotionally unavailable to them, and who have a lack of warmth or affection later come to the attention of professionals. Consequently, some psychologists or psychiatrists take the attitude that parents should be encouraged never to let their child cry, for fear of encouraging a cold parent-child relationship. As a general-practice pediatrician, however, I don't share this view, because I see that the vast majority of parents are loving and sensitive to their child's needs. These parents should not fear letting their child cry at night to learn to sleep.
Q: How long do I let my baby cry ?
A: To establish regular naps, no more than one hour, but to establish consolidated sleep, there is no time limit at night if the child is not hungry or ill. If we place an arbitrary limit on the duration of crying at night, we train the child to cry to that predetermined time. When it is open-ended, the child learns to stop protesting and to fall asleep.
Q: Why is it good for my child to cry? Why not delay sleep training until he is older and more reasonable ?
A: Crying is not the real issue. We are leaving the child alone to learn to sleep. We are leaving him alone to forget the expectation to be picked up. We allow him to cry; we are not making him cry in the sense that we are hurting him. When he is older and still not sleeping, it will be harder for him to learn how to sleep well. Plus, losing sleep is physically unhealthy, just as is too little iron or too few vitamins in his diet.
Q: Isn't crying harmful?
A: Not necessarily. In fact, studies have proven that crying produces accelerated forgetting of a learned response. So when a child cries, she may more quickly unlearn to expect to be picked up. When trying to stop an unhealthy habit, crying may have some benefit, because crying acts as an amnesic agent.
Let's look at several of the most common unhealthy sleep habits at this age, and the proven, effective strategy to deal with each one.
Abnormal Sleep Schedule
When the bedtime hour and sleep periods are not in synchrony with other biological rhythms, we don't get the full restorative benefit of sleep. Please refer to Figures 5 and 6 (see pages 43 and 44) for age-appropriate times when children fall asleep or awaken.
At any age, abnormal sleep schedules often lead to night wakings and night terrors in older children. The schedule often gets shifted to a too-late bedtime hour because mom or dad (or both), returning late from work, wants to play with the baby, or because parents deliberately keep their baby up late to encourage a later awakening in the morning.
The strategy for bringing sleep schedules back to normal is based on developing an age-appropriate wake-up at 6:00 or 7:00 A.M.; a midmorning nap around 9:00 A.M.; an early afternoon nap, usually around 1:00 P.M., but always starting before 3:00 P.M.; an early bedtime, 6:00 to 8:00 P.M.; and unfragmented night sleep. This package of advice ensures good sleep quality, and it is quality, not always quantity, that really matters.
MAJOR POINT
The major fear that inhibits parents from establishing an earlier bedtime is that this will cause their child to get up earlier to start the day. In fact, the opposite will occur. An earlier bedtime will allow your child to sleep later, just as a too-late bedtime will eventually cause a too-early wake-up time. Remember, sleep begets sleep. This is not logical, but it is biological.
Q: Why do you recommend 6:00 to 8:00 P.M. as an appropriate bedtime ?
A: Survey data from my earlier research showed that the vast majority of children between the ages of four and twelve months went to sleep between 7:00 and 9:00 P.M., and so I used to recommend those hours. However, as I have helped families correct sleep problems over the past thirty years, it has become clearer that children who go to bed earlier tend not to develop sleep problems in the first place. In addition, children in this age range who did have sleep problems almost always benefited from an earlier bedtime. I think we have simply grown accustomed to having overtired children in the evening hours, and because it is so common, we have assumed that fussiness or irritability near the end of the day was normal. Imagine what was a “normal” bedtime before electric lights, radio, television, videos, commuting, or dual-income families traveling from work to day care to home.
When your nine-to twelve-month-old child does not promptly go to sleep at his nap times, you should leave him alone for one hour, maximum. If a nap develops and you are trying to establish a healthy sleep schedule, you would want to limit that nap to about one or one and a half hours in order to have the next nap or bedtime occur on time. If your child is overtired and you allow a two-or three-hour nap to occur, then it will be difficult, if not impossible, to establish a good twenty-four-hour schedule.
PRACTICAL POINT
You are enforcing an age-appropriate nap and bedtime schedule. Your child initially may not cooperate by falling asleep immediately. Don't give up.
Studies have shown that when sleep disturbances are associated with abnormal sleep schedules, control of the wake-up time may be sufficient to establish a healthy twenty-four-hour sleep rhythm. In other words, you set the clock in the morning!
Here's an account of one mother who left my office determined to set the clock that night and not wait until the morning.
“HE WAKES UP SMILING”
Our son did not like to sleep. In fact, if it can be said that babies are born with an aversion to any particular thing, for Ryan, sleep was it.
From the day we brought Ryan home from the hospital, he had shown himself to be a night owl. Through Letterman and 2:00 A.M. reruns of The Mary Tyler Moore Show, we would pace and nurse until sleep would overcome us sometime around Sunrise Semester. By the time he was four and a half months old, he was down to one nap a day. He didn't sleep through the night (and in my book, that's eight hours straight or better) until he was ten months old, and that lasted for only one night.
Not knowing any better, since Ryan was our first child, I thought this kind of behavior was perfectly normal for a majority of babies. When other moms would talk about their children sleeping through the night at three months of age and napping twice a day for two hours or better at a crack, I figured that it was either so much idle boasting or their children had some sort of neurological disorder. But when our pediatrician told me at Ryan's eight-month checkup that it was not normal for a child his age to go to bed at 1:00 A.M. and sleep until 10:00 A.M., I started to realize we had a problem. The thought of my husban
d and me looking like Dawn of the Dead rejects from years without sleep was not a pretty one.
We put Ryan to bed at 9:00 that evening and, as expected, he started to cry. We shut his door and went into the den, closing two more doors between the baby's room and the den in an attempt to muffle what were now becoming very loud screams. After a half hour had passed, the crying was more muffled but continued, so I headed for Ryan's room to “reassure him.” “Don't go in there now,” Tom suggested. “He'll just get worked up again if he sees you. Do something else for a while.” I could see the logic and agreed to hold off. A half hour later, I cracked the door open and again heard the crying. But now I could hear something else mixed in. Ryan was talking to himself. In a very hurt tone he was babbling and complaining between the sobs. My heart was breaking. “My God,” I said to Tom. “Now he's going to grow up hating us. I have to go to him.” For the second time that night, Tom talked me into leaving the baby alone.
The next fifteen minutes seemed like fifteen hours, but the next time I opened the door, there it was… silence. I could finally look in on Ryan without undoing all that we had just accomplished. So as not to awaken him with its squeaking, I turned the light on at its dimmest setting. In this low light and from across the room, I saw what appeared to be Ryan's blanket hanging over the side of his crib. As I moved closer to remove it, however, I discovered that it wasn't the quilt draped over the side—it was Ryan. Our son had fallen asleep standing up!
The next night we again put him to bed at 9:00 and again he fell asleep standing up. But this time he only cried for one hour. The third night, he cried for twenty-five minutes and fell asleep lying down.
These days, with few exceptions, he cries for only a few minutes before falling asleep. He also usually wakes up smiling, thus dispelling any fears I once might have had that he would grow up to hate us for letting him “cry it out.”
One mother solved the problem of her child waking up and always standing up in the crib immediately after being put down almost asleep by putting her drowsy child in the crib standing up. Now the child had only one way to go, down.
Nap Deprivation
Nap deprivation is a common occurrence between nine and twelve months of age. Children at this age are fearless, full of grace and self-confidence, and very explorative. Doing things with parents and siblings is simply a lot of fun. Unsure of when a child naturally shifts to needing only one nap, some parents try to get by with one nap before their child is ready. Afternoons full of activities help smooth over rocky moments of heightened emotionality or grumpiness. Anyway, mom or dad returns from work about then, so there is a loving play period early in the evening.
However, the fatigue from nap deprivation leads to increased levels of arousal and alertness, and this causes difficulties in falling asleep, staying asleep, or both. These changes in the direction of disturbed sleep and behavioral changes during the day may be very gradual, so initially it may appear that a single nap is all right. The effects of persistent sleep deficits are cumulative, though, and eventually the fatigued child starts to behave differently.
I was consulted about two children, five and six months of age, who had severe bobbing, turning, and jerking of the head and wincing or grimacing of the face. Both children had been hospitalized and evaluated for seizures or epilepsy, but all the test results were normal. Nap deprivation turned out to be the problem, and both children recovered completely when they were better rested, though the movements transiently returned to each child during a temporary period of overtiredness.
Here is one parent's account of how “the program”—that is, shortening the interval of wakefulness—helped her child sleep better.
“I WAS CERTAIN SHE WOULD
GROW OUT OF THIS BAD HABIT …
OUR OTHER TWO HAD”
On November 19, 1984, our third daughter, Rebecca, was born. Our other girls, Lauren, nine years old, and Karen, four years old, were busy with school activities, Hebrew lessons, and ballet. At that time I prided myself on how well I schlepped our new baby everywhere and how wonderfully she slept in and out of the car seat all day.
Our days were filled with errands and car pools, Rebecca nursing and napping on and off all day. What a cooperative baby, I used to think. But I was so exhausted by evening that I found the only way to survive was to sleep with the baby, waking up every hour or so to shift her so that she could nurse on the other side. I knew then that having her in bed with me wasn't such a terrific idea, but it was the only way for me to get any rest.
When Rebecca turned five months old, I placed her in her crib instead of going to sleep with her at my breast.
As I expected, every few hours she began to cry, expecting me to be by her side. I would quickly run into her room and rock and nurse her back to sleep … until the next time she woke up.
And so our next pattern began. She would wake up every few hours and I would faithfully run in and get her back to sleep. I was certain she would grow out of this bad habit … our other two had.
A few months passed. By now Rebecca was weaned to a bottle and I was sure things would change for the better. That didn't happen. In fact, things got worse. There were many nights when Rebecca would get up every hour on the hour. I tried letting her cry, fifteen minutes at a time, but it was much easier to just go in and give her a bottle.
When Rebecca was a year old, this pattern of frequent waking continued. It was difficult leaving her with a baby-sitter on the occasional evening we went out. I knew that within an hour or so of our leaving she would be up crying for me. I actually felt sick leaving her.
When Rebecca was almost thirteen months old we went to see Dr. Weissbluth. Rebecca was charming for him. Could this delightful child really be causing all this trouble? I wondered.
Our appointment went well. After our story was poured out, Dr. Weissbluth explained what steps we needed to take to change Rebecca's sleeping patterns. He cited studies, gave us graphs … this really was going to work! When we left his office I felt prepared for battle—armed with all the mental ammunition I needed to change Rebecca's nightly wakings. We started “the program” the next day.
In a week's time, the change in Rebecca was phenomenal! She was always a happy baby, but when she began to sleep better, she became even more relaxed, more affectionate, and more fun to be with.
The change in her sleeping pattern has had an effect on everyone in the family. I don't yell and lose my patience with my older children quite as much, for I am better rested. Ironically, for the first few nights of our “training program” I continued to get up every two hours, waiting for her to cry. I now also have learned how to sleep through the night once again, and I feel so much better physically and emotionally.
Throughout some of Rebecca's crying periods, especially in the beginning, there were moments when I was sorry that we started this whole thing. I just wanted to soothe my poor, crying baby! Both my husband and I kept reminding ourselves that we were trying to teach Rebecca how to sleep and that we had to stay with it without sabotaging the plan. (Maybe knowing that we would be checking in with Dr. Weissbluth every few days helped us to stick with it.)
This has been one of the most rewarding and positive experiences that we have shared as parents. We are so proud of Rebecca and also pat ourselves on the backs for a job well done.
Shhh! Rebecca's sleeping!
The treatment strategy involves (a) shortening the interval of wakefulness before the first nap and reestablishing the early afternoon nap by focusing on the midday interval and making sure this wakeful period is not too long, (b) making sure the afternoon nap does not start too late in the afternoon, in order to protect a reasonable evening bedtime, and (c) consistency in the nap time ritual.
If the afternoon nap is needed but that is when the child fights sleep the most, consider shortening the midday interval of wakefulness. Start the afternoon nap earlier. Perhaps you were allowing him to stay up too long and he became overtired and overaroused.
So during a retraining period, it's easiest to establish good night sleep and easier to establish regular morning naps than afternoon naps. Don't expect improvement to occur equally at all times. Still, it's best to implement a twenty-four-hour sleep retraining program, because if you focus only on one feature, such as bedtime, and ignore naps, you will be less likely to succeed.
In general, I recommend a twenty-four-hour sleep package to help restore healthy sleep habits. Here is an example of an exception. The single mother has limited resources for soothing and is completely exhausted. The child does not sleep well day or night. The mother wants to continue breast-feeding but now wants to transition the baby from her bed to a crib. The first step might only be a temporarily ultra-early bedtime in the mother's bed to help the child get more sleep. Everything else stays the same. The advice is to do whatever is necessary to maximize sleep and minimize crying during the day. After the child is a little better rested, the second step might be to make the transition to the crib. This might involve crying, but because both child and mother are better rested, the crying may be very little and the mother is more able to cope. The third step is to work on naps. This will now be easier because everyone is better rested. If, instead, this mother had an enormous soothing support system to help her, she might try to do everything at the same time. Her child might become better rested faster and the greater stress in making all these changes abruptly would be shared by people other than the mother.
Healthy Sleep Habits, Happy Child Page 30