Preventing and Solving Sleep Problems
In one study of children between one and two years of age, about 20 percent woke up five or more times a week, while in a study of three-year-old children, 26 percent woke up at least three times a week. Unfortunately, you simply cannot assume that difficulty returning to sleep unassisted will magically go away. Returning to sleep unassisted is a learned skill; you should expect problems to persist in your child until she learns how to soothe herself back to sleep without your help.
Also, in the study of one-and two-year-old children, those who woke up frequently were much more likely to have an injury such as a broken bone or a cut requiring medical attention than those who slept through—while only 17 percent of good sleepers had injuries, 40 percent of the night wakers were injured! (Chapter 11 will discuss further the connection between injuries and disturbed sleep.)
The majority of children between the ages of one and five have a bedtime routine less than thirty minutes long, go to sleep with the lights off, and fall asleep in about thirty minutes after lights out. Night waking occurs in the older children in this group once a week; only a few awaken more than once a night. If your child's pattern between the ages of one and five is substantially different, consider the possibility that your child is among the 20 percent of children in this group with disturbed sleep. If so, then you might also later notice the excessive daytime sleepiness that has been observed in about 5 to 10 percent of children between the ages of five and fourteen years.
Your child's developing personality and awareness of himself as an individual means that his second and third years will be a time of testing, noncooperation, resistance, and striving for independence. Your child has stronger self-agency. Sleep problems in twelve-to thirty-six-month-olds are related to this normally evolving stubbornness or willfulness in children, who now want to do their own thing. For example, they may want to get out of their bed or crib at night, not take naps, get up too early to play, and, of course, resist falling asleep and wake up at night. This last problem might have started during the first year and may now continue during the second year as an ingrained habit. Let's look at each of these major problems in turn.
PRACTICAL POINT
Don't confuse these issues:
Needs versus wants
A sad cry versus a protest cry
Being abandoned versus beingalone
Getting Out of the Crib or Bed:
The Jack-in-the-Box Syndrome
It's quite natural for two-and three-year-olds to climb out of the crib or bed to check out the interesting things they think their parents are up to. Or maybe they just want to watch the late, late movie or have a bite to eat. Of course, what they like to do most is to come visit with their parents and/or get into their bed. This not only disrupts their parents’ sleep, but it also harms the child. Here's how.
When a child has a naturally occurring partial arousal during sleep, instead of soothing himself back to sleep, he learns to force himself completely awake to get out of his bed or crib. The result is sleep fragmentation—for him, and for his parents, too. Here's a five-step treatment plan to put your Jack back in his box at night.
Step 1: Keep a chart, log, or diary to record key sleep events: time asleep, time awake, number of times out of bed, and duration of protest calling, fussing, or crying. This will make you a better observer of both your child's behavior and your own. The chart or log enables you to determine whether the strategy is working, and helps remind you to be regular according to clock times and to be consistent in your responses.
Step 2: Ask yourself whether your child behaves as if he is tired in the late afternoon or early evening. If the answer is yes, then consider the possibility that naps are insufficient or that the bedtime hour is too late. Deal with these problems at the same time you are working on his getting out of the crib or bed. If needed, keep data in your sleep chart regarding naps, such as the time he falls asleep, how long he sleeps during the day, how long he cries in protest before napping, and the interval between the end of his nap and when he goes to sleep for the night.
Also, consider whether your child is snoring or mouth-breathing more and more at night. Please read the section on snoring in Chapter 10 if this is now a problem.
Step 3: Announce to your child that there is a new rule in the house: Down is down—no getting out of bed until morning. Tell him that you love him very much but that you need your sleep, and he needs to put himself back to sleep by himself; getting out of bed is not allowed. Tell him that when he gets out of bed, you are going to put him back to bed and you are not going to talk to him or look at his face while you are doing so. Let's call this “silent return to sleep.” Silence when you take your baby back to bed is important, because if you are sweet or stern while trying to explain why everyone needs sleep, the verbal attention will reinforce your child's desire to get out of bed to get more attention. Attending to a problem will cause the problem to occur more often. Many parents do not understand that negative attention—yelling or getting angry—is still attention, and it will encourage your child to continue the behavior.
Depending on your child's age, he may or may not understand what you are saying. But he will certainly sense that tonight something different is going to occur.
PRACTICAL POINT
Be silent and unemotional; appear disinterested or mechanical. No more night entertainment.
Step 4: Place yourself where you can easily hear him get out of his crib or bed. Place a bell on a rope on his door to signal when he leaves his room or enters your room, or use an intercom if you must be out of earshot. The signal makes him aware of what he's doing and it helps you to be consistent.
Every time you determine that he is out of his crib or bed, or discover him in your bed, gently place him back in his bed. Maintain silence. Plan not to sleep the first night, as he may try many, many times to get back to his old style. Parents might want to alternate nights so that at least someone gets some sleep. Do not take turns on the same night, because the child might think one parent would behave differently. Children learn quickly that there's no benefit in getting out of bed, so they stay in bed and sleep through the night.
Step 5: Every morning, shower the child with praise or affection for cooperating with the new rule. Perhaps offer a favorite food that was previously withheld or go on a special outing. Try small rewards for partial cooperation and larger rewards for more complete cooperation.
In addition to praising or rewarding your child when he cooperates, you might consider changing some of the routines when he doesn't cooperate. For example, past fifteen to eighteen months, you might close the door in a progressive fashion every time he gets out of bed. You can put three or four white tape marks on the floor, and for the first three or four times he gets out of bed, the door is closed a little more until it is barely open or completely closed. If he stays in the bed, the door is left open to the first tape mark. A similar progressive strategy could be used with brighter or dimmer night-lights.
Expect this plan to dramatically reduce or eliminate the get-ting-out-of-bed routine within a few days, usually three or four. All you had to do was remove the previous nighttime social interaction (whether pleasant or unpleasant) as a reinforcer to the habit of getting out of his crib.
In short, every time your child gets out of bed, he encounters a silent, unemotional parent who gently picks him up and returns him to bed.
Here are some typical questions and answers about this strategy.
Q: Won't my child hurt himself when he climbs or falls out of his crib?
A: This is a common worry and often used as an excuse to go to your child or buy a “big kid's” bed. But the truth is that serious injuries rarely occur when the child bumps on the floor as he lets himself down.
Q: Can the plan fail?
A: Yes, when both parents aren't committed, so that one partner passively or actively sabotages the program. One father in my practice loved to sneak a bottle of
formula to his baby once or twice a night. This caused the baby to suffer excessive wetness and a severe, persistent, and painful diaper rash. Only in the course of trying to eradicate the rash did the father's behavior come to light. Failures also sometimes occur when the child is still chronically fatigued from too late a bedtime hour or nap deprivation.
Q: What if he stays in his crib but cries’?
A: Letting your child cry when he protests going to sleep or staying in his crib is not the same as making your child cry as if you were hurting him. Leave him alone (extinction) or try controlled crying (graduated extinction).
One family instituted this five-step program when their daughter was twenty-six months old—after twenty-six months of poor sleeping. She had always had difficulty in falling asleep and difficulty in staying asleep. Nicole always wanted to, and did, get out of her bed and go into her parents’ bed. After the birth of Daniel, her brother, her parents decided this had to stop.
Their record showed the following results:
Night 1: Between 8:13 and 9:45 P.M.—69 return trips to bed. Slept until 8:30 A.M. with one brief awakening at 2:15 A.M.
Night 2: Between 8:20 and 10:30 P.M.—145 return trips to bed. Slept until 7:20 A.M. with one brief awakening at 2:15 A.M.
Night 3: After 9:14 P.M. (bedtime)—0 return trips to bed! Slept until 7:40 A.M., awakening once at 3:20 A.M.
PRACTICAL POINT
Do not underestimate the enormous power of partial reinforcement to ruin your efforts to overcome baby's habit of getting out of die crib. If you are not silent and you discuss getting out of bed when it is occurring, your social behavior reinforces getting out of the crib.
That's it!
An important point is that almost all of Nicole's getting out of bed occurred within the first hour or two of the night. Many children follow this pattern, so don't expect that you will necessarily lose a complete night of sleep during this training period.
After the third night of Nicole's program, the curtain calls at bedtime ceased. Furthermore, at naps her mother would now leave after fifteen or twenty minutes of reading, whereas before she stayed in the room until Nicole fell asleep. The parents described Nicole as easier in many ways: less resistant in dressing, less argumentative, more charming, and better able to be by herself.
Crib Tents and Locking the Door
Some families know that they are unable or unwilling to do the silent-return-to-sleep routine when their child climbs out of the crib. For a minority of children, moving them to a bed solves the problem; they want to sleep in a bed and they will stay put to enjoy it. In others, moving to a bed simply means it is now easier to go visit mom and dad.
A crib tent will prevent your child from getting out of the crib, and it allows you to remove yourself from his protest crying without fear that an injury might occur. Sometimes duct tape is needed to cover the zipper because your child otherwise figures out how to escape. Don't worry about some theoretical sense of failure if the child has to return to the crib with a crib tent. Some parents feel that the crib tent “locks their child in the crib like an animal caged in the zoo” and they would prefer to lock the door instead. Most families find the crib tent more acceptable and effective, but let's talk about locking the door.
To me, this is absolutely the last thing a desperate family might want to try, and because it sounds so extreme I want to share with you my observation in some detail. The reality is that not all marriages are made in heaven, not all jobs allow parents to spend much time with their children, not everyone can begin sleep training early and prevent sleep problems, and, to be perfectly honest, it is difficult and inconvenient to be consistent in handling sleep routines. Circumstances beyond your control, such as twins in a one-bedroom apartment, sick relatives who need your attention, or medical problems such as frequent ear infections conspire to rob children of healthy sleep. So what are we to do when all else fails and the entire family is stressed from sleep loss?
Locking the child's bedroom door to prevent social interaction at night, which interferes with sleep, is discussed further in the next chapter for older children, about three years old or more. But for younger children, around age two, some parents find that if they lock their bedroom door, while protecting the child's safety with gates if needed, everything begins to turn around. First, however, you'll need earplugs in order to ignore the banging, crying, or yelling. Second, place the child back in his crib or bed after he falls asleep. Third, praise him well when he eventually stays asleep in his own room.
Sleep Rules
A crib tent may be most appropriate for a child close to one year of age, and locking the parents’ door might be needed for a two-year-old. However, as the child gets closer to the age of three, consider sleep rules. Sleep rules should be implemented for both nap time and nighttime in order to be consistent. The family makes an elaborate, decorative, theatrical poster, which they put on the wall in the child's bedroom. Use stars and stickers; the more colorful and dramatic it is, the more motivational it will be. The poster looks like this:
SLEEP RULES
At bedtime we …
Stay in bed.
Close our eyes.
Stay very quiet.
Go to sleep.
Insert your child's first name before the title so that “John” will listen carefully when a parent recites “John's sleep rules” every time he is put to sleep. You simply say, “John, remember your sleep rules. One, stay in bed; two, close your eyes; three, stay very quiet; and four, go to sleep.”
Rewards and privileges are an important component of this plan.
One family placed next to the poster a calendar called a “bedtime star chart.” The mother read the rules at bedtime. If the child followed the rules, she got to put a star on the chart the next morning, which meant that she could choose a treat later that day. No star, no treat. She caught on very quickly to the relationship between following the rules and getting treats.
In general, even if there is no problem around naps, for the sake of consistency, also give the treat or star after the nap. Often a big glass bowl filled with treats on top of the refrigerator, where it is visible to the child, will enhance motivation. Either the treat or a token to be exchanged for the treat is given immediately upon awakening. Later, the treats can be placed in a “treat bowl” to delay gratification, and later the child will substitute heightened self-esteem for the treats. One caveat: This method is guaranteed to fail if the treats are insufficiently motivational.
Let's take a moment to look more closely at the difference between rewards and bribes. I am sensitive to the fact that some people will claim that it is wrong to give something to a child to make a behavior occur—that it is like a bribe. The simple answer is that we smile, hug, and praise our children when they perform in a socially desirable way. This is how a child learns to share toys and develop manners and desirable social habits. But our social rewards simply aren't powerful enough to change the behavior of a strong-willed two-or three-year-old who is dead set on fighting sleep for the pleasure of your company. Opponents to giving rewards come up with theoretical objections, but the fact remains that when rewards are used in the context in which I am describing them, they work.
Actually, rewards are only half the story here. Think of what your child loves to do around the house. Exclude creative activities such as reading, painting, or building things. Think of somewhat passive things, such as watching videotapes, DVDs, or television; playing with the computer; or perhaps playing with some favorite dolls or trucks. Choose one activity and call it the “privilege.” So, after you recite the sleep rules, you say “John, remember to follow the sleep rules so that when you wake up you can choose a treat and play with your trucks.” All the trucks are put in a box in the closet. If he follows the rules, after he wakes up you say, “Thank you for following the sleep rules. Here, choose a treat. And here are your trucks to play with.” Or, if he did not abide by the rules, say, “You did not follow the sle
ep rules, so no treat and no trucks to play with until you follow the rules.” If John decides he doesn't care about his trucks, then restrict some other privilege next time in addition to the trucks.
When a child refuses to comply with sleep rules during the day when a nap should be taking place, and anytime a problem behavior occurs at night, employ the silent-return-to-sleep strategy. Put a bell on his doorknob so you know when he is leaving his room. One very cute and bright girl ripped up three sleep rules posters before she got the message. Then she started to tell friends, with great pride, that she now sleeps by the rules!
What we are simply trying to accomplish is to encourage behaviors (described as sleep rules) that are compatible with allowing the sleep process to happen and to discourage behaviors (such as singing, calling, and running around) that are incompatible with sleeping.
When you employ sleep rules or the silent return to sleep, do not be surprised if your child's behavior gets worse for a short time. It's as if he is putting forth more effort to get back to the old way.
PRACTICAL
POINT
Problems may
get worse
before they get
better during a
retraining phrase.
Healthy Sleep Habits, Happy Child Page 34