Also, we know from many studies that when you think you have finally solved a problem, it will resurface sooner or later. This is called a “response burst,” either because your child is testing to see if the rules still apply or because you have slipped a little regarding consistency in enforcing the rules or maintaining a healthy sleep pattern. Don't be dismayed. Stick to what worked and usually the problem will subside for good.
Refusal to Take Naps
Playtime in the park or shopping together is so much fun; who wants to take a nap? Ask yourself whether napping is your child's problem or your problem. Some parents simply find it too inconvenient to hang around the house to enable their child to get his needed daytime sleep. But reflect on how inconvenient it is to drag a tired child around while shopping. Please review the first chapter of this book if you feel that naps are not that important.
Let's consider two common problems regarding naps: (a) resistance for one nap and (b) no naps.
Resistance for one nap: This often occurs after a special event, such as a holiday, party, or vacation. There was so much excitement the day before, the children don't want to miss anything again! Sometimes this becomes apparent because of unappreciated chronic fatigue due to an abnormal sleep schedule, brief night-sleep duration, or sleep fragmentation. If these problems are present, work on them as you work on day sleep.
The trick to solving the problem of resisting a nap is judging when your child is tired but not overly tired. This is usually after being up about three or four hours. If the interval is too short, the child may not be tired enough. If the interval is too long, she may be overpooped and not able to fall asleep easily.
Keep a sleep chart, log, or diary; pick a time interval that you think is right, and put your child down in the crib at that time. You are controlling the nap time. Spend however much time you want—ten, twenty, or thirty minutes—hugging, kissing, rocking, and nursing to soothe your child. Then down is down—leave him alone for one full hour.
If your child has been quite well rested up to now, the crying may be brief. But if your child has a history of chronic fatigue, prepare yourself for a full hour of crying. Here's one mother's account of how her fourteen-month-old daughter responded.
“SHE WOKE IN THE MORNING
SMILING … WE WERE
REASSURED THAT SHE LOVED US”
My daughter was fourteen months old, ate poorly, resisted naps, woke two or three times in the night, needed to be rocked to sleep, and was tired all the time. My husband and I were exhausted, angry, resentful, and blaming each other for the situation we were in.
We were ambivalent, scared, concerned, and skeptical about letting our daughter cry, as the treatment plan recommended. We thought she would feel unloved and worthless if no one responded to her.
After only one episode of crying, she learned how to lie down and fall asleep on her own! It was very difficult listening to her crying, but when she woke in the morning smiling and kissing us good morning, we were reassured that she loved us. Now she naps regularly, sleeps through the night, eats better, plays better, and is able to play in her crib before going off to sleep on her own.
The more rested the child is, the quicker you'll see improvement. A very tired child might require several days of training before he relearns how to nap.
Your goal is to establish an age-appropriate nap routine so the child comes to associate being left alone in a certain place and a familiar soothing routine with feelings of being tired and taking a nap. No more playtime, no more games, just sleep. If the child is young, then every day at about 9:00 A.M. and 1:00 P.M. the parents should put their child down to nap; older children may be put down only in the afternoon. I call this “nap structuring;” we are trying to use natural sleep rhythms to help the child sleep best. After one hour, if there is no nap, then we go to the next sleep period, but a little earlier.
Parents who would rather hold their child in a rocking chair or let her catnap in the stroller are robbing their child of healthy sleep. This lighter, briefer, less regular sleep is less restorative—it's not as effective in returning your child's energy and attentiveness to its best levels.
No naps: If your child is a young two-year-old, you might simply establish a pattern as described under “Resistance for one nap” and sticking with it, especially if the duration of not napping wasn't too long. But if you have an older two-year-old who hasn't napped for a long time or is very tired because of unhealthy sleep habits in general, try the methods described on page 313 for how to reestablish naps in the older child.
Q: My problem is not that my child refuses to nap or resists naps, but that her nap schedule is very irregular. What's wrong?
A: If your child is well rested, it may be that you are in fact very sensitive to her need to sleep and place her in an environment conducive to sleep when she needs it. Differences in daily activities produce differences in wakeful intervals and differences in the duration and timing of naps. Perhaps you have unrealistic expectations regarding the regularity of naps according to clock times. If your child is very tired, however, she might be crashing at irregular times when she is totally exhausted. A common problem here is a slightly too-late bedtime. Early bedtimes appear to regularize and lengthen naps.
Q: My problem is that my baby takes such long naps that we don't have much time to play together. Are long naps a problem?
A: There may be a problem if your child snores or mouth-breathes when asleep. These are symptoms of respiratory allergies or large adenoids or tonsils (see Chapter 10). Another possible problem is that the bedtime is too late and the long naps are attempts to compensate for the lost sleep. In the long run, this compensation will fail because the too-late bedtime causes cumulative sleep deficits.
Getting Up Too Early
Getting up too early is another major problem in toddlers. The first question to ask is: How early is too early? If your child gets up at 5:00 or 6:00 A.M. and is well rested, perhaps this pattern is not changeable. You may wish to try encouraging her to sleep later by making the room darker with opaque shades. Getting everyone together in a family bed at that hour may also allow all of you to get some more snooze time. Often families have established the habit of giving the baby a bottle at this early hour, after which she returns to sleep for a variable period of time.
While bottles given early in the morning may help the child return to sleep, be aware that if the baby is allowed to fall asleep with a bottle of milk, formula, or juice in her mouth, the result is decayed teeth. This will not occur if the bottle contains only water. Unfortunately, many parents go to their child at 4:00 or 5:00 A.M. with a bottle of milk and then let the baby feed herself.
Treatment for the well-rested child who has the early-morning-bottle habit is to first switch to juice, and then gradually, over about a week, dilute the juice more and more, until it is only water. Once the child is drinking only water, place a water bottle at either end of the crib and point them out to her at bedtime.
One mother used to allow her child to watch a videotape every morning as soon as she woke up. This allowed the mother to have some free time to take care of herself. Her child woke up earlier and earlier in order to enjoy the videotape. Stopping the routine of watching videotapes in the morning was part of the solution.
If your child wakes up too early and is not well rested, work hard to establish a healthy sleep pattern. In the morning, don't go to her until the wake-up hour.
REMEMBER
Getting up too early may be caused by going to sleep too late. Earlier bedtimes often prolong night sleep and prevent early wake-ups.
For a three-year-old child, we can try a variation of controlling the wake-up hour using stimulus control. We previously used a timer as a signaling device at bedtime. Now we are going to use a digital clock. Place a digital clock in her room and set the alarm for 6:00 or 7:00 A.M., which may be after the expected spontaneous wake-up time. Draw a picture of the clock face showing 6:00 or 7:00—the time that co
rresponds to when the alarm will go off. You do not respond to her cries before this wake-up time. Then, at the wake-up time you have picked, you bounce into her room, exclaim how the clock matches the picture, shower her with affection, open the curtains, turn on the lights, bring her into your bed, or give a bath. Be dramatic, wide-eyed, and happy to see her. Point out the numbers on the digital clock and on the picture of the clock and exclaim, “Oh, see, it's time to start the day!” The child learns that the day's activities start at this time. The pattern on the digital clock acts as a cue, just as a green traffic light tells you to start moving. Before the wake-up time, the child has her water bottles but no parental attention.
Resistance to Falling Asleep/Night Waking
The last major problem centers on enforcing the bedtime hour and on waking at night. Time cues can also be used as stimulus control to enforce the bedtime hour. Use a digital clock and say, “Oh, look, it's seven o'clock [say “seven, zero, zero”], time for your bath.” After the bath, hugs, stories, and kisses, say, “It's now seven-thirty [seven, three, zero], time to go to sleep.” Then turn out the lights and close the door. No returning or peeking. The child learns that after a certain hour, no one will come to play with him, so he falls asleep and stays asleep until the morning. He learns to amuse himself with crib toys or other toys in his room until the wake-up time.
If your child has had a long history of resistance to falling asleep or of night waking, then read the earlier chapters and work on establishing a healthy sleep pattern in general. Prepare yourself for some long or frequent bouts of crying as you extinguish the habit. A fade procedure probably won't work if your child is chronically tired and has long-standing disturbed sleep; he'll outlast you. The following published account of a cold-turkey strategy in a twenty-one-month-old boy shows that it is effective, that the improvement occurs over several days, and that the treatment has no ill effects. This account was published in a professional journal for psychologists, so please forgive the dry style of writing.
CASE REPORT: THE ELIMINATION
OF TANTRUM BEHAVIOR
by Carl D. Williams
This paper reports the successful treatment of tyrantlike tantrum behavior in a male child by the removal of reinforcement. The subject child was approximately twenty-one months old. He had been seriously ill much of the first eighteen months of his life. His health then improved considerably, and he gained weight and vigor. The child now demanded the special care and attention that had been given him over the many critical months. He enforced some of his wishes, especially at bedtime, by unleashing tantrum behavior to control the actions of his parents.
The parents and an aunt took turns in putting him to bed both at night and for the child's afternoon nap. If the parent left the bedroom after putting the child in his bed, the child would scream and fuss until the parent returned to the room. As a result, the parent was unable to leave the bedroom until after the child went to sleep. If the parent began to read while in the bedroom, the child would cry until the reading material was put down. The parents felt that the child enjoyed his control over them and that he fought off going to sleep as long as he could. In any event, a parent was spending from one half to two hours each bedtime just waiting in the bedroom until the child went to sleep.
Following medical reassurance regarding the child's physical condition, it was decided to remove the reinforcement of this tyrantlike tantrum behavior. Consistent with the learning principle that, in general, behavior that is not reinforced will be extinguished, a parent or the aunt put the child to bed in a leisurely and relaxed fashion. After bedtime pleasantries, the parent left the bedroom and closed the door. The child screamed and raged, but the parent did not re-enter the room. The duration of screaming and crying was measured from the time the door was closed.
The child continued screaming for forty-five minutes the first time he was put to bed. The child did not cry at all the second time he was put to bed. This is perhaps attributable to his fatigue from crying.
By the tenth occasion, the child no longer whimpered, fussed, or cried when the parent left the room. Rather, he smiled as they left. The parents felt that he made happy sounds until he dropped off to sleep.
About a week later, the child screamed and fussed after the aunt put him to bed, probably reflecting spontaneous recovery of the tantrum behavior by returning to the child's bedroom and remaining there until he went to sleep. It was necessary to extinguish this behavior a second time.
No further tantrums at bedtime were reported during the next two years.
It should be emphasized that the treatment in this case did not involve aversive punishment. All that was done was to remove the reinforcement. Extinction of the tyrantlike tantrum behavior then occurred.
No unfortunate side-or aftereffects of this treatment were observed. At three and three-quarters years of age, the child appears to be a friendly, expressive, outgoing child.
Q: Does this mean that after my baby falls asleep I can never peek, never go in to soothe or comfort him?
A: No. Only during the period when you are establishing a new sleep pattern is it important to avoid reinforcement. After your child is sleeping better and becomes well rested, there is nothing wrong with going in to check on him at night.
Q: I took his older brothers out of their bedroom so his crying wouldn't disturb them. When can they go back into their old bedroom?
A: Allow several days or a couple of weeks to pass before making changes. The more rested the baby becomes, the more flexible and adaptable he will be. Changes then will be less disruptive.
Q: My two-and-a-halfyear-old son understands what I'm saying; why can't I discuss these problems with him?
A: You want to avoid discussions or lectures at the time the problem is taking place because your reasoning calls attention to the problem and thus reinforces it. Instead, choose some low-key playtime to voice your concerns regarding his lack of cooperation. But when there is some cooperation, make sure to praise the specific behavior: “Thank you for staying in bed” or “Thank you for trying to sleep.” Praising the child (“Thank you for being a good boy”) does not tell him exactly what it is that you want him to do again.
Q: My fifteen-month-old child shows separation anxiety during the day, and at night she wants me to hold her and sit with her on the sofa until she falls asleep. How can I leave her alone at bedtime, when she is most anxious?
A: Separation anxiety, stubbornness, or simply exhibiting a preference for parents’ company over a dark, boring room might separately or in combination cause your child to behave this way. Please understand that it is normal for children to feel some anxiety, and learning to deal with anxiety and not be overwhelmed by it is a healthy learning process. Let's not use separation anxiety as an excuse for our own problems in dealing with a child's natural disinclination to cooperate at bedtime.
If there has been long-standing ambivalence or inconsistency regarding putting your child to bed at night, then the naturally occurring separation anxiety will only aggravate or magnify the problem. The same could be said of the naturally occurring fears of darkness, death, or monsters that children often express around age four. In order to deal with separation anxiety or fears at night, we must understand that all children experience them, and that they can learn not to be overwhelmed by them at the bedtime hour with the help of the consistent, calm resolve of their parents. The routine of a set pattern in a bedtime ritual reassures the child that there is an orderly sequence: Sleep will come, night will end, the sun will shine again, and parents will still be there smiling.
Some children go to bed later than I recommend and get up later in the morning. This may fit the parents’ lifestyle and they might not appreciate that this is not healthy for their child. One recent study examined children at eighteen months and again at three years and noted that those children who went to bed at a late hour not only woke up late in the morning, but they also had longer naps compared to those children who went t
o bed earlier. However, neither the late wake-up time nor the longer nap compensated for the reduced sleep time caused by the late bedtime. In other words, late bedtimes cause less sleep. In addition, sleeping out of phase with your natural rhythms, like shift workers or when crossing time zones, is as unhealthy as jet-lag syndrome.
PRACTICAL POINT
Don't hide behind excuses; there will always be one handy! Some families use extreme fussiness/colic (birth to six months), teething (six to twelve months), separation anxiety (twelve to twenty-four months), “terrible twos” (twenty-four to thirty-six months), and fears (thirty-six to forty-eight months), one after another, to “explain” why their child wakes up at night and has trouble returning to sleep by himself.
Summary
Previously, the terms sleep/wake organization (duration and time of occurrence of the sleep period) and sleep quality (consolidated or fragmented sleep and the duration of different stages of sleep) were introduced. Now add two more terms to the vocabulary. Temporal control means establishing age-appropriate sleep/wake schedules. In other words, the time when you do your soothing to sleep coincides with the naturally occurring biological rhythms of sleep. Stimulus control means that you are trying to avoid behaviors that disrupt sleep or are incompatible with sleep and promote behaviors that allow the sleep process to surface both at sleep onset and throughout the night.
Action Plan for Exhausted Parents
Months Thirteen to Fifteen: 1 percent have three naps, 43 percent have two naps, 56 percent have one nap
Earlier bedtimes usually help the child get through the transition to a single afternoon nap.
Healthy Sleep Habits, Happy Child Page 35