I think this study points out the importance of working with professionals who can provide guidance that is directed toward changing the child's behavior without dwelling on current psychological/emotional problems within the mother or father. The exception, of course, is when these problems are directly related to marital discord or the parents’ ability to maintain a behavioral management program.
Another study from England included children who took at least an hour to go to bed, who woke at least three times a night or for more than twenty minutes at a time, or who went into their parents’ bed. Treatment started with the parents recording the present sleep pattern in a sleep diary. A therapist worked with the parents to develop a program of treatment based on gradually reducing or removing parental attention, adding positive reinforcement for the desired behavior, making bedtime earlier, and developing a bedtime ritual. Target behaviors were identified, and an individual treatment program was developed for each child. Also, mothers were evaluated for psychiatric problems. Mothers who showed psychiatric problems were more likely to terminate treatment, which again points out how stressful treatment can be. But for those families who completed four or five treatment sessions, 90 percent showed improvement. The authors concluded:
The evidence that children's nighttime behavior could thus change so radically, often within a surprisingly short time, suggests that parental responses were extremely important in maintaining waking behavior…. A rapid achievement of improved sleep pattern with reduced parental attention would be unlikely if anxiety in the child or lack of parental attention were causing the sleep difficulty. … Parents needed help in analyzing goal behavior into graded steps so they could achieve successes. Once some success was obtained, the morale and confidence of the parents rose and they were reinforced in their determination to persist by the more peaceful nights.
MAJOR POINT
The rapid improvement of sleep patterns produced by reduced parental attention tells us that neither lack of parental attention nor anxiety in the child was causing the sleep difficulty.
I have seen this over and over again; when you see even partial improvement, you gain confidence and you no longer feel guilty or rejecting when you are firm with your child.
Often it appears that the child is listening to the treatment plan in the office, because they often sleep better that very night, as if they knew something was going to be different. I think they are responding to the calm resolve and firm but gentle manner in their parents, which tells them that things are going to be different.
Another sleep strategy appropriate for three-year-old or older children is called “Day Correction of Bedtime Problems.” The idea here is that because everyone is tired and less able to cope with the stress of bedtime battles or night-waking problems at the end of the day, daytime behavior should be tackled first. The following instructions explain this strategy in detail. Under item number 3, “Relaxed,” the author says, “Perhaps the easiest way to teach self-quieting, during the day, is by allowing your child to self-quiet during naturally occurring times of frustration.” In my conversation with Dr. Edward Christophersen, a prominent child psychologist, he clarified this statement by explaining that you do not always rush to help a child struggling with a puzzle or accomplishing some task. When there is something that is slightly bothering him, it is sometimes better to leave him alone to learn to deal with it. Dr. Christophersen's observation is that some mothers need to be taught to disengage or ignore some of the child's low-level distress. He does not mean you should ignore your child when he comes home from school crying or has had a very frightening experience. In one study, when children learned how to cope with frustration during the day, they were observed to settle themselves better at bedtime and later at night when they awoke.
Day Correction of Bedtime Problems*
There are three important components to getting a child to go to sleep at night. The child must be:
Tired
Quiet
Relaxed
When these three components are in place, children who have adequate “self-quieting skills” will be able to go to sleep rather easily.
1. Tired. The easiest way to make sure that your child will be tired when he or she goes to bed is by getting him or her up at the same time every day and by getting him or her an adequate amount of exercise during the day—vigorous exercise that requires a good deal of energy. For an infant include several long periods of time when he or she is on the floor and can see what you are doing, but the infant must hold his or her head up in order to really see much. For almost any child, twenty minutes of good exercise each day, after a nap, is usually adequate.
2. Quiet. You can elect to either quiet down the entire house or quiet down your child's room. Quieting down your child's room by closing the door and keeping it closed is probably the easiest. … You might need to turn on the furnace or air-conditioning fan as a masking noise for the first few nights.
3. Relaxed. Children can relax only if they have learned self-quieting skills. Self-quieting skills refer to a child's ability to calm himself or herself, with no help from an adult, when the child is unhappy, angry, or frustrated. Whereas older children (at least age six years) can be taught relaxation procedures, infants and toddlers need to practice self-quieting skills in order to know what works for them. Perhaps the easiest way to teach self-quieting during the day is by allowing your child to self-quiet during naturally occurring times of frustration.
Self-quieting behaviors. The baby who goes to sleep with help from one of his or her parents by nursing, rocking, or holding learns only adult transition skills and needs an adult present in order to fall asleep. The baby or toddler who goes to sleep alone cuddling a stuffed animal, holding his or her favorite blanket, or sucking his or her thumb learns valuable self-quieting skills that can be used for many years to come.
How they feel. Children who go to bed easily and sleep through the night uninterrupted get a good night's sleep. They will feel better during the day, just as the adults in their household will feel better during the day. It may take from several nights to one week to teach a child the skills he or she needs for going to sleep alone, but this is one behavior that the child will be able to use for the rest of his or her life.
These three components described here have the added advantage that they can be taught during the day, which removes many of the fears parents have about handling behavior problems at bedtime. Even parents who choose cosleeping can allow their infant or toddler the opportunity to fall asleep on their own, with the parent joining the child at the parents’ regular time for retiring. In this way, the infant or toddler gets the perceived advantages of cosleeping and the known advantages of learning self-quieting skills.
Q: How important are regular bedtimes’?
A: In general, the bedtime should reflect your child's needs. With decreasing naps and increasing physical activity, your child's night-sleep needs may increase. Therefore, the bedtime often needs to be earlier not later simply because he is older. To maintain orderly home routines such as meals and baths, you might want to keep the bedtime within a narrow range.
Dr. John Bates's study on 204 four-to five-year-olds examined in great detail the home environment, behavior at preschool, and sleeping patterns. The researchers noted that the more variable bedtime, as well as the lateness of bedtime, predicted poor adjustment in preschool, even after considering the roles of family stress and family management/discipline practices. This study provides evidence that sleep problems directly cause behavioral problems in children at preschool. Other research suggests that when older children are overtired, they learn to no longer bother their parents, but instead, they bother their teachers.
Regularizing the sleep/wake schedule has also been shown to reduce daytime sleepiness and promote long-lasting improvements in alertness for well-rested young adults. It appears that regularity itself improves the ability of sleep to reverse daytime drowsiness. But some children are so excit
ed at the end of the day, they have trouble unwinding whether they are overtired or not. Hot lavender bubble baths (described in the next chapter) may help make the transition to sleep easier.
Some previously well-rested children who slip into a night-waking mode need only gentle reminders to return to sleep. My wife used to teach the “dolphin game” to one of our sons. She would read a story about how the dolphin swims deep in the water but sometimes has to come up for air before returning to a deep swim. Then she told our son to pretend that he was a dolphin at night and that it was perfectly all right to come up from sleep, but that he had to go back by himself. It worked.
Some previously very overtired children are so unmanageable at night that the family resources are stretched to the limit. In such cases the idea of more extreme measures may come up.
Q: Do I ever lock my child in her room?
A: Let's say that you've already tried other sleep strategies, patient reasoning, threats, and criticisms. Perhaps you've even tried spanking, which of course never works by itself, but all methods have failed. Also, let's assume that you are not working with a therapist to gradually reduce reinforcing behaviors. What's left to be done? Maybe the answer is a stiff door hook that, when locked, holds the door in a slightly open position but prevents opening or completely closing. The door is held locked in a slightly open position to protect the child's fingers from a crush injury. Completely closing and locking the door may be an overwhelming degree of separation for either you or the child.
By doing this you establish the unambiguous message that leaving the room after a certain time is unacceptable. The child learns that you mean business. The usual result is that after a night or two the child negotiates to stay in bed, and does, even if you do not lock the door. Also, you avoid the repeated prolonged stresses of your trying to physically separate from a child who is clinging to you, or of trying to pull the door closed while your child is in the room trying to pull the door open.
Take your child with you to the store when you purchase the lock, and make your child watch you install the lock on the door. Often this observation alone will cause a change in your child's behavior. In fact, for many families who once had a well-rested child, they never actually had to use the lock, because the child knew on the first night that this was the beginning of a new routine.
Simply locking the door solves nothing if your child is going to bed too late, getting up too late, not getting the nap he needs, taking a nap too late in the afternoon, having a very irregular bedtime, or talking to you through the closed door. You will still have an overtired child. No quick fix, whether a locked door, or, worse, drugs to make your child sleep, will make an overtired child less tired.
SLEEP RULE
#5
Do not leave your
room until you hear
the music (or the
birds, or the alarm).
Sleep rules, as described in the previous chapter, are often helpful. Rewards are frequently used to encourage the child to cooperate. They must be items the child really wants. One mother rewarded cooperation by placing a piece of candy under a special doll after her child had gone to sleep; part of the motivation was the excitement of discovery in the morning when the child looked for her treat. Paper stars on a chart may be used, but by themselves might not be sufficiently motivating. One strategy that often works is withholding a favorite wholesome food and giving it only as reward for cooperation. Other rewards might be small toys, surprise trips, or wholesome snack foods. By using a timer, you can give measured amounts of extra time for games, stories, TV, or free play as rewards. As the new behavior becomes a habit, the expectation of a specific reward is usually forgotten and the child's heightened self-esteem seems to substitute for the pleasure of the reward.
Now, let us consider the fifth sleep rule for the older children.
This rule is for older children who like to get up too early, leave their room, and bother their brother, sister, or parents. Set a clock radio, a CD player on a timer, or an alarm clock—placed under a pillow to muffle the loud noise—to the time it is okay for your child to leave her room. Some children who have never slept well and have just turned three might completely disregard all five sleep rules and trash their room or simply stay up late playing in their room with the lights on. These children might have to be placed in a crib with a crib tent for a while, or maybe the lightbulbs have to be removed to keep the room dark.
Q: Why can't I just keep my child up later at night to see if he will sleep in later in the morning?
A: If your child has been well rested up to now, then slowly try a later bedtime. If you move it too late, he might just become more overtired and have difficulty falling asleep and staying asleep in the morning. If your child has always been a problem sleeper and overtired, a later bedtime will only make matters worse.
Q: My child is scared at night and I don't want to leave her alone.
A: Try to spend extra time soothing her to sleep, buy a dream catcher or guardian angel to protect her, or go around the room catching all the monsters and put them in a bag that you take out of the room. Maybe give her a bell that she can ring once at night when she is scared, and you then respond promptly and use a timer for a measured amount of middle-of-the-night soothing. This could be a sixth sleep rule: If you are scared, ring the bell and I will come, but I will come only once. Tell her not to abuse ringing the bell. Ringing the bell many times would violate the sleep rule.
PRACTICAL POINT
Always reward even partial cooperation: small rewards for small efforts, bigger rewards for more cooperation. Rewards are best given in the morning after awakening or immediately following a nap.
Day Sleep
You may conclude that life is impossible if your child does not take a nap, but it is also impossible to get him to nap. You've worked at sleep schedules, night wakings, and resistance to sleep, and things are better, but he also really needs a nap. Not necessarily a long one, but no nap at all is no good.
Some parents have successfully reestablished naps as a routine even when the naps have been absent or sporadic for several months. The method involves taking a nap with your child (at least initially): Take her into your own bed, dress yourself for sleep, and nap together. The idea is to make this a very comforting, soothing event. Try to be fairly regular according to clock time. Use a digital clock as a cue, and be consistent with the routine of cookies and a glass of warm milk or reading from a favorite book. Try to fall asleep yourself.
Tell your child what is expected of him. If he sleeps with you, then A occurs; if he rests quietly next to you but doesn't fall asleep, then B occurs. You decide what kind of reward A and B will be. If he doesn't cooperate at all and jumps on the bed or runs around the room, then you might restrict or withdraw some pleasurable activity or privilege. If you are able to get him to nap with you, then eventually you'll want to try to shift him into his own room for a nap. This should be done in a graded or staged fashion. You might decide that the next step is for the child to be in his bed and you're in the room resting as long as needed. Rewards are now given only for this new behavior. This process of reinforcing successive approximations to the desired target behavior is called “shaping.”
Preschool children who slept well when they were younger might develop problems because too many activities interfere with napping or, as discussed in Chapter 10, because allergies interfere with sleep at night. Reorganizing daytime activities or managing allergies may provide a rapid solution. On the other hand, preschool children who have not previously slept well may have ingrained habits or expectations that are not easily changed. Parents should seriously consider working with a professional if they think their child is so tired that he might not do well in school.
One recent study of 499 children from ages four to fifteen showed that sleep problems at age four years predicted behavioral and emotional problems, such as depression and anxiety, in adolescence. So, although your older overtired chil
d may not bother you as much as he did when he was younger, that does not mean that the problem has gone away.
No Apparent Solution
Parents with older children have more scheduled activities to attend and they are more likely to have more than one child requiring attention. What happens if the parent is a shift worker, or works in a bakery or restaurant, or travels a lot for her job, or has irregular hours built into the job like some physicians? It is hard to be with your children when they participate in an important scheduled school or sports event. I have met some mothers and fathers who are absolutely dedicated to their children and try very hard to strike a balance between the time requirements of child care and their work outside the home. Usually there is a sharing of responsibilities regarding putting the children to sleep at night. However, what do you do if both parents have work schedules that make it difficult to be home reasonably early at night for bedtimes? To further complicate matters, one parent alone cannot easily manage different bedtimes for two or more children. To make it even more of a problem, what if the parents are blinded by their love for their children and cannot see that the late afternoon tiredness, headaches, or developing academic problems are connected to unrelenting mild sleep deprivation in their child? For some parents, it appears impossible to change his or her lifestyle or work schedule in order for their children to have a reasonably early bedtime. When the children were much younger, as infants and preschoolers, morning times were available to enjoy being together as a family, but now mornings are a frantic blur trying to get ready for out-of-the-house activities. So the night is the only quiet and relaxed time the family has together. These factors converge into a too-late bedtime. The solution is apparent, but not easy.
Healthy Sleep Habits, Happy Child Page 37