Behavioral Insomnia

Bedtime with our four-year-old has become Armageddon. How can we get her to go to bed without wearing all of us out?

Bedtime battles. You’re not alone. Somewhere between 20 and 30 percent of all children have some form of childhood insomnia. This can be the result of a medical issue, such as obstructive sleep apnea (yes, young children can develop this as well as adults.), medications, pain, and anxiety, as well as developmental issues. But far and away, the most common cause of sleep disturbances in children is something known as a “behavioral sleep problem.” This can come in various forms, but the most common are bedtime resistance/refusal, delayed sleep onset, and night-time awakenings. What can make it challenging—as if it wasn’t enough already—is that some of these problems can coexist.

This condition is most common in young children from birth to five years of age, but it can persist into middle childhood and adolescence. By definition, in order for your child to have a “sleep disorder,” the symptoms need to occur at least three times a week, and persist for at least three months. In addition, there has to be some degree of dysfunction in the child, parents, and/or family.

“Bedtime resistance” sounds straightforward. Every parent has experienced the child who refuses to go to bed, and we’ve heard a lot of different and imaginative excuses. Some degree of this is common, probably normal, but should be a passing problem. When it persists, difficulties arise. Delayed sleep onset is just what it says—a prolonged amount of time for your child to fall asleep. There is no specific number here, but 15-30 minutes is a reasonable expectation. Prolonged night-time awakening is frequently the first problem we encounter, and can easily result in insufficient sleep. Children experience a normal 60 to 90 minute cycling of specific types of sleep (REM as an example) and a certain amount of arousal occurs at the end of each cycle. Should the child awaken, they may not be able to go back to sleep. This is the 3 a.m. crying that awakens the entire house, or the toddler who climbs out of her bed and into yours.

These behavioral problems are generally caused by one of two things. The first is “sleep-onset associations.” The infant or child has learned to fall asleep only when a specific routine takes place. This can be rocking until asleep, or being fed right before sleep. This leads to the problem of the child awakening briefly during the night, but there is no one to rock or feed her. They are unable to “self-soothe” and simply seek their usual routine—loudly announced by their crying or getting out of bed. There are effective ways to deal with this, and we’ll look at those a little later.

The other factor that causes these behavioral problems is… you guessed it— inadequate or ineffective parenting. Here we see most of the verbal protests, active resistance, or repeated demands for stories or the presence of the parent. The disorder usually develops from our unwillingness or inability to set and keep bedtime rules. First-time parents are especially at risk, but so are those of us with much more experience and who should know better. It’s easy to fall into a routine that is harmful to your child, to you, and to the rest of the family.

But all of my four children have had problems with their sleeping. It must be genetic.

Hmm. All of your children…the problem might not be in their genes. In fact, we know that only about 25 percent of childhood sleep disorders are “intrinsic”—genetically influenced. The remainder and vast majority are due to “extrinsic” factors, such as parenting techniques, environmental factors (sharing of bedrooms, temperature), and emotional stress in the home.

So, given that the majority of children’s sleep disorders are “behavioral” and that the majority of those are due to “extrinsic” factors, let’s look at some proven ways to resolve these problems. And they can be resolved. More than 80 percent of children will see significant improvement with the use of simple techniques, and no study exists that shows any detrimental effects. In fact, once we’ve addressed and improved the sleep disorder, other positive things start to happen, such as better day-time behavior, less crying and irritability, and enhanced overall emotional well-being. That’s true for our children, and it’s true for everyone in the house. Now for those “simple techniques.” These can be divided into several types of interventions.

Bedtime routines.

This needs to be consistent and should routinely take 20 to 40 minutes. It’s okay to include several activities during this time, such as taking a bath, dressing in pajamas, and reading a story or two. The key is for any bedtime activity to be soothing. No television or electronic devices. It’s also okay to provide a comforting object, such as a blanket or toy. This can help your child fall asleep, and can also provide a source of comfort or “self-soothing” should they wake up during the night. And here’s an important point: your child should be put to bed when drowsy, but still awake. This will help reduce the need/demand for your presence as they fall asleep.

Systematic ignoring.

This addresses the problem of your child demanding your presence at the onset of sleep. This occurs when they demand that you stay in the room with them until he or she falls asleep. It also occurs when they awaken in the middle of the night. There are two ways to deal with this. The first is to let them “cry it out.” This works, and does no harm. But some parents, especially those with a first child, aren’t able to do this. That’s alright. We can accomplish the same goal by a gradual weaning of our presence in their bedroom. Again, it starts with putting your child to bed when drowsy but awake, and waiting for progressively longer periods of time to check on them. When checking, the time spent needs to be brief—only a minute or two—and with minimal contact. A pat on the shoulder is fine, but we need to avoid picking them up and cuddling them. That only reinforces the behavior we’re trying to alter, and is a step backwards.

Strategic napping.

This is where we need to know the recommended sleep requirements for our infant or older child and know that it includes night-time sleep and napping. As a general rule, children will need at least four hours between sleep periods in order to be able to fall asleep again. A late afternoon nap, extending into the early evening, can disrupt their normal routine.

This is a good time to consider your child’s “sleep window.” Once more, you need to know the amount of recommended sleep, based on their age. For example, a four-year-old needs 10 to 13 hours of sleep each day, including naps. If your daughter routinely takes a 2 or 3 our nap in the afternoon, you’ll need to match their “in bed” time at night to their remaining sleep requirement. That should be somewhere between 9 to 10 hours. If we put them in bed and expect them to stay there for 12 hours, we’ve created a mismatch. They will either take longer going to sleep or wake up earlier, both of which can be problems. It’s not rocket science, but it’s important. Know your child’s sleep requirement.

Positive reinforcement.

It’s true that you can catch more flies with honey than vinegar, but who wants to catch flies? We want our child to go to bed peacefully, get a good night’s sleep, and awaken alert and in a good mood. Positive reinforcement in the form of a reward is effective and acceptable. We need to keep in mind that any such reward needs to be immediate (the next morning), something obtainable (matching the desired behavior to something your child can do), and something that interests/motivates your child. Multiple small rewards seem to be more effective than a few larger ones.

With all that in mind, here are some pointers for your child’s healthy sleep:

• Have a set bedtime and routine, and be consistent.
• Weekday and weekend bedtimes should also be consistent, with no more than one hour of variance.
• Don’t send your child to bed hungry. A big meal just before sleep can be a problem, but a protein-rich snack will help.
• Make the hour before bed a shared and meaningful “quiet time.” These years and opportunities will pass all-too-quickly. Eliminate television, computer games, or high-energy activities.
• As your child gets older—and the same applies for you—avoid caffeine in any form for several hours before bedtime.
• Make sure your child is getting plenty of exercise, preferably outdoors, weather permitting.
• Make sure their bedroom is cool. It appears that 70 degrees or less provides the best temperature environment.
• Their room needs to be quiet and dark. A fan or “sleep machine” can provide soothing, ambient background noise. If a night-light is needed, make sure it’s not too bright.
• No TV in the bedroom!
• Don’t use your child’s bedroom for any form of punishment or “time out.”

Keep these things in mind, map out an appropriate strategy, and stick with it. It won’t happen overnight, but your child’s quality of sleep will improve, and everyone will rest a little easier.

And about Armageddon—remember who wins.

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This is an excerpt from the new book I’m writing with pediatrician Dr. Robert Alexander. The book will address 100 questions from parents regarding their children’s health. Feel free to email us with questions: askthedox@yahoo.com