Disturbed Sleep
We really do not know how young children feel because they cannot talk to us; all we can do is observe them and guess their feelings. When they do not sleep well, their behavior changes and presumably they feel worse. I think we should carefully consider how we feel and behave when our sleep is disturbed, so that we can better understand and sympathize with our children.
Daytime sleepiness resulting from disturbed sleep typically causes us to feel a mild itching or burning in the eyes. Our eyelids feel heavy. Our limbs feel heavy, too, and we tend to be lethargic. We are less motivated, lose interest easily, and have difficulty concentrating. Our speech slows; we yawn and rub our eyes. As we get sleepier, our eyes begin to close and we may even find our head nodding.
But this familiar picture of adult sleep is not usually seen in infants and young children who suffer from disturbed sleep. While it is true that infants who are usually well rested yawn on occasions when they are overtired, it seems that chronically tired infants do not yawn much or nod off. Instead, when most tired young kids get sleepy, they get grumpy and excitable. My first son at age three coined the perfect word to describe this turned-on state: upcited, a combination of upset and excited, as in “Don't make me upcited!” when we admonished him for behaving like a monster.
Mood and Performance
Before we look at common sleep problems, let's review how disturbed sleep affects mood and performance.
REMEMBER
When your infant or young child appears wired, he may be tired.
Two very interesting Australian studies on adults have helped to shed light on childhood “upcited” behavior. One study showed that the level of activation of the nervous system was associated with certain personality traits, sleep habits, and activity of the adrenal gland. Poor sleepers were more anxious and had higher levels of the hormone cortisol, which typically rises during stressful situations.
The second study was complex, but I think its results will better help you to understand your child's behaviors.
Adult volunteers report their moods on four scales:
1. Tired to rested
2. Sluggish to alert
3. Irritable to calm
4. Tense to relaxed
The first two scales reflect degrees of arousal, while the third and fourth scales reflect degrees of stress.
The researchers measured four different chemicals (cortisol, noradrenaline, adrenaline, and dopamine) that our bodies make naturally. These powerful chemicals affect our brain and how we feel, and they are related to the four scales in different ways.
For example, fatigue produces an increase in adrenaline concentrations. That is, when we are tired, our body chemically responds with a burst of adrenaline to give us more drive or energy. We become more aroused, alert, and excitable. Concentrations of cortisol, a stress-related hormone, also increase with increasing alertness. In children, cortisol concentrations remain high when they do not nap. Perhaps the nap allows the brain to be alert without needing the added boost cortisol would provide. Increasing irritability and tenseness—stress factors—are both associated with increasing concentrations of adrenaline, noradrenaline, and dopamine. Yet the specific chemical patterns or biochemical fingerprints for irritability and tenseness are not the same.
These studies support the notion that when an overtired child appears wired, wild, edgy, excitable, or unable to fall asleep easily or stay asleep, he is this way precisely because of his body's response to being overtired. Think of how you feel when you work hard and lose sleep in order to finish a major project. You are highly motivated and fight the daytime sleepiness. The impairments of performance and discomfort of sleepiness increase. After a while, you feel keyed up. This hyperalert state is a natural, protective, biologically adaptive response that enabled Neanderthal man to fight, flee, or hunt prey even when tired. Thankfully, modern man is able to get out of this state by taking vacations. But have you noticed how, at the start of a vacation, it takes a few days to unwind?
IMPORTANT POINT
Some chronically tired children are always keyed up and never unwind.
It's a vicious circle: sleep begets sleep, but sleeplessness also begets sleeplessness. When babies miss the sleep they need, the fatigue causes a physical or chemical change in their bodies. These chemical changes directly affect their behavior and interfere with maintaining either the quiet alert wakeful state or blissful sleep. The children are fractious because they are overtired.
Other studies also have proven that adults who sleep for only brief durations are more anxious. When we study adults who are irritable, feel tense, are poor sleepers, and have high concentrations of these hormones, we find the old chicken-or-egg dilemma: Which came first?
I think an experience familiar to all of us can help resolve the dilemma. As previously described, if we work hard to get an important job done, we can push our bodies with lots of caffeine-laden coffee and cola and very little sleep. At the end of the project, though, if we suddenly stop and take a vacation, it takes a few days to get rid of our accumulated nervous energy. We really cannot enjoy low-intensity pleasures, like walking barefoot on the grass or playing quietly with children, because we are all keyed up. After a few days, we eventually calm down, unwind, and relax, and then we can enjoy recreational reading and quiet activities. This tells me that our lifestyle and sleep habits can affect our internal chemical machinery, which in turn causes us to feel certain ways. In a study at Dartmouth College, coronary-prone type A students had more night wakings than type B students. A vicious circle could develop whereby the fragmented sleep causes increased arousal, the student feels more energized, and, sensing this greater level of energy, works even harder late into the night to achieve more, but at the same time loses more sleep.
IMPORTANT POINT
Loss of sleep produces central nervous system hyperarousal.
Babies only two or three days old also have elevated cortisol levels during the period of behavioral distress following circumcision. Infants over four months of age as well as older children can push themselves hard fighting sleep in order to enjoy the pleasure of their parents’ company and play. The resulting sleep disturbances might produce fatigue, and the body would naturally respond by turning up production of those chemicals, such as cortisol, responsible for maintaining alertness and arousal. Perhaps researchers may someday find that different patterns of sleep deprivation (total sleep loss, abnormal schedules, nap deprivation, or sleep fragmentation) produce different patterns of chemical imbalances.
Here are some terms used by professionals to describe the behavior of hyperalert, or “wired,” children with disturbed sleep:
· Physiological activation
· Neurological arousal
· Excessive wakefulness
· Emotional reactivity
· Heightened sensitivity
Obviously we all get slightly irritable, short-tempered, and grumpy when we do not get the sleep we need. Jokes and cartoons don't seem very funny when we're tired. But children might be even more sensitive to mild sleep loss, and yet simply appear to be wilder or more unmanageable. Perhaps off-the-wall behavior in children is due to sleep loss that is severe, chronic, and prolonged but not recognized as such by parents.
So often I have heard comments like “She's so tired, she's running around in circles.” This is not a new observation; a classic paper published in 1922 described the “increased reflex-irritability of a sleepy child.” In dramatic contrast, over and over again I have seen well-rested children in my practice who spend enormous amounts of time in a state of quiet alertness. They take in everything with wide-open eyes, never missing a thing. They find simple little toys amusing or curious. They never appear bored, although the toy they pick up is one they have played with many times. Parents of children four to twelve months of age can dramatically change their children's behavior depending on how much sleep they allow their kids to get.
In a study published in 2002 of four-to five-year-olds, author John E. Bates stated, “In clinical treatment of young, oppositional children, we have seen some spectacular improvements in manageability associated with the parents instituting a more adequate schedule of sleep for their children. Our clinical impression in these cases was that the changes were too rapid to be accounted for by other changes, such as parental discipline tactics.”
REMEMBER AGAIN
A sign of sleeping well is a calm and alert state. Upon awakening, well-rested children are in good cheer and are able to play by themselves.
I believe that in infants and young children, a cause-and-effect relationship exists between disturbed sleep and fitful, fussy behaviors. In addition, as described in Chapter 2, the harmful effects of excessive daytime sleepiness do not stay the same, but rather tend to accumulate. This means that there is a progressive worsening in a child's mood and performance even when the amount of lost sleep each day or night is constant. So a baby becomes increasingly crabby even if her nightly sleep is constantly just a little too brief.
PRACTICAL POINT
A constant small deficit in sleep produces a cumulative reduction in daytime alertness.
As the child develops, the relationship between disturbed sleep and problems of mood and performance becomes less clear because of the increasing complexity of psychological and intellectual function. It is even possible that chronically disturbed sleep causes children to grow up experiencing excessive daytime sleepiness, low self-esteem, or mild depression. In one study, about 13 percent of teenagers with disturbed sleep were reported to be like this. They usually took longer than forty-five minutes to fall asleep or woke frequently at night. Some of these teenagers may simply have never learned self-soothing skills to fall asleep easily when they were much younger. As adults, they are described as insomniacs.
One theory of adult insomnia is that it is characterized by an internalization of emotions associated with a heightened or constant state of emotional arousal plus physiological activation, which causes disturbed sleep. But distinct differences exist between adult insomniacs whose insomnia started in childhood and those whose insomnia started in adulthood. The childhood-onset insomniacs took longer to fall asleep and slept less than the adult-onset insomniacs. I think this kind of data tends to support the notion that the failure to establish good sleeping habits in infancy or early childhood may have long-term harmful effects, such as adult insomnia. And among psychologically unhealthy adults, the more severe the sleep difficulty, the more severe the degree of mental illness.
Let's now review some of the most common sleep problems that can disrupt our children's sleep and their solutions.
When you consider solutions for your child's sleep problems, it is important to think of healthy sleep as a collection or group of five related elements, described in Chapter 2, grouped together to form a “package.”
FIVE ELEMENTS OF HEALTHY SLEEP
1. Sleep duration: night and day sleep
2. Naps
3. Sleep consolidation
4. Sleep schedule
5. Sleep regularity
All five elements must be present to ensure good-quality or healthy sleep. In the following discussions, I might emphasize one part of the “package” as being especially important for solving a problem, but keep in mind that the solution might fail if other elements of healthy sleep are absent. Also, some sleep problems occur at specific ages. Here, I will provide a brief outline of the solution and I will refer you to the chapter appropriate for your child's age for more detailed instructions. It is best to first read here and then read the appropriate chapter for your child based on his age. Reading the preceding and following age-appropriate chapters will also help.
For any particular problem, there may be more than one cause or solution. Your child's age and temperament might influence which solution you will want to try first. Also, not all solutions are practical for all families. So please read the entire section for any particular problem before trying to help your child. Also, because many of these problems are interrelated, it might be worthwhile to browse through this entire chapter; you might discover some additional solutions. One important principle for solving sleep problems is to execute a schedule or behavioral change for several days to determine whether the change helps before making another change in routine. Be patient and keep a sleep log.
Sleep Log
A sleep log is a series of bar graphs showing on each day when your child was awake, asleep, quiet in bed or crib, and crying in bed or crib. On the horizontal axis, show the day of the week and on the vertical axis, the time of day. Each bar represents a twenty-four-hour snapshot of a day and the graphic view of all the bars allows you to see trends in sleeping patterns. A detailed diary makes it hard to see the forest for the trees.
REMEMBER, SLEEP BEGETS SLEEP
The more rested you are, the easier it is to fall asleep and stay asleep. The more tired you are, the harder it is.
Excessive Daytime Sleepiness
Superficially, we tend to think of being either awake or asleep. But just as there are gradations between light sleep and deep sleep, there are gradations of wakefulness. Task performance, attentiveness, vigilance, and mood may be influenced by the degree of daytime wakefulness. When we do not feel very awake during the day, we say that we feel “sleepy.” Excessive daytime sleepiness or impaired daytime alertness is a result of disturbed sleep.
The Stanford Sleepiness Scale is a self-rating instrument developed at Stanford University to describe the different states or levels of daytime sleepiness. Obviously, children who are depressed or irritable due to sleep deprivation will have high numerical ratings.
LEVEL DESCRIPTION
1. Feeling active and vital; alert; wide awake
2. Functioning at a high level, but not at peak; still able to concentrate
3. Relaxed; awake; not at full alertness; responsive
4. A little foggy; not at peak; let down
5. Fogginess; beginning to lose interest in remaining awake; slowed down
6. Sleepiness; preferring to be lying down; fighting sleep; woozy
7. Almost in reverie; sleep onset soon; lost struggle to remain awake
Morning Wake-up Time Is Too Early
Make sure that the bedroom is dark and quiet in the morning. Window-darkening shades and a white noise machine or noise from a humidifier will help reduce the startling effect of street noises. Keep a sleep log to help find the best bedtime.
The most common cause for waking up too early before four months of age is extreme fussiness/colic (see Chapter 4). The most common cause, after four months, is a too-late bedtime.
If you suspect the bedtime is too late, slowly make the bedtime earlier. Try twenty minutes earlier for four nights to see whether your child will fall asleep at the earlier time and sleep in later. Do everything you currently are doing at bedtime but simply start the bedtime ritual at an earlier time. If this seems to help a little, repeat the process with an additional twenty-minute earlier bedtime for four more nights. You can again repeat this process until it is clear that you have reached a too-early bedtime because your child no longer easily and promptly falls asleep. Now you might want to return to the last step and let your child stay up an additional twenty minutes. This gradual shift in bedtime may produce no protest crying.
If you think the bedtime is too late because your child appears tired much earlier, then move the bedtime much earlier right away. The abrupt shift may or may not produce protest crying. For young children, at night, use Ignoring, discussed on page 211; Partial Ignoring, discussed on page 214; or Check and Console, discussed on page 215. For older children, use Sleep Rules, discussed on page 325 and 353, or Silent Return to Sleep, discussed on page 320. Ignoring your child until 6:00 to 7:00 A.M. will probably be needed. For younger children, the option of bringing them to your bed for soothing may produce extra ZZZs in the morning.
Sometimes, after four months, a child is already going to bed very early, around 5:30 or 6:00 P.M. The entire schedule becomes shifted: too early a wake-up time causes too-early or poorly timed naps and a very tired child in the late afternoon who goes to sleep easily very early in the evening. For young children, it should help to simultaneously move their bedtime a little later, maybe twenty to thirty minutes every four nights, and ignoring them until about 6:00 A.M. For older children, use the fifth Sleep Rule, discussed on page 353, with a clock radio to tell them when they can leave their room. If you move the bedtime too late, your child might become so overtired that the wake-up time does not become later, instead he simply wakes up more overtired. However, for some older, persistent children, I have temporarily pushed the bedtime to a very late hour and it caused them to sleep in later. They receive lavish praise and token rewards (such as a small treat, stickers, or stars) for sleeping in later. Then the bedtime is slowly and gradually moved to an earlier time but the later wake-up time is preserved because the child continues to receive the praise and rewards.
Finding the bedtime that is just right for your child might require some back-and-forth adjustments; make one change and then wait four days to see whether it helps. And be patient.
Morning Nap Is Absent, Too Short,
Too Long, or at the Wrong Time
The morning nap develops at three to four months of age in 80 percent of children and a few months later in 20 percent of children who had colic. Correcting a too-early wake-up time or a too-late bedtime might be needed.
Sometimes the morning nap is short because that is all the sleep your child can get at that time—that is, your child is a short napper. About 20 percent of children between about six and twenty-one months always have short naps in the morning and afternoon, no matter what parents do. Between six and nine months of age, they may appear to be too short because the child requires many short naps, or “snaps,” throughout the day and often appears tired. As long as the bedtime is early, by nine or twelve months, most of these children are taking fewer and longer naps and no longer appear tired. I think that most of these short nappers are those who had colic when younger.
The most common cause of an absent or a too-short morning nap is an interval of wakefulness that is too long between the wake-up time and the beginning of the nap. For the child under four months of age, sometimes starting the morning nap after only one hour of wakefulness allows the child to be soothed back to sleep before she becomes overtired. In an older child, starting the nap at the wrong biological time may either shorten the nap or make it less restorative; either too early or too late, it messes up the rest of the day. Use the morning nap rhythm that is well developed, 9:00 to 10:00 A.M., as an aid to help the child sleep. If needed, stretch the interval of wakefulness using 9:00 A.M. as your target time. You might only get to 8:30 or 8:45 A.M. because your child is becoming overtired. It's a balancing act: You want to start the nap when the biological nap time begins, but you also want to avoid the overtired state. You are willing to allow the child to become a little overtired but not become so wigged-out that he has great difficulty falling asleep.
Sometimes an older brother or sister has a scheduled activity that interferes with the morning nap. Some options are to try to get relatives or a neighbor to watch your younger child at home while you drive your older child to the activity, or try to carpool to reduce the number of days per week your younger child misses out on a good morning nap. Often the young child might fall asleep in the car seat during the drive and the parent allows the child to continue to nap in the car seat, either in the car or when the car seat is placed in the crib. It looks awkward to us, but many young children appear to sleep well in the cozy car seat.
Sometimes the wake-up time is too late because the bedtime is too late and the child cannot fall asleep at 9:00 or 10:00 A.M. “Control the Wake-up Time” simply means waking your child around 7:00 A.M. in order to get a good-quality nap to begin around 9:00 A.M. TO avoid an overtired child, the bedtime will have to be moved earlier. Parents or a parent may not like this solution because they like to play with their child late at night and/or they like to sleep in later in the morning.
If the morning nap is too long or too late in the morning, it may interfere with your child's ability to fall asleep easily around 12:00 to 2:00 P.M. for the second nap, and the result is an overtired child by late afternoon. The reason the morning nap is too long or too late is usually because the bedtime is too late. Limiting the morning nap to one to two hours by waking your child is necessary because it is important to protect the second nap. At the same time, moving the bedtime earlier will cause your child to awaken in the morning better rested, and this will then automatically shorten the morning nap.
NAP HINTS
Before the morning or afternoon nap, go outside to, briefly but intensely, stimulate your child with physical activity at the park or in the sandbox; expose your child to light, wind, clouds, voices, music, traffic sounds; go for rides in the jogger or stroller. Then tone it down as you get near nap time. Now spend an extra long time soothing; include a bath if it is soothing in the nap time routine. Make the room dark and quiet.
Afternoon Nap Is Absent, Too Short, Too Long, or at the Wrong Time
The afternoon nap usually lasts until about three years of age and gradually disappears after the third birthday. If the afternoon nap disappears too soon, your child may become overtired in the late afternoon and have difficulty falling asleep at night. Either reestablishing the afternoon nap (if your child is substantially under age three) or moving the bedtime earlier (if your child is substantially over age three) should help. If the afternoon nap persists in much older children the bedtime might progressively get later and later, causing bedtime battles to develop. Eliminating the afternoon nap will permit an earlier bedtime and help erase bedtime battles.
Bad timing is a common cause of problems associated with the afternoon nap. If the afternoon nap is too early, way before noon, because of a too-short morning nap, it will not be as restorative and your child might be way overtired by late afternoon. One mother said her son was a “French fry” by the end of the day because he was crispy. Under nine months of age, this might lead to a late or long third nap that causes the bedtime to become too late. If the afternoon nap is too late, way after 2:00 P.M., it may interfere with an early bedtime.
Sometimes the afternoon nap conflicts with scheduled activities, such as preschool for the child or scheduled activities for the older brothers and sisters. Try to minimize these conflicts regarding the older children by using baby-sitters, car pools, or skipping some, but not all, of the classes for your infant. An earlier bedtime might be essential when the afternoon nap is shortened or skipped.
Day care may be associated with poor-quality naps because there is bad timing, too much noise, not enough help for long soothing, or crying from other children. The morning nap usually goes easier in day care because the child is already better rested in the morning from the previous night's sleep. Sometimes there are no alternatives available to the family in their choice of day care, and although it is especially hard on these families, an earlier bedtime will help these children.
IMPORTANT POINT
If the morning or afternoon nap is sometimes way too short or skipped, try to keep the child up and go to the next scheduled sleep time, but move it a little earlier. Protect the sleep schedule.
Third Nap Is Absent, Too Short,
Too Long, or at the Wrong Time
The third nap, around 3:00 to 5:00 P.M., is variable: It may be short, long, or absent. It usually disappears by nine months of age. If it is a long nap, your child might be able to go to bed later at night. But if it is too long, the very late bedtime might become associated with bedtime battles because your child is way past his biological time for evening sleep. So either shorten (if your child is way under nine months) or eliminate (if your child is nine months or older) the third nap. Even a brief, baby power nap lasting twenty to forty minutes late in the afternoon or early in the evening might interfere with an early bedtime. So if you are struggling with bedtimes, consider eliminating this third mininap and try for an earlier bedtime.
Sometimes, around nine to twelve months of age, a child falls asleep around 5:30 P.M. and is up around 7:30 or 8:00 P.M., then is up playing with parents for a few hours until 10:00 P.M., and finally goes back to sleep but does not sleep well at night. The parents think the child is taking a third nap at 5:30 P.M. But in reality the child needs a very early bedtime, maybe around 6:00 P.M., and no playing between 7:30 and 10:00 P.M.
REAL LIFE
Special events often result in skipped or shortened naps for children. Do not become a slave to your child's nap schedule. The more you protect the sleep routine for regular days, the less disruptive those special days will be.
Needs Two but Can Get Only One
The bedtime might be too late and/or the wake-up time too early, causing your child to be very tired in the morning. This morning fatigue causes him to take a meganap in the morning that interferes with his ability to take an afternoon nap. As a result, he is not well rested in the late afternoon or early evening. Or, scheduled morning activities might conflict with a nap around 9:00 to 10:00 A.M., resulting in a very late morning nap around 10:30 or 11:00 A.M. Even if this is a brief nap, it may recharge your child's battery and interfere with a long afternoon nap. During the transition between two naps and one nap, roughly twelve to twenty-one months, there may be some days when one nap works well and other days when your child takes two naps. This transition time, however, might be associated with an inability to get in two naps when he clearly needs them. The solution here is a twenty-or thirty-minute earlier bedtime.
Needs a Nap but Refuses to Nap
Holidays, trips, illnesses, or other changes in routine might cause your two-to three-year-old child to give up napping and be very tired during the day. Another common cause of no napping occurs when the child drops the morning nap but the parents do not make the bedtime a little earlier. Over many weeks or months, your child develops “cumulative sleepiness” until he hits a wall and becomes way overtired. In this state, it is difficult for him to nap because his body is geared up to fight the fatigue. When you try to reestablish the nap, he either just plays in his crib, or cries, or a combination of both.
If your child is substantially under three years old, try a temporarily super-early bedtime to help him wake up better rested. In other words, for four or five nights, put him to sleep when he is drowsy at 5:00 or 5:30 P.M. This might backfire and cause him to wake up too early. If this happens, for those four or five mornings, ignore him until 6:00 A.M. Often, the early bedtime will help erase his sleep debt so he is more able to relax and take a nap. To help reestablish the nap habit, you might want to have intense morning stimulation and an extra long and soothing nap time ritual. Leaving him alone in his crib for no more than one hour, even if he cries, often will allow the nap to occur because he is tired and not receiving any stimulation from his parents. Or, you might have to lie down with him in your bed to help induce sleep. If successful, then you would very slowly and gradually transition him back to his crib. (See page 177 for transitioning children from parent's bed to child's crib.) Once the nap has been reestablished, the bedtime can be made a little later. Children who slip in and out of good sleeping patterns are usually the ones who are always going to bed slightly too late. They don't usually have major problems, but they are always on the edge of becoming overtired and they easily and quickly become overtired whenever there is a disruption of sleep routines.
If your child is substantially past his third birthday, trying to reestablish the nap may not make sense, and trying to establish an earlier bedtime will help your child sleep better. Here is a report of how a temporarily super-early bedtime and the use of the “nap hints” on page 123 helped create long and regular naps.
A 5:30 P.M. BEDTIME UNTIL HENRIK'S NAPPING GOT BETTER
When our pastor asked us if our eight-month-old son, Henrik, was a “serious, sullen” boy, I knew we had a problem. Just one month before, my friend had sent us a note saying how Henrik was the happiest baby she'd ever seen. She could elicit a belly laugh from him with just a sideways glance. Now, our pastor, an experienced grandfather, was pulling out all the stops—goofy faces and exaggerated sneezing—and Henrik wouldn't crack a smile. But it wasn't because he was suddenly sullen or serious; he was exhausted.
What I had hoped was just a napless phase that he'd outgrow was catching up to him and choking his vibrant personality. We needed help.
I called our pediatrician's office and explained our predicament: While Henrik was sleeping better at night, his daytime naps were becoming history. Over the past two months, his decent, if erratic, nap schedule had faded into two brief naps and then disappeared altogether.
Getting my son to fall asleep was never a problem; nursing or rocking soothed him easily. It was getting him to stay asleep once I set him down where the trouble began. As soon as I'd set him in his crib, his back would arch and he'd be choked up before he touched the mattress. “Nap time” had come to mean Henrik crying in his crib until my nerves couldn't take it anymore, or him sleeping soundly on me.
I knew he needed to learn to soothe himself to sleep, but crying it out just didn't seem to work. The longer I'd let him cry, the more he would work himself up. I knew sleeping on me wasn't a good solution, but when I'd see the dark circles under his eyes and hear his voice husky from crying—and especially when he got his first cold—I just couldn't let him cry anymore. He needed sleep. So I'd get comfortable with him on the sofa and hope a good movie was on cable.
When the nurse at our pediatrician's office suggested Dr. Weissbluth's Healthy Sleep Habits, Happy Child (a book I had already devoured and loved), I decided to take it a step further and make an appointment to see Dr. Weissbluth himself, since his office was near our home.
Eight days later, with a copy of his book and a sleep journal in tow, we set off for our consultation with Dr. Weissbluth. As soon as he walked into the room, I knew we'd find help. Dr. Weissbluth listened to, empathized with, instructed, and encouraged us in a manner that assured us we would get back on track.
After studying our son's erratic sleep patterns, he recommended an earlier bedtime and regular wake-up times for my son. Dr. Weissbluth explained that Henrik was going to bed too late and wasn't getting enough sleep at night. (Henrik usually fell asleep between 8:00 and 9:00 P.M. and woke up around 7:00 A.M.) This lack of sleep and a consistent schedule—as odd as it may seem—is what was keeping him from being able to cry himself to sleep during the day. He was too overtired to sleep! Dr. Weissbluth suggested a 7:00 P.M. bedtime and a 7:00 A.M.wake-up for the long-term goal, but said that we'd probably be looking at a 5:30 P.M. bedtime until Henrik's napping got better.
Once Henrik was up in the morning, we were to stimulate him through walks, outings, and vigorous play. After that, a soothing period would precede his attempt at a 9:00 A.M. nap. I was to continue putting Henrik to sleep in my normal way (nursing and rocking) and then set him down in his crib. I was then to leave him alone for one hour either to sleep, cry, or a combination of the two.
Then, after his morning nap, we were to repeat the process for his attempt at a 1:00 P.M. nap (or earlier if no morning nap was taken). And then we'd go about our afternoon until it was time for the evening soothe. He asked us to chart our sleep data so we could clearly see Henrik's progress.
After a round of handshakes and encouraging words, we left the office equipped to help our son become the sleeper he needed to—and could—become. We were to report back to Dr. Weissbluth in a week. His confidence that we'd see improvement by then rubbed off on us. We couldn't wait to get going.
When we got home, we played and played, and then I soothed Henrik to sleep. When I set him down for his afternoon nap, he cried. I said a quick prayer, told him I loved him, walked out, and closed the door on my wailing son.
As I walked down the stairs, I breathed in slowly, reminded myself that I was doing this for my son's well-being, and hit the pause button on my emotions. I spent fifty-nine minutes e-mailing friends with one ear to the monitor to see if and when he'd stop crying. “Didn't work today,” I was telling myself on the way back up the stairs. But by the time I got to his door I realized he was quiet. He fell asleep after fifty-nine and a half minutes of crying. If I had gone up one minute sooner, I would've cheated him out of this accomplishment. We were on our way.
The afternoon nap was the first to get back on track. It took about a week for him to be able to go down at all without crying, and he was still only sleeping for a half hour at a time. But he was sleeping—and on a schedule! I used to think that because Henrik was an erratic sleeper, a sleep schedule wouldn't work for him. Now I know that Henrik was an erratic sleeper because he lacked that schedule. (While the idea of a schedule sounds limiting, establishing a schedule was the most freeing thing for our family. We are now able to make accurate plans instead of having to wait around and guess when our son would be ready to go.)
The morning nap was more of a challenge. For two weeks he cried through his entire morning nap. It was difficult to put him down each day knowing he would cry, but his success in the afternoons, along with the giant hug I'd receive when I came to get my teary son, gave me the strength to keep going. Then one day he cried himself to sleep after twenty minutes, and from then on he would stay sleeping after we put him down. It took two weeks for Henrik to get back to two naps a day, but he did it.
Despite sleeping for only thirty to forty-five minutes at a time, Dr. Weissbluth told us we should get him as soon as he woke up. He suggested we keep the 5:30 bedtime, which would naturally help lengthen his naps. Our days are now virtually tear-free.
My son is thriving on his new schedule. He's back to his giggly, healthy, and well-rested self. Instead of being the sullen boy in church, he's now the chipper angel who sings out loud with joy—with or without the rest of the congregation.
Bedtime Is Too Late:
Sometimes or Always a Battle
Past six weeks of age, biologically driven bedtimes tend to become earlier. If you are unable or unwilling to allow these early bedtimes, your child will become overtired. Common problems occur (1) in the postcolic child who is dependent on the family bed and breast-feeding to sleep but now wants to sleep much earlier than the parents do, (2) parents who have to use day care so extra time at night is required to bring the child home, or (3) dual-career families with long commute times from work. Solutions involve using others to help prepare the baby or child for bed (bathing, dressing for sleep, and feeding) and, as early as possible, the parents begin a brief bedtime routine. Although you will see your child less at night, you will have lovely morning time. To really enjoy the mornings, some parents will have to go to sleep earlier themselves! Other parents may be able to alter their work schedule to come home early on some days or do some of their work at home in the evenings after their child has gone to sleep. Obviously, not all parents can come up with a solution. Review the list of resources for soothing on page 74.
If circumstances cause your baby to go to bed too late, do the best you can but try for the earliest bedtime possible.
Night Waking, Difficulty Staying Asleep
Night waking occurs normally in all children, and the real problem is not developing the ability to return to sleep unassisted after the awakening. Night waking is the most common postcolic sleeping problem and is discussed in Chapter 4. All sleep problems eventually lead to night waking. The specific treatments depend on the child's age and are discussed in the appropriate chapter.
More Than One Child
Creates Bedtime Problems
An older child, about age three years, might not nap and need to go to sleep around 6:00 or 6:30 P.M., especially if he has a very active day. His younger sister, about age six months, might be taking three naps and be able to stay up later. A parent cannot ignore the baby and attend to the three-year-old's bedtime routine. A solution is to eliminate the third nap for the baby so she goes down earlier, around 6:00 or 6:15 P.M., while the three-year-old is playing by himself. Twins who have different sleeping schedules, causing different bedtimes, are challenging to parents and sometimes there is no solution except putting them down at about the same time and if there is any crying associated with falling asleep, then temporarily separate them.
Unable to Fall Asleep
Young babies or children may have difficulty falling asleep except when they are in bed with their parents or in their arms. Most of these are children who had colic (see Chapter 4) or whose parents had used the family bed from the beginning. Read the sections on the Family Bed in Chapter 6, and “Transition from Family Bed to Crib” on page 177. Older children and adolescents may have difficulty falling asleep and these are discussed in Chapter 9.
Afraid of the Dark or Being Alone
Fears are very common between the ages of two and four years. Thunder, lightning, barking dogs, shadows, and many other scary items over which we have no control can frighten children. A light on in the closet or even a conventional seven-watt night-light might keep a sensitive baby from sleeping well. A quarter-watt guide light that produces a faint yellow glow will usually be sufficient illumination. Extra long and soothing bedtimes will help. A new protecting teddy bear might help fight off fears and protect your child. A father might walk around the room and capture the “monsters” and put them into a bag or box to remove them from the room. Guardian angels, charms, or dream catchers may help make your child feel more secure. An older child might be given a bell to summon his mother or father with the understanding that he can use it only once. The parent will then come to soothe him, once, for a predetermined period of time, using a kitchen timer placed under a pillow or cushion to control the duration of the soothing time. Knowing that he can have some attention at night gives the child confidence and he will sleep better. The goal is to provide extra attention at night without it becoming open-ended and a ploy to fight sleep.
Will Not Stay in His Crib or Bed
One-or two-year-olds who climb out of their bed may receive too much social interaction from parents and therefore may continue the behavior because they are curious and social. To protect their sleep and prevent the development of sleep problems, buy a crib tent. You may have to use duct tape to keep the child from getting to the zipper. Parents are often reluctant to use a crib tent because they imagine their child will feel like a caged zoo animal, restricted, or abandoned. Of course, there might be some protest crying for a few days. However, many children quickly seem to enjoy the comfort zone like a teepee or fort; they do not appear sad or angry. Some parents do not want to use a crib tent but feel more comfortable putting a latch lock on the door. If you stand at the door preventing your child from leaving the room, your child will fight sleep all the more because he is getting attention from you.
“Sleep Rules” (page 325) and “silent return to sleep” (page 320) are used for the older child who will not stay in bed. Here, too, some parents know that they cannot be consistent at night, so they want to put a latch lock on the door. Whenever parents want to put a lock on the door, I ask that they have the child watch them put the lock on. One parent felt that the additional step of bringing her three-year-old child to the store where she purchased the lock for the door helped convince him that she was serious. The child is told that if he leaves the room, he will be put back in and the door will be locked. Almost all the time, the child picks up on her parents’ serious demeanor and does not even attempt to leave the room in the first place. If, however, the child tests the rules and leaves the room, and the parents place her back into the room and lock the door, although there may be loud and long protest crying, it is usually only for one night, because the child is now highly motivated to prevent the door being locked.
Will Not Sleep Anywhere Else
Maybe your baby sleeps well in your home but does not sleep well at grandma's. Try to play the same music only at sleep times at both homes. Buy something soft and safe for your baby to feel or clutch and use it only at sleep times at both homes. Spray some fragrance or perfume around the crib or bed only at sleep times at both homes. Use the same sleep schedules and nap time and bedtime routines at both homes.
Only One Bedroom
When your baby becomes more curious and aware of the sounds and movements of people around him and you are using a crib, it might be time to move your baby to his own room. What do you do if you do not have an additional bedroom? Some families have their baby sleep at night in their bedroom and they use a sofa bed and convert their living room into their bedroom at night. In this way, the baby can go to bed early in a dark and quiet room and the parents know that their nighttime sounds will not wake awaken him.
Transition from Family Bed to Crib
Moving your baby from a family bed to a crib will be easy or difficult depending on whether the family bed was unwanted but occurred in reaction to extreme fussiness/colic or was wanted from the beginning. This will be discussed in detail on page 177.
Action Plan for Exhausted Parents
Young children and infants cannot tell us how they feel, so parents need to watch their behaviors. Does your child behave as though he were active, alert, vital, and wide awake, or is he fighting sleep, woozy?
MAJOR POINT
Junk food is bad for the body. Junk sleep is bad for the brain.
This chapter and the two previous chapters describe the terms healthy sleep and disturbed sleep. Obviously, sleeping is not an automatically regulated process such as the control of body temperature. Sleeping is more like feeding. We do not expect children to grow well if all they eat is junk food. Children need a well-balanced diet in order to grow. If the food that is provided is insufficient or unbalanced, this unhealthy diet will interfere with the child's growth and development. The same is true for unhealthy sleep patterns.
REAL LIFE
If your child has a sleep problem that requires multiple changes but you are only able to make some of the changes, go ahead and do the best you can.
Be consistent. Anytime you make a change, allow at least four to five days before making another change to see whether you have helped your child. Be patient.
1. Keep a sleep log as described on page 118
2. Identify the main sleep problem as described in this chapter
3. Read the brief solution outline and the age-appropriate section in later chapters or the action plan for that chapter
4. Identify the elements of sleep that need improvement or correction for your child's sleep problem
Sleep duration: night and day sleep
Naps
There are good naps and bad naps. Occasional nap strikes may not be harmful, but nap-stubborn kids are usually overtired.
Sleep consolidation
Sleep schedule
Sleep regularity
5. Determine what you can and cannot do
Ignore morning crying that is too early versus bringing your baby to your bed
Control the wake-up time
Change the schedule for nap times
Eliminate the third nap
Change the schedule for bedtimes
Change the nap time or bedtime routine
Provide more soothing at sleep times
Give less attention at night when your child is not hungry
Use a crib tent or lock the door
IMPORTANT POINTS
Sleeping well is a 24/7 process. It's not just about how we get them to go to bed at night without crying.
Solving sleep problems may be a very tough prescription and demands a consistent approach.
There may be increased crying in the beginning, but the upside is that crying around sleep should be eliminated altogether.