When your child starts to walk, babble, and show more personality, you will naturally begin to treat him less as an infant and more like a person. Please try to avoid the trap of endlessly explaining, negotiating, or threatening when it comes to sleep times. Save your breath; let your behavior do the talking.
Months Thirteen to Fifteen: One or Two Naps
At twelve months of age, 82 percent of children have two naps and 17 percent take only a single afternoon nap. But by fifteen months of age, 43 percent of children are taking two naps and 56 percent take a single afternoon nap. This is a dramatic change occurring over a short time period.
This transition, however, may not be smooth. You might have a few rough months when one nap is not enough but two are impossible. Here are some ideas for making the transition easier.
Move the bedtime earlier. The morning nap is always the first nap to disappear naturally. We do not know why. If the bed time is moved up a little, most parents will notice that the morning nap becomes briefer or turns into a quiet playtime without sleep. Most of these children do not appear to become very tired.
Other children take longer and longer morning naps and then appear to actively resist or be unable to take the second afternoon nap. Because this second nap was short anyway, many parents forget it. The result is a child who is tired late in the afternoon or early evening and who quickly becomes overtired by bedtime. One solution is an earlier bedtime because your child will wake up rested and take a briefer morning nap. In addition, you might want to shorten the nap by waking your child after about one or one and a half hours so she will be more tired around the midday nap time. Also, try to get out of the house immediately following the morning nap to provide intense stimulation but tone it down as you get to the middle of the day. Provide extra long and relaxing soothing to sleep for the midday nap. Maybe consider moving the midday nap to a slightly later hour so your child is a bit more tired. Sometimes your child continues to take a morning nap but none of the above causes her to take a midday nap, so here's another plan. At the time of the morning nap, delay its onset by ten or twenty minutes. This might require more intense and prolonged soothing to sleep. Slowly, over many days or weeks, continue to delay the morning nap until it is occurring near the middle of the day. During this transition, the bedtime might have to be temporarily ultra-early because your child gets pooped every afternoon. Some of these children appear to hate their bedroom in the afternoon and scream as you approach it. One mother solved this by doing all the prenap soothing in the living room and then quickly went into his room.
The earlier bedtime means that a working parent coming home late does not see the child then. If that is the case, that parent can get up extra early to have a longer morning playtime with the child before going off to work. Another solution is to declare some days as two-nap days and other days as one-nap days, depending on when the baby awakens, how long the morning nap lasts, scheduled group activities, or the time you want your baby to go to sleep at night. Flow with your child and arrange naps and bedtimes to coincide with his need to sleep as best you can. Be sensitive to the growing need for earlier bedtimes.
Here is one mother's account of how an early bedtime helped her child.
Sophie has always been inconsistent when it comes to napping. Some days she would sleep for half an hour, others she wouldn't sleep at all. And if I was lucky, she would take an occasional hour nap. I decided it was time to get help before the situation became worse.
Sophie was thirteen months old when I met with Dr. Weissbluth. She was sleeping for thirty minutes in the morning; her afternoon naps were unpredictable. At night, getting her to sleep was even more frustrating. Sophie had always been a great nighttime sleeper. Then, all of a sudden, she was waking up several times throughout the night. Not only was her mental state unbearable, but physically she did not look well. As for me, I was becoming mommy the monster. There were days when I thought I was going to lose it. I blamed myself for her sleeping disorder, even though I was doing everything right—putting her to bed early, keeping a consistent nap time, and putting her down in her crib for her naps instead of allowing her to sleep on the go.
After looking over Sophie's sleep log, Dr. Weissbluth gave me several options: try an earlier bedtime (5:00 P.M.), lots of stimulation when awake, and soothing her longer at night. The goal was to allow her to catch up on her sleep.
My husband and I put the plan to work. He supported the decision of an earlier bedtime, even though his time with her was already limited. Unfortunately, Sophie's sleeping did not improve. She continued to take one nap for thirty or forty-five minutes and then skip her afternoon nap. She and I were both exhausted and my frustration level was sky high at this point.
During our follow-up conversation, Dr. Weissbluth asked if I would consider dropping her morning nap. He recommended the continuation of an earlier bedtime (5:00 P.M.), which, surprisingly, she welcomed. Although I was hesitant to drop her morning nap, I was determined to get my happy child back.
So, I put plan B to work. For the first several days, Sophie could barely keep her eyes open past 10:30 A.M. I was able to keep her up until 11:00 A.M. and then 11:30 A.M. for the next several days. She continued to take thirty-minute naps. I called Dr. Weissbluth and he reminded me that she was still trying to catch up on sleep, that it would take several days for her to feel rested. After day four, she was staying awake until 12:30 and sleeping for an hour. And she was sleeping through the night—no more nighttime waking. By the end of the week, she was starting her nap at 12:30 and waking up at 2:00 P.M. And Sophie and mommy were happy.
Sophie continues to have thirty-minute naps every once in a while, and she looks forward to her nap time. She no longer cries; instead, she falls asleep quickly. As for me, I am feeling more confident. Sophie is not the only one who is sleeping better. I am spending more time enjoying her and less time being tired and frustrated.
Obviously, any combination of parents’ scheduling for their convenience and the baby's need to sleep can determine nap patterns. If you are a napper yourself, you may protect your child's nap schedule differently from the parent who does not customarily take naps.
Q: How long should my child nap ?
A: Does your child appear well rested? You be the judge. All of us have good days and bad days, but if you notice a progression toward more fussiness, brattiness, or tantrums, your child may need longer naps.
Months Sixteen to Twenty-one:
Morning Nap Disappears
The morning nap is on its way out. At eighteen months, 77 percent of children take a single afternoon nap; by twenty-one months, 88 percent sleep only in the afternoon. Sometimes the child is taking only the morning nap and the plan discussed above does not work because the general recommendation of an early bedtime backfires. You try an early bedtime and all you get is an earlier wake-up time, which makes your child more tired in the morning and makes him need the morning nap all the more. Under these circumstances, you might temporarily put your child to bed a little later at night with the hope that he will sleep in later. If you put him to bed much too late, he will have difficulty falling asleep and staying asleep, so this will require some patience and trial and error. Still, wake him, if he is asleep, at 7:00 A.M. and then proceed with one of the plans previously described to get an afternoon nap.
Q: What do I do if my child is healthy but cries at night, and the crying stops as soon as I pick him up?
A: Ask yourself if there is anything you can do to regularize the total sleep pattern, such as timing naps better or making the bedtime earlier. Was there anything that recently disrupted his schedule to cause him to become overtired? Does he snore or mouth-breathe during sleep, or might he be starting to become ill? Look at the big picture, not just the night crying. In general, you will not want to attend to the night crying because you want to encourage consolidated sleep. If you go to your child, you will cause fragmented sleep, which is poor-quality sleep. If your head says that not going to your child is the right thing to do, but your heart won't let you do it, try some of these suggestions.
One parent tied a ribbon around her ankle and her husband's ankle so that she did not shift into autopilot mode at night and go to her child when he cried. Another mother waited for her husband to go away on business for a few days so she could ignore the crying without having her husband undercut the plan. Sleep temporarily farther away from your child; use earplugs, earphones, pillows over the head; take a shower. Do what is best for your child, but don't torture yourself.
Months Twenty-two to Thirty-six:
Only a Single Afternoon Nap
Naps
At twenty-four months of age, only 5 percent of children have two naps and 95 percent are taking a single afternoon nap. By thirty-six months of age, no children are taking two naps, 91 percent are taking a single nap in the afternoon, and 9 percent are not napping at all. A common problem occurs when the nap disappears but the child appears very tired during the day and really seems to need to nap. The closer the child is to his second birthday, the more likely you should try to reestablish the nap, because most probably it is biologically needed. But if he is almost three, you might not be as successful in reestablishing the nap because he might have outgrown the need for it.
Here are two plans to try to reestablish a nap. First, consider the situation where the bedtime is already quite early or you observe that when you moved the bedtime earlier it only caused your child to get up earlier in the morning. Try to slowly move the bedtime later by about twenty to thirty minutes each night with the hope that your child will sleep in later, wake up better rested, and be more able to take an afternoon nap. Second, if the bedtime is quite late, move the bedtime slowly earlier by about twenty to thirty minutes each night with the hope that your child will wake up better rested. In either case, try intensive stimulation in the morning, followed by a wind-down, then a prolonged prenap soothing routine, and try to nap him when he's tired but not too overtired. Consider lying down with your child in your bed temporarily, mother or father, to reestablish the nap routine. After five to seven days, reevaluate and make adjustments of bedtimes and nap times.
Between twenty-two and thirty-six months, most children still need to nap. The average amount of daytime sleep at thirty-six months is about two hours. But there is much individual variation; the range is from one to three and a half hours. If your child is at either extreme of this range, ask yourself if he appears well rested at all times.
The majority (80 percent) of children between the ages of two and three years have a nap length in a narrower band between one and a half to two and a half hours. Most children nap for about two hours. The model nap duration is two hours between the ages of two and six years. The stability of the two-hour nap over different ages is another argument for a strong biological influence over sleep, but it does not necessarily mean that your child needs a two-hour nap. Some children need less and some need more daytime sleep.
Q: When do I transition my child from a crib to a bed”?
A: As he approaches his third birthday, let the child ask for a big bed. If you move him too soon, he will not stay in his bed because he is curious and wants to see what's going on elsewhere in the house.
Fears
Nightmares, monsters, fear of separation, fear of darkness, fear of death, fear of abandonment … don't fears cause disturbed sleep at this age? Many experts tell us that night fears are common among children between two and four years old. Thunderstorms, barking dogs, loud trucks, and many other events over which we have no control can frighten children. If your child has been a good sleeper up to now, you should expect any disturbed sleep triggered by these events to be shortlived.
Some child care experts believe severe sleep disturbances are caused by night fears. Usually, though, children with serious sleep problems did not sleep well at younger ages, and their current difficulty is simply misinterpreted as caused by an age-appropriate concern or “stage.”
Reassurance, frequent curtain calls, open doors, night-lights, or a longer bedtime routine will help your child get over his fears. My recommendation is to spend extra time soothing your child to sleep or go to him once for reassurance, but use a kitchen timer to control the duration of the extra time. The timer is set to the number of minutes you want to spend with your child and is then placed under a pillow or cushion to muffle the noise. Tell your child that when the buzzer or bell sounds, you will kiss him and leave. The child learns to associate the sound of the time with your departure and learns that this signals the end of your hugging, massage, or lullabies. This is called “stimulus control,” which is discussed further in Chapter 9. Just as when the final curtain call ends, you know the play is really over, or just as you know to slow down as the green light turns to yellow, your child learns to associate the sound with the end of your soothing effort. Because crying will not bring you back, the crying ends.
If your child has never been a good sleeper and now also appears during the day to be extremely frightened, withdrawn in new surroundings, shy, or fearful, then it is very difficult for parents to give less attention at night, even if the goal is to enhance consolidated sleep. If this is the case with your toddler, a child psychologist can give you good advice on where to draw the line between supporting the child and encouraging him to learn to overcome his fears.
Routines and Schedules
At about two to three years of age, although most children in my research survey go to sleep between 7:00 and 9:00 P.M. and awaken between 6:30 and 8:00 A.M., I think that an earlier bedtime is better. A single nap between one and three hours occurs in over 90 percent of children. Try to be reasonably regular about nap time and bedtime, and be consistent in your bedtime rituals. There are no absolute, rigid, or firm rules, because every day is somewhat different. Reasonable regularity and consistency implies reasonable flexibility. Be aware that your lifestyle helps or hinders your child's sleep patterns, and remember that there will be changes due to growth and rearrangements in relationships within the family.
How about scheduled, organized activities that take place when your child needs to take her afternoon nap? If she is unable to take her afternoon nap two or three times each week and you are able to get an extra-early bedtime on those days, then there may be no problem, as long as the child is sleeping well in general. For the child who is not sleeping well, for whatever reason, losing a few naps can be quite problematic. Also keep in mind that children are likely to pick up minor illnesses from each other in group settings, and not feeling well may disrupt your child's sleep and push her into an overtired state. In general, be cautious. Have fun with your child, but occasionally have what my wife called a “declared holiday.” Missing a swim class, gym class, or any other preschool event now and then because your child is tired and needs to nap, or leaving soon after you arrive because the other children look sick will notjeopardize your child's college plans!
A Regular Bed and the Arrival of a New Baby
One rearrangement is moving your child to a “big kid's” bed. There is no special age when you should make this change. As long as the crib is large enough, you should not feel that your child must be placed in a regular bed by a certain age. Many parents make the switch around the second or third birthday. Let your child ask for a big bed. One mother described how she felt that she had made the move too soon and the big bed must have seemed “oceanic” compared to the crib, because her son always slept curled up in one corner of the bed—that is, when he slept. He slept better when returned to his crib. Before she made the move back to the crib, his mother wondered whether this would cause a “regression” in her child. It did not. But it did result in a better-rested family.
If the move to a regular bed is needed because of a new baby brother or sister, consider making the move when the newborn is about four months old. By then, the newborn has regular sleeping habits. Before the baby reaches this age, there is a constant shifting of household routines due to the infant's naturally irregular sleep pattern. This may cause confusion or insecurity in the older child because he does not know when mom or dad will be available, or why he has to wait when he wants to go outside and has been used to doing just that. When the newborn is four months old and her sleep pattern is stable, events in the house are much more predictable. The older child now becomes adjusted to the new family arrangements. The baby goes to the crib and the older child graduates with pride to the big bed for big kids. He does not feel displaced. Before the newborn is actually moved from the bassinet to the crib, feel free to leave the crib up and empty for a while with the understanding that if the older child gets out of bed once, then it's back to the crib.
Moving to a big bed too early, before the birth of the new baby, often invites a problem: The commotion and excitement surrounding the arrival of a new baby creates confusion or insecurity in the older child, who may call out or cry at night. The more difficult situation is when the older child starts to get up every night to visit his parents.
If the move to a regular bed prompts frequent nocturnal visits, curtain calls, calls for help going to the bathroom, or calls for a drink of water, think before you act. A habit may slowly develop in which your child learns to expect you to spend more time with her, putting her to sleep or returning her to sleep. Imagine what would occur if a baby-sitter gave your two-year-old candy every day instead of a real lunch. Once you discovered this, you would immediately stop the candy for meals. Your child might protest and cry, but would you give in and let her have the candy? No. If you are spending too much time at night with your child when she should be sleeping, consider what you are doing to be “social candy”—not needed and not healthy for the child. Be firm in your resolve to ignore the expected protest from your child when you change your behavior.
Preventing and Solving Sleep Problems
In one study of children between one and two years of age, about 20 percent woke up five or more times a week, while in a study of three-year-old children, 26 percent woke up at least three times a week. Unfortunately, you simply cannot assume that difficulty returning to sleep unassisted will magically go away. Returning to sleep unassisted is a learned skill; you should expect problems to persist in your child until she learns how to soothe herself back to sleep without your help.
Also, in the study of one-and two-year-old children, those who woke up frequently were much more likely to have an injury such as a broken bone or a cut requiring medical attention than those who slept through—while only 17 percent of good sleepers had injuries, 40 percent of the night wakers were injured! (Chapter 11 will discuss further the connection between injuries and disturbed sleep.)
The majority of children between the ages of one and five have a bedtime routine less than thirty minutes long, go to sleep with the lights off, and fall asleep in about thirty minutes after lights out. Night waking occurs in the older children in this group once a week; only a few awaken more than once a night. If your child's pattern between the ages of one and five is substantially different, consider the possibility that your child is among the 20 percent of children in this group with disturbed sleep. If so, then you might also later notice the excessive daytime sleepiness that has been observed in about 5 to 10 percent of children between the ages of five and fourteen years.
Your child's developing personality and awareness of himself as an individual means that his second and third years will be a time of testing, noncooperation, resistance, and striving for independence. Your child has stronger self-agency. Sleep problems in twelve-to thirty-six-month-olds are related to this normally evolving stubbornness or willfulness in children, who now want to do their own thing. For example, they may want to get out of their bed or crib at night, not take naps, get up too early to play, and, of course, resist falling asleep and wake up at night. This last problem might have started during the first year and may now continue during the second year as an ingrained habit. Let's look at each of these major problems in turn.
PRACTICAL POINT
Don't confuse these issues:
· Needs versus wants
· A sad cry versus a protest cry
· Being abandoned versus beingalone
Getting Out of the Crib or Bed:
The Jack-in-the-Box Syndrome
It's quite natural for two-and three-year-olds to climb out of the crib or bed to check out the interesting things they think their parents are up to. Or maybe they just want to watch the late, late movie or have a bite to eat. Of course, what they like to do most is to come visit with their parents and/or get into their bed. This not only disrupts their parents’ sleep, but it also harms the child. Here's how.
When a child has a naturally occurring partial arousal during sleep, instead of soothing himself back to sleep, he learns to force himself completely awake to get out of his bed or crib. The result is sleep fragmentation—for him, and for his parents, too. Here's a five-step treatment plan to put your Jack back in his box at night.
Step 1: Keep a chart, log, or diary to record key sleep events: time asleep, time awake, number of times out of bed, and duration of protest calling, fussing, or crying. This will make you a better observer of both your child's behavior and your own. The chart or log enables you to determine whether the strategy is working, and helps remind you to be regular according to clock times and to be consistent in your responses.
Step 2: Ask yourself whether your child behaves as if he is tired in the late afternoon or early evening. If the answer is yes, then consider the possibility that naps are insufficient or that the bedtime hour is too late. Deal with these problems at the same time you are working on his getting out of the crib or bed. If needed, keep data in your sleep chart regarding naps, such as the time he falls asleep, how long he sleeps during the day, how long he cries in protest before napping, and the interval between the end of his nap and when he goes to sleep for the night.
Also, consider whether your child is snoring or mouth-breathing more and more at night. Please read the section on snoring in Chapter 10 if this is now a problem.
Step 3: Announce to your child that there is a new rule in the house: Down is down—no getting out of bed until morning. Tell him that you love him very much but that you need your sleep, and he needs to put himself back to sleep by himself; getting out of bed is not allowed. Tell him that when he gets out of bed, you are going to put him back to bed and you are not going to talk to him or look at his face while you are doing so. Let's call this “silent return to sleep.” Silence when you take your baby back to bed is important, because if you are sweet or stern while trying to explain why everyone needs sleep, the verbal attention will reinforce your child's desire to get out of bed to get more attention. Attending to a problem will cause the problem to occur more often. Many parents do not understand that negative attention—yelling or getting angry—is still attention, and it will encourage your child to continue the behavior.
Depending on your child's age, he may or may not understand what you are saying. But he will certainly sense that tonight something different is going to occur.
PRACTICAL POINT
Be silent and unemotional; appear disinterested or mechanical. No more night entertainment.
Step 4: Place yourself where you can easily hear him get out of his crib or bed. Place a bell on a rope on his door to signal when he leaves his room or enters your room, or use an intercom if you must be out of earshot. The signal makes him aware of what he's doing and it helps you to be consistent.
Every time you determine that he is out of his crib or bed, or discover him in your bed, gently place him back in his bed. Maintain silence.Plan not to sleep the first night, as he may try many, many times to get back to his old style. Parents might want to alternate nights so that at least someone gets some sleep. Do not take turns on the same night, because the child might think one parent would behave differently. Children learn quickly that there's no benefit in getting out of bed, so they stay in bed and sleep through the night.
Step 5: Every morning, shower the child with praise or affection for cooperating with the new rule. Perhaps offer a favorite food that was previously withheld or go on a special outing. Try small rewards for partial cooperation and larger rewards for more complete cooperation.
In addition to praising or rewarding your child when he cooperates, you might consider changing some of the routines when he doesn'tcooperate. For example, past fifteen to eighteen months, you might close the door in a progressive fashion every time he gets out of bed. You can put three or four white tape marks on the floor, and for the first three or four times he gets out of bed, the door is closed a little more until it is barely open or completely closed. If he stays in the bed, the door is left open to the first tape mark. A similar progressive strategy could be used with brighter or dimmer night-lights.
Expect this plan to dramatically reduce or eliminate the get-ting-out-of-bed routine within a few days, usually three or four. All you had to do was remove the previous nighttime social interaction (whether pleasant or unpleasant) as a reinforcer to the habit of getting out of his crib.
In short, every time your child gets out of bed, he encounters a silent, unemotional parent who gently picks him up and returns him to bed.
Here are some typical questions and answers about this strategy.
Q: Won't my child hurt himself when he climbs or falls out of his crib?
A: This is a common worry and often used as an excuse to go to your child or buy a “big kid's” bed. But the truth is that serious injuries rarely occur when the child bumps on the floor as he lets himself down.
Q: Can the plan fail?
A: Yes, when both parents aren't committed, so that one partner passively or actively sabotages the program. One father in my practice loved to sneak a bottle of formula to his baby once or twice a night. This caused the baby to suffer excessive wetness and a severe, persistent, and painful diaper rash. Only in the course of trying to eradicate the rash did the father's behavior come to light. Failures also sometimes occur when the child is still chronically fatigued from too late a bedtime hour or nap deprivation.
Q: What if he stays in his crib but cries’?
A: Letting your child cry when he protests going to sleep or staying in his crib is not the same as making your child cry as if you were hurting him. Leave him alone (extinction) or try controlled crying (graduated extinction).
One family instituted this five-step program when their daughter was twenty-six months old—after twenty-six months of poor sleeping. She had always had difficulty in falling asleep and difficulty in staying asleep. Nicole always wanted to, and did, get out of her bed and go into her parents’ bed. After the birth of Daniel, her brother, her parents decided this had to stop.
Their record showed the following results:
Night 1: Between 8:13 and 9:45 P.M.—69 return trips to bed. Slept until 8:30 A.M. with one brief awakening at 2:15 A.M.
Night 2: Between 8:20 and 10:30 P.M.—145 return trips to bed. Slept until 7:20 A.M. with one brief awakening at 2:15 A.M.
Night 3: After 9:14 P.M. (bedtime)—0 return trips to bed! Slept until 7:40 A.M., awakening once at 3:20 A.M.
PRACTICAL POINT
Do not underestimate the enormous power of partial reinforcement to ruin your efforts to overcome baby's habit of getting out of die crib. If you are not silent and you discuss getting out of bed when it is occurring, your social behavior reinforces getting out of the crib.
That's it!
An important point is that almost all of Nicole's getting out of bed occurred within the first hour or two of the night. Many children follow this pattern, so don't expect that you will necessarily lose a complete night of sleep during this training period.
After the third night of Nicole's program, the curtain calls at bedtime ceased. Furthermore, at naps her mother would now leave after fifteen or twenty minutes of reading, whereas before she stayed in the room until Nicole fell asleep. The parents described Nicole as easier in many ways: less resistant in dressing, less argumentative, more charming, and better able to be by herself.
Crib Tents and Locking the Door
Some families know that they are unable or unwilling to do the silent-return-to-sleep routine when their child climbs out of the crib. For a minority of children, moving them to a bed solves the problem; they want to sleep in a bed and they will stay put to enjoy it. In others, moving to a bed simply means it is now easier to go visit mom and dad.
A crib tent will prevent your child from getting out of the crib, and it allows you to remove yourself from his protest crying without fear that an injury might occur. Sometimes duct tape is needed to cover the zipper because your child otherwise figures out how to escape. Don't worry about some theoretical sense of failure if the child has to return to the crib with a crib tent. Some parents feel that the crib tent “locks their child in the crib like an animal caged in the zoo” and they would prefer to lock the door instead. Most families find the crib tent more acceptable and effective, but let's talk about locking the door.
To me, this is absolutely the last thing a desperate family might want to try, and because it sounds so extreme I want to share with you my observation in some detail. The reality is that not all marriages are made in heaven, not all jobs allow parents to spend much time with their children, not everyone can begin sleep training early and prevent sleep problems, and, to be perfectly honest, it is difficult and inconvenient to be consistent in handling sleep routines. Circumstances beyond your control, such as twins in a one-bedroom apartment, sick relatives who need your attention, or medical problems such as frequent ear infections conspire to rob children of healthy sleep. So what are we to do when all else fails and the entire family is stressed from sleep loss?
Locking the child's bedroom door to prevent social interaction at night, which interferes with sleep, is discussed further in the next chapter for older children, about three years old or more. But for younger children, around age two, some parents find that if they lock their bedroom door, while protecting the child's safety with gates if needed, everything begins to turn around. First, however, you'll need earplugs in order to ignore the banging, crying, or yelling. Second, place the child back in his crib or bed after he falls asleep. Third, praise him well when he eventually stays asleep in his own room.
Sleep Rules
A crib tent may be most appropriate for a child close to one year of age, and locking the parents’ door might be needed for a two-year-old. However, as the child gets closer to the age of three, consider sleep rules. Sleep rules should be implemented for both nap time and nighttime in order to be consistent. The family makes an elaborate, decorative, theatrical poster, which they put on the wall in the child's bedroom. Use stars and stickers; the more colorful and dramatic it is, the more motivational it will be. The poster looks like this:
SLEEP RULES
At bedtime we …
1. Stay in bed.
2. Close our eyes.
3. Stay very quiet.
4. Go to sleep.
Insert your child's first name before the title so that “John” will listen carefully when a parent recites “John's sleep rules” every time he is put to sleep. You simply say, “John, remember your sleep rules. One, stay in bed; two, close your eyes; three, stay very quiet; and four, go to sleep.”
Rewards and privileges are an important component of this plan.
One family placed next to the poster a calendar called a “bedtime star chart.” The mother read the rules at bedtime. If the child followed the rules, she got to put a star on the chart the next morning, which meant that she could choose a treat later that day. No star, no treat. She caught on very quickly to the relationship between following the rules and getting treats.
In general, even if there is no problem around naps, for the sake of consistency, also give the treat or star after the nap. Often a big glass bowl filled with treats on top of the refrigerator, where it is visible to the child, will enhance motivation. Either the treat or a token to be exchanged for the treat is given immediately upon awakening. Later, the treats can be placed in a “treat bowl” to delay gratification, and later the child will substitute heightened self-esteem for the treats. One caveat: This method is guaranteed to fail if the treats are insufficiently motivational.
Let's take a moment to look more closely at the difference between rewards and bribes. I am sensitive to the fact that some people will claim that it is wrong to give something to a child to make a behavior occur—that it is like a bribe. The simple answer is that we smile, hug, and praise our children when they perform in a socially desirable way. This is how a child learns to share toys and develop manners and desirable social habits. But our social rewards simply aren't powerful enough to change the behavior of a strong-willed two-or three-year-old who is dead set on fighting sleep for the pleasure of your company. Opponents to giving rewards come up with theoretical objections, but the fact remains that when rewards are used in the context in which I am describing them, they work.
Actually, rewards are only half the story here. Think of what your child loves to do around the house. Exclude creative activities such as reading, painting, or building things. Think of somewhat passive things, such as watching videotapes, DVDs, or television; playing with the computer; or perhaps playing with some favorite dolls or trucks. Choose one activity and call it the “privilege.” So, after you recite the sleep rules, you say “John, remember to follow the sleep rules so that when you wake up you can choose a treat and play with your trucks.” All the trucks are put in a box in the closet. If he follows the rules, after he wakes up you say, “Thank you for following the sleep rules. Here, choose a treat. And here are your trucks to play with.” Or, if he did not abide by the rules, say, “You did not follow the sleep rules, so no treat and no trucks to play with until you follow the rules.” If John decides he doesn't care about his trucks, then restrict some other privilege next time in addition to the trucks.
When a child refuses to comply with sleep rules during the day when a nap should be taking place, and anytime a problem behavior occurs at night, employ the silent-return-to-sleep strategy. Put a bell on his doorknob so you know when he is leaving his room. One very cute and bright girl ripped up three sleep rules posters before she got the message. Then she started to tell friends, with great pride, that she now sleeps by the rules!
What we are simply trying to accomplish is to encourage behaviors (described as sleep rules) that are compatible with allowing the sleep process to happen and to discourage behaviors (such as singing, calling, and running around) that are incompatible with sleeping.
When you employ sleep rules or the silent return to sleep, do not be surprised if your child's behavior gets worse for a short time. It's as if he is putting forth more effort to get back to the old way.
PRACTICAL
POINT
Problems may
get worse
before they get
better during a
retraining phrase.
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 corresponds 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 'font-size: 13.5pt;font-family:"Times New Roman",serif;color:black'>
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 to 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.
Months Sixteen to Twenty-one: 23 percent have two naps, 77 percent have one nap at eighteen months; 12 percent have two naps, 88 percent have one nap at twenty-one months
· If you have only a morning nap, try to delay its onset by shifting it slowly toward midday. Try a ten-to twenty-minute delay every few days.
Months Twenty-two to Thirty-six: 5 percent have two naps, and 95 percent have one nap at twenty-four months; 0 percent have two naps, 91 percent have one nap, and 9 percent have no naps at thirty-six months
· If your child refuses to nap but still needs to nap, experiment with earlier or later bedtimes to help him get more rest.
· If your child climbs out of his crib, practice a “silent return to sleep” (see page 320), whereby you always promptly return him to the crib without any talking. If this fails, consider buying a crib tent (see page 323).
· Around age three, consider sleep rules (see page 325) to help keep your child in his crib or bed.
· If your child gets up too early, use a digital clock to provide a visual cue that signals the start of the day.
· If your child has fears, spend extra time soothing to sleep and return once during the night for reassurance; use a timer to control the duration of the middle-of-the-night soothing.