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Problems with sleep behaviors are commonly seen in children. Sleep
is of primary importance at all stages of human development, and
in the newborn, is the primary activity other than eating. Childhood
sleep disturbances affect not only the child but also the whole
family. There is an abundance of different beliefs and lore on
this topic. Sifting through the enormous amount of material, approaches,
and opinions about kids’ sleep can be daunting for parents. There
is not one correct way to deal with your child in regard to sleep.
Each child is unique and has his own special set of circumstances
and needs. What’s important is for parents to identify what they
feel comfortable with and what they feel is best for their child.
I will delineate here some general principles and guidelines that
I have found to be helpful for parents in making choices about
how to handle their child’s sleep. I will also discuss some of
the most common childhood sleep disturbances and some of their
treatments.
Development of Sleep
When addressing difficulties that your child may be having with
sleep, it is important to be aware of the general developmental
progression of sleep behavior in kids. Newborns alternate between
sleep and wakefulness every 3-4 hours, awakening often associated
with hunger. As the child grows this develops into what is called
a "diurnal" pattern. This means there are progressively longer
periods of wakefulness during the daytime as well as longer periods
of sustained sleep at nighttime. By about 12 weeks, an infant
may sleep at night for periods up to 8 hours. At 3-4 months, more
than 70% of infants are sleeping for sustained periods of time
at night. This is sometimes referred to as "settling in" and it
occurs as the infant’s brain matures. If we look at EEG patterns
(an EEG is an instrument that measures brain waves) we can see
the patterns becoming increasingly organized into distinctive
stages differentiating sleep from wakefulness. An infant probably
spends 16 hours of a 24-hour period asleep. This decreases to
12 hours in the second year of life, 10 hours by age 3, and to
9 hours from ages 8-12. Remember that this varies according to
the child. With some children, this kicks in quite early and with
others it happens much later on. This is simply a variation in
normal development.
While the development of the brain plays a very important role
in the establishment of the sleep-wake cycle, learning and conditioning
are equally important. This is good news for parents because it
means they can also play a role in enhancing and facilitating
the development of their child’s sleep behavior. Just as parents
pay attention to their children’s general hygiene, they can also
address their sleep hygiene. This can help to establish life-long
patterns of good sleep. It’s much easier to prevent a sleep problem
than to treat one. The important keyword in sleep hygiene is consistency.
Bedtime should occur at the same time each night. This can be
made a pleasurable event. A regular habit of storytelling, reading
a book, or talking about the day’s events are often nightly rituals
that parents implement. This can be a meaningful period of engagement
for both the parent and the child. Typical bedtime sequences take
around 30 minutes. Often children engage in what has been referred
to as "curtain call" behaviors. These are behaviors by the child
that delay separation from the parents before bedtime. Kids will
often get up and say they need to go to the bathroom, or that
they need to get a glass of water. Sometimes these behaviors become
problematic. I recommend children be asked to do these things
for themselves. This avoids reinforcing these behaviors by granting
more contact with the parents.
Different sleep difficulties tend to cluster around different
ages. Before the age of three it is common for infants to have
problems going to sleep and nighttime awakening. Nightmares, fear
of the dark, and night terrors usually begin to occur between
ages 3-6, and sleepwalking usually has its onset after age 6.
Sleep problems appearing later and in adolescence are more frequently
associated with underlying psychiatric disorders, drug abuse,
or medical conditions like narcolepsy.
Should Johnny Be Sleeping In His Own Bed?
There are different philosophies about children sleeping in the
same bed as their parents. Western culture expects children to
sleep alone from a very early age. In non-Western cultures, families
tend to sleep together for a much longer period of time. Parents
generally have to decide what works for them and their lifestyle.
This issue can sometimes be a source of conflict between parents.
I recently consulted with a set of new parents who disagreed about
whether their 4-month-old son should be sleeping in their bed.
Mom found this convenient for breast-feeding, enjoyed having her
son sleep with her, and felt that this was an important bonding
experience for them. Dad complained of feeling tired at work the
next day and felt frustrated about the lack of sex with his wife.
I advise parents that the older a baby is when he is sleeping
with his parents, the more difficulty they are likely to experience
when making the transition from their bed to the child's own bed.
Kids generally love to sleep with their parents. Once used to
this they can be quite resistant to changing. It's important for
parents to be aware of the impact that this has on their own time
for both sexual and emotional intimacy.
Night Wakings
Infants sleeping alone often wake at night and fall back asleep
without the parents being aware of the arousal. Some infants,
as most parents know, cry upon awakening and this can become a
regular and frequent habit. The concerned parent may rush in to
see that the child is okay and to provide comfort. If a healthy
baby continuously awakens this can be a source of distress for
the parents. One popular intervention is "Ferberizing." This is
a method popularized by Dr. Richard Ferber. Basically it involves
letting the child continue to cry for increasingly longer periods
of time without intervening. The goal is to foster the child’s
ability to "self-sooth" or put themselves back to sleep. This
is effective after a few days for many children. However, some
parents don’t feel comfortable with what they perceive as a "cold
turkey" approach. Parents need to do what they feel comfortable
with and often do well with modified approaches. I advise parents
to try and not respond instantaneously to the child’s awakening
and crying. An instant response is likely to be gratifying to
the child and increase the likelihood that this behavior will
recur. Frequently a baby will cry for 20-30 minutes and then fall
back asleep. A timer is often useful to keep track of how long
your child has been crying (20 minutes at 2 am can seem like 2
hours). Children often respond rather quickly to methods like
"Ferberizing." However, transitions, changes in environment, travel,
and illnesses can causes these difficulties to recur.
Mommy There's a Monster in My Closet!
Around ages 3-5 children commonly experience fears around going
to bed and the dark. This is a period of a child’s development
in which the boundary between fantasy and reality is commonly
blurred. Our culture is replete with stories of nighttime visitors
like the toothfairy and Santa Claus as well as stories of monsters
and the bogeyman. Children’s imaginations are quite vivid and
bedtime can be a particularly scary time for some youngsters.
A night-light can help some of those monsters go away. Nightmares
also begin to occur at this time. Sometimes these awaken the child
in the middle of the night. Listening to your child’s fears and
concerns while reassuring him is the best response. I recommend
trying to avoid bringing your child into your bed for comfort.
Your child will certainly welcome it, but this can quickly become
a favorite habit.
Night Terrors versus Nightmares
Night terrors start to occur in the 3-5 age range, as well. Night
terrors are distinct from nightmares. With night terrors, children
will begin to scream and cry in the middle of the night but still
be asleep. These episodes are self-limited and it is best to hold
the child, not attempt to awaken them, but comfort them until
they have settled down again. Night terrors tend to run in families
and usually resolve spontaneously. At times the problem will be
frequent and severe enough that medication is used.
Bed-Wetting
Enuresis is what doctors call bedwetting. This can be quite embarrassing
for older children, who are often fearful of having sleepovers
at a friend's house, knowing they could have an "accident". Devices
that set off an alarm to awaken the child when he urinates in
bed can be quite effective for some. Different drugs have been
used to treat this but I generally do not recommend them. Most
medicines stop working after a period of time or the problem recurs
as soon as the medicine is discontinued. Most children grow out
of this problem eventually and parents need to be patient and
supportive.
Sleepwalking
Sleepwalking, like night terrors, tends to run in families. This
problem emerges more frequently sometime after age 6. A child
can get up and walk around while still in a sleep state. At times,
the child can open doors and go outside. When the problem is this
severe and can possibly endanger the child, medication is used.
Generally the child should be led back to bed without attempting
to awaken him. Sleepwalking tends to spontaneously resolve.
Summary
Sleep is a complex and vital behavior for children. The development
of regular sleep-wake cycles is vital for their healthy development.
Each child is unique and varies according to his own unique needs
and environment. Both brain function and external factors influence
sleep-wake cycles. Parents play an important role in facilitating
the development of their child’s sleep behavior. Sleep disturbances
can be caused by a number of factors. It is important to consult
your pediatrician to rule out medical causes for sleep problems.
Parents have many tools at their disposal to enhance their child’s
sleep. The adage "an ounce of prevention is worth a pound of cure"
holds particularly true for sleep behavior in children. Good sleep
hygiene is the best way to facilitate appropriate sleep behavior
for kids.
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