Letter to Kate

Dear Kate:

My 11 month old "spirited" girl has been ill with an ear and upper respiratory infection for about a month now. She was waking during the night 4-5 times to be held to ease her discomfort. By the time I would get back to sleep, she would wake up again. I got tired of this routine so I started sleeping in the recliner with her so I could get some form of continued sleep. Now I think she is used to it and wakes not because she is ill but because she wants to be held! Do I just let her cry and make her get used to sleeping in her crib? I really need to get some real sleep! I can't function like this anymore.

Please give me some perspective!

Thank you,

Sleepless in Omaha

Dear Sleepless in Omaha:

It is very common for youngsters to acquire new falling-to-sleep habits after they have been ill and parents have been very attentive. As you say, you daughter is probably "used to it". She likely does not deliberately wak up for attention. All of us (children and adults) experience partial wakings during sleep but most of us settle ourselves back down. Videotapes of babies sleeping clearly show how some infants partly wake, clutch a blanket and snuggle back down whereas others wake up completely and cry for the paren to come and settle them.

The good news here is if your daughter quickly learned to need you to settle her she can probably just as quickly learn not to need you, but to settle herself. The bad news is that if your daughter becomes ill again (and she likely will), and you quite rightly attend to her during the night for pain or fever, then she may very well go back to calling you in the night and you will need to retrain her all over again.

Such is the night life of responsive, loving parents! We are there to attend to our children wben they truly need us, then we reteach them good sleep habits when a good night's sleep is what they now need.

Good luck and best wishes for tons of sleep for all of you!

Kate

Many youngsters resist going to bed. This is not surprising. All the things they value most - parental attention, play and other sources of fun - suddenly disappear at bed time. An episode on a television sitcom illustrated this point very well. A scene showed the fantasies of a little girl who was the youngest child of a large and active family. While lying in bed, in her mind she pictured her parents and older siblings holding parties and playing wonderful games as soon as she was tucked into bed and her bedroom door closed. This must be the way many very emotionally healthy children feel. Their lives are full of good things and at bed-time those good things stop. My point is that resisting going to bed is not always a sign of an underlying emotional problem. Resisting going to bed at night should be distinguished from having trouble falling asleep, although the two problems can occur together.

However, emotional problems can play a role in bed-time resistance. Insecure children understandably feel suddenly more anxious as soon as they are alone in bed. The methods used to keep worries at bay during the day-time are often not available any more. As well, developmental fears of the dark or of separation will obviously intensify when a child is put to bed alone and in the dark. These fears can lead to calling in the parent and the child may work hard to prolong the visit and fight any attempt on the part of the parent to leave, expressing worries that there are boogie men in the closet or that they heard strange noises.

The most helpful approach to night-time fears is to address them during the day-time by increasing children's feelings of security. Developing complicated reassurance rituals at bed-time often intensifies the fears as the involvement of adults in searching under the bed for monsters can cause children to wonder if there must be some reality to their concerns. When addressing children's anxieties during the day-time, parents and helpers need to explore the basis for the fears or worries, such as overhearing parents arguing or the loss of a playmate when a family moves away. Sadness about real but not ongoing events can often be sorted out by working through them with blackboard stories, books or puppets. These real feelings need to be acknowledged and not seen as problematic behavior. Even after children have come to terms with the loss of a pet, for example, tears can return when memories are evoked. This is a natural and normal form of grieving and in itself a sign of healthy emotional development.

Other fears and worries require that adults change their behavior and not subject children to scenes or words which will foster anxiety. This includes frightening television shows which do not have to be violent to terrify young children. Helpers can play a very helpful role in pointing out to parents that young children including babies, even if they are too young to understand what is going on, are profoundly affected by what they hear and see.

When temperament-environment stress is present, anxiety at night may represent a secondary emotional disturbance as a result of the conflictual interactions. Some parents do not realize that the child whom they perceive as 'feisty' and 'tough' is often quite fearful under the negative and oppositional exterior. The child may speak of monsters or strange noises but in fact be symbolically expressing feelings of being unloved or unacceptable. Clearly the best remedy for anxiety with this basis is to improve the parent-child (or caregiver-child) fit.

Not all resistance to going to bed is based on anxiety. Sometimes it is just plain typical childish misbehavior. With infants, however, bed-time battles are not disciplinary issues and should be treated as falling-to-sleep problems, which we address in the next section. Toddlers who have started being non-compliant about staying in bed or in the bedroom can be taken back to bed repeatedly until they give up the struggle. Often a better solution is not to put toddlers (as opposed to preschoolers) to bed until they are truly showing signs of being sleepy. Then, if struggle still continues, the methods discussed under "falling-to-sleep problems" can be used. Punishments and threats should not be used.

Preschoolers who fight going to bed just as they fight following other orders can be trained to go to bed with the same methods used to induce compliance in other areas. Often when a period of child-led play is assigned as homework, and a system of incentives developed for the child, such a praise, stickers or other tangible rewards, these methods can be used to gain cooperation at bed-time. Preschoolers who usually have difficulty with delayed rewards may nevertheless understand the very familiar concept of "when you wake up in the morning" and may go to bed without any fuss in exchange for a reward in the morning. The more powerful the reward, the more likely this method will be successful because the child will be able to keep a powerful reward in mind more easily and, as a result, stay on track with the plan. (Some parents put a picture of the reward on the bedroom wall as a reminder to the child about the plan.) A powerful reward could be a special breakfast, depending on the individual child's preferences. This is perfectly acceptable. It works best if the reward is something the child can have almost immediately upon waking up in the morning.

Regrettably, but in keeping with my general point that children are different and respond differently to methods of management, there are a few highly excitable young children for whom such a powerful reward can cause overstimulation, leading to the opposite of the intended effect - a child too wrought up to sleep because he or she is waiting for the morning and what it will bring. This may be especially likely with a child who has difficulty delaying gratification and/or linking cause-and-effect. With such children, often staying in their rooms at bed-time is more manageable if they have stories on cassette-tapes to listen to or some other way of occupying themselves before they become truly sleepy. If special tapes are set aside for this purpose only, the effect can be to condition the child to this routine just that much more easily. Other bed-time routines can also help to put children into the right frame of mind for settling down for the night.

Although positive methods are preferable, lack of cooperation can require bringing in some weakeners, such as visibly removing allowance tokens (for example, pennies) from a jar, a method that works best with older preschoolers who have some idea of the worth of pennies and value them and what they can purchase. Positive approaches are best, particularly at bed-time. Parents to try to keep a very calm and neutral atmosphere at bed-time. Any power-struggles, exciting games or disturbances in routines or moods are likely to complicate any plans to establish stable and effective bed-time routines. Many wise parents take their telephones off the hook for this important part of their jobs as parents.

However, children can only be trained to go to bed in this manner. Going to sleep is another question. The two tasks are separate and should be treated separately.

Many infants and young children have trouble falling asleep by themselves. Their parents have to rock them, sit with them, lie down with them or repeatedly return to the room to deal with requests that sometimes seem legitimate ("I need to go to the bathroom") or requests that are clearly designed just to keep the parent involved. Parents are often very caught up in this struggle because of the strong messages of distress sent out by the children. (It is easy to see how temperament can play a role here in shaping the intensity of these messages.) Yet the vast majority of these problems are simply poor falling-to-sleep and poor falling-back-to-sleep habits. Sleep experts advise that after the age of four to six months, parents truly can teach their children to fall asleep promptly and to settle themselves during night-time wakenings, without the need of complicated rituals or constant parental attention.

Along with long or late naps, overexcitement, and excessive caffeine consumption, temperament can play a role when children are not sleepy at 'bed-time'. The child's biological rhythms are out of sync with the parent's expectations. When children with temperamental irregularity are put to bed when they are not truly tired, they may develop any of a number of ways of coping. Lucky are the parents whose child simply lies in the crib or bed and babbles and sings until he or she eventually falls asleep. Some children will settle in their beds or their rooms with toys and play quietly until they are sleepy. While this is something that some children appear to learn by themselves, it is also something that parents can train their children to do.

Requiring that a not-sleepy youngster stay in the bedroom at bed-time and play until he or she is sleepy gives parents some much-needed time to themselves and trains children to wind down after a busy and stimulating day. It is best if children do not play in bed because that can interfere with the development of good sleep associations. Children can be taught to identify when they are feeling sleepy and to call the parent for tuck-in time at that point. Then, after a quick story or cuddle, the parent should leave the room while the child is still awake. Turning off the light and switching on a night-light can create conditioning cues that will help the child to fall more easily. It is fine and often reassuring to young children to be allowed to sleep with a night-light, but not in full light.

A large number of infants and young children also waken during the night and call their parents. What parents need to learn is that all infants and children (and indeed adults) experience these wakenings but most manage to fall back to sleep without ever realizing that they had woken up. Infants and children who get a visit from a parent during these wakenings become dependent on that cue for falling asleep again.

Many parents have difficulty accepting the idea that the problems of falling to sleep and night-waking are just poor habits. It needs to be understood that the difficulties for the children are very real - hence the intense distress and often demanding behavior displayed. The children have truly become dependent on the rituals and routines and cannot be reasoned out of them. They cannot fall to sleep without them. They need to learn new falling-to-sleep and falling-back-to-sleep habits.

Everyone has their preferred sleeping conditions, although individual differences exist in how much people rely on them. It can be pointed out that many people, including infants and young children, have difficulty falling asleep in a strange bed because the normal cues such as the texture of the pillow, the subtle sounds through the window and other conditions, are different. Rocking, rubbing, singing, nursing, lying beside the child, and all the other things that help a child fall asleep are the conditions that have come to be associated with sleep by the child.

It is usually only the parental attention that has to be removed when changing sleep habits. The pillows, stuffed animals, position of the door and other ritualistic features, including nursing, are not usually causing a problem. These cues can remain as long as the parent is not involved with them and does not need to remain in the room while the child falls asleep. A parent can nurse the child in a rocking-chair, making sure not to permit the child to fall asleep while nursing, then place the child in bed and leave the room. Indeed, the less that has to be changed, the easier it will be for the child to cope.

A commonly-recommended way to change sleep associations that involve the parents' attention is to discontinue giving the attention, which most of the time amounts to the 'cold turkey' method of "letting the child cry". This solution is unacceptable to very many parents and some sleep experts feel that the crying itself may make it difficult for children to acquire new healthy sleep associations. The biggest problem is that so few parents can ever avoid going in once in a while and this strongly reinforces crying rather than falling asleep. Some sleep experts have argued that letting babies and children cry is confusing to the child and that a more gradual approach works just as well and is kinder to everyone involved. There are concerns when a child is truly not getting enough parental attention during the day, is receiving only negative parental attention or when the child has recently been traumatized. Under these conditions, the child's emotional needs must be addressed before a change in sleep habits can reasonably be expected. Some children do begin to sleep well again once frightening television is banned or once parents stop arguing in front of the child. However, even when emotional problems are resolved, poor habits can remain and then methods of 'unlearning' them are needed. When parents are positive and loving during the day, they can use 'cold turkey' methods in good conscience when parents are willing to do it. However, for the large number of families and practitioners for whom 'cold turkey' methods of letting the child cry are not acceptable, a gradual approach is often very reassuring.

The key idea with a gradual approach is that the child must fall asleep when the parent is out of the room. Parents need to decide how many minutes of crying they can tolerate before going in to pat the child on the back briefly before leaving, with the child still crying. This could be as little as one minute or it could be up to fifteen minutes. Then parents gradually increase the amount of time they wait before going in. This procedure can go on all night until the child finally falls asleep during one of the periods when there is no parent in the room. The procedure will need to be repeated for several nights before the new sleep habit becomes entrenched. The same procedures used for night-time sleep should be used for waking in the night and for naps. If the child then becomes ill or for any reason starts falling asleep in the presence of a parent, the old habit will come back very quickly and the procedure will have to be repeated. Whether parents are using the cold turkey method or the more gradual approach, often the period of the children crying themselves to sleep is quite short, sometimes just a couple of nights, especially with infants and toddlers. However, those early nights can be very difficult as the children intensify their crying to levels which alarm parents. Even if parents only wait a few minutes before going in, they may note that the crying has taken on a more urgent quality. It is highly likely that temperament will play a role here, too, with temperamentally intense children making a very big protest. Helpers should prepare parents for this intensification which is part of the unlearning process. Parents need help understanding the basis of this extra effort on the part of the child so that they do not misread it as a sign of severe emotional trauma and give up on their plan.

As well, since the training period can go on for many hours each night, parents must be prepared to accept the loss of sleep and the interruption of their time. In cases of severely stressed parents, especially if they are parenting solo, it can be very valuable if a spouse or supportive person sits through these nights with the parent. There is often a dramatic improvement in the quality of family life once children sleep properly. Family therapists report that sometimes resistance to changing a family's complicated sleep rituals reflects a problem in the marriage. By being over- involved with the children, especially at night, difficulties with intimacy or other relationship problems are avoided. In the case of solo parents, sometimes being involved with the child at night compensates for lack of adult companionship. Parents may wish to consider whether such dynamics are relevant in own particular family.

Nightmares are frightening dreams that can cause a child to wake in a very fearful state. Nightmares are more common in girls and occur in emotionally healthy children and adults. Nightmares are normal and are often linked to unresolved day-time anxieties. The content of the nightmare may not match the cause of the anxiety. For example, a child nervous about starting kindergarten might have nightmares about being chased by bears.

Very young children have difficulty distinguishing reality from fantasy and so may have trouble realizing that what they experienced was just a dream. They may become very distressed, insisting that the parent try to get rid of the feared creatures, such as monsters, that they are sure are really under the bed. Parents can help the child to begin to understand that nightmares are not real by labelling them as 'bad dreams' and assuring the child although the dream is not real, their frightening feelings certainly are and the parent has firm empathy for the feelings. I state 'firm empathy' because parents should avoid being so sympathetic about the fear that they feed into the child's anxiety. In time, children will come to understand the unreality of nightmares and often talk themselves back into sleep. As with all anxiety-based behavior, nightmares are best addressed by increasing emotional security in the day-time. The methods described in the previous section under Anxiety and Fears should be used, and the cautions about how readily children acquire poor sleep habits after receiving parental attention at night discussed in the section on Sleep Problems kept in mind.

Parents need to understand the way in which nightmares about monsters and animals may be related to parent-child conflict, including a poor tempermental fit and temperament-environment stress:

Zach was a very bright and imaginative four-year old. He had a very extreme temperament, having nearly all the traits that parents find challenging. His parents were coping well with Zach but his mother relied a great deal on her husband's support in this task. When Zach's father had to go out-of-town for business, she became very anxious and tense and so did Zach. At the age of four, when his father was out-of-town, Zach started waking up terrified, telling his mother that he had seen a large bat in the window. Zach, being a nature lover and very advanced reader, knew all about bats and could describe the species he had seen right down to the last detail. His mother, knowing how bright and perceptive Zach was, at first believed there really had been a bat and became very frightened herself. It took several months of work with a psychologist for the family to sort out what was real and what was not, and to uncover the real basis of Zach's nightmares. When he went out-of-town, Zach's father now left a reassuring message on the family's answering machine that they could listen to whenever they felt worried. He also telephoned his wife and son from out-of-town. Zach's mother visited friends more often when her husband was away and worked on being more relaxed and warm with Zach in her husband's absence.

Although children like Zach clearly need help when they are so distressed, eliminating nightmares altogether is not a realistic goal. Nightmares in themselves are not abnormal and, as the case of Zach demonstrates, may serve an important function in bringing buried worries to the surface, albeit in symbolic form, where they can better be addressed.

Medical causes of sleep problems are much more rare than parents tend to think. However, there are some children who have neurological problems and other medical contributors to sleeping difficulty. These extend beyond the scope of this newsletter and parents who suspect such problems in their child should seek help from a specialist..

Click here to subscribe to the free BDINews. Simply put the word "subscribe" in the subject line or body of your email. Or send an email to:BDInews-subscribe@yahoogroups.com and put the word "subscribe"in the subject line or body of your email.