Solve Your Child's Sleep Problems: New, Revised, and Expanded Edition

Chapter 1 At the End of Your Rope

The most frequent calls I receive at the Center for Pediatric Sleep Disorders at Children's Hospital in Boston are from a parent or parents whose children are sleeping poorly. When the parent on the phone begins by telling me "I am at the end of my rope" or "We are at our wits' end," I can almost predict what will be said next.

Typically, the couple or single parent has a young child (often their first), who is between five months and four years of age. Their child does not fall asleep readily at night and/or wakes repeatedly during the night. The parents are tired, frustrated, and often angry. Their own relationship has become tense and they are wondering whether there is something inherently wrong with their child, or if they are unfit patents.

In most cases the parents have had lots of advice on how to handle the situation from friends, relatives, even the pediatrician. "Let him cry; you're just spoiling him," they are told, or "That's just a phase; wait until she outgrows it." They don't want to wait but begin to wonder if they will have to, since despite all their efforts and strategies the sleep problem persists. Often the more the parents do to try and solve the problem, the worse it gets. Sooner or later they ask themselves, "How long do I let my child cry -- all night?" And if he or she gets up four, five, and six times at night, "Will this phase pass before we collapse from our own loss of sleep?"

Everything seems pretty hopeless at first. If your child isn't sleeping well or has other problems -- such as sleep terrors, bedwetting, nightmares, or loud snoring -- which are sources of worry and frustration, it won't take long for you to feel as if you're at the end of your rope too.

Let me assure you there is hope. With almost all of these children we are able to at least reduce the disturbance significantly, and often we can actually eliminate the sleep disorder entirely. The information in this book will help you to identify your child's particular disorder and will give you practical ways of solving the problem.

At the Sleep Center I meet with the family -- parents and child together -- and learn all I can about the child's problem. How frequent and long-lasting has it been? What are the episodes like? How do the parents handle the child at bedtime and during the nighttime wakings? Is there a family history of sleep problems, and are there social factors that might be contributing to the problem? With this detailed history, a physical examination, and, in certain cases, after laboratory study, I can usually identify the disorder and its causes. At that point I can begin to work with the family to help them solve their child's sleep problem.

Our methods of treatment for the "sleepless child" rarely include the use of medication. Instead, I work with the family to set up new schedules, routines, and ways of handling their child. Sometimes the child's biological rhythms may need normalizing or he may have to learn new conditions to associate with falling asleep. The family may have to learn how to set appropriate limits on the child's behavior, and the child may need an incentive to cooperate. I always negotiate the specifics of the plan with the family. It is important that they agree with the approach and feel confident that they will be able to follow through consistently. If the child is old enough, we include him in the negotiating. Thus we use a consistent, firm, but fair technique, tailored to the child, the family, and the particular sleep disorder. This works, time after time.

Usually the sleep problem has nothing to do with poor parenting. Nor are the episodes (with a few exceptions) part of a "normal phase" that must be waited (and waited and waited) out. And finally there is usually nothing physically or mentally wrong with the child himself. Most parents are immensely reassured to know that sleep disorders are common in all types of families and social environments, and that most children with such disorders respond well to treatment.

In certain cases, such as in sleep apnea, or less often in bedwetting, medical factors may be involved and our intervention may include medication or surgery. In other instances, such as the sleepiness of depression, recurrent nightmares, adolescent sleep terrors, and extreme nighttime fears, emotional factors may play a role. Here the source of these feelings must be identified and satisfactorily dealt with before the sleep problems will resolve. Sometimes professional counseling may be recommended.

The case studies in this book are based on my experience at the Sleep Center. The discussions of these cases, along with descriptions of the underlying sleep disorders and explanations of the methods of solving them, will help you to identify, understand, and deal with your own child's sleep problem.

Can a Child Just Be a "Poor Sleeper"?

If your child is a restless sleeper or can't seem to settle down at night, you should be very cautious about assuming that he is just a poor sleeper or doesn't need as much sleep as other children of the same age. Your own expectations can have a very strong influence on how your child's sleep pattern develops from the day you bring him home from the hospital. I have seen many families who were told by the nurse in the maternity ward, "Your baby hardly sleeps at all. You're in for trouble!" Because these parents were led to believe their child was just a poor sleeper and there wasn't anything they could do about it, they allowed their baby to develop poor sleep habits; they did not believe there was anything they could do to help him develop good ones. As a result the whole family suffered terribly. Yet I have found that almost all of these children are potentially fine sleepers and with just a little intervention can learn to sleep well.

It is true that children differ in their ability to sleep. Some children are excellent sleepers from birth. In the early weeks they may have to be waked for feedings. As they grow older, not only do they continue to sleep well, but it is difficult to wake them even when you want to. They sleep soundly at night in a variety of situations -- bright or dark, quiet or noisy, calm or chaotic -- they tolerate occasional disruption of their sleep schedules, and even sleep well during periods of emotional stress.

Other children seem inherently more susceptible to having their sleep patterns disrupted. Any change in bedtime routines, an illness, hospitalization, or guests in the house, may cause their sleep patterns to worsen. Even though these children may have always been considered "non-sleepers," we usually find that they too can sleep quite satisfactorily once we make appropriate changes in their routines, schedules, surroundings, or interactions with the family. Such children may still have occasional nights of poor sleep, hut if the new routines continue to be followed consistently, the more normal patterns will return quickly.

There are, of course, children who sleep very poorly for reasons we have, as yet, been unable to identify. For these few, our treatment may help very little, or not at all. If your child is up a great deal in the night it may be tempting to assume that he is one of these poor sleepers. But this almost certainly is not the case. Such instances of truly poor sleep ability are quite rare among young children, and in all probability your child's sleep problem can be solved.

Virtually all children without major medical or neurological disorders have the ability to sleep well. They can go to bed at an appropriate time, fall asleep within minutes, and stay asleep until a reasonable hour in the morning. And while it is normal for each child (and adult) to have brief wakings during the night, these arousals should last only a few seconds or minutes and the child should go back to sleep easily on his own.

It is very probable that your child, regardless of his present patterns, is just such a child, with a normal inherent ability to fall asleep and remain asleep. This is true even if he has a sleep disturbance such as sleepwalking or bedwetting. These events occur during sleep or partial waking, and children with these symptoms still have a basically normal ability to fall asleep and stay asleep. Sleepwalking and bedwetting are actually a bit more difficult to treat than sleeplessness, but nevertheless they too usually improve, and are often resolved, with the appropriate intervention.

How to Tell Whether Your Child Has a Sleep Problem

When your child's sleep patterns cause a definite problem for you or for him, then he has a sleep problem. This is true, for example, if he complains of inability to fall asleep, or if you find you must be up with him repeatedly during the night. Sleep problems such as sleep terrors, sleepwalking, or bedwetting are also readily apparent and quite easy to identify as sleep disorders. But others may be less obvious. You may not recognize that your child even has a problem, or you may not realize that the problem he does have should be considered a disorder that can and should be treated. You may not be aware that loud snoring every night, besides keeping you awake, may be a warning that your child is not breathing satisfactorily while asleep. Other symptoms of possible sleep abnormalities which should be identified and treated are: frequent difficulty falling asleep at bedtime, waking during the night with inability to go right back to sleep alone, waking too early or too late in the morning, falling asleep too early or too late in the evening, or being irritable or sleepy during the day.

One of the least obvious of sleep problems is that of insufficient sleep. There is no absolute way of measuring whether the amount of sleep your child gets per day is appropriate. Figure 1 on page 19 shows the average amount of sleep children get at various ages during the night and at naptime. But each child is different. We can watch each child's behavior during the day closely to see if he seems excessively sleepy or cranky. But the symptoms of insufficient sleep in a young child can be very subtle. If your two-year-old sleeps only eight hours at night but seems to be happy and functioning well during the day, it is tempting to assume he doesn't need more sleep. But eight hours is rarely enough sleep for a two-year-old, and with the proper intervention he can learn to increase his amount of sleep time considerably. You may begin to notice an improvement in his general behavior and only then will you be aware of the more subtle symptoms of inadequate sleep that actually were evident before you adjusted his sleep schedule. Now your child will probably be happier in the daytime, a bit less irritable, more able to concentrate at play, and less inclined to have tantrums, accidents, and arguments.

Adolescents often do not get enough sleep. Teenagers are not likely to wake spontaneously on school days and tend to sleep at least one hour longer on weekends. When adolescents have the opportunity to sleep as much as they like, they will average about nine hours per night, and this is probably closer to the optimal level for their age.

It is also difficult to decide when nighttime wakings are "abnormal." A young child from six months to three years may be getting adequate amounts of sleep at night, even though he wakes several times during the night and has to be helped back to sleep. Parents will say to me, "Tell me if this is normal. If it is, I will continue getting up; but if it is not, then we would like to do something about it!" I assure them that most healthy full-term infants are sleeping through the night by three or four months of age. Certainly by six months all healthy babies can do so.

If your baby does not start sleeping through the night on his own by six months at the latest, or if he begins waking again after weeks or months of sleeping well, then something is interfering with the continuity of his sleep. He should be able to sleep better, and in all likelihood his sleep disruption can be corrected. Chapters 5 through 9 will help you to identify his problem and show what you can do to remedy it.

How well your child sleeps from the early months affects not only his behavior during the day but also your feelings about him. I have often heard a parent say, "He is such a good baby. I even have to wake him for feedings." Although the parent is saying the baby is a good sleeper, the words imply that the baby is "good" in the moral sense. It is easy to see that this distinction will influence how you relate to your child.

If your child does not sleep well, he may well be making your life miserable. It isn't hard to think of such a bad sleeper as a "bad" baby. You will probably feel enormously frustrated, helpless, worried, and angry if you have to listen to crying every night, get up repeatedly, and lose a great deal of your own much-needed sleep. If your child's sleep disturbance is severe enough, your frustration and fatigue will carry over into your daytime activities and you are bound to feel increasingly tense with your child, your spouse, family, and friends. If this is the case in your home, you will be pleased to learn that your child is almost certainly capable of sleeping much better than he is now, and you should be able to get a good night's sleep yourself. To do this, you will need to learn how to identify exactly what your child's problem is, and then you can begin to solve it.

First, I want to explain briefly what we know about sleep itself. Although it is not necessary for you to be conversant with all the scientific research on sleep, it will be helpful for you to have some understanding of what sleep really is, how normal sleep patterns develop during childhood, and what can go wrong. Then you will be better able to recognize abnormal patterns as they begin to develop, to correct problems that have become established, and to prevent others from occurring.

Although the information on sleep in Chapter 2 is not overly technical, you may be eager to read the chapters that follow it to learn about the actual sleep disorders and their treatments. If that is the case, I suggest you scan the material on sleep in the next chapter and then come back to read it more closely when you have identified your own child's sleep problem. The information is very interesting to almost everyone, and especially important to parents who want to help a child sleep better at night.

Copyright © 1985 by Richard Ferber, M.D.