Sleep problems in children are more widespread than commonly believed and may a significant impact on both the child and their family.
Childhood sleep problems span infants to teenagers and most have their origins in behavioural issues. A simple tool kit of evidence based strategies such as sleep diaries allow many sleep-related problems to be treated effectively in the home with the help of community health practitioners.
All humans require sleep for their wellbeing. In children it is particularly essential in promoting healthy growth and development. In framing potential solutions to sleep related issues, it is useful to understand what constitutes normal sleep patterns. In normal sleep, children cycle between rapid eye movement (REM) light sleep and non-REM or deep sleep phases throughout the night. Children often appear to be more restless than adults as they have proportionally more REM based sleep.
In falling asleep, children are dependent on both parental (rocking the baby to sleep) and non-parental (teddy bear) cues. Once asleep, children tend to fall into a deep non-REM sleep for a few hours before cycling between REM and non-REM sleep roughly every 40 minutes.
Common Childhood Sleep Problems
Behavioural based child sleep issues can include difficulty falling asleep, frequent waking during the night or early waking. The way a child falls asleep (such as holding their teddy bear) is the way they expect to go back to sleep after waking during the night. These ‘sleep associations’ can be the root cause of childhood sleep problems.
Some parents experience difficulties in establishing a regular sleep pattern for their children, with the child refusing to go to bed or re-joining their parents rather than sleeping.
Other forms of childhood sleep problems are:
- Anxiety related insomnia (child takes 30 minutes to fall asleep worrying about something)
- Delayed sleep phase (child goes to sleep late and wakes late)
- Medical (sleep apnea caused by tonsil and adenoid issues, ear infections)
In diagnosing an appropriate solution a detailed 24-hour sleep diary kept over successive days, starting with dinner and running through until morning is an important information source.
Managing Behavioural-Based Childhood Sleep Problems
The first step in mitigating sleep problems in children is to establish a consistent bedtime routine:
- Setting a regular bedtime
- Keeping the bedroom dark and quiet
- Avoiding food and drink containing caffeine after 3:00 pm
- Setting a regular morning waking time
Limiting screen time for tablets, computers, game consoles, smartphones and television is also important as blue light can suppress endogenous melatonin levels, impacting sleep onset and affecting the quality of sleep. In a typical sleep-wake cycle, melatonin rises two hours prior to the onset of sleep so exposure to blue-lit screens should be restricted at least one hour before bedtime.
There are a number of techniques parents can teach their children to help them fall asleep without parental intervention.
Sleep Associated Insomnia
Dealing with these issues requires swapping parental intervention for a transition object (comforting blanket that stays with the child overnight). In healthy infants older than six months, falling asleep may be associated with feeding. To break this association, the last feed should be given outside the bedroom twenty minutes before bedtime.
There are two primary strategies to help transition children from parental intervention:
- Controlled comforting
- Camping out
Controlled Comforting
This strategy involves parents setting their child in the cot by patting or stroking them until they are quiet but not yet asleep, then leaving the room. Parents respond to crying by checking and comforting, gradually increasing the gaps between checks. The process is continued until the child falls asleep without parental intervention – typically after one week.
Camping Out
As its name suggest, this involves a parent placing a chair beside the child’s cot and staying with them until they fall asleep. The parent then gradually withdraws over two to three weeks. For the first few nights, the parents comfort the child until they fall asleep. When the child settles without patting, the parents spend the next few nights by the cot but not touching. When the child becomes used to this, usually after two to three nights, the parents move the chair a foot or so away from the cot, again staying until the child falls asleep. After this, the chair is moved to the doorway before being removed completely.
Harm Free Behavioural Strategies
While these strategies trigger incidences of crying, extensive studies show these strategies reduce maternal depress and have no impact on child behaviors, parent-child relationships or parenting styles two to three year on.
Setting Limits
As children gain language and mobility, bedroom bargaining and battles over bedtime emerge. To avoid the onset of behavioural insomnia, parents should enforce a consistent bedtime routine with clearly defined limits. Frequently, improvement is preceded by short-term increase in negative behaviours, making initial treatment challenging for parents.
For change to be successful, parents need to set clear expectation of bedtime behaviours (you need to stay in your bed at night). Parents can then choose between the controlled comforting strategies explored earlier or the ‘extinction’ or ‘bedtime pass’ methods.
Extinction Method
Here, the child’s unwanted behaviours are ignored by the parents and avoid responding when the child’s demands escalate which can worse those behaviours.
Bedtime Pass Method
This method is suitable for children three to five years of age. The child gets one pass out at bedtime but parents will ignore any other requests.
Anxiety Related Insomnia
Anxiety is a common cause of sleep problem amongst children. It may surface as a sleep-onset disorder requiring parental presence for the child to fall asleep. Older children can be taught to draw their anxiety in a book before they go to bed, closing the book on their troubles before they sleep or try visual imagery or relaxation techniques in addition to the sleep-onset disorder treatment methods discussed above. If these simple methods fail, consider referring the child to a specialist child psychologist.
Delayed Sleep Onset Amongst Adolescents
Problems with falling asleep until very late is a common teenage malady. If it takes teenagers longer than 30 minutes to fall asleep, the ‘bedtime fading’ may prove to be an effective strategy.
Set bedtime at the time the teenager readily falls asleep. Then, progressively move the bedtime forward by 15 minutes every few nights, allowing the teenagers circadian rhythms to adjust.
Support your ‘bedtime fading’ strategy with:
- Consistent early morning wake times
- Eliminating daytime naps to encourage night time sleepiness
- Avoid exposure to blue light screens an hour before bedtime
- Increase exposure to natural light in the morning
Extinction Bursts
A child’s behaviours may suddenly revert back to their previous state some weeks after successfully altering their unwanted behaviours. This is thought to occur in approximately 20 to 30 percent of children who experience sleep-related issues. Parents should simply reinforce the desired behaviours and the child will usually revert back to their newly acquired good-sleep habits after two to three nights.
Follow Up Checks
Ideally, a health practitioner should check on the family within the first two weeks of starting treatment to monitor their experience and provide counselings and support. If treatment does not appear to be succeeding, the practitioner should review for:
- Inconsistency in applying techniques
- Disagreement between parents on the treatment path
- Parents finding the experience overwhelming and disorienting
If parents find the treatment experience to be overwhelming, consider breaking the treatment into simple steps such as applying a good bedroom routine for one week before moving on to the next phase.
Summary
Childhood sleep problems are a common experience yet they can have a significant impact on both the children and their families. Following four simple steps will greatly simplify the anxiety parents experience in resolving the problem while providing them with a simple, proven road-map for treatment:
- Implement consistent bedtime routines and oversee good sleep hygiene
- Offer fact-based strategies, tailored to the parents’ specific situation and parenting style
- Follow up with parents and review evidence for progress and roadblocks via their sleep diaries
- Warn parents about the potential for an extinction burst and equip them to deal with it
