Sleep is a vital ingredient in creating a strong foundation in mental health. For some families, bedtime is a peaceful time of night filled with opportunities to grow closer as a family. For others, it is filled with struggles and is a source of great stress. Bedtime battles not only impact the amount of sleep the child gets but also reduce the amount of sleep the parents get. Sleep-deprived children are more likely to have emotional, behavioral, and academic problems during the day. Sleep-deprived parents may have problems concentrating at work. Families who have difficulty establishing a positive nighttime routine are likely to have more fights between parent and child and between parenting partners, enjoy fewer social activities, and have a less satisfying family life overall.
Establishing Positive Sleep Routines
Parents set bedtimes in order to ensure that their children will get an appropriate amount of sleep. Preschoolers usually need 11—13 hours a night, while school-aged children typically need 10—11 hours a night. There are many reasons why children may not adhere to a set bedtime, but most children will respond better to bedtime rules if a routine is established. Establishing a regular set of activities with your child every night before bed, even on the weekends, is essential. Effective Bedtime Routines First-time routines or new bedtimes should begin at a significant time during the year, such as a birthday or the beginning of the school year. Forewarning children about the upcoming change for weeks ahead of time helps them prepare for the change and understand that changes in routine are part of growing up. Effective routines include: • Establishing the steps to get ready for bed (including room cleanup) • Establishing what is needed to get ready for the next day (packing a backpack or choosing clothes) • Establishing regular parent-child conversation at bedtime (what happened today) • Reading a bedtime story • Singing a calming lullaby or song
Intervening With Resistant Sleepers Many children experience some difficulty falling or staying asleep at some point in their development. For resistant sleepers, effective strategies include:
A daily routine that facilitates sleep. The more active children are during the day, the more likely it is that they will be tired at bedtime. A regular routine as suggested above helps children wind down, prepare for the next day, and ease into sleep.
Systematically ignoring attempts to get out of bed. While this method can be very difficult for parents initially, it is effective in getting children to accept bedtime and fall asleep. Parents should focus attention on preparing for bed, but once the routine is completed and the parent or caregiver has said good night, the child should receive no signs that indicate continued attention. Do not answer any questions, comments, or statements the child makes for the remainder of the night. If the child gets out of bed, take the child back to bed with as little fanfare and conversation as possible. Parents can expect an initial increase in negative behaviors during the first few nights, but in many cases children go to bed with little protest after about three nights. If this period become too disruptive to others in the household, attention can be gradually faded over a longer period of time.
A bedtime pass. This technique involves making a "get out of bed free” pass. The child receives one ticket with the understanding that he or she must use the ticket to get out of bed (for a drink, to talk with a parent). A ticket cannot be used more than once per night. This serves to give the child a sense of ownership over part of the bedtime schedule and some personal power to make a choice about bedtime. The game-like nature of this technique may be attractive to children who are particularly vocal in their response to systematic ignoring.
Serious Sleep Problems
Establishing sleep routines and regular sleep habits is most helpful in preventing serious problems that interfere with a child’s rest. However, some children and teens are more susceptible to disruptions in sleep routines and more likely to suffer from primary sleep disorders. Sleep disorders among children include primary insomnia, nightmares, sleepwalking, and night terrors. Adolescents may experience other sleep dis- orders triggered by hormonal changes and stress. Insomnia Difficulty falling asleep or staying asleep without any underlying medical condition is called primary insomnia. Sometimes children are also sleepier than normal (primary hypersomnia). Both of these problems are most likely related to poor sleep patterns and erratic sleep schedules. Strategies noted above to establish effective sleep routines are often sufficient to reduce or eliminate primary insomnia, as well avoiding any food or drink with caffeine and regular exercise. For persistent insomnia, consultation with the pediatrician or a mental health professional might be helpful to rule out other conditions that interfere with sleep.
Nightmares Many children (up to half of all children) suffer from nightmares or bad dreams. Perhaps as many as one quarter of all children have a nightmare once a week. Nightmares are most common in preschool and ele- mentary grades and tend to decline over time, starting around age 2 and peaking between 4 four and 6. Bad or scary dreams can occur at all stages of life. Causes of nightmares in both children and adults include stress (including normal stressors); fevers; traumatic life events; viewing television, videos, or movies that are frightening to the individual; strong or vivid imaginations; fear (especially of the dark in little children); and some medications. If a child has a nightmare, the parent or caregiver should calm the child and repeat a shortened version of the usual going-to-bed routine to help ease the child S1H5-2 Bedtime back to sleep. There are many helpful children’s books that may be useful for children who have frequent nightmares. Many parents find that installing small nightlights can ease a child’s fear.
Sleepwalking Sleepwalking occurs during the deepest part of the sleep cycle, which means it is difficult to awaken the child and, when awakened, the child may appear a little dazed and confused. Children usually sleepwalk within the first 1—2 hours after falling asleep. A child might simply sit up in bed or might actually get out of bed and wander down steps or even outside the house. Sometimes children may engage in normal activities but in the wrong place. It is not that unusual, for example, for a child to mistake a closet for the bathroom. Children often have no memory of the event. After sleepwalking, a child should be comforted and returned to sleep. Chronic sleepwalking occurs in about 5% of children, and as many as 15% experience at least one episode. Although sleepwalking may continue to occur into adulthood, it usually stops in later childhood.
Night Terrors Night terrors occur when a child seems to awaken from sound sleep, often screaming, confused, and anxious, and without recognizing the parent or caretaker. Night terrors usually occur between ages 3 and 8. They are particularly frightening to parents because the child typically seems to be awake but terrified. Unlike after a bad dream or while sleepwalking, a child having a night terror is not consciously awake and may kick or fight with the parent who is attempting to calm him or her. The child may abruptly awaken with panic, screams, agitation, and pounding heart. Eventually, the night terror will subside (sometimes taking 10-15 minutes) and the child will return to sleep with no memory of the event or of being frightened. While very disturbing for parents, there is little impact on the child. Night terrors usually occur well into the sleep cycle and may occur as long as 3 hours after falling asleep. Parents and caregivers should respond by gently holding the child until the event subsides. Night terrors seem to have some genetic roots and are not a sign that a child is troubled or disturbed. They typically dissipate by age 12.
Sleep Problems in Adolescents
While children usually outgrow sleepwalking, night terrors, and nightmares by adolescence, other sleep problems sometimes emerge in teenagers. Sleep problems in adolescence are strongly related to changes in the sleep cycle triggered by puberty, hormonal imbalances typical in adolescence, and the stresses of growing up, including school activities and increasing academic and social expectations. Basically, most teenagers do not get enough sleep, nor can they readily get to sleep when they lie down for the night. Adolescents probably need at least 8 1/2 hours of sleep per night. Because most school days start between 7:30—8:30 a.m., teens would need to go to bed fairly early in the evening to get the requisite hours. Activities, homework, part-time jobs, and their own body chemistry (melatonin, a sleep hormone, is produced later at night in teens) all conspire against going to bed early and being able to actually fall asleep. Consequently, as most parents well know, many adolescents have trouble getting up in the morning and many teens feel sleepy throughout the day—as most teachers well know. This pattern of sleep problems in adolescents is sometimes referred to as delayed sleep phase syndrome. Intervention involves reducing stress for the teen, encouraging regular exercise, eliminating caffeine and high energy drinks in the evening, and removing light or other distracters from the bedroom. While establishment of a regular bedtime routine is helpful, it can be difficult to implement or enforce for many adolescents.
DOES MY CHILD HAVE A SERIOUS SLEEP DISORDER?
Consider the following questions if you are concerned that your child may have a more serious sleep disorder:
Does my child have health problems or troubles at school that could be affecting his or her sleep?
Is there a power struggle between my child and me?
Is my child’s sleeping problem interfering with family work or social activities?
A good way to keep track of information that could help to answer these questions is to create a sleep diary, charting starting and waking times of your child‘s sleep, including naps. Keep a detailed section documenting each night’s bedtime routine, including information such as where sleep took place, what happened before the child fell asleep, and how many times he or she briefly awoke. Focus on what actually happened, not what was supposed to happen. If you continue to be concerned that your child or teen has a serious sleep problem, consult your family physician. Your observations and the information you record in a sleep diary may prove valuable in determining if your child has a sleep disorder.