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SLEEP: Good Night!

How much sleep do we need?

Text Box:  Infants usually sleep about 16 hours and  2-year-olds sleep about 10 to 14 hours (including naps).

How common are sleep problems?

25% of kids demonstrate bedtime resistance and/or night-waking at some point during childhood.

 

“Should I worry if my child snores?”
Yes. You should always tell your pediatrician about chronic snoring, which could mean an obstructed airway (e.g., enlarged tonsils and adenoids, obesity or facial abnormalities).  Snoring may warrant a referral to an ear, nose and throat specialist or to a sleep center for assessment and a formal sleep study.  (Of course, if the snoring is only occasional, like when your child has a cold or seasonal allergies, there is probably nothing to be concerned about.  To be conservative, though, it is always best to mention your child’s snoring to the pediatrician).

Good Habits & Preventing Sleep Problems

·         Establish a Bedtime Routine (e.g., Bath->Book->Bed)

·         Establish a Regular Waking Time

·         Diet (e.g., eliminate caffeine, avoid spicy/gassy foods)

·         Exercise (during the day but not just before bedtime)

·         Try Drinking Milk (just before bedtime)

·         Use Bed for Sleep (Not eating, working, jumping, wrestling, TV)

·         Reduce/Eliminate Light and Noise

·         Cool Temperatures are Best

·         Medical Issues (e.g., ear infections, congestion, allergies, etc.)

·         DO NOT Medicate to Induce Sleep (e.g., Benadryl)

·         Eliminate any “Sleep Associations” at bedtime that will not be present later during the night (e.g., television, music, lights, YOU, etc.). 

 

These suggested “Good Habits” are not meant to “solve” a sleep problem, but rather these suggestions are only intended to increase the success-rate of the “Sleep Solutions” offered in the next section.

“What’s YOUR sleep solution?

Sleep arrangements are very personal decisions.  Try to have all caregivers come to an agreement about goals and techniques.  Remember, there are a lot of different ways to get to your goal.  Be prepared for some bed-time and/or middle-of-the-night turmoil (for anywhere between a few days to a few months!).  Not all of the techniques recommended by various “experts” are for every parent and child, and even so-called “experts” have disagreements about which technique is best to improve a child’s sleep.  This leaves the parent a lot of decision-making room.  The purpose of this literature is not to advocate a specific technique, but rather to simply make information available to help parents make an informed choice.  That said, here are some commonly recommended techniques that should be effective if used correctly and consistently. 

 

(1) The FAMILY-BED (or “CO-SLEEPING”):

Cross-culturally, about half of the world’s parents sleep in bed with their kids (i.e., the so-called “Family-Bed” or “Co-Sleeping”).  There are many strong proponents who argue that the “Family-Bed” increases bonding, trust, and security.  These experts and parents are quite happy to foster the closeness that results from a shared bed.  While positive effects on bonding, trust, and security can indeed result from the use of the “Family Bed,” to be fair it must be stated that there is no peer-reviewed research-based evidence that children who sleep alone are any worse-off in the areas of bonding, trust, and security.  It must also be stated that the American Academy of Pediatrics (AAP) explicitly recommends NOT sleeping with infants due to the possibility of suffocation.  That said, if your goal is for your child to sleep independently in his/her own crib or bed, consider these 3 well-researched and effective techniques detailed below. 

 

(2) EXTINCTION:

“Let him cry himself to sleep.”

This approach was popular with baby-boomers, during a time in the U.S. when it was politically correct to be “tough” (i.e., we just defeated the Nazi’s, James Dean rode free).  The approach has withstood the test of time, and “Extinction” still remains the most commonly given advice by pediatricians.  “Extinction” involves first ensuring the bedroom is safe and “child-proof” (e.g., bolt the dresser to the wall, make sure windows are locked, put cords from blinds up out of reach, remove or secure large objects that may fall on your child, etc.).  Next, with the “Extinction” approach, your child must be physically contained in the bedroom (i.e., for a child who is still in the crib, a crib-tent may be necessary; for an older child in a bed, a gate or a locked door may be necessary). 

 

“Oh No! I couldn’t possibly lock my child in his room!”

You “lock” your child in little box (called a “crib”), and you lock him in a BIG BOX (called “your home”), so then why be opposed to locking him in a medium-sized box (called “his bedroom”)?  We also “lock-up” our kids in countless other situations (e.g., the car-seat, the stroller, the yard, etc.).   While there are plenty of strong opinions on this issue, there is no research that indicates “Extinction” causes any emotional damage to children.  Still feeling guilty about “containing” your child in his room?  Remember that his bedroom is a safe, familiar place, and teaching him to fall asleep can indeed help him build independence and strength/self-esteem. 

 

“I tried ignoring my child -- but it didn’t work.  He NEVER STOPPED screaming!”

Eventually every human-being must fall asleep.  When parent report, “My son NEVER stopped screaming,” probing deeper will almost inevitably find that eventually the parent had enough, and went in to “rescue” their child.  Interestingly, the true duration of “never” in “NEVER stopped crying” varies greatly among parents (e.g., 10 minutes, 3 hours, etc.). 

 

“I tried ignoring, but it didn’t work.  He BANGED HIS HEAD -- He VOMITED!”

Regarding potentially self-injurious behavior at bedtime, share the details of the behavior and ask your pediatrician to assess the possibility of injury.  For example, “Head-Banging” 1 or 2 times on the rug is indeed different from more serious “Head-Banging” incessantly on the door.  Next ask yourself if you are able and/or willing to tolerate the potentially self-injurious behavior, until such time as it ceases. 

 

Vomiting, too, is especially challenging – it’s miserable for a child, it’s messy, and it hurts any parent to see their child get so upset.  However, it is a fact that vomiting can eventually become a means to an end for your child.  Depending on his age/development, the behavioral/”thought”-process may go something like this: “When I vomit, I get a lot of attention/ I get to go back in bed with mommy/ I get even with my mom who put me alone here in my room in the first place.”  Once again, ask your pediatrician about the potential physical “costs” of vomiting, then ask yourself if you are able and/or willing to tolerate the vomiting until your child figures out that it will not get him anything or anywhere good. 

 

“Yeah, but what about my child’s emotional well-being if he’s ignored when he vomits/bangs his head at bedtime?”    Sure there may be some immediate resentment, but after more than 60 years of parents using this approach, there have been no research-based demonstrated long-term negative effects.  This is obviously an emotionally charged topic, so disagreement with this approach is indeed understandable.  The fact remains, there is simply no evidence that children will harbor sustained resentment/hatred/abandonment issues because they head-banged/vomited during the “Extinction” approach to fixing sleep.  NOTE:  Some “old school” folks may say, “Let the child sleep in the vomit and he’ll never do it again.”   While this may be anecdotally true, this appears to be both unhealthy and inhumane. 

 

“How long can I let my child’s crying and screaming go on?”

You may ask, “How long can I let my child cry or scream?”  Proponents of the “Extinction” approach would advise that you let him cry until he falls asleep.  Perhaps for hours?!  Usually crying is quite intense and long the first night, and subsequently less intense and shorter over the next one or two weeks (or months!), and the crying/resistance is ultimately “extinguished” (or at least drastically reduced). 

 

“I should have done this sooner!”

If you successfully implement Extinction, solve your child’s

 sleep problem, and reclaim the night as your own, you will probably say, “I should have done this sooner!”

 

“I CAN’T (or WON’T)  let my child cry for that long!”

To be objective, you CAN indeed let your child cry/scream himself to sleep.  If you CHOOSE to reject the Extinction approach (due to concerns with emotional or physical well-being), so be it—there are other effective sleep solutions.  Read on! 

 

(3) GRADUATED EXTINCTION (“Ferber-izing”):

And so it was that a generation of parents in the U.S. successfully put their kids to sleep independently with the above “EXTINCTION” approach.  But, alas, then came the 1960’s, 70’s, and 80’s, which brought a war in Vietnam, the “Humanistic” movement, the “Self-Esteem” brigade, and the “Politically Correct” (all of which colored the cultural and academic landscapes).  Dr. Richard Ferber (1985) offered an alternative for the resulting generation of “kinder, gentler” parents who preferred to help their off-spring fall asleep with the periodic reassurance that they have not been “abandoned” (as was alleged to result from “Extinction”). 

 

How do I begin to implement “Graduated Extinction?” 

To implement “Graduated Extinction” you must first secure the bedroom, which includes child-proofing and safely “containing” your child (see the first two paragraphs of the “EXTINCTION” Section above).  Next, hug and kiss him “Goodnight”, then leave the room. 

 

“But my child will cry and scream!”

Of course it is likely that your child will cry/scream to protest, but to correctly implement “Graduated Extinction” you need to remain strong – at least for a little while.  More specifically, you will now begin a series of brief visits with increasing durations between each. 

 

“Can I have a sample schedule of Graduated Extinction?”

To help your child learn to fall asleep independently, your visits to him should be “stretched” longer and longer over not only a given night, but also “stretched” longer and longer over consecutive nights.  Your 15-second visits should be conducted according to a schedule, such as:

DAY

BEDTIME

FIRST

15-second

Visit

SECOND

15-second

Visit

THIRD

15-second

Visit

FOURTH

15-second

Visit

FIFTH

15-second

Visit

Monday

8:00 pm

You wait 5

minutes  then

visit at 8:05

You wait 10 minutes then

visit at 8:15

You wait 15

minutes then

visit at 8:30

You wait 20

minutes then

visit at 8:50

You wait 25 minutes then

visit at 9:15

Tuesday

8:00 pm

You wait 10

minutes  then

visit at 8:10

You wait 15 minutes then

visit at 8:25

You wait 20

minutes then

visit at 8:45

You wait 25

minutes then

visit at 9:10

You wait 30 minutes then

visit at 9:40

Wednesday

8:00 pm

You wait 15

minutes  then

visit at 8:15

You wait 20 minutes then

visit at 8:35

You wait 25

minutes then

visit at 9:00

You wait 30

minutes then

visit at 9:30

You wait 35 minutes then

visit at 10:05

Thursday

8:00 pm

You wait 20

minutes  then

visit at 8:20

You wait 25 minutes then

visit at 8:45

You wait 30

minutes then

visit at 9:15

You wait 35

minutes then

visit at 9:50

You wait 40 minutes then

visit at 10:30

Friday

8:00 pm

You wait 25

minutes  then

visit at 8:25

You wait 30 minutes then

visit at 8:55

You wait 35

minutes then

visit at 9:30

You wait 40

minutes then

visit at 10:10

You wait 45 minutes then

visit at 10:55

 

Saturday

(…and every subsequent night until you succeed)

 

8:00 pm

Continue with the above

Friday schedule

Continue with the above

Friday schedule

Continue with the above

Friday schedule

Continue with the above

Friday schedule

Continue with the above

Friday schedule

 

“But my child does NOT calm down when I visit for 15-seconds!?”

If the goal of your 15-second visits is to calm your child, you will almost certainly fail.  But you will no doubt succeed if you (properly) define your goal as being to simply reassure and let him know that you still exist.  When you enter the room, give a “Reassuring Pat” rather than a “Comforting Coddle”, thereby achieving your goal of letting your child know that he has not been abandoned. 

 

“But when I visit, my child gets more angry, and desperately tries to clutch on to me!”

Yup, increased anger and desperate clutching commonly occur when “Graduated Extinction” is first implemented.  So you will need to make a decision about how you’re going to handle it: 

You may

(A) “cave in,” give-up, and (rationally or irrationally) decide, “This is not worth it!”, or you may

(B) view this increased anger and desperate clutching as evidence that “Graduated Extinction” is in the process of working, peel your child off of your body, lay him down safely, give a “Reassuring Pat” , leave/run out of the room, then watch your clock until it’s time for your next 15-second long visit.   

 

“I tried ‘A VERSION’ of “Graduated Extinction” with my child -- but it didn’t work!”

When parents report that their “version” of Graduated Extinction “didn’t work,” there are a few reasons:

(1)   The circumstances around the bedroom and bedtime were not set-up correctly (please see and implement most of the suggestions on the above checklist of “Good Habits and Preventing Sleep Problems”); 

(2)   The parent did not stick to the time-schedule, and gave up too quickly (please see and implement a schedule similar to the example above). 

(3)   The parent “pulled-the-plug” on the process after deciding that their child was somehow being “damaged” (emotionally or physically) by the “Graduated Extinction” process (please see the “Extinction” Section above for a discussion of crying, screaming, head-banging, vomiting, and “locking” a child in a safe and familiar place).

(4)   The parent implemented their own “version” of Graduated Extinction, but their “modifications” undermined the effectiveness of this technique (e.g., the parent stayed in the room with their child and tried to calm him, the parent visited too frequently without “stretching” the visits over the course of a night and over the course of several nights). 

 

(4) SUCCESSIVE APPROXIMATIONS:

 

So what do you do if you dislike “Co-Sleeping”, “Extinction” AND “Graduated Extinction”?  Fear not--there are always options.  “Successive Approximations” is a technique where you begin in your child’s bed, then move further and further away from the bed toward the hallway, thus “successively approximating” your goal of getting out of the room!  There are TWO PHASES of Successive Approximations: 

 

PHASE I: “GET in your crib/bed!”

Night 1:  For the first night, the parent stays right next to the crib (or if a bed is being used the parent lays in be with their child).  The parent may soothe him (e.g., talking quietly, rubbing his back).  The parent remains at the crib (or in the bed) until the child falls asleep.

Night 2:  On the second night, the parent moves a bit farther away—to the foot of the crib or sitting at the foot of the bed—until the child falls asleep.

Night 3:  By the third night, the parent moves a couple of feet away from the bed or crib. 

Nights 4 through 7:  Each subsequent night the parent moves increasingly farther from the crib/bed toward the door/hallway.  

 

PHASE II: “STAY in your crib/bed - - alone!”

“Yeah, but my child screams and won’t stay in the crib/bed when I move away!”

Of course, most children will strongly resist when the parent moves away from the bed during Phase I, so you will need to introduce PHASE II—training your child to remain in the crib/bed independently during increasingly long periods of parental absence.  When he screams to protest, you immediately leave the room and close to door/gate for a short period.  Specifically, you remain out in the hall for only about 5 or 10 seconds, then you crack open the door and prompt your child (verbally, physically, OR BOTH) to calm/get back in the bed.  You repeat the process incessantly until he “gets” (i.e., understands AND complies with) the deal (i.e., “Yes Mommy will stay in the room, when you stay quiet and remain in your bed).  Once your child complies with the rule, you begin to leave the room for longer and longer periods, while leaving the door open.  For example, you tell him, “Mommy needs to get a drink/use the restroom/make a call/check on something/etc.”  Initially your absences may be about 5 to 30 seconds, but you will work up to absences of 5 to 30 minutes over the course of a couple of weeks (or months), depending on your time frame and level of patience .  When (or if) your child “tests” limits by screaming/trying to leave the room when you’re gone, you stick to the deal and close the door for several seconds, then open the door and prompt him (verbally and/or physically) to calm/get back in bed. 

 

“My child is too young (and/or too defiant) to understand (and/or comply with) the rule: ‘Mommy will  stay here when you stay calm/ in bed’”

If you repeatedly prompt your child (BOTH physically AND verbally), you will ultimately get to your goal.  But if you choose ‘Successive Approximations’ you must be prepared to prompt him between 100 and 300 times (literally) over the course of a couple of nights (or weeks!).  By way of analogy, when your baby is very young you prompt him to wave “goodbye” by physically moving his arm up and down again and again (and again and again) until he ultimately “gets” (i.e., understands and complies with) the societal “rule” called “waving.” 

 

Now that I have chosen a ‘Sleep Solution,’ what else should I watch out for?

Nap-time

Ideally, use the same technique at NAP-time that you use at BED-time. 

 

‘Night-Waking’ and ‘Sleep Associations’

There are two important concepts that must be considered as you implement a Sleep Solution: 

(1) “Night-Waking” and (2) “Sleep Associations”.

“What is ‘Night-Waking’?”

There is a universal phenomenon known as “Night-Waking”, whereby ALL human beings wake several times in the middle of the night.  This is part of the normal “sleep-dream-wake” cycle.  As with most human phenomenon, Night-Waking occurs with individual variability.  For example, one person may wake for a half-second, rollover and unconsciously adjust the covers before returning to sleep.  Another person may use the restroom and return to sleep and only barely recall the event the next morning.  And yet another person may wake, watch an infomercial on ‘Deal-A-Meal” while eating a Smores bar, and ruminate for an hour before returning to sleep.

“What is a ‘Sleep Association’?”

“Sleep Associations” refer to those things that are present at the time that a person falls asleep.  These may include things like television, lights, music, a teddy bear, a bottle/pacifier, a specific person, a certain temperature, darkness and silence, etc.  Some people are quite flexible in their ability to fall asleep without their sleep associations (e.g., I have dozed off/fallen asleep at a Jet’s Game, at a Bruce Springsteen concert, and while driving), while others depend quite heavily on their Sleep Associations to fall asleep. 

 

How are “Sleep Associations” and “Night-Waking” related?

Many parents allow their child to fall asleep with certain “Sleep Associations” that will not be present in the middle of the night when the child experiences the aforementioned universal phenomenon of “Night-Waking.”  Common Sleep Associations include parental presence, television, rocking, etc., but these often ultimately “backfire” and prove to be problematic because many parents do not want to match these conditions in the middle of the night.  The solution is simple:  Make your bedtime conditions (i.e., “Sleep Associations”) match the conditions in the middle of the night (when “Night-waking” will occur).  When you do so, you will successfully train your child to put himself to sleep on his own at 8:30 pm, as well as at 3:00 am! 

Waking Others

“I can’t implement a “Sleep Solution” because my child’s screaming will wake up my other kids/other adults in the home (and maybe even the neighbors!)”

Indeed, sustained screaming is typically observed when Extinction and Graduated Extinction are implemented.  It is important to note that when either of these two techniques are implemented correctly, this screaming is usually only temporary (e.g., for a few days or weeks).  When the screaming child wakes other siblings, they too will ultimately fall asleep when you implement use of Extinction or Graduated Extinction with them. 

There are many reasons why families choose not to use Extinction or Graduated Extinction (e.g., waking others in the home, waking neighbors, a choice not to allow the child to experience sustained negative emotion, etc.), so if you can not tolerate (or decide not to tolerate) the screaming (for whatever emotional or physical reason), then use “The Family Bed” or “Successive Approximations” which minimizes noise and emotional turmoil. 

Whichever Sleep Solution you choose, it is advised that you begin to implement when you have one or two days of vacation (e.g., perhaps over a weekend), so that everyone involved can have a little tolerance for less sleep and/or disrupted sleep. 

If (and When) Sleep Problems Re-emerge

 

“Sleep Solution X worked for a while, but then my child regressed”

There is a robust phenomenon among all animals (including human animals!) called the “EXTINCTION BURST.”  Specifically, when a negative behavior appears to be “extinguished”, it sometimes “bursts” back, without readily apparent reason or provocation.  Common examples are observed with dieting (e.g., a person loses 30 pounds but then gains back 34!) and smoking (e.g., a person quits smoking for 2 years, but suddenly goes back to smoking a pack a day).  Bedtime-resistance and Night-Waking are no different.  Parents often report, “(Extinction)/(Graduated Extinction)/(Successive Approximations) worked for a while, but then the child regressed.”  The cause of the regression may indeed be interesting (e.g., “he got sick”; “we went on vacation and his schedule got thrown off”; “we had to adjust for daylight savings time”; etc.), but rather than discuss the reason for the regression, the more productive thing to do is simply implement again the Sleep-Solution that you used successfully the first time around.  If for some reason you don’t like the approach that worked the first time, choose another Sleep Solution from our list above, but whatever you do remember that YOU are largely (although not entirely!) in control of the process and the outcome.

A Word (and a World) of Encouragement for You

Choose a Sleep-Solution, implement, stick to it, and keep sticking to it until you get to the goal that benefits your child and family.  If you don’t wish to stay-the-course with a given Sleep-Solution, make a rational, well-informed decision, then implement another Sleep-Solution, stick to it, and keep sticking to it until you get to the goal that benefits your child and your family.  Remember, whichever Sleep Solution you choose, YOU WILL “WIN” if you remain consistent, because it is an inevitable biological fact that your child must ultimately fall asleep at some point!  He WILL ALSO “WIN,” as he will eventually benefit from a predictable routine and sleep well throughout the night.  The “prize” of a good night’s sleep for you and your child does not come without “cost,” but then again nothing worth having comes without cost.  GOOD LUCK and GOOD-NIGHT!

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