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 Boston are from parents whose children are sleeping poorly. When the parent on the phone begins by saying "I am at the end of my rope" or "We are at our wits' end," I can almost always 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 old. The child does not fall asleep readily at night or wakes repeatedly during the night, or both. 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 and whether they are unfit parents.
In most cases the parents have had lots of advice from friends, relatives, and even their pediatrician on how to handle the situation. "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 they are beginning 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 the child gets up four, five, or six times a night, "Will this phase pass before we collapse from exhaustion?"
Everything seems pretty hopeless at first. If your child isn't sleeping well or has other problems that worry and frustrate you — such as sleep terrors, bedwetting, nightmares, or loud snoring — it won't take long for you to feel as if you're at the end of your rope, too.
Let me assure you that there is hope. With almost all of these children, we are able at least to reduce the sleep disturbance significantly, and usually we can eliminate the problem entirely. The information in this book will help you identify the type and cause of your child's particular disturbance, and it will give you a variety of practical ways of solving the problem.
When a family visits the Sleep Center, I meet with the parents and child together and learn all I can about the child's problem. How often does it arise, and how long has it lasted? 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? Given this detailed history, a physical examination, and, in certain cases, laboratory study, it is usually possible to 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.
At the Sleep Center, our methods of treatment for the "sleepless child" rarely include medication. Instead, I work with the family to set up new schedules, routines, and ways of handling their child. Often the child's biological rhythms may need normalizing, or at least his sleep-wake schedule may need to be changed. He may have to learn to associate new conditions with falling asleep or get used to fewer and smaller nighttime feedings. 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. And any anxiety in the child (or parent) must be taken into account. 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. As much as possible, I offer choices. The best solution frequently differs considerably from family to family, and from one culture or social group to another. If the child is old enough, we include him in the negotiations. Thus we use a consistent and firm but fair technique tailored to the particular sleep problem and to the needs and desires of the child and family.
Sleep problems are rarely the result of poor parenting. Nor (with a few exceptions) are they part of a "normal phase" that must be waited (and waited, and waited) out. Finally, there is usually nothing physically or mentally wrong with the child himself. Most parents are immensely reassured to know that sleep problems are common in all types of families and social environments, and that most children with such problems 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. Emotional factors may play a role in other instances, such as in the sleepiness of depression, recurrent nightmares in an anxious child, sleep terrors in the adolescent, and extreme nighttime fears. Here it is important to identify the source of these feelings and deal with them satisfactorily so the sleep problems can resolve. Sometimes professional counseling is recommended.
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 parents say, "He is such a good baby. We even have to wake him for feedings." Although the parents are really just commenting on the baby's ability to sleep, they may start thinking that their baby is "good" in the moral sense.
It is easy to see how this distinction can influence the way 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 child 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, 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, letting you get a good night's sleep yourself. To make that happen, you need to learn how to identify your child's problem; then you can begin to solve it.
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 identify, understand, and deal with your own child's sleep problem.
CAN A CHILD JUST BE A "POOR SLEEPER"?
Parents often believe that if their child is a restless sleeper or can't seem to settle down at night, it's because he is by nature a poor sleeper or doesn't need as much sleep as other children of the same age. These beliefs are almost never true. 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 a child (or an adult) to wake briefly a few times 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.
In fact, the mistaken belief that your child is unable to sleep normally can have a strong influence on how his sleep pattern develops from the day you bring him home from the hospital. I have seen many parents who were told by the nurse in the maternity ward, "Your baby hardly sleeps at all. You're in for trouble!" Because parents like these are led to believe their child is a poor sleeper and there isn't anything they can do about it, they allow him to develop poor sleep habits; they don't think it is possible for him to develop good ones. As a result, the whole family suffers terribly. Yet almost all of these children are potentially fine sleepers, and with just a little intervention they 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 wakened for feedings. As they grow older, not only do they continue to sleep well, but it becomes difficult to wake them even if one tries. They sleep soundly at night in a variety of situations: bright or dark, quiet or noisy, calm or chaotic. They can tolerate an occasional disruption of their sleep schedules, and they sleep well even during periods of emotional stress.
Other children seem inherently more susceptible to having their sleep patterns disrupted. Any change in bedtime routines — an illness, a hospitalization, or the presence of houseguests — can cause their sleep patterns to worsen. Even when these children have always been considered "non-sleepers," we usually find that they, too, can sleep quite satisfactorily once we have made appropriate changes in their routines, schedules, surroundings, or interactions within the family. Such children may still have occasional nights of poor sleep, but if the new routines are followed consistently, normal patterns will return quickly.
There are, of course, children who sleep very poorly for reasons we have as yet been unable to identify; however, these problems are extremely uncommon and account for only a tiny percentage of the children we see with difficulty sleeping. For these few, our usual behavioral treatments may help very little or not at all, and medication may even be required. If your child is up a great deal in the night, it may be tempting to assume that he is one of these genuinely poor sleepers. But that is almost certainly not the case. Such instances of truly poor sleep ability are quite rare among otherwise normal young children. In all probability your child's sleep problem can be solved. He almost certainly has 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 problems, occurring during sleep or partial waking, are sometimes bigger management challenges than is sleeplessness, but with the appropriate intervention, they too can usually be decreased significantly if not resolved completely.
HOW TO TELL WHETHER YOUR CHILD HAS A SLEEP PROBLEM
If your child's sleep patterns cause a problem for you or for him, then he has a sleep problem, whether this problem is just an undesirable expression of normal function or a reflection of an actual underlying emotional or physical "disorder" in the sense of a true psychological disturbance or a physiological abnormality of body function. Sometimes it is easy to see that such a problem exists. Other times sleep problems may be less obvious and easier to miss.
It is usually clear that a problem exists, for example, if your child commonly complains that he can't fall asleep, or if you find you must be up with him repeatedly during the night. In fact, the most common problems are easy to recognize. They are: frequent difficulty falling asleep at bedtime; waking during the night with an inability to go right back to sleep without parental support or intervention; waking too early or too late in the morning; falling asleep too early or too late in the evening; difficulty getting up for school or day care; and being excessively sleepy during the day. Sleep terrors, sleepwalking, and bedwetting are also readily apparent and quite easy to identify.
Your child could also have a sleep problem that you do not recognize. You may not be able to tell if your child routinely gets too little sleep at night to function normally during the day or if by sleeping late on weekend mornings he decreases his ability to learn during the week. You (and his teacher) may think that when he falls asleep every day in school and on the bus it is because he is bored or unmotivated; in fact, he may not be getting enough sleep, his sleep may be of poor quality, or he may even have a disorder, such as narcolepsy, that leaves him unable to stay awake during the day no matter how much sleep he gets and regardless of his motivation. You may see him as lazy or irritable, not recognizing that his behaviors are a reflection of poor sleep or of a sleep disorder. You may know he snores loudly every night, but not realize that the snoring is a sign that he might not be breathing satisfactorily, a problem that can interfere with his sleep and leave him overtired and irritable during the day.
It is important to remember that poor sleep affects daytime mood, behavior, and learning. At the same time, you should also know that sleep problems don't explain all daytime problems. If you don't know enough about normal sleep patterns, you may fail to recognize sleep problems as the cause of your child's behavioral or learning difficulties, or you may be tempted to blame these difficulties on poor sleep even when your child's sleep is perfectly normal.
One of the least obvious problems of sleep is simply not getting enough of it. There is no absolute way to judge from numbers alone whether the amount of sleep your child gets per day is appropriate. After the very early months, total sleep time per twenty-four-hour period drops to about eleven or twelve hours, diminishing only very gradually after that. The total amount of sleep differs surprisingly little among children, although the way they choose to distribute it may differ. One nine-month-old may sleep nine hours at night and take two solid ninety-minute naps. Another may sleep close to twelve hours at night and nap only briefly during the day.
Children should fall asleep quickly, sleep well at night, wake spontaneously (or at least easily) in the morning, and nap only as appropriate for their age. If they do all these things and function well during the daytime, then they are probably getting enough sleep. If it's always hard to wake them, or if they sleep an extra hour or two on weekends, then they are almost certainly not getting enough sleep. This is especially likely if they also sleep inappropriately (or at least get very sleepy) during the day, or if their behavior and ability to concentrate deteriorate markedly, typically in the mid- to late afternoon. But each child is different.
We can watch a 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 happy and functions 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. If you can find out why he sleeps so little and make appropriate changes, he will probably sleep an hour or two longer every night. 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 were actually present before you adjusted his sleep schedule. 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 almost never get enough sleep. Teenagers are not likely to wake spontaneously on school days, and they almost always sleep late on weekends (at least one hour later than on weekdays, often three to five hours later). When adolescents have the opportunity to sleep as much as they like every night, they average about nine to ten hours per night, and that is probably closer to the optimal level for their age.
Nighttime wakings are another potential problem that can be difficult to recognize as "abnormal." A young child (between six months and three years old, say) 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 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 (which really means that they go back to sleep on their own after normal nighttime wakings) 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 five or 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 the disruption can be corrected.
STARTING WITH A BASIC UNDERSTANDING OF SLEEP
Before we begin to discuss specific problems and their solutions, you will need some background information about sleep itself, which is covered in Chapter 2. Although you don't need to be familiar 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 other problems from occurring.
Although the information on sleep in Chapter 2 is not overly technical, you may be eager to read the later chapters to learn about specific sleep disorders and their treatments. If that is the case, I suggest that you scan the next chapter first and then come back to read it more closely once you have identified your own child's sleep problem. Most people find the information interesting, and it is especially important for parents who want to help a child sleep better at night.
Copyright ©1985, 2006 by Richard Ferber, M.D.