Ok. This one has been a long time coming. I’ve been putting it off because there is a lot of ground to cover. So, we’ve covered why fixing your child’s sleep problem is not selfish because it is good for you and for them. I imagine that lots of parents fix their kid’s sleep issues without a lot of difficulty. Then there are the parents who have made it to see me in Sleep Clinic. Generally, these parents have tried and failed to address their child’s sleep problem, for various reasons. Since there is a lot of information to cover, I’m going to break this out into a question and answer format.
What do you mean by sleep training?
When I refer to sleep training, I’m talking about behavioral (non-medication based treatment) of two common problems, sleep onset association disorder and limit setting disorder. Some kids have a mixture of both.
When should I consider sleep training?
I would wait until a child is at least 6 months of age. Preferably once he is no longer feeding during the night. However, if your child is still feeding multiple times during the night and is over six months of age, that could be part of the problem. If your child has issues such as autism or developmental delay, these techniques will still work but must be applied very slowly.
When should I not start sleep training?
- If you are worried that your child may have a medical problem which is disrupting sleep, please talk to your pediatrician.
- If you want to pursue co-sleeping as a lifestyle, you may find it more difficult to adopt these recommendations, although they can be put into play if you are room or even bedsharing– it is just harder.
- If you have a major life event coming up– a move, a visit from the in-laws, a big project do at work.
- If you have major stresses in your that would make embarking on about a week of disruption.
Ok, we’re ready. Whats the first step?
I think the most important thing is taking a hard look at your child’s bedtime ritual. I just saw the great Jodi Mindell speak at the 2012 Sleep Meeting here in Boston. (Here’s a question and answer she did on some of these issues at Parents.com. She emphasized that bedtime need to be consistent, positive, and have a clear trajectory. Let’s break this out a bit:
- Consistency means bedtime happens about the same time on typical days, and has the same events in the same sequence. A good bedtime for babies and preschoolers through early elementary school age is between 7:30-8:30 PM.
- Bedtime should included enjoyable, positive activities like stories and songs, with the last part occurring where the child sleeps.
- Bedtime should be short and sweet (<45 minutes), with a forward momentum. Meaning that you go to the bathroom, then the bedroom, then lights out. Keep things simple and moving. Don’t move your child towards bed, then away, then towards it again.
- If your child has an aversion to being in their crib or room, it’s important to spend some pleasant, fun time playing there during the day to emphasize that it is a positive place.
In our house, we mark the start of bedtime by going upstairs with the boys between 7-7:15 PM. They brush teeth and bathe every other night. When one or the other attempts a digression (Wrestling! Running around naked! Peeing on the floor!) we firmly redirect them to the task at hand. They get in their pajamas, read stories, sing songs, and go to sleep on their own. If one parent is doing both bedtimes, the older one helps put the younger one to bed. Lights out is by 8 PM for the older boy.
We already do all that stuff. Our child still can’t go to sleep without us and wakes up at night!
Here’s where it gets a little bit more complicated, and this is the place where many parents struggle. Children who can’t fall asleep on their own and who wake up frequently at night likely have inappropriate sleep onset associations and will require a little bit more intervention. The goal of all of these interventions is the development of the ability to self soothe– specifically, falling asleep solo at night. There are a couple of evidenced based tools you can use if you put your child in bed and he cries or fusses until you come back into his room:
- Bedtime fading: This strategy involves temporarily moving your child’s bedtime later while teaching him to fall asleep on his own. Usually I recommend moving the bedtime later by 30-60 minutes depending on prior experience. For example, if the family has previously tried to put their son down and he cried for 45 minutes before they gave up, I will move the bedtime 45 minutes later or more. There is evidence that removing the child from bed if they do not fall asleep after 15-20 minutes then putting them to bed again a few minutes later (a “response cost”) is effective but I think that it is generally too complicated. Once your child can fall asleep within 15 minutes, you can move the bedtime later by 15 minutes every two days until you reach the desired bedtime. It’s important to avoid letting your child sleep in in the morning or falling asleep in the late afternoon in the stroller or the car, as they will be less tired at bedtime.
- The “cry it out” approach: The behavioral term for ignoring an undesirable behavior is “extinction”; obviously most parents don’t love the term. There are two ways to do this. Unmodified extinction involves putting your child down at the appointed hour, closing the door, and letting things play out. Many people struggle with this quite a bit. Graduated extinction is the method popularized by Dr. Ferber, where you check on your child at set intervals (e.g. 1 minute, 2 minutes, 3 minutes, then every five minutes until they fall asleep). When you check, the interaction should be very brief and without physical contact. Dr. Mindell recommends the script, “It’s night night time. I love you. I’ll see you in the morning”. This method is very effective but can be challenging to carry out. Some children may vomit. If this occurs, I recommend going in, cleaning up the child and bed, and leaving. It feels horrible, but you don’t want to reinforce vomiting as a tool to get what you want. Trust me.
- Nursing moms should try to avoid having nursing be the final activity prior to sleep onset. Ideally, the other parent should put the child to bed.
- The binky can be challenging. The American Academy of Pediatrics recommends pacifier use up until 6 months as part of a number of interventions to reduce the risk of sudden infant death syndrome (SIDS). In older babies and toddlers you may find yourself replacing it frequently at night. If you are not ready to get rid of it, Dr. Mindell recommends keeping some pacifiers in the corner of the crib. When you put your child to bed, guide their hand to the binky and have her put it in her own mouth. That may help her find it on her own in the middle of the night.
What do we do if she wakes up at night once we start this?
My child is an older and primarily has issues with bedtime. Any specific tips on working on this?
- Bedtime fading as noted above can be really helpful in this context.
- A bedtime chart showing what is expecting of your child every night can be really helpful. Here’s a nice one you can purchase here. Sticker charts can be helpful as well. Dr. Wendy Sue Swanson has tips on implementing this here. Dr. Deborah Gilboa discusses the limitations of sticker charts here.
- One strategy which I love is the bedtime pass. This works like a hall pass. Give it to your child and explain that she can use the pass to come out of the room one time for a curtain call e.g. a glass of water or another trip to the bathroom. After that one instance, she is expected to stay in her room and will be brought immediately back if she comes out. The research on this technique showed that kids tended to hoard the pass and not use it at all. Dr. Greene has a great summary of how to implement this. Here is also a hand-out from OHSU.
- You may need to carry out an extinction strategy which is more challenging to implement in a child in their bed who can easily get out of his bed, and out of his room. I strongly advise against locking children in their room. If your child comes out of his room, take him back to his room with the brief speech noted above (“It’s night night time. I love you. I’ll see you in the morning”.) If he comes out, put him back in his bed and close the door for one minute. If he is not in his bed when you reopen the door, close it for two minutes. Keep increasing the interval until he gets the message that you expect him to be in his bed. Another alternative can be putting a gate or two in the doorway of the room. (The second, higher gate is for kids that can climb).
What else do we need to know to succeed?
- You can carry out these steps gradually. Let’s say your child falls asleep nursing in your lap in the rocking chair. You can stop nursing to sleep for a few nights (often useful to nurse earlier and have the non-nursing parent put the child to sleep), then stop rocking for a few nights, then put your child to sleep drowsy but awake.
- Keep sleep diaries so you can monitor your progress. Here’s the log we use in clinic: PEDIATRIC SLEEP LOG
- Be consistent. Intermittently giving in is a very strong way to reinforce undesirable behavior.
Will my child hate me? Am I hurting her?
There is no evidence to suggest that sleep training causes any damage to children, and lots of evidence that it helps– that children and adults are both happier and better adjusted after sleep training. This is touched on in the AASM article below. Dr. Mindell noted in her presentation that she is publishing a review of 35 studies which showed no significant evidence of harm. Over at Science Of Mom, there is a great review of this science as well.
There was a great summary published by the American Academy of Sleep Medicine in 2006 which reviews the evidence for all of these recommendations. You can download it here: Practice Parameters for Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children.
If you are consistent, your child should be sleeping better within a week. Remember, things get a bit worse (the “extinction burst” of worsening behavior) often on the second or third night. Don’t give up!
Parents: please share your experiences in the comment section below. What worked? What didn’t? Are you still struggling with these issues? If you are, let us know and I’ll try to help.