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.
My son is just over a year old and has been diagnosed with Merosin Muscular Dystrophy. He has never had a problem seeping as an infant but now we find oursleves up all night….he cries in his sleep, he is constantly thristy and needs to be repositioned…..we are going on no sleep for months….not sure what to do…..any suggestions???
Dear Sandra. A child with muscle weakness can certainly have a behavioral cause of sleep disruption. However, I think that it is important to rule out a medical cause of sleep disruption, especially if he was sleeping well before and falls asleep on his own. I would discuss this issue with his neurologist and consider an overnight sleep study if clinically indicated.
Any thoughts for older kids (3.5 yo) who makes the bed time process painful for all involved by refusing to stay in her bed. She finds every excuse to get out and we’ve tried putting back in bed with little to no interaction, a gate and removal of privileges. Every night is 20 – 30 minutes of torture. I don’t want to lock the door, but i’m definitely tempted. once asleep there are no problems, but getting her there is trying.
I might try moving her bedtime later by 20-30 minutes. Try the bedtime pass as well and stick with it. How long have you been in the current state of affairs?
Thanks for the input! Not offended, just finishing up my twitter comments making the point a method is not necessarily an ideology! I don’t know how much in parenting should be. But cosleeping is so common and varied, it fits lots of different types of families. I’ve heard many kids are like yours as well…
Anyway. I’ll try a gentle fading routine. I tried around six months and found i couldn’t commit and didn’t want to, but now I’m worried about his naps and he clearly needs to crawl it out or whatever. Good point about sep- I recall that it actually may begin to uptick too. My daughters was not bad, so this is new for us.
Dear Joanne
I’m curious to know if she sleeps sitting up. I suspect that she does if she in fact sits up all night. I have seen this pattern in some children with significant obstructive sleep apnea. I would recommend discussing it with your pediatrician.
Hi Craig
No I don’t believe she sleeps sitting up – at least not properly – her head would start to droop and then jump awake much like anyone would. She does have some physical developmental problems and has been in hospital quite a bit but there has never been talk of sleep apnea – I have spoken to her pediatrician and she doesn’t think there should be any problem and that it is a case of a very strong willed child!!! Perhaps I should push for a Sleep study?
thanks for commenting on my post about sleep training because after that, i remembered that i had meant to read this post of yours before. i’ll be sure to keep re-reading it as it has some excellent tips and advice.
I really like the link you posted on controlled comforting as well; very good and succinct advice.
Craig,
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I’m not sure how I missed this informative post back in June. We did recently implement a plan for helping our daughter (6 months) sleep better during the day and at night. I was very hesitant, but the book we read (not Ferber) had some good suggestions for those hard parts. You have mentioned some of the important parts that I have learned through this (still ongoing) process. What worked for our family:
setting concrete goals of why you are implementing a plan. (I really wanted to sleep through the night without having to reinsert pacifiers and I wanted her to nap longer than 35 minutes)
acknowledge that crying is going to be very hard to listen to. Enlist the help of friends (preferably who have used an extinction method) and get them on the phone, FaceTime, instant message when you may hear crying. Don’t glue yourself to the monitor. Or, like you said, send your wife out of the house for a relaxing evening at a spa, shopping, dining or other lacking activities in her life. That IS what you recommend, right?
Check-ins often made her cry harder, so we added a few minutes to the recommended increments.
We purchased a video monitor that helped a lot. I could see when she was starting to fall asleep and help us know when we could delay a check-in.
Every child is different, but I don’t think she was ready for this prior to 6 months old.
We saw significant progress after 4 nights!
For naps, we are seeing mixed results, but this is only day 3 of working on naps. She typically sleeps (in her crib now) for 35-40 minutes and wakes up playing with her hands or talking to herself. Sometimes she will fall back to sleep on her own after 5 minutes or so, sometime she fusses/cries after 10-15 minutes. During crying I start the check-ins again and after another 15 minutes will usually fall back to sleep. The second half of the nap can last another 50-60 minutes!
Your post was helpful and encouraging- Thanks!
Fantastic insights. Thanks so much, Rebecca! And I absolutely do recommend an outing for moms during the process. I wish I had done that the night our older son cried for 2 hours. We were lucky in that the next night it was 20 minutes, and then he was fine.
Dear Rebecca: Part of the default answer to the crib escape issue was recommending a crib tent, but sadly these devices were all recalled. Thus you may be stuck making your son’s room more “crib-like”– place the crib mattress on the floor, remove any objects that he can climb on or hurt himself on (like an unsecured bookshelf), and gate the door. Sometimes, you may need to place a second gate above the first if your son is a skilled climber. I agree with you that transitioning to a bed at this age and in this context is not ideal, but safety comes first.
I would also consider fading his bedtime as detailed above for a bit. If he falls asleep elsewhere besides the crib mattress you can cover him with a blanket or move him to the mattress.
The upside to this situation is that this issue will be resolved well before your second child is born and you will not have to buy a second crib. Good luck!
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Ah. I suspect the hoarseness is from a cold and not from crying last week.
The critical piece is falling asleep on his own at bedtime. I suspect you will find this easier to start once he is in his own room; I would not spend a lot of time and energy training him now as everything will change in a few weeks. When you get in the new place try fading his bedtime later then letting him fuss himself to sleep.
Thank you so very much for the advice!! Now we’re going to be less apprehensive about the upcoming changes – really really appreciate it! We would love to thank you in person if you visit Zürich sometime
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I’m pretty sure she meant cosleeping “rip”.
And…that’s what I wanted to address: in an otherwise thoughtful post, your comment felt condescending and dismissive. It’s certainly possible that I’m oversensitive on my parenting choices, but I read it as though you assume that a co-sleeping family is too out-there for vaccines. I fully agree that families should get their children vaccinated; maybe instead of marrying an appropriate vaccine reminder to the co-sleeping comment, you could find a different time & place to emphasize the importance of vaccines. Thanks for reading my comment.
Fair enough. I have changed the comment.
Hi, I really appreciate this post and would love some further help! My 19 month old is a stubborn, vocal toddler who will work herself into a tantrum when she wants me and doesn’t get me. For this reason I am intimidated about trying to put her to bed without one of us there, but at the same time, she fidgets and talks, tosses and turns for 45min-1.5 hours at bedtime, then wakes numerous times throughout the night. My son was an easy, deep sleeper, with no attatchment issues and I never had any of these problems with him, so I feel at a loss.
My second one was fairly stubborn as well! If she is fussing that much I would move her bedtime later by about an hour as described in bedtime fading as well. The key is being firm and consistent.
What a relief! I stumbled onto this blog post after altering my Google search. I’ve struggled to find answers to our sleep issues for almost a year. After reading these posts I’m realizing that our problems are almost 100% controllable. We have sleep onset issues for sure. Not scheduled or routine enough. I love to blame my husband, but I haven’t exactly been firm myself.
Now that wr are
First, congratulations on the new arrival! Exciting times for your family.
In answer to your first question, as painful as it may be, I would hold on sleep training until you are settled in on the new arrival. I would also do one thing at a time. Perhaps sleep training and waiting until it is established until you switch beds, if you have the luxury of not needing the crib for a bit.
As for the sleep apnea issue, I would try seeing another provider in the office. If you do not make headway ask for a referral to an Ear Nose and Throat doc or sleep doc.
I’ll call the pediatrician to discuss and rule out any medical issues.
I know bringing into our bed will make them worse but wasn’t sure what to do otherwise, thank you for the suggestion of the mattress in her line of site.
I love this post – I just referred some parents to it today! Eventually, I will link to it from my website. Thanks for the great info.
Thanks so much. Looking forward to checking out your site.
Thank you so much for your reply and for your blog in general. I think you are helping more exhausted parents than you will ever know. I had a quick question about your response. When you say some children are not ready to sleep through, do you mean nutritionally or is it something neurological?
It is related to the development of the ability to soothe themselves and nutrition as well. Most kids need to be over 12 lbs to sleep through the night. In terms of self soothing, newborns have very little ability and it develops slowly over time.
Erin– if I were you I would wait until after the move. Otherwise you’ll have to do it all again. Perhaps an acceptable compromise would be having her sleep in a crib or on an air mattress in your room and then starting with a clean slate when you move.
Dear Craig,
I really hope you can help us. We have a 15 month old that from birth has been cosleeping. When we coslept, Emma would wake up 3-5 times to nurse since she didnt know how to self soothe. About two weeks ago I weaned her completely off breastfeeding and after a week of weaning, she began sleeping through the night! Fast forward two weeks later. We are now transitioning her to her crib. It’s been about 5 days since we stopped cosleeping and we are still having problems with her waking up crying hysterically. She’s just now starting to fall asleep a bit easier at bedtime(we’re in her room any where from 10-30 minutes) but every night, around 3am, she wakes up hysterical. It takes my husband or myself an hour or more to put her back to sleep. We usually have to pat her back, talk her down or I will have to keep my arm on her so she feels me while falling asleep. After she finally goes to sleep, she’ll wake up a few more times crying but falls back asleep without our help. We’ve been consistent with bedtime routines: bath, hugs and kisses, and bedtime by 8:15-8:30. She naps once in the early afternoon for about 1.5 hrs(we removed the second nap since she was sleeping so late). How can we fix her night time wake ups? Are we just to early in the sleep training to see dramatic results?
Hard to know for sure without knowing her age. I would make sure she is falling asleep on her own and have her pediatrician check her out for any medical issues which could be disrupting her sleep.
Dear Holly– I think you should try the “camping out” method of slowly moving yourself away from his bed at bedtime. I think this will be effective for you. Good luck.
Thank you for your blog. These posts are a great help. We are now on our fifth night of sleep training for our 11 MO daughter. She’s has previously been nursed to sleep and co-sleeping, but have still had several awakenings every night. Bedtime is starting to work out fine, but she wakes at night and it is very hard for her to fall asleep again, and she cries for 1-2 hours. We have taken away her last nighttime nursing this week. I noticed in your post that you believe nocturnal awakenings will go away over time if bedtime is working fine. Do that mean we can co-sleep for the rest of the night when she wakes after having slept 5-6 hours? Or should we continue to keep her in her own bed in the middle of the night?
Typically the awakenings will resolve on their own with time with the new bedtime, over the course of a few weeks. If you insist on her staying in her bed during the night it will result in more a quicker resolution but can be more difficult. I’m a firm believer in doing what you need to survive during the night. If the awakenings persist after a month you might need to be more strict.
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Great article! One question. Do you have any recommendations about teething? My 11 month old has a molar growing in. He’s been falling asleep well on his own for 3 week, until now. Aside from the obvious teething aids, I have been picking him up to console him and but now he gets hysterical when I put him back to the crib.
I would recommend having your pediatrician check his teeth and ears to make sure that there are no other sources of discomfort. Best of luck.