By Barbara Howard, MD
Why be concerned about sleep problems? Between 20% - 30% of healthy children under age 5 struggle with sleep issues, making it a very common issue. Raising children can be challenging enough, but add sleep deficit to the mix and you could also have these issues:
Sleepiness and irritability
Parents become exhausted
Interferes with attention, mood, hyperactivity, and mood
In teens sleep deprivation is just as dangerous as driving under the influence (DUI)
Destabilizes mental disorders, e.g., bipolar, ODD
Lasts over three years if left untreated
The good news is, that it can easily be resolved, see how.
Here is a look at the Average Sleep Requirements by Age:
Age Nighttime Daytime
1 week 8.25 hours 8.25 hours
1 month 8.5 hours 7 hours
3 months 9.5 hours 5.5 hours
6 months 10.5 hours 3.75 hours
9 months 11 hours 3 hours
12 months 11.25 hours 2.5 hours
18 months 11.5 hours 2 hours
2-3 years 11-11.5 hours 1-1.5 hours
4-6 years 10.75-11.5 hours
7-11 years 9.5-10.5 hours
12-18 years 8.25-9.25 hours
When assessing sleep use the mnemonic BEARS
Excessive sleepiness
Awakenings
Regularity and duration
Snoring or gasping
Bedtime Problems and Solutions
Sleep Hygiene
Cool, dark room used mainly for sleep (avoid electronics in bedrooms - 25% of toddlers have TVs in their rooms they can turn on themselves)
Regular schedule 7 days per week – circadian rhythm can be altered with as little as one to two nights of change in sleep schedule and increase sleep problems.
Avoid exercise within 2 hours of bedtime
Avoid stimulants, e.g., caffeine, tea, nicotine, medications
Routine: make bedtime feel safe, e.g., no arguing, media – instead bedtime story/positive talk
Avoid sleep associations that kids can’t reproduce on their own in the night. Sleep association are: - Circumstances of falling asleep need to be replicated to instill sense of safety for fall asleep. - Most commonly body contact and sucking - Place in bed awake starting by two months - Nighttime and naps both need same treatment - AAP recommends: back sleeping, pacifier - If it’s not broken, don’t fix it
Difficulty Falling Asleep
- Usually a phase shift problem – child not sleepy at bedtime often because they have had a nap that is too long, at home or at daycare. After one year usually only one p.m. nap is required. If child is not sleepy at bedtime, shorten nap and naps should end before 4:00 p.m. If a teen is having problems not being tired at bedtime make sure they are not napping after school or sleeping in too late.
Sleep Management
Sleep chart – explain issues to parents and 40% of sleep issues are resolved with sleep chart and attention to sleep hygiene
Increase exercise, but not after two hours before bedtime
Establish a bedtime routine
Start bedtime at a natural time and then work backwards – wake up time should be the same every day. For example, if they aren’t tired until 11:00 p.m. have the bedtime at 11:00 and then wake up at 7:00, then the next day go to bed at 10:45 and wake up at 7:00, the next day go to bed at 10:30 and so on until you get to the appropriate bedtime. Then be consistent 7 days per week.
Limit naps
Keep meals, sleep the same all week
Prolonged Routines
If there are sleep issues, limit bedtime ritual to 30 minutes or less
If the child asks for one more story, one more drink, etc., they may need increased daytime attention. Allow the child special daytime attention so they don’t feel they have to prolong their special time at night before bedtime.
Bedtime Fears
Usually occurs in preschool and reflects daytime stresses and their lack of being able to control their impulses.
Fears and impulses may include aggression/fights they had with siblings, media exposure that frightens them (TV or video games), struggles with parents, etc.
Fears may come from the past stressful events
Make bedtime safe
Have appropriate limits – don’t hit child
Avoid caffeine
Acknowledge fear, but make sure they know the “monster isn’t real.” “Monsters are scary, but good thing they are not real.”
Teach them a way to cope or to relax themselves at night. Buy the child their own flashlight and show them that they can turn the light on to make sure there are no monsters.
Worst case scenario, parent can “exorcise” they monster by spraying “monster spray” or some other ceremony to rid the room or closet of monsters.
Curtain Calls
Kids come out of their rooms after being tucked in and usually it is for some secondary gain, they aren’t tired, or they have problems adhering to limits in general.
Managing Curtain Calls
Prepare parents for excuses
Manage child’s limits in general
Tell the child the plan – put a behavioral plan in place. Give the child a “ticket” that they can spend if they need “one more” thing, but if they use it, they have to stay in bed they rest of the night.
Another alternative would be to put the child back in bed silently, without talking and/or close and hold the door with the lights off. The child will be upset, but after ten seconds open the door and say “Will you stay in your bed? If you stay in your bed, I will keep the door open.”
Combine the above with “two story or one story.” They get 2 stories the next night if they stay in bed, but only one story if they get up again.
Other options are to put a gate or screen door up on bedroom and think of the whole bedroom as their “bed or crib.”
For those children who sneak into the parents’ bed without the parent waking, put a bell on the parents’ door to wake them. Come back next month for Childhood Sleep Problems - Part 2, a clinical perspective.
CHADIS offers tools to help doctors, educators, and parents screen for and monitor sleep problems including the BEARS Sleep Screening Tool.
CHADIS is a unique screening, decision support and patient engagement system designed to streamline and optimize healthcare by providing clinicians with evidence-based data that improves diagnosis and management of health, emotional, developmental and behavioral concerns. www.chadis.com