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sleep trouble

Putting Your Child's Sleep Problems to Rest

If you’re awake and alert enough to read this article and make sense of it, you may not be struggling with young children’s sleep problems as much as the average parent. The early years of raising children are famously sleepless years for most parents. Many wonder how they will make it through…but of course, most do. Some children, however, continue to experience problems with sleep into their later childhood and adolescence. This article addresses problems with falling or staying asleep, nightmares, sleep terrors, and sleep apnea.

Getting them to fall sleep, and stay that way.
Long and vehement battles have been waged in the parenting section of bookstores on the best method of getting your infant to sleep through the night. Some parents will swear by (and proselytize) a specific program or method, complete with TradeMarks, and indeed, some children seem to develop adaptive sleeping patterns exceptionally early and consistently based on parents maintaining regimented scheduling and responses to the infant’s needs. Many of these programs recommend that once an infant reaches an age at which sleeping several hours through the night is healthy (there is some disagreement as to this age cutoff), parents do not jump to the child’s rescue at the first sound of crying, but allow the child to cry for a period of time before picking him or her up from the crib. Some physicians decry this method of sleep regulation for young infants, as parents may be all too willing to let children cry themselves back to sleep at too young an age (“Well, we used the ****** program, and Priscilla was sleeping through the night by three weeks!”). Be sure to consult with your paediatrician before attempting any specific sleep program for your infant. In many cases, it is my clinical opinion that Get-Your-Child-to-Sleep-Through-the-Night programs are as much for parents’ health and wellbeing as for the infant’s.

If a child’s problems with falling or staying asleep persist after the first year, most physicians agree that it is time for parents to enact a more directive approach. A highly effective approach to preventing bedtime struggles and night wakings entails establishing extremely consistent bedtime rituals and routines (putting aside any daily inconsistency of your family’s evening life) that foster relaxation and drowsiness. These must be consistent and persistent. If children resist sleep despite these rituals, it can be effective for parents to be firm and consistent in not responding to cries. Children aged 3 to 5 will benefit from an explanation of this method, through a story that explains how the parent is going to ignore cries or requests, including a sticker or small reward in the morning for sleep-attempting behaviour. It is important to note that this type of extinction technique is easy for the "experts" to talk about, and extremely difficult for parents to apply (their heartstrings are so intensely entangled in the child’s requests and tears). Nonetheless, it has proven to be an effective method of helping everyone sleep a little better.

Nightmares.
Nightmares (distinct from sleep terrors – see next section) usually begin between 3 and 6 years of age. They usually occur during REM sleep (rapid eye movements, waking/drowsy sleep pattern, irregular pulse and respiratory rate), and typically occur during the last third of the sleep cycle, when REM sleep predominates. In contrast to sleep terrors, nightmares are vivid, elaborate, and usually clearly remembered. Isolated nightmares are often related to a specific incident, such as watching a frightening scene in a media program or overhearing an adult conversation regarding frightening topics. When children experience chronic nightmares, it is thought to stem from emotional stress, such as marital conflict, the arrival of a new sibling, or toilet training, or a single traumatic event such as an injury or accident. Intervention for nightmares typically revolves around reducing stressors in the child’s life, providing reassuring and comforting the child in his or her own bedroom, and providing some age-appropriate education around the nature of dreams. Other approaches include reading stories about children who experience nightmares, or individualized anxiety-reducing therapy such as systematic desensitization or behavior therapy such as contingency management.

Sleep Terrors
Distinct from nightmares are confusional arousals such as sleep terrors or somnambulism (sleepwalking). These occur during the first one to three hours of sleep, during transitions from deep sleep to REM sleep. They are more common in boys than girls, and likely result from arousal of the central nervous system. They are relatively rare (only about 3% of young children experience them), and the upshot is that they often go away with no intervention (very rarely do they occur in children older than 6 years). A sleep terror involves the child sitting up in bed or cowering in the corner, though they are fast asleep and can not be awakened, staring blankly, and screaming or crying inconsolably. They can be quite disconcerting to the concerned parent. Children often breathe rapidly, sweat, and have a racing heartbeat during these episodes. The next morning, the child usually has no memory of the incident.

More commonly experienced in childhood are confusional arousals (almost every young child experiences mild versions sometime during their first six years). They begin with tossing and turning and crying out, but children appear confused and agitated rather than terrified. In the case of sleepwalking, children wander away from their bed and may engage in unusual behaviour such as trying to leave the house or urinating on the floor. It is highly difficult to awaken a child from a confusional arousal, and they do not remember the incident later.

In severe cases, parents can be encouraged to time the occurrences, and then systematically awaken the child 15 minutes before the typical time of confusional arousal for several weeks in a row, which has been found to reduce the problem.

Sleep Apnea
Sleep apnea occurs when a child’s airways are blocked during sleep, preventing the passage of oxygen. They may occur any number of times per night, and may last anywhere from 10 seconds to 2 minutes. They can be damaging to a child’s health, and can interfere with optimal cognitive functioning during the day. Problems can include irritability, emotional struggles, impaired concentration and attention, poor visual-motor performance, and social and academic difficulty. Snoring is the foremost symptom of sleep apnea, but it should be noted that while many children snore (up to 10% of children), few of them actually have sleep apnea (only 1 to 2% of children). Other symptoms of sleep apnea include mouth breathing, profuse sweating, and uncomfortable-looking, neck-extended sleep positions. Sleep apnea is sometimes treated by removal of tonsils and adenoids.

Sources include:

Schroeder, C. S., & B. N. Gordon. (2001). Clinical Problems of the Preschool Child. In C.E. Walker & M.C. Roberts, Handbook of Clinical Child Psychology, 3rd ed. Toronto: John Wiley & Sons.