Night awakenings can be difficult to deal with. Here we try to shed some light into the darkness of problems with sleep maintenance, with emphasis in children.
Though some individuals complain about being able to fall asleep, others may have concerns that they are unable to stay asleep. This is a concern that spans all age groups.
It is important to make sure there is not a medical cause for an inability to maintain sleep, as there are disorders that can fragment sleep. However, assuming there is no underlying medical disorder, Then there are 2 concepts that are important to understand, and with children yet a 3rd.
1. Night awakenings are normal.
2. If you needed something to fall asleep, you will need that to get back to sleep.
3. Kids are smart. They do what works. They stop doing what does not work.
The same concepts described in Sleep Association with Sleep Onset also hold here. However, now we add another variable. It is advised to put an emphasis on sleep association with items that will be there when a person awakens, and to reduce emphasis on things that will not be there when the individual awakens. Note, I state “when” a person awakens and not if.
Good night baby!
In working with examples, the earliest example that can be provided is that of infant sleep. The first few months are indeed chaotic sleep cycles, as infant sleep cycles revolve around feedings and not sleep/wake cycles (circadian rhythm) as we know it. However, around 3-6 months of age most infants do have circadian rhythms developing.
Many times, one will rock an infant to sleep. It is equally soothing to the parent as it is to the infant. Baby falls asleep in your arms, then you place the baby in the crib. When the baby wakes up, it will cry. The baby fell asleep in rocking arms, then wakes up elsewhere. The associated soothing to sleep stimulus is not there. So many people rock the infant back to sleep. This can go on for several hours at a time. If the baby learns to associate being rocked to sleep with ending up in a different place, the baby may even start to fight sleep, exhibiting early sleep avoiding behavior. A parent may get desperate, they may drive around in the car with the infant as the rumbling rocking motion gets the child to sleep. I have heard of parents turning on the washing machine and placing the infant car seat on the washer. Several infant loungers have either rocking or vibrating models. What is happening is that the infant is not learning to associate its crib with sleep, but rather its association with soothing is the rocking.
Here is a different example that one can view – Funny baby sleep at sink.
This baby is sleeping in the white tub, but it is not the white tub that the baby associates with sleep (the tub is not the sleep stimulus). Its the running water that the baby is associating with the soothing. — Must be an expensive water bill!!!
Getting back to sleep!
Concept: If you need something to get to sleep, you will need that to get back to sleep.
Now lets take the infant model and reexamine a different scenario. You take the infant, you recognize that the infant is tired. Its funny how an experienced parent can hear a child crying in public and by note the tone recognize the kid needs a nap. You recognize the tired cranky tone. You swaddle the infant, or place in sleep wear per your pediatrician’s recommendations. Eyes are starting to open and close, the reopening of the eyes could me mild initial sleep avoiding behavior. You place the infant in the crib when in the drowsy state, then you leave and the infant saw you leave. When the infant wakes up, it is in the same place it fell asleep. There is less startle and though there may be an initial cry, but the infant is able to associate the crib with sleep and can self soothe back to sleep.
Now there are several other potential factors that can affect infant sleep, both medical and environmental issues. This is true with all age groups and intellectual levels. These can be further described and discussed in chapters later that are age and disorder specific.
For now, will give several other examples of age appropriate Sleep Associations.
Reduce stimulus that will NOT be there when you awaken.
Sometimes a parent is at the bedside till the child falls asleep or pat the child till they fall asleep. Others may fall asleep on a parent’s lap or bed, and then moved to there room. There is a chance that if the child will not be able to self soothe when they awake. When this occurs frequently they go back to the parent room in pursuit of what soothed them to sleep. Other times, if they don’t have that soothing stimulus, they may just wonder around the house and make noise, waking other family members. Essentially, the child does not associate its own bed with soothing, rather the child associates the parent with the ability to fall asleep. — I always find it interesting how a parent may complain there child does not sleep, however when the child sleeps in the parent room the child sleeps through the night.
Emphasize stimulus that will be there when you awaken.
I advise to place an emphasis on what will be in the room/bed when the child awakens, and to reduce the emphasis on things that will not be there when the child awakens. Again, note I state “when” the child awakens and not if. I would like to discuss some examples that I have seen work in my sleep practice. Early, build an association with something that will be in the room. This could be a certain teddy bear or pillow, or even the texture of a certain blanket. Do not allow this sleep association object out of the room in the daytime. If you use an object that they play with in the daytime, many times they will play with that object at sleep onset and you can see hyperactivity and sleep avoiding behavior.
I find that there are some kids with sensory sensitivity. Some these children like to have there back patted to sleep, or have a circular rub on there back. I find these kids do well with soft fuzzy thick blankets. You may rub there back in affection in daytime, or when you say good job during a daytime activity. However, at night, you have them pat or rub the textured object. This has been successful in allowing a subgroup of children back to sleep.
Real life example, with my son Manuel.
I would like to give an example of what I did with my son. Around 10 months of age, Manuel received a stuffed panda bear. We named him Panda. Also, around that same time he received a little soft puppy. We always had the same routine, bath-time wawa, then dry with towel, then brush teeth with towel wrapped, then jamas, then go downstairs and hug mommy. Then when we come upstairs, it was Puppy and Panda that would read a story. Panda had a deep, but silly yet soothing voice. Panda would read the story, Puppy would just squeak after every few Panda sentences. We then put the book aside, he snuggles with Puppy and Panda, then I say goodnight and turn off the lights. When we would come in the morning to awaken him, his first instinct was always to search for Puppy Panda and to hug them, if he wasn’t already snuggling with them.
Eventually we accumulated other stuffed animals, Shamu from Sea World, Big Dog and Little Dog were buddies, and my son had fuzzy hair like a Monchichi so one of those too. Approaching 2 years of age he had about 10 stuffed animals at his bedside, However still it was Puppy Panda that would put him to sleep.
At 2 years of age, there were times that when I would wake him up in the morning, all the stuffed animals were in his bed, even though it was just Puppy Panda that put him to bed. My initial though was no harm no foul. Then there started to be nights where he would awaken with loud crying between midnight and 3 a.m. I would check on him, but it was always Panda’s silly voice that would tuck him back to bed, never my own. Then one day, as vocabulary developed better, he cried in the middle of the night and he cried “I can’t find Shamu”. That was the end of 10 different animals. That morning when we made the bed together, I put Puppy Panda at the bedside, and we went together and but Shamu, Monchichi, Monkey, Big Dog Little Dog, White Dog, and Gold Fish all outside in the play area. A rule was set. All animals live in the playroom, except Puppy Panda which stay in the room and do not leave the room.
The moment of last request.
In the prior chapter of Sleep Association at Sleep Onset, I discussed the importance of a bed time routine. We discussed how the wind down time is a soothing time for sleep onset. At higher levels of intellectual development, I would advise a moment of last request. The reason for this goes back to the concept of : Kids are smart. They do what works. They stop doing what doesn’t work. Many kids eventually develop too many curtain calls, can I have water, just 5 more minutes, one more story, etc… If you institute the moment of last request, then that should be your answer to everything.
I need another glass of water, “No you don’t, you had your moment of last request”. I need to tell you something, “No you don’t, you had your moment of last request”. Can I have hug? No really who can resist a hug, However if they are getting out of there bed and going to the parent room to ask for this, direct them back to bed and promise the hug first thing in the morning because they had the moment of last request.
Tough love does mean you set limits, and after enforcing them you say I love you. Though that hug seems so innocent, I have seen it lead to several requests for hugs. I have also seen it lead to the child realizing they can find something to get out of bed again. I have seen children yell “help” at night, because it works. Another child I saw would yell “I’m bleeding” and they would pick a scab. The most universal one is “I had a nightmare” because somewhere they heard the parent ask if the child had a nightmare. My general experience is that these are not isolated night behaviors, but rather there may be some daytime behavior issues as well. In this circumstance it is important to address the daytime behaviors first with a behavioral specialist.
We need reinforcement!
The moment of last request can be reinforced by rules as well as by positive reinforcement.
For example, if they sleep through the night without coming out, there can be a prize. I have found it is amazing how kids will do anything for a sticker, just how every booboo feels better with a bandaid.
At higher social and intellectual development, if they sleep through the night, you can give them a token or a card. At the end of the week, after 3 tokens on a Sunday through Thursday basis, they get a prize, privilege, or maintenance of a privilege. For example, with 3 tokens you get to go to Chucky Cheese, or the park, etc… Or, now in order to keep your game boy or TV privileges, you need 3 tokens. If not, no game boy, X-Box, or no TV. And when you take away the privilege, and they ask why, you state 3 tokes are required. Why 3? Well if you are looking for 5 out 5 nights on the weekdays, or 7 out of 7 days during the week, then if they get one night off, they won’t care anymore. Perfect every night is not a reasonable expectation. In this regard, it may be best to start with small daily prizes to see immediate response/reward.
At early stages of social and intellectual development, they reinforcement can be daily. If they break the rule of the moment of last request, the consequence could be implemented the next day. No television, or a particular show, or video game use the next day. “That is not fair” and “why” will be the first words when you don’t allow them to watch the TV, etc… You have to explain, the reason why, is because they broke the rule. Each time they ask “why can’t I” or each time they ask to have the activity, it needs to be explained that it is a consequence, that is why. Otherwise its not tough love, its just tough luck.
More association examples.
Its amazing how you can see all types of associations as children develop. I would like to give an example of a random association I observed with my son. We took Manuel to Naples Zoo on New Years day in January of 2012, He just turned 3 years of age. Of course, he would see an animal and make there appropriate sound (funny how every kid pauses when you ask what sound a giraffe makes). We come by an exhibit of antelope. Manuel says look at the reindeer. My wife says, no Manuel those are antelope. He proceeds to say “Trust me. Those are reindeer”. Then he starts to look around, and he says “Where is Santa Clause”. Just coming off the heels of Christmas, anything brown with four legs and antlers were reindeer, makes sense in his mind.
I noticed he was making other associations as well. Manuel loves the No David books. I found this was a way for me to teach him rules, when No David would do something bad, I taught him what is the proper way to do things. Interesting, the first time I saw this was when we were waiting in line to take a picture with Santa Clause that same Christmas, He started to walk to Santa and I told him you have to wait in line, and on his own he said “Just like David”.
Manuel – Its Light Outside / Dark Outside.
You can use these associations for night time as well. In reading books to Manuel, I started to emphasize how whenever children were playing and having fun, the sun was out. And whenever the moon or stars were out, characters were yawning. The association that I started was, When its dark outside it is time to go to sleep, When its light outside it is time to wake up. Before going to bed, I would have him look out the window, “its dark outside, its time to go sleep” he would say. At time of wake up, I ask if he could look out the window and he would say “its light outside” what does that mean I would ask “its time to wake up”. The thing is, he is too young to tell time. One morning when he was 3 years of age, he asked me what time is it? I told him 8a.m.. His response was “no its One o’clock”. There were nights that he started to wake up and cry. I would go to his room, and I would ask him to go look out the window and tell me if its dark or light outside. He was say “its dark outside”, so I would say go to the bathroom and then get back to bed because it is dark outside.
Also, there were nights that I would put him to bed, and then he started to come down stairs. First time he did that actually scared me because I was watching a Star Trek rerun with aliens and I hear “Hi” behind me. We made the rule, if it is dark outside you have to stay in your room, unless you need to go to the bathroom of which you go upstairs and then go back to bed. This did become confusing to him on days I needed to take him to school, because I leave early for work and at times it was still dark outside. I had to convince him that the sun was about to come out, and by the time we got to school the sun was out and I reminded him that I promised the sun would come out.
Shortly after he would wake up my parents when they would stay over, or my wife, after 6 a.m. when it is not daylight savings. Manuel would walk into the room open up the shudders and say “its light outside, time to wake up”. Though neither my wife nor my mother appreciated this, at least he wasn’t waking us up in the middle of the night.
The concept of light outside / dark outside is not perfect. It does not conform to our society that does have time changes with daylight savings. Also, I remember how much darker the winters were and how brighter the early and later times were in summer when I lived in Nashville as opposed to Florida – And that’s just Tennessee, so there is greater variability in Northern states, Canada, and Alaska. Its a concept that worked for my situation, one that gave Manuel a clear visual cue rather then a “time” when he cannot tell time.
Alternatives: There are lights that are sold with an internal clock. It can be programmed to turn on at 7a.m., or whatever time you wish to establish as the wake time. Or, If your child knows numbers, you could get a digital clock, cover the minutes and just use the particular number of “8” as time to go to bed and “7” as time to wake up. Note, every child has a different amount of total sleep time, there is no magic number.
Vague concepts vs. Clear visual boundaries.
Children are able to recognize visual boundaries better then stated concepts. For example, if a child sees an ice cream truck across the street, the majority of children will not bolt across the street. They pause when the see the street, they look both ways, they turn there head and look for the parent in search of permission. A child may not have the concept of life and death just yet, but they do have the concept that there are consequences if the run across the street, they will get in trouble. Same cannot be said if the ice cream truck is at a soccer field, children flock to the sound and a long line appears in no time.
More Real Life Example, Courtesy of Manuel.
I did observe this in my son as well. Around 2 years of age, After dinner, I would make Manuel a glass of chocolate milk. He was amazed how the powder hits the white milk and then turns the milk chocolate color, and loved the taste of course. So after dinner, he started to get into the pantry to get the box of chocolate powder, seemed innocent. However, then he started going in there and getting juice boxes, then one day he brought me a snack for me to open for him, and finally I saw him climbing bottled water stack to get a set of trash bags to help me change out the trash. He just wasn’t getting what things he was allowed to get out of there. We made a rule, If the pantry door was closed, you could not open it. That one simple measure, gave him a boundary that he could see rather then conceptualize.
Another example, Manuel loves pirates, and he had all kinds of pirate toys down stairs. Then I started stepping on them. I made a rule, pirate toys cannot be in a place where we could step on them. One day he saw me step on a toy, he looked up at me and said “sorry”. He knew a rule was broken, but still had a difficult time with the concept. Next day I got painters tape from a hardware store, which traditionally is blue, and doesn’t peel off paint or leave film behind. I made a half circle up against the wall, and I told him all toys needed to be behind the blue water after he was done playing. It worked. In fact one day he was walking downstairs, saw a toy outside of the blue water, stopped in his tracks and said oops, put the toy behind the blue water and kept walking. My mother in law laughed.
Create clear rules And clear boundaries.
A night gate creates a visual boundary. A gate at the door, with a rule that once it is closed they cannot come out, they have to stay in bed. Can they knock it down or climb it, yes. But the concept isn’t to lock them into the room and create a fire hazard, the concept is to give the child a boundary that they can physically see, creating a psychological associative boundary for sleep in there room.
Hard to play catch up!
Though still challenging, It is easier to start the associations from the beginning then it is to try to retrain our associations. None the less, retraining the associations is the majority of what I do in my clinic. A frequent question I would ask my parents, Is it a rule that if you get into bed that you are not allowed to come out of the room? No, is the majority answer. I tell them to go back to bed, is the second most common answer. However, you have to understand, If it is not a rule then really they are not doing anything wrong.
Chances are there have been many times a parent told them to get back to bed, but after several times they would end up in the parent bed. It is logical for the parent to say they need rest, but in the child the perception is that if they try enough times they will eventually get to stay in the parent’s bed. So the first step indeed is setting rules and limits, not just telling them to get back to bed as that has not worked prior.
Time for change?
When initiating these rules and limits, this is a good time to perhaps have a change of scenery of some time. Maybe it is transition from crib to toddler bed, or toddler bed to twin size bed, or maybe even a change in sleeping arrangements. It could be more simple, such as a new comforter and pillow. Creating a physical change, can create a psychological association if it is emphasized. The reward system of the moment of last request described previously with tokens to be cashed in can be helpful. At this time, an additional caveat can be placed. The token, or even a “bed pass” can be given at the time of sleep onset. A bird in the hand, so to speak. If they get out of bed, they can have another glass of water or tell the parent something, but they have to cash in the pass. Again, at the end of Sunday through Thursday 5 day period, they need 3 passes in order to maintain the privilege of TV, X-Box, etc… Also, if they act up, keep getting out of bed, etc… If you need to go back to the room, then you take away the pass at that time.
Real example.
I had a patient that had complaint that the kid never slept since infancy. At length, I discussed all these concepts. When I saw them in follow up, child was sleeping great. I asked what was most helpful. The mother stated the child wanted an I-pad, and mother said “no”, because he would not sleep in his room through the night. From that night on the child slept in his room. And yes brought the i-pad to that appointment because he was so proud he wanted to show me.
All of these concepts have worked for different children. No two children, including siblings or identical twins, are the same in thought process. What works for one, may need a tweak for another.
Cautions!
A large caution is to make sure there is not a medical disorder or behavioral disorder occurring. Consult with your pediatrician prior to making these changes. If a child indeed has sleep apnea, we don’t want to punish a child for having breathing problems at night. And sometimes, the same problems a child may have rule breaking in night time, can be the same that is occurring in day time as seen in poor impulse control from ADHD or from Oppositional Defiant Disorders. Daytime behaviors and general behavioral issues need to be addressed first by a behavioral specialist.
What about the rest of us?
For teenagers and going into adult hood. The same concepts apply, that if you needed something to get you to sleep, you will need that to get back to sleep. If you needed the TV to fall asleep, when you wake up you may need it to get back to sleep. Problem with that is you need to look for the remote, to do that you need to open your eyes and wake up, so essentially you need to wake up to get back to sleep – see the paradigm? Some people may have this problem with hypnotics and sleep aids. Some do not become “physically addicted” but rather “psychologically dependent”. Sleep aids in general are short acting, the reason is so it does not give blunted cognitive effects in the morning. Some over the counter preparations such as cold and flu medication may be longer acting, and hence give you “medicine head” when you wake up.
In adults as well, I advise a routine associated with sleep onset. If something is needed to relax to sleep, white noise may be helpful. The sound of a fan, an MP3 player with ocean or rain forest sounds can be helpful for soothing and even imagery. This can be left on at low volume, and if you awaken put the emphasis back on the sound. I have had some patients have success with the rock fountains, can be bough anywhere. There is a sound of running water, turn it on at time of sleep onset, and when you wake up at night put your mind back to the running water. First thing in the morning, after awakening, turn the water off. Do not use the fountain in the daytime, or you will lose its sleep association.
For help staying asleep, I would advise:
