Ages & Stages: 0-5: Why Doesn’t My Child Sleep?
Q: Our 5-year-old has never been a good sleeper, and now we have a new baby who is 6 months old. My husband and I are exhausted. How much sleep do most 5-year-old children need? Of course, the baby is not sleeping through the night yet, and we are terrified that we will have the same sleep issues with her, too. My sister says that at some point you have to just let them “cry it out,” and they will be better sleepers. Can you help?
A: Adequate sleep is critical for effective waking thought, emotion and behavior. Acceptance of and confidence in sleep are not always innate or reflexive. Sleep maturity develops through learning and relatedness, and sleep outcome is a determinant of growth and development.
Fetal sleep patterns are developed by the sixth or seventh month of gestation. Newborn infants sleep 70 percent of each 24-hour day in patterns of several hours with feeding in between. By 9 months old, the majority of infants are settling into a predominantly nighttime pattern of sleep. By age 1, about 70 percent of infants have settled into sleeping most of the night and self-soothing their brief night wakings back to sleep. Crying out or waking parents is called “signaling.”
Bedtime routines usually start around age 1 or 2. By the start of school, children spend approximately 50 percent of their time in sleep and 50 percent in play. By age 5, total sleep time per day is expected to be 11 to 12 hours. During brief wakings, good sleepers self-soothe their return to sleep, often without being aware or remembering waking. Girls’ sleep cycles may mature slightly earlier than boys. Approximately 25 percent of 5-year-olds cry or call out to parents at least once nightly, whether needed by the child or reinforced by the parent.
Sleep problems continuing from infancy are most prevalent during the preschool years. Bedtime refusals and tantrums are often present, including “curtain call” repeated demands by the child after being put to bed for the night. Children who fall asleep on their own are more likely to return to sleep on their own upon waking in the middle of the night. Signaling during wakings elicits behavioral chains of response from parents surrounding resumption of sleep — parent involvement becomes an essential condition for the child to fall back asleep. Then, when parents withhold response when the child “signals,” it leaves the child with new needs and protests, and parents with aversive feelings and thoughts.
Sleepy self-doubting parents over-respond, reinforcing the signaling and establishing a behavioral trap.
Behavior modification to eliminate sleep problems and develop effective sleep requires careful planning and acceptance before being applied by parents. Parents can progressively lengthen their time of response when the child “signals.” Very elaborate and protectively structured procedures for letting the child “cry it out” can be established, especially through formal behavioral therapy, such as in the research of the Canterbury New Zealand Sleep Program. Systematic ignoring — appropriate to and workable for the family and situation — can be established. The concept is not risky, but parents must sustain the change in order for it to be effective and tolerable.
At your son’s age, positive rewards are the most acceptable mechanism for successful behavioral change of sleep problems. Establish a secure bedroom environment conducive to sleep, and free of play and stimulation, to help your child believe in sleep and in his ability to do so.
Organize your family life in order to support and provide good models of sleep and waking times. To build an emotionally rewarding sleep experience, defer any negative consequences and positive rewards to the following morning. The hope is that a difficult night can always be reworked the next day — with another chance to succeed the next night.
Help relax your child’s body and mind with stories, singing, music, back rubs, prayers and snacks endowed with themes of calm secure sleep as though nothing else is to be done. A clean, cool environment with warm covers and comfortable pillows can help. Complex carbohydrates and honey are snacks (before brushing teeth) that are conducive to sleep.
In summary, I might suggest establishing a pleasurable 20 minutes of vigorous physical play as a reward for your son the day after each good night. You might consistently include him in initial preparation for getting his younger sister to bed, after which there is time for him alone with parents for bedtime preparation. Each time, emphasize how much help this provides for his sister, as well as the benefits of having time alone with Mom and Dad. There is no reason to conclude that his baby sister will have the same sleep problems that you are now solving with your son.
Glenn Jennings, M.D., is the medical director of Child and Adolescent Inpatient Services at Moses Cone Health System Behavioral Health Center in Greensboro.