Sweet Dreams (are made of these), part 2

In last month’s post I shed a little light on infant sleep patterns (see post). This month, I will try to do the same by discussing common sleep problems in the toddler years and beyond. I have organized this month’s post into a question and answer format as I did in last month’s post, based on similar questions I’ve received in clinic. Please don’t take the following advice as “the end all be all.” What works for one child, doesn’t always work for another. However, I have found many of these suggestions to be helpful to my patients and their families and personally as a mother myself.
           
1) We recently moved our 3-year-old son to a toddler bed to prepare for his baby sister’s arrival in a few months. Prior to this, we had no trouble putting him to sleep in his crib. Now, bedtime is a struggle and we cannot seem to get him to stay in bed. As soon as we put him down for the night, he either calls out crying for us to come into his room or he just gets up out of bed. Sometimes this happens multiple times a night. How can we get him to stop this behavior?

Answer: It is normal for children of this age to resist going to sleep, especially if they have older siblings that are still awake. First, it is important to have a bedtime routine in place and that you are consistent with it. For example, I often suggest that the hour before bed be designated “quiet” time. This means no stimulating activities about an hour before bed. This is true for all age groups. This includes TV, video games, electronic toys, and active play. All of these activities could make your child too excited to sleep. It is also helpful to use this time to carry out a bedtime routine--taking a bath, brushing teeth, listening to quiet music or reading a story, and then going to bed. It is also helpful to have your child take a favorite thing to bed each night like a teddy bear or blanket and to make sure he or she is comfortable. By addressing your child’s needs (a drink of water, using the bathroom or leaving the door open a crack to let a little light in the room) before bedtime this will hopefully make it less likely that he or she will feel the need to use them as excuses to avoid going to sleep later.

The preschool age group (children ages three to five) is also a time when I like to discuss the idea of a “bedtime pass”, especially for parents who are at their wits end. The bedtime pass is basically a 5 x 7 index card that you give to your child explaining that the pass is good for one bedroom exit per night. That could be anything, an extra hug and a kiss, a trip to the bathroom, or a drink of water. After the pass has been used for one choice off the list each night, your child is not allowed to leave his or her bedroom or call out for you as the pass has been used. The idea is that, over time, your child won’t want to use up their one pass at night because they want to be able to use it when they REALLY need it and the night time “calling outs” and getting up out of bed will happen less and less until they become non-existent. The bedtime pass also makes a highly stress-ridden situation less emotional and more transactional, giving both the parent and child control in the matter. It ends up being a win win.
 
2) My 2-year-old daughter has been waking up screaming in the middle of the night. When I go to check on her, she looks like she's still sleeping, but it sounds terrible. Is there anything I can do to help this?

Answer: Night terrors are particularly distressing for parents. They occur most often in toddlers and preschoolers and take place during your child's deepest stages of sleep. Some signs of night terrors are crying uncontrollably, sweating, shaking, or breathing quickly. Your child might have a glassy-eyed gaze, a terrified or confused look on his or her face. He or she may thrash around in bed, scream, or kick. Your child may not recognize you or realize you are there and they may push you away if you tried to hold him or her. Night terrors can last anywhere from seconds to minutes, sometimes up to 45 minutes. Most children will fall back to sleep immediately following a night terror because they actually haven't been awake. Also, most children don't end up remembering night terrors and will have no recollection of the events of the previous night the next morning. Night terrors are often an inherited disorder, meaning parents of children with night terrors often suffered from night terrors themselves. They also are a product of sleep debt or being overtired, meaning your child likely hasn't been getting enough sleep recently.

So what can you do? If your child is having a night terror make sure that you relax, as again, they are usually more frightful for you than for your child. Don't try to wake him or her. And, keep your child safe. If your child tries to get out of bed, gently restrain him or her. Finally, the best way to prevent night terrors from happening in the first place is to make sure your child is getting enough sleep. For example, if your child's current bedtime is 8 pm, try putting him or her down about half an hour earlier, so 7:30 pm and see if that helps. Many times, parents can recall a week of late bedtimes or not good sleeping as the culprit and once back into a good routine, they happen less or not at all.
 
3) My 5-year-old son is constantly bouncing off the walls. He has trouble focusing during the day, sitting still, and is quick to act out. He will often lose his temper and lash out at his younger siblings too. He seems to be doing fine in school, but I worry that these might be the beginning signs of ADHD? What should I do?

Answer: While these can all be signs of a child with ADHD (see this post for more information on ADHD), what is more likely, given his age, is he’s not getting enough sleep. There exists a lot in the scientific literature that shows getting less the recommended amount of hours of sleep each night leads to attention, behavior and learning problems in children. In addition, in a child with ADHD, poor sleep can make these condition even worse. However, as a clinician in this scenario, it is important to make sure that this child is getting adequate sleep before jumping to any conclusions. According to the American Academy of Sleep Medicine, there are an average number of hours of sleep per night your child should be getting for optimal health and functioning. The amount of hours differs depending on the age of your child and it decreases as your child grows, but it is probably more than you think it is (see here). Some of my first questions to this parent would be what time is bedtime, what does your child do in the hour leading up to bedtime, and do you have a nightly routine? More often than not, we find that the hyperactivity and temperament of the child is due to a late bedtime or poor sleep pattern more than ADHD or any other medical diagnosis.
 
4) Help! I feel like I always have to drag my 15-year-old daughter out of bed in the morning. She says she “just can’t fall asleep at night.” She is in bed at 10 pm most nights, but says she lies in bed, tossing and turning for hours each night. Should I start her on a sleep medication?

Answer: Before starting your daughter on any kind sleep aid medication, it is important to first make sure she doesn’t have any bad bedtime habits that are making it difficult for her to fall asleep. We live in a technological age and that has made falling asleep more difficult for many people. So what to do in this situation? First, make sure your daughter avoids any kind of screen time one hour or more before bedtime. That means no cell phone, computer, tablet, TV screen, etc. Basically, "if it lights up it’s off limits." Many of my teenage patients are aghast when I suggest this. They tell me “How will I get up in the morning? My cell phone is my alarm clock.” I think they are even more surprised to realize there were and still are these things called alarm clocks that ring and they can be used instead of their cell phones to wake up in the morning. Now, I know sometimes this rule isn’t always realistic because homework sometimes needs to be completed on a computer and it can’t always be started by a certain time with activities and/or sports in the mix. However, if for the most part, this rule and bedtime is respected, falling asleep will become easier.
Second, no electronics are to be allowed in her bedroom. For example, if her phone is on silent or sleep mode, her brain still knows the phone is in the room and she could be tempted to look at it and see who texted her. By not allowing electronics in the bedroom, it is used only for sleeping and her body will know that too. Many parents will have their kids “turn in” their cell phones for the night after a certain hour which helps carry out this idea.

Finally, as mentioned in the first question above, a nighttime routine is helpful for good sleep hygiene. A ritual of quiet time, taking a shower or bath, brushing teeth and reading before bed, can help settle down the brain at night. Hopefully, by making these simple changes, your teenager will be falling asleep easier in no time.

It is my hope that you found some applicable solutions to sleep challenges your family is facing at the moment. If you have more specific questions, or any question for that matter, please don’t hesitate to contact us here at ABC Pediatrics. Sweet dreams!
 
Information presented adapted from:
American Academy of Pediatrics, Bedtime Trouble. https://www.healthychildren.org/English/healthyliving/sleep/Pages/Bedtime-Trouble.aspx
 
American Academy of Pediatrics, Sleep Problems.
http://www.pediatricspec.com/resources/SleepProblems.pdf
 
American Academy of Pediatrics, AAP endorses new recommendations on sleep time.
http://www.aappublications.org/news/2016/06/13/Sleep061316
 
Clark, Wendy Mitman, The Bedtime Pass Help Parents And Kids Skip the Sleep Struggles.
http://www.npr.org/sections/health-shots/2015/09/18/441492810/the-bedtime-pass-helps-parents-and-kids-skip-the-sleep-struggles