Solve Your Child's Sleep Problems

by Richard Ferber

Nevertheless, we do not fully understand why we need to sleep, what causes us to sleep, and what purposes sleep serves.

Until the 1950s, doctors and other researchers believed that sleep was a single state distinguishable only from waking. However, we now know that sleep itself is divided into two distinctly different states: REM (pronounced as a single word, “rem”), or “rapid-eye-movement” sleep, and non-REM sleep. During non-REM sleep you lie quietly, with a regular heart rate and breathing pattern; it is probably closest to what we usually think of as “sleep,” and it provides most of sleep’s restorative properties. There is very little dreaming in this state, if any, although thoughtlike processes may continue. In REM sleep physiological systems are much more active, and it is in this state that we do nearly all of our dreaming. During the night you cycle back and forth between periods of non-REM and REM sleep as well as having the (usually brief) occasional waking.

Waking a person from REM sleep can be easy or difficult, depending on how important the waking stimulus is to her and how involved she is in her dream. So the clock-radio may not wake you immediately from a really interesting dream; you may even incorporate something you hear on the radio into your dream. On the other hand, an important stimulus such as a burglar alarm will wake you easily and, unlike someone awakened from Stage IV sleep, you will become alert quickly.

A child remains in Stage IV for about an hour or two. After that she undergoes a brief arousal. This partial waking may last for only a few seconds or up to several minutes. Her brain waves change abruptly, showing a mixture of patterns from deep sleep, light sleep, drowsiness, and waking. She will probably move about, perhaps rubbing her face, chewing, turning over, crying a little, or speaking unintelligibly. She may even open her eyes for a moment with a blank stare or sit up briefly before returning to sleep. Occasionally, and briefly, she may even wake fully before the progression of sleep stages continues.

The middle part of the night, after the first REM episode, begins with another period of non-REM sleep followed by another arousal and a longer and more intense REM episode. Throughout this part of the night, usually lasting about four hours, the child alternates between progressively longer and more intense periods of REM and relatively light periods of non-REM sleep. It is during these hours of light sleep, particularly at the transitions between REM and non-REM sleep, that wakings are most common.

by five or six months, then you should take a close look at his bedtime routines. If your child is always nursed or rocked to sleep, he may have difficulty going back to sleep alone after normal nighttime arousals.

Bedtime is often a time of separation that can be difficult for many children, especially young ones. Simply sending a toddler or young child off to bed alone is not fair to him, and he may even find it scary. It also means you will miss out on what could be one of the best times of the day. So set aside ten to thirty minutes to do something special with your child before bed. The final routine should take place in the room where your child sleeps so he will learn to look forward to going there. If it takes place elsewhere, then he’ll learn that he must leave that pleasant place to go to bed, and the bed or bedroom can take on negative associations, signaling the end of that happy interactive period and perhaps the start of a separation. If a child is to fall asleep alone, it should be the parents who leave: he should stay where he just had an enjoyable time. Avoid teasing, scary stories, and anything else that will excite your child at this time—save the wrestling and tussling for other times of the day. You might both enjoy a discussion, quiet play, or story reading.

Over the more than twenty-five years I’ve spent working with families and children with sleep problems, I’ve come to the conclusion that children can sleep quite well under a surprisingly wide range of conditions. As long as the children are sleeping well, there is little evidence that any of these ways is inherently better for them psychologically than the others. Children do not grow up insecure just because they sleep alone or with other siblings, away from their parents; and they are not prevented from learning to separate, or from developing their own sense of individuality, simply because they sleep with their parents. Whatever you want to do, whatever you feel comfortable doing, is the right thing to do, as long as it works.

Children generally fall asleep quickly and sleep soundly at night, regardless of where they sleep. In the absence of any problems, most are asleep 98 percent to 99 percent of the time from lights out to final waking—that is, they are awake only a tiny fraction of that time, perhaps five to ten minutes during the night in all. Even during those five or ten minutes, they are drowsy, usually barely aware of anything other than the need to find a comfortable position and return to sleep. Thus, for most of the night children are not conscious of where they are or of who else is or is not with them.

Thus, for most of the night children are not conscious of where they are or of who else is or is not with them.

Finally, and very important, if you choose co-sleeping, you must plan when and how to stop. Far too many families start co-sleeping early, assuming it will stop on its own at some point, and then find themselves years later with a five-, seven-, ten- or twelve-year-old that they “can’t get out of” their bed. The parents are unhappy and the child is embarrassed, feeling “different” and unable to host or attend sleepovers. At that point most children want to leave their parents’ bed even more than the parents want them to go.

Of course, you want to show your baby that he has been born into a good and caring world, so you respond when he cries, and you try to do whatever it takes to soothe him. But helping him develop good sleep schedules is also an important part of his care, and to do that, you may have to tolerate some crying or find ways to calm him other than feeding him. Babies often stop crying if they are walked, rocked, or stroked for a while, and sometimes these are useful temporary measures to help you accustom your baby to falling asleep without an unnecessary feeding. (If

By the time your baby is three months old and has developed a fairly predictable twenty-four-hour pattern, it becomes more important for you to provide increasingly consistent structure. If you do your best to establish a reasonable and consistent daily routine and keep to it as much as possible, then it is likely that your child will continue to develop good patterns. If instead you allow the times of your child’s feedings, playtimes, baths, and other activities to change constantly, chances are his sleep will become irregular as well. Remember from Chapter 2 that when there is no schedule, people (including children) tend to run on a twenty-five-hour day. So if you don’t stick to a schedule for your child’s sleep, a pattern might emerge that would surprise you (although it wouldn’t surprise a sleep scientist).

It is equally important to help our children maintain consistent schedules through infancy, childhood, and adolescence. In fact, all of us, regardless of age, function best when we keep regular schedules. Studies on adults have shown that irregular sleep-wake patterns cause significant changes in our moods and sense of well-being and undermine our ability to sleep at desired times. The same is true of young children.

So if you are beginning to address a sleep problem in your child, be sure to set up a firm schedule and stick to it rigorously for several weeks after your child has begun sleeping well again.

Teething, an illness, a trip, or an upset in the family can interfere with his sleep pattern. The disruption can continue for months unless you intervene. You may need to reestablish your child’s schedule, help him unlearn bad habits, address his anxieties, and be firmer in setting limits. We will discuss all of these approaches in detail throughout this book.

If your child is not sleeping through the night by three or four months of age, when most full-term infants have “settled,” it may be time to start thinking about what could be causing the problem and, perhaps, to begin to correct it; if more than occasional wakings are still happening when your child reaches five or six months of age, you not only can but probably should take definite steps to address them. If you do nothing, his sleep will eventually improve on its own, but the process could take months or even years. If you can figure out why your child is sleeping poorly and make the necessary changes, he should be sleeping well much sooner—usually within a few days, two weeks at the most.

The root of the problem often lies in your child’s sleep associations. All children learn to connect certain conditions with falling asleep. For most children, that means being in a particular bedroom, lying in a particular crib or bed, and perhaps holding a favorite stuffed animal or a special blanket. When they wake periodically during the night, as all children do between sleep cycles, most will promptly fall back to sleep, because the conditions they associate with falling asleep are still present. But if the conditions have changed, such children may not be able to fall asleep again without help reestablishing them.

he should generally go to sleep in the place where he will be spending the rest of the night.

What most parents do not realize is that in most cases the “abnormal” wakings at night are actually quite normal—children always wake from time to time at night, between sleep cycles. In fact, in their attempts to treat their child’s “abnormal” wakings by helping him go back to sleep, the parents are actually causing the disturbances, or at least reinforcing them.

normal nighttime arousals are prolonged because the conditions the child associates with falling asleep are no longer present. From the child’s point of view, something is wrong. Instead of going back to sleep, he wakes more fully and begins to cry. The wakings during the night are not the problem; rather, the problem is that the child cannot fall back asleep after these normal wakings, because of his particular associations with falling asleep.

Perhaps you’ve had the experience of waking during the night just enough to notice your pillow missing. Most likely, instead of going straight back to sleep, you wakened a little more, enough to find the pillow on the floor and pull it back into bed before returning to sleep. But if you couldn’t find it right away, you probably wouldn’t be able to ignore it and go back to sleep. Instead, you’d become more fully awake so you could look around for it. If you still couldn’t find it, eventually you might turn on the light, get out of bed, and begin searching the room. You might get angry and perhaps curse—showing the same kind of frustration that a child shows by crying. Even if your pillow falls out of your bed once or twice every night, it will hardly disturb your sleep: retrieving the pillow from the floor doesn’t require you to wake up very much or for very long. But suppose that you are physically unable to get the pillow yourself, and you have to call someone else—perhaps a nurse—to come into the room to replace it whenever you wake up and find it missing. The nurse will soon learn that once you have your pillow back you’ll fall asleep quickly, but your frequent wakings during the night might still seem abnormal to him or her. To stretch the analogy a bit further, suppose you discover that someone has been sneaking into your room each night and stealing your pillow. Once you know that, you might have trouble falling asleep at bedtime for fear that the pillow will be take...

As you help your child learn a new set of sleep associations, you will need to be understanding, patient, and consistent until he adapts. Since you will be changing some familiar patterns, at first you will not always be doing what your child wants. Anytime you have to say no to a child, there will probably be protests and there may be some crying, but you can keep them to a minimum. A young child’s sleep will show marked improvement, usually within a few days to a week.

10. If your child sleeps in a crib in your room, you should put him into the crib at bedtime and then either speak to him briefly at the scheduled intervals from your bed, or—if your presence in the room is too stimulating, or if you prefer it—leave the room and come back in to check him at those intervals, as you would if he were in his own bedroom. (If he learns to fall asleep with you out of the room, you will have more freedom in the evening. You can accomplish the same thing even if you stay in the room as long as he doesn’t know you’re there—for example, if he can’t see you from his crib, or if it is fairly dark and you are quiet.) When he wakes at night, do the same.

I find that three to five minutes is usually a good starting point, but, as noted in Figure 4, if that seems too long you can even start with one minute.

At any point, if she stopped crying or subsided to mild whimpering between checks, they were not to go back in: the one thing they did not want to do was to interrupt Betsy as she was starting to learn how to fall asleep on her own.

At nap times, Betsy’s parents would use the same routine. But if after half an hour Betsy had either cried the whole time or had fallen asleep and wakened again, they would end that nap period. If she fell asleep later on the floor or in the playpen, that would be all right. The important thing was that she was falling asleep alone, without being rocked. As long as she had to spend time in her crib every day, she would eventually start to nap there once she had begun to associate that environment with falling asleep.

I told them to expect the first night or two to be difficult—though only rarely will a child cry for several hours—but by the third or fourth night things should be going fairly well. I also told them that if things were not improving markedly over the first few days, or at any time that they decided that the amount of crying was more than they were willing or able to accept, that we would consider shifting to an even more gradual multistep approach (as described in the next section).

If you abruptly began staying out of his room all night, he would still learn that you always come back eventually and that you aren’t abandoning him, but the lesson would be unnecessarily harsh. By waiting only a short time before going in to check him, you put him through much less uncertainty. He will begin to see after only a few wakings that you are still around and responsive to him. He may be angry that you are not rocking him, but since you keep returning, he will not be frightened by your apparent disappearance. As you increase the waiting times, he’ll learn to anticipate that as well. Eventually he will simply find it preferable to go back to sleep than to cry for fifteen or twenty minutes knowing he won’t be rewarded with rocking, holding, or nursing. At the same time, he is learning to fall asleep, and feel comfortable, alone in the crib or bed.

Children are very quick learners. A child who has always fallen asleep one way can learn to fall asleep a new way after just a few nights’ practice. (It’s their slower-learning parents who may take a month or more to master new sleep habits.) That is both good news and bad news: sleep problems can develop over just a few days, but they can be solved just as quickly.

Similarly, while spacing out nighttime feedings in an effort to reduce or eliminate them, as discussed in Chapter 6, many parents initially prefer to respond to their child whenever he calls and in whatever way will comfort him (other than feedings). In one or two weeks, after the nighttime feedings have been phased out, the parents can change the child’s other associations as a second step.

If your child is consuming large amounts of liquid at night, his sleep may be disturbed for reasons other than sleep associations (such as hunger signals, altered body rhythms, and increased wetting, as discussed in Chapter 6). But a sudden end to nursing at night would be hard on both you and your child; it’s better to gradually reduce the number and frequency of feedings.

Stopping the pacifier at night is easier than most people realize, particularly for a child between four months and twelve months old.

If he wakes at night, you can try lying quietly in bed, responding to him at timed intervals as before.

Some parents prefer to sleep in another room for a few nights, until the child has mastered the new patterns. You may also be able to make a “room within a room” with an accordion-style room divider or by hanging a sheet or blanket from the ceiling—if your child cannot see you in bed, you can limit your responses to him without having to leave the room yourself. The inside of the divider could be decorated for him.

Younger children are usually easier to deal with but, at least after the first three months of life, children of all ages with these problems will respond well to the program if their parents are willing to stick to it.

Common errors include letting your child fall asleep on his own at bedtime, but then rocking him during the night; staying with him until he falls asleep at bedtime but insisting that he fall back asleep alone later in the night; letting him fall asleep alone at bedtime and early in the night, but moving him into your bed when he wakes near morning; handling his pleas or crying differently from night to night, or responding differently when you think he is making enough noise to wake his siblings; and, in two-parent families, having each parent enforce the program in his or her own way. If you do any of these things, matters may not improve.

The best thing you can do for your child at night is to give him a clear and definite understanding of what is to happen. Enforcing routines inconsistently will only make problems worse.

If your child loses sleep while you are teaching him new patterns because he is up crying during the night, don’t let him sleep later than usual or take more naps or longer ones the next day. If you let him make up in the day the sleep lost at night, you will only succeed in shifting some of his sleep from the nighttime to the daytime, ensuring that he will be awake and crying more the next night. If he ends up short on sleep one night, that’s okay: it will actually work to your advantage the next night.

To take another example, your child may fall asleep alone at bedtime and nap time but need to be rocked after nighttime wakings. Or perhaps he falls asleep easily at day care, even though his sleep associations there differ completely from those he has at home. Children with sleep patterns like these have learned to associate different conditions with falling asleep at different times or in different places. This is no more or less normal than needing the same conditions each time one falls asleep. 7. If your child falls asleep by himself at nap time but needs you at night, then you can expect the relearning to go very quickly. He already knows how to fall asleep on his own; he simply has to learn to associate that behavior with the nighttime as well as with nap times.

You may want to wait until a Friday night to begin, so that you have the weekend to catch up on any missed sleep.

13. In two-parent households, parents should share the responsibilities, if possible, so that the same adult does not have to handle all bedtime and waking interactions during the relearning period. Your child should feel comfortable with either parent at bedtime and after wakings, so it is better if both parents participate.. You do not have to alternate strictly; just pick a schedule that suits you.

If one parent has handled all the bedtimes and wakings until now, the other parent may have better luck breaking the old associations. When a child cries and one of the parents responds, it is probably best if that parent continues to be the one who responds until the child falls asleep, so that the child won’t sense that he can control who comes in by crying enough. For similar reasons, it is good advice not to let your child insist “I want Mommy” or “I want Daddy.” Decide who will handle each night’s bedtime routines, and stick to it.

In addition, if your child drinks large amounts of milk or juice at night, her sleep may be disturbed for other reasons as well: for instance, if her diaper is soaked, the discomfort can certainly wake her. Furthermore, extra nutrients ingested at night will stimulate your child’s digestive system, which should ordinarily be relatively inactive during the night. The process of metabolizing those nutrients will alter patterns of functioning in other body systems; it will trigger or inhibit the release of many different hormones, and it will raise the body temperature, which is normally low at night. The overall result is that many important biological rhythms that are closely tied to the ability to sleep are disrupted.

If your child nurses only for a minute or so at the nighttime wakings, or takes just a few sips from the bottle, she is not taking in much food. Rather, she is behaving like a child who is dependent on a pacifier: it is the breast or bottle itself that she needs before she can go to sleep, not the food. This pattern can be stopped immediately, as discussed in Chapter 4.

If you have chosen to work on the nighttime hunger problem first and change sleep associations second, then don’t change the bedtime ritual yet. Let your child fall asleep in your arms during or after feeding, if that is what she has been doing. If she wakes and cries before it’s time for her next feeding, you can try to comfort her, if it helps. Do whatever seems to comfort her most: hold her, soothe her, rock her, or talk to her. The purpose is only to calm her down and help her fall asleep while she learns not to expect a feeding. Sometimes it’s best not even to try to help: if she sleeps in her own room, she may become more upset if you go in but refuse to feed her, and she may calm down more quickly without you there. If you are a nursing mother, it may be difficult to hold your child without nursing her. You may have a letdown response, and your child will smell the milk and expect to nurse. In a two-parent family, it is often easier for the non-nursing parent to settle the child at times when she is not being fed. Your child may still seem a bit frustrated, but in this way she will learn not to expect you and to nurse so often during the night.

If she still needs you to hold her, rub her back, or rock her before she can go to sleep, you can now begin to correct those associations, as described in Chapter 4. Once excessive feedings are no longer complicating the picture, the rest of the relearning process usually happens quickly.

Decreasing nighttime feedings generally won’t affect your child’s daytime feedings much, unless she has been getting a significant part of her nourishment at night. In that case, you will probably notice that over several weeks she gradually feeds more during the day as her patterns of hunger and satiation change.

You should always avoid feeding your child when she is lying in her bed or crib, even if sleep disruptions aren’t a problem. Simply handing a bottle to a child lying supine is a way to cause ear and dental problems. Because the eustachian tube (a small passageway to the throat that vents or drains the middle-ear cavity) is short and horizontal in young children, liquid—and bacteria—can easily pass from the throat to the middle-ear space if a child sucks on a bottle while lying on her back. The result can be a middle-ear infection, otitis media. Also, once your child’s teeth erupt, she is at risk for tooth decay if she goes to sleep with milk or juice in her mouth, and this is just what happens when she falls asleep with a bottle in her mouth.

Each stage of your child’s development brings with it particular vulnerabilities to certain anxieties. For example, when she begins nursery school, her concerns about separation may increase for a while. She may be reluctant to leave your side during the daytime, and she may not want you to leave her at bedtime. If you get sick, she may feel guilty, imagining that her angry words or thoughts caused your illness and made you less available to her than usual.