Establishing Good Sleep Habits Early Rachel J. Valleley, Ph.D. Munroe-Meyer Institute University of Nebraska Medical Center Overview Occurrence of sleep problems Impact of sleep problems Common sleep disturbances in infancy and young children Strategies to encourage healthy sleep habits Pediatric Sleep Disturbance 20-30% of children 15% of adolescents Highly disturbing to parents (stress & depression) Few children outgrow sleep problems Study found 84% of babies with sleep problems still experience problems 3 years later Related to daytime behavior problems Impact of Sleep Problems Mood and affect (irritable, sad/depressed, crying/temper tantrums) Behavior problems (noncompliance, aggressiveness, hyperactivity, poor impulse control) Neuro-cognitive deficits (attention, concentration, memory) Performance deficits (learning, task persistence) Family disruption The Sleepy Child…. May May May May May not report feeling tired not act tired or lethargic look hyperactive & impulsive be irritable & easily provoked show low frustration tolerance How much sleep should your child be getting? Total sleep Naps 1 year 12-16 hours 2-4 ½ hours 2 years 11-14 hours 30 m.- 3 hours 3 years 11-14 hours 30 m.-2 hours 4 years 11-13 hours 0-1 ½ hours 5 years 10-13 hours 0-1 ¼ hours 6 years 10-12 hours none Bed-sharing or Co-sleeping Cultural issues Marital issues Family values Behavioral issues Regular Part-time Reactive Common Sleep Problems: Infancy Sleep-onset association disorder Nocturnal eating/drinking syndrome Sleep Onset Association Disorder All children wake at night Good sleepers quietly go back to sleep Poor sleepers cry, call-out, enter parents room Lack independent sleep onset skills Child cries until parent responds to reestablish familiar conditions to “put” child to sleep Rocking, feeding, patting, sleep with parent Nighttime Feedings By 4 months of age, there is no nutritional basis for nighttime feedings Waking to feed is a learned behavior Nocturnal feeding patterns prevent the development of a more mature sleep pattern Strategies for Stopping Nighttime Feedings for Infants Break association between feeding and sleep Lengthen daytime feeding intervals Delay time between nighttime awakening and feeding (re-swaddle, diaper, walk around) Reduce fluid intake gradually during nighttime awakenings If child falls asleep during feeding, awaken briefly before placing back in crib Non-contingent waking for feeding Strategies for Teaching Independent Sleep in Infants Have child fall asleep in crib alone for naps or at bedtime first Use a structured bedtime routine and stick to it A couple of bedtime options Place child in bed & return in morning, unless ill or in danger Crib checks every 10 minutes when crying (Ferber method) Common Sleep Problems in Young Children Obstructive Sleep Apnea Nightmare Disorder Sleep Terror Disorder Sleepwalking Disorder Bedtime Resistance Sleep Problems Most common: Bedtime resistance Sleep-onset delays up to 1 hour Night awakening Morning wake-up problems Sleep Problems Most common: Bedtime resistance Sleeping independently is a skill Laying in bed is “time-out” Pitfalls to Healthy Sleep Habits in Toddlers No regular bedtime and routine Child determines how & when to go to bed Parent in room as child falls asleep Attending to “curtain” calls Allow child to sleep in living area & then transfer to bed When child awakens in night, stay in room until back asleep or allow child into bed Resolving these bedtime struggles Provide consistent bedtime routine Get child to bed at determined time Establish bedroom conducive to sleep (calm, quiet, dark) Prohibit stimulating bedtime activities (TV, videos, radio, rough play) Sample Bedtime Routine Take bath Put on PJ’s Light snack Brush teeth Read book Get in bed at 8 PM Bedroom Environment Non-stimulating Relatively dark Quiet (can use white noise machine) Comfortable temperature *Familiar setting (child used to sleeping in own bedroom) Teach & reinforce sleep/bedtime skills Independent sleep onset Remain in bed quietly while awake Reinforcement for remaining in bed Reinforce sleep compatible behaviors (“Excuse Me Drill”) The Excuse-Me Drill: (Reinforce Sleep Compatible Behaviors) Make sure child is sleepy Late bedtime Keep wake-up and naptimes same “Excuse me, I need to…” Give attention when child is laying in bed, quiet, relaxed Slowly move bedtime earlier once child develops independent sleep onset skills Reinforce Sleep Compatible Behaviors Amazon.com or behavenkids.com Burke, R. V., Kuhn, B. R., & Peterson, J. L. (2004). Brief Report: A "Storybook" Ending to Children's Bedtime Problems--The Use of a Rewarding Social Story to Reduce Bedtime Resistance and Frequent Night Waking. J. Pediatr. Psychol., 29(5), 389-396. How to handle “curtain calls”, nighttime wakings Build in common curtain calls in routine (bathroom, drink, kiss) If wake up in middle of night, quietly escort back to bed May need some type of signal to alert you when child gets out of bed How to handle nightmares Listen while child talks about it Remind child it is a dream Point out strange aspects of dream Avoid scary movies Avoid lengthy discussions, monster proofing, and psychoanalyzing dreams Naps: Steps to good sleep Demonstrate sleep compatible behavior Prompt sleep compatible behavior Praise sleep compatible behavior FREQUENTLY at first Use stickers for sleep compatible behavior Offer incentive to follow nap if quiet during naptime Use a time out if absolutely necessary Summary Independent sleep is one of the 1st skills a child should master Break feeding/parent association with sleep onset Use a routine Set up room to be conducive to sleep Reinforce sleep compatible behavior Minimize reaction to sleep incompatible behavior www.babycenter.com www.sleepfoundation.org www.aasmnet.org http://www.sleepeducation.com Behavioral Pediatric Sleep Clinic Sleep Books for Parents: Mindell JA. Sleeping through the night: How infants, toddlers, and their parents can get a good night's sleep. New York: HarperPerennial/HarperCollins; 1997. Ferber R. Solve your child's sleep problems. New York: Simon & Schuster; 1985. Weissbluth M. Healthy Sleep Habits, Happy Child (Revised Edition). New York, NY: Fawcett Columbine; 1999. Durand, V. M. (1998). Sleep better! A guide to improving the sleep for children with special needs. New York: Paul H. Brookes.