Establishing Good Sleep
Habits Early
Rachel J. Valleley, Ph.D.
Munroe-Meyer Institute
University of Nebraska Medical Center
Overview
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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
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20-30% of children
15% of adolescents
Highly disturbing to parents (stress &
depression)
Few children outgrow sleep problems
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Study found 84% of babies with sleep problems
still experience problems 3 years later
Related to daytime behavior problems
Impact of Sleep Problems
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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….
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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
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Cultural issues
Marital issues
Family values
Behavioral issues
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Regular
Part-time
Reactive
Common Sleep Problems:
Infancy
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Sleep-onset association disorder
Nocturnal eating/drinking syndrome
Sleep Onset Association
Disorder
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All children wake at night
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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
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Rocking, feeding, patting, sleep with parent
Nighttime Feedings
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By 4 months of age, there is no
nutritional basis for nighttime feedings
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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
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Break association between feeding and sleep
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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
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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
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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
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Obstructive Sleep Apnea
Nightmare Disorder
Sleep Terror Disorder
Sleepwalking Disorder
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Bedtime Resistance
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Sleep Problems
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Most common: Bedtime resistance
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Sleep-onset delays up to 1 hour
Night awakening
Morning wake-up problems
Sleep Problems
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Most common: Bedtime resistance
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Sleeping independently is a skill
Laying in bed is “time-out”
Pitfalls to Healthy Sleep Habits
in Toddlers
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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
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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
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Take bath
Put on PJ’s
Light snack
Brush teeth
Read book
Get in bed at 8 PM
Bedroom Environment
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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
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Independent sleep onset
Remain in bed quietly while awake
Reinforcement for remaining in bed
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Reinforce sleep compatible behaviors
(“Excuse Me Drill”)
The Excuse-Me Drill:
(Reinforce Sleep Compatible
Behaviors)
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Make sure child is sleepy
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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
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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
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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
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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
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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
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Independent sleep is one of the 1st skills a
child should master
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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
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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.