Posts Tagged ‘
sleep problems ’
Sunday, September 30th, 2012
In response to the publication of the recent study on sleep training methods in Pediatrics, many of the headlines focused on the conclusion that the cry-it-out method does not harm kids. In reality, the implications of this are more nuanced than those headlines would lead you to believe. Here are 5 things you should know:
1) This paper was important because there are few studies that have evaluated sleep training methods using scientific designs. This one is especially interesting because the research team followed 225 7-month-olds – reported by their parents to have sleep issues – for 5 years. This longitudinal design permitted the researchers to examine short- and long-term effects of sleep training.
2) The study examined 2 types of sleep-training methods – controlled comforting and camping out. Controlled comforting is a variation on what you might think of as cry-it-out (or pure extinction). In contrast to pure extinction (which is let baby cry until they fall asleep – however long that is), controlled comforting involves settling a baby in to sleep, leaving the room, and establishing short intervals of tolerated crying (say, 2 minutes) before going in to soothe the baby. These intervals can be increased slowly with the idea being that baby will stop crying and fall back asleep. Camping out involves starting off in the room with baby – typically next to or near baby – and waiting until baby falls asleep before leaving. After a period of success, the parent then changes the routine by sitting in the room, but not right next to baby, and again staying until baby is asleep. And here the idea is that parent can get to the point of leaving the room before baby falls asleep. In the study, 3 conditions were used. Some parents could choose to be trained (by a nurse) in either controlled comforting or camping out (conditions 1 and 2) – and some parents were offered just general advice but received no sleep training.
3) The results were that either sleep training method was successful in improving the babies sleep and reducing levels of maternal depression – both conditions produced better results than no sleep training. So in the short term sleep training worked.
4) The positive effects on sleep did not extend out for 5 years. This is not surprising, as each developmental period raises new sleep challenges. In terms of kids’ outcomes – behavioral and emotional – there were also no differences across all 3 groups. Sleep training (either method) had no positive or negative effects. The headlines here were that “cry-it-out” didn’t harm kids. Well, not exactly. Controlled comforting did not have negative consequences 5 years later – and neither did camping out. The camping out part of this was typically left out of many news stories.
5) The key takeaway is that when parents are trained in reputable methods, they work to reduce sleep problems and indirectly help parents sleep better and feel better. Parents can feel comfortable choosing either controlled comforting or camping out, based on the results of this study. What didn’t work so well was not receiving instruction in sleep training – in the short term, these families continued to experience all the negative stuff that happens when baby won’t sleep at night. Keep in mind the point made above – the sleep training will certainly take for awhile, but sleep problems could happen again during different developmental periods (e.g., age 2, age 5). The inference to be made, however, is that sleep training will work again, but it will of course be somewhat different and tailored to the age of the child.
This study is a welcome addition to the scientific literature and also to the endless debates about sleep training that we all have. Modern sleep training methods work – especially if parents are trained to use them properly and stick with them. And you can feel comfortable picking a method that suits your style. Just remember to talk to your pediatrician (or other experts) when you are ready to start – and also remember that these kinds of sleep training methods are typically recommended for infants at least 6 months of age.
Image of adults sleeping – via Shutterstock – as a reminder that when baby sleeps, parents sleep too!
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Tuesday, January 17th, 2012
I’ve heard from a lot of (tired!) parents about my recent blog post on the sleep challenges you’ll face in the toddler years - many have asked for more specific advice. So I’m offering some tips I received as a parent who took my toddler to a sleep clinic (as I was befuddled by the whole thing and waved the white flag!).
You need to convince your toddler that sleep is not a punishment. This to me is the biggest hurdle. Telling a toddler that it’s time to go to sleep can get translated in their head as “It’s time to stop doing something fun.” While you won’t be able to solve this entirely, you will need to find appealing – but not overly stimulating – things to do before bedtime that will transition them to sleep. Your child loves having books read to them and love it when you tell them stories. The trick is to establish these activities (or a combination of them) as the first stage of the bedtime ritual – and it helps even more if you pick a favorite spot in the house where this happens. Make it fun and something to look forward to and plan on around 15-20 minutes of this. AND STICK WITH IT EVERY NIGHT – NO EXCEPTIONS! You are trying to create a routine. TV and any other electronic device is not advised during this transitional time.
You could make going to bed a bit of a game. Maybe it sounds silly to you, but you could try to put a little fun into that difficult time (for some) of actually making the move to your child’s room. Use your imagination. Put a voice to a stuffed animal who coaches them into their room. The idea is to do something that kids like and will look forward to. Kids love rituals if they are fun – and you want to create a “get in bed” ritual.
You may need to get them a big kid bed. We thought it was too early, but the clinic suggested that it was time and gave guidelines about making sure it was safe. The bigger point here is that change may be a good thing for some toddlers – and a big kid bed might make them feel a little pumped up about their development (which you can then use to your advantage by pointing out that big kids go to sleep at a proper time at night – all’s fair in sleep wars!)
You need to help your toddler handle their new emotions about sleep. Expect to do a lot of soothing. Toddlers start to experience changes in their sleep cycles which make them wake up after a few hours of sleep. They may be afraid of being apart from you. They may remember bad dreams. They may be a little scared about the big kid bed you just introduced! Find a transitional object (I used to use one of my T-shirts) for your kid to cuddle with along with a stuffed animal. And then consider that …
“Graduated extinction” can be a very helpful method for toddlers with sleep issues. We all have our favorite methods. But since the assumption is that nothing is working now (remember, I was at a sleep clinic), we started from scratch following the principles of graduated extinction. Here’s how we did it. Week 1: We sat up on the bed for about 10-15 minutes and then left the room (this was with full disclosure to our daughter). If she woke up crying, we would sit on the bed for 5-7 minutes. Week 2: We sat up on the bed for 5 minutes and then sat in a chair for 5 minutes (if she woke up crying we sat on the bed for 2 minutes and in the chair for 2 minutes). Week 3. Same as week 2, except we sat in the chair for 2 minutes and then left the room (if she woke up crying we repeated the process – the point being we eventually left the room). Week 4: Realized that she preferred if we sat on the bed for 10-15 minutes (the Week 1 routine) and then left the room before she was fully asleep (the sleep clinic clinician loved this on our follow-up visit because our daughter partnered with us to let us know what she liked). We stayed with this for quite a long time and she hardly ever woke up overnight.
Reward sleep behaviors! Find a simple (and cheap!) reward system. Stickers worked really well. Every morning if we met a goal (like getting back to sleep if she woke up or sleeping through the night) our daughter would pick out a sticker to place on a fun calendar in her room. If it’s a bad night for no reason (e.g., she wasn’t sick) – no sticker.
Monitor the naps really closely. Part of the deal was to calibrate the daily nap – 1 hour every day around 2 in the afternoon. We did whatever it took to make this happen. Walked her in a stroller. Drove her in the car. Didn’t care. The point was the nap was from 2-3 every day, no matter who she was with. The sleep clinic endorsed this and wan’t concerned with how we got her to sleep (the faster the better!) as long as we woke her up after an hour. Following this routine, she was tired around 9 at night and slept until 8 the next morning nearly every night.
Be vigilant about changes in the routine. Life happens. Kids get sick. Schedules change. Holidays arrive. Visitors arrive. Whenever you get thrown off, try to get right back into the routine and be really strict about sticking with it.
So that’s it – some tips from a real life visit to a sleep clinic. Will these tips work for you? Some may and some may not. Every kid is different. Some toddlers may seem “hard-wired” to not sleep much. But the principles discussed here are really important, as is the very serious endorsement of talking to your pediatrician about visiting a pediatric sleep clinic if these tips (or others you come across) don’t work. They will come up with a plan for you, your child, and your situation. And you all will sleep much better as a result. One other tip: there may be a wait of several months or more for an appointment at a sleep clinic. So if you are thinking of doing this it’s good to get the ball rolling ASAP.
Image of little girl not ready to go to bed via Shutterstock.com
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Saturday, December 31st, 2011
Making sure your child gets enough sleep is a challenge every parent faces. And the reality is that sleep needs to be managed differently as kids pass through different developmental stages – their sleep requirements change, their daily schedules evolve, and the cognitive and emotional platforms they bring to the sleep issue also can pose issues. With all this in mind, this is the first of a three-part series that takes a look at the sleep challenges that emerge during key developmental phases. First up – the toddler years.
What are the expectations? During the toddler years – I’m focusing on ages 2-4 – the idea is that your child will settle into a consistent pattern of sleep. This should happen no matter what sleep method you choose. The two big transitions in sleep patterns that are expected to happen between ages 2 and 4 are:
- decreasing the number of daytime naps (going from 2 naps a day to 1 and then to none)
- decreasing the amount of total sleep during a 24-hour period (dropping from about 13 hours a night at age 2 to 11.5 hours a night at age four)
What are the challenges? The biggest challenge is that you are, um, dealing with a toddler. As you have found out (or will find out), toddlers like to express their independence and their emotions and can be very strong willed. They might resist going to sleep or start waking up during the night. All of this is normative, reflecting both their expanding repertoire of behavior and also some physiological changes in sleep patterns. There can also be transitions in terms of moving from a crib to a bed and potentially from your room to their own room. New routines may be introduced. They may start daycare or preschool, which could change wake-up times, nap times, and amount of energy expended during the day.
How should you handle these challenges? Most importantly, be prepared to modify your child’s sleep routine (you may not have to modify it much, but it’s better to be prepared for a bigger transition in case you need one) – especially in light of the changes in sleep patterns noted above (e.g., stopping the daytime nap routine; getting less sleep at night). Some ideas to think about include:
- Work backwards from the reality of your child’s daily routine (e.g., What time to they need to be at preschool? How much time do you all need to get ready?) AND the amount of sleep they should be getting for their age. Figure out the new bedtime and wake-up time and try to stick to it as much as possible.
- Reevaluate sleep methods that have worked well and see if you can modify them to be more age appropriate. Whatever the method, this probably means more talk about when it’s going to be bedtime (to get your child to partner with you and to help them understand that you are setting a limit that is going to be upheld) and finding good pre-bedtime rituals to get them relaxed and ready for bed (this typically means more soothing talk from you – stories, songs, whatever – along with reading).
- Turn off the electronics. TV is not considered a good winding down bedtime ritual. Neither is any other form of electronic stimulation.
There are lots of changes that happen throughout the toddler years. Knowing what the changes will be in terms of sleep patterns and altering your sleep methods to acknowledge the complexity of dealing with a toddler may help both you and your toddler handle these challenges well.
Image of toddler sleeping via Shutterstock.com
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Thursday, November 17th, 2011
My fellow blogger Jill Cordes recently shared that her daughter Fia is waking up at night, after nearly 20 months of sound sleeping. And as a parent who dealt with this myself not that long ago, I had a good (sympathetic!) laugh at Jill’s take on Fia’s new sleep tent. Although Jill’s family is in the middle of big transitions (like moving from the East Coast to the West Coast), what caught my eye was Fia’s current age – she’s 23 months. And the reason for that is toddlerhood is a developmental period when the biology of sleep starts to change dramatically, and as a result, sleep methods often need to be revisited. Here’s why.
When babies fall asleep, they tend to fall into the REM phase – which is the part of the sleep cycle where you can dream, but your body doesn’t move (you are zonked out). As babies turn into toddlers, they start to adapt more adult-like patterns of sleep, in which they cycle between light and deep sleep. The result is that the perfectly sleep-trained toddler (it doesn’t matter how they have been trained) starts to experience the part of the sleep cycle when they wake up out of nowhere – sometimes repeatedly. It can be very disorienting for them, particularly since they don’t have much experience in getting themselves back to sleep when they wake up from light sleep. So they do what any rational toddler would do – they cry for you. (Click here if you want to read more about kids’ sleep issues).
As Jill discussed, there are lots of other things that go on with toddlers that can mess with their sleep. In addition to life transitions, the newly independent toddler may want to rebel against sleep (amongst other things). But it’s good to keep in mind that there is some biology that is driving this, and so even though it’s discouraging when it happens, it’s not unusual. And one more thing – what worked before doesn’t necessarily work as well now. So sometimes those inclined to use Ferber find they need to modify it some as their kid gets older (not all do, of course). And some who used alternate methods sometimes gravitate more to the Ferber end of the spectrum (not all do, of course). I’m no sleep expert, but this is why my mantra is “sleep outcomes – not sleep methods – matter most” – whatever gets kids to get the amount of sleep they need is good for them and good for their parents.
So I hope things go well for Jill and Fia. I look forward to following their story. I’d like to offer some specific tips or advice, but the thing is, when I was dealing with this, we ended up throwing our hands up in the air and headed for the nearest pediatric sleep clinic. It worked wonders.
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