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My 4-year-old son, Pete, came into my room and said something about breakfast. "I'm up; I'm up," I said, wondering why my alarm hadn't gone off. I headed toward the kitchen and noticed I was having trouble walking in a straight line. That's when I saw the clock: It was 3:45 A.M.
I coaxed him back to bed, only to wake up two hours later to the sound of him playing with every car and truck in his toy box. At naptime, I thought he would fall asleep in a snap. No such luck. He tossed and turned, played with his cars, put on his Superman costume and jumped off his bed, until I finally -- an hour and a half later -- gave up on a nap.
Having endured bouts of insomnia myself during stressful times, I had to wonder if Pete was experiencing something similar. We'd recently moved cross-country, which meant he was getting used to a new house, a new climate, a new preschool, new friends, new everything. But was it possible for a 4-year-old to have insomnia? The thought struck me as silly.
It turns out that it's not silly at all. In fact, there are more than 40 accredited pediatric sleep centers around the country established to help the estimated 20 to 30 percent of children older than 6 months who suffer from insomnia or other significant sleep problems. The experts working in these facilities would certainly agree that there are children who suffer from insomnia. However, they don't always agree on what qualifies for the diagnosis.
Most people think of insomnia as night after night of sleeplessness, followed by a string of bleary-eyed days. But insomnia simply means sleeplessness -- even for just one night. All children, at some point, will have trouble sleeping, whether it's because they watched a scary show earlier in the day, haven't established a regular bedtime routine, or are simply excited about the next day's events. Of course, one or two bad nights wouldn't merit a trip to a sleep center.
Some experts consider a sleep difficulty to be significant when it takes someone more than 30 minutes to fall asleep on three nights a week for at least three months. But most pediatric sleep experts use looser criteria for diagnosing insomnia in kids, focusing mostly on whether the sleep issues cause problems during waking hours for either the child or his parents. The more nights of disrupted sleep that a child experiences, the more likely he'll be to develop a habit of enduring sleeplessness, explains Parents advisor Jodi Mindell, Ph.D., associate director of the Sleep Center at The Children's Hospital of Philadelphia. Your child isn't likely to outgrow a bout of sleeplessness that lasts more than three or four weeks, she says. That's because every time he goes to sleep, he's developing his sleep behavior. The longer he has difficulty falling asleep, the higher the likelihood that he is unwittingly teaching himself not to sleep. But, she adds, "You can always solve a sleep problem. It's never too late."
Sleep specialists say there are two main types of insomnia in kids. Sleep-onset-association insomnia is more likely to be seen in children younger than 5 and usually involves interruptions in sleep during the night. All children naturally wake ten to 12 times during the night and most roll over and fall back asleep, explains Daniel Glaze, M.D., medical director of Texas Children's Hospital Sleep Center, in Houston. But a child who's used to having a parent help him fall asleep could cry out until she appears.
Limit-setting insomnia, on the other hand, is mostly seen in children older than 5, who are able to get out of bed. A child with this issue makes prolonged bedtime curtain calls -- asking for water, claiming there's a scary monster under the bed, or suddenly needing an explanation of what happens when the toilet flushes. When his parent gets him a drink or tries to discuss his fears, it only reinforces his behavior.
Spotting Side Effects
When children don't get enough sleep (12 to 14 hours total for toddlers; 11 to 13 hours for preschoolers) they can have a drop in IQ points equivalent to what's typically seen in a child who has lead poisoning, according to a study from the University of Virginia, in Charlottesville. And if sleep problems persist for many years, they can impair a child's ability to complete tasks that require a higher level of thinking later in life, according to researchers at the University of Colorado, in Boulder, who tracked the sleep habits of twins.
It's not exactly clear why a child's brain is affected when she loses sleep, but studies suggest that a sleep deficit causes neurons to lose their ability to adapt, says Judith Owens, M.D., a Parents advisor and director of sleep medicine at Children's National Medical Center, in Washington, D.C. In other words, a tired brain becomes incapable of forming the connections needed to embed new knowledge, memories, and skills. One study found that elementary-school students who had missed just one hour of sleep three nights in a row performed two years below their actual grade level on academic tests.
What's more, a growing body of evidence is turning up proof that insufficient sleep is one of the culprits behind the childhood obesity epidemic, most likely because sleep plays a crucial role in regulating the hormones that determine appetite. In one large Canadian study, children between the ages of 2 and 6 who got less than ten hours of shut-eye a night were more than four times more likely to be overweight or obese than kids who consistently got 11 hours of sleep a night. Research in adults also suggests that there may be long-term cardiovascular risks from a lack of sleep, which Dr. Owens says could mean similar trouble in children.
The number of children at risk for these side effects is probably greater than the estimated 20 to 30 percent of kids suffering from insomnia, says Sarah Honaker, Ph.D., a behavioral sleep specialist at the University of Louisville School of Medicine. After all, a parent is better able to recognize when she's tired than when her own child is tired. And fatigued kids often become hyperactive, making it even harder to recognize the real problem.
Finding Sleep Solutions
Dr. Mindell says that even when parents are aware of a child's sleep deficit, they don't always seek out help. I, for one, did not go to my pediatrician to discuss my son's bad bedtime behavior -- and that 3:45 A.M. wake-up call was certainly not the first time we'd had sleep issues in our house. As a working mom, I've often felt guilty when I don't see my children during the day, so I lie in bed with them for at least an hour every night, rubbing their backs until they fall asleep. I knew my children's sleep snafus were a monster of my own making and I saw no need to tattle on myself to their doctor.
As it turns out, the pediatrician is the first person any parent should turn to when sleep problems arise. Insomnia is a symptom that may signal the possibility of another problem, say Drs. Mindell and Owens, who together wrote the book Take Charge of Your Child's Sleep. This could be a mental-health issue, such as ADHD, anxiety, depression, or autism, or a medical condition like reflux, restless legs syndrome, or sleep apnea. After your doctor has ruled out other causes, your child may need a consultation with a sleep expert and possibly even an overnight sleep study.
Most of the time, though, the cause is what sleep specialists call "behavioral" and what my guilty conscience calls "my fault." Fortunately, experts are more than willing to cut parents some slack: Some children have a predisposition to have sleep problems or a tendency to worry. Although parents can contribute to the problem, they can also be a part of the solution. On the next pages are the most common reasons why kids don't go to sleep and strategies you can try tonight.
Fears of the dark or monsters
Play games during the daytime that will make your child more comfortable when the lights are out, suggests Dr. Honaker. For example, give her a flashlight and let her hunt for a few stuffed animals in her room. You can go with her the first couple of times, but then coax her to go it alone as she becomes more comfortable. If she asks to sleep with the light on, try to resist. It's okay to use a night-light, but bright lights can interfere with the release of the sleep-regulating natural hormone melatonin.
Put a stop to repeat runs to the bathroom and requests for water by creating bedtime passes, explains Dr. Owens. Studies conducted on 3- to 10-year-olds prove that this technique delivers. Give your child two passes: one for a hug and another for a bathroom break or a drink. Tell him he can use the passes after lights-out, but after that, he can't get out of his bed. Praise him for using the passes, but put him back to bed with little emotion if he gets out of bed sans pass. When he doesn't use both of his passes, he can trade them in for a reward the next day.
More Strategies for Better Sleep
Need for a night watchman
If your child requires extra attention at night, or even just the presence of a parent to find her way to la-la land, Dr. Glaze recommends a technique called extinction -- as in, make her need for you at nighttime extinct. This is more of a cold-turkey approach, where you explain to your child that you love her and want her to get a good night's rest, but then you close the door and ignore any shouts. (It's helpful to turn off the monitor if you still have one.) Alternatively, you could slowly move out of her room over a period of several nights. Start out by sitting on your child's bed, then sit on the floor by the bed the next few nights, then on the floor close to the door, and finally walk out the door.
For a child who's still awake for 30 minutes or more after you put him to bed, Dr. Honaker suggests a technique called bedtime fading. First track what time he's actually falling asleep by making frequent post-bedtime checks for two weeks. Then use the latest time -- say it's 9:30 P.M. -- as his bedtime for the next few nights. When he begins falling asleep soon after getting into bed, start moving closer to his ideal bedtime. The theory behind this: All the time he's spent tossing and turning has probably caused your child to associate the fruitless behavior with his bed. Being ready to fall asleep shortly after climbing under his sheets should help him connect his bed to the idea of a peaceful slumber.
An active mind
If your little one generally has a tough time winding down at bedtime, try an infusion of the mundane. This means no screen time near the end of the day. Elisa Nebolsine, a children's cognitive behavioral therapist in McLean, Virginia, says a kid's body and mind need to be relaxed -- even bored -- in order for them to fall asleep. Try tricks like having your child count backwards from ten (or 20) over and over to help her zone out. Or read her a picture book that is a little too young for her (one she knows by heart); she may find the familiarity and repetition soothing.
It's tempting to just scooch over when your child wants to get into bed with you. But stay strong and walk him back to his room. And if he tends to climb in while you're sound asleep, Dr. Mindell suggests attaching a bell to your child's doorknob or yours. When you hear it ring, get up and quickly and quietly escort him back to his room.
Originally published in the January 2013 issue of Parents magazine.
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