Pediatric Behavioral Sleep Disorders

Sleep problems are common in children and can affect all aspects of a child's functioning. Some problems are a result of the interactions between behavior, environment and psychosocial issues

Common behavioral sleep problems in children include:

Bedtime fears
Bedtime resistance/refusal
Difficulty falling asleep (e.g., taking a long time to fall asleep or can't fall asleep alone)
Difficulty waking in the morning
Insufficient sleep
Night wakings (frequent and/or prolonged)
Poor sleep habits
Sleep-related head banging, body rocking, or body rolling
Sleep schedule issues
Sleep terrors
Sleep walking
Undesired co-sleeping or bed-sharing

There are also primary sleep disorders in children (e.g., obstructive sleep apnea) that can lead to daytime behavioral problems. Sleep problems and/or sleep disorders may result in daytime sleepiness, behavior problems (e.g., hyperactivity, inattention) or irritability. It is important for children to not only have good quality sleep, but also to get enough sleep every night. Healthy sleep habits can help children with both sleep quantity and sleep quality.

I'm Dr. Lisa Meltzer, a licensed clinical psychologist and board certified behavioral sleep specialist at National Jewish Health.

And today we're going to talk about bedtime problems and night wakings in young children.

The most common problem we see in young children are bedtime problems and night wakings.

And as a disorder, this is called behavioral insomnia of childhood.

And there's two different types, sleep onset association type and limit setting type.

So sleep onset association type is what we see mostly in infants.

And this is a complaint of multiple night wakings, so babies who wake up every hour, every hour and a half, all night long.

This is not necessarily an issue of the child waking up, it's an issue of how they fall asleep.

And a sleep onset association is something that we use to help us fall asleep, and everybody has one.

And in young children we see, you know, a lovey, a pacifier, thumb sucking, those are all positive sleep associations because children can do those for themselves to help them fall asleep at bedtime.

A negative sleep association is something that involves a parent. So rocking the child to sleep, nursing them to sleep, putting them in the car and driving them around, all of those things are okay at bedtime.

But what happens during the night is at the end of every sleep cycle, we wake up. Everyone does it four to six times a night. So every time your baby is waking up during the night, that's normal.

The issue is that they can't then put themselves back to sleep if they need you or that association of being nursed, rocked, driven in the car, whatever it is to go back to sleep.

And so that can become very problematic in changing it. The other type of sleep disorder is limit setting or combined type.

And a limit setting type is what we see typically in toddlers and preschoolers.

And this is the bedtime stalling and the bedtime refusal, no, no, no, I don't want to go to bed, please just one more drink, please one more trip to the potty, one more story.

And this can go on for two hours.

And once a child finally falls asleep, they sleep fine.

But the issue is this prolonged bedtime that makes everyone in the family very tired.

It all starts with bedtime.

The first is having a very consistent bedtime schedule and bedtime routine.

Putting infants down in their cribs drowsy but still awake is the first step to helping them fall asleep.

Then you can do what we would call a progressive checking method.

So for some families that means you put the infant into the bed, you kiss them good night, you leave, and then you come back and you check on them as often as you want.

Every 30 seconds, every 45 seconds.

But the goal is that the child learns to fall asleep independently.

In terms of the limit setting type, it is important parents have to be consistent and they have to say no, they have to set limits.

And some quick and dirty tricks to help with that is to have a bedtime chart.

And this is a picture chart with a picture of a bath, a book, the pajamas, not necessarily in that order.

So it's a bedtime chart that has a picture of a bath, the pajamas, one book, two books, a drink of water, and the bed.

And you check it off each one as you go along. And when you're done, that's it.

And when the child says one more book, you say, I'm sorry, honey, the chart says no more books tonight.

And then it becomes the chart's fault and not the parent's fault.

Another thing at bedtime when children complain of bedtime fears is to use monster spray, which is a water bottle the child can spray around the room to keep monsters away the same way that bug spray keeps bugs away.

And that gives the child control over their environment. And the last trick that you can use with some of your older toddlers and preschoolers is the sleep fairy, who is a good friend of the tooth fairy.

And she comes at night after you fall asleep and leaves something like a sticker under your pillow.

And the sleep fairy comes every night for two weeks.

And this helps a child learn that they're going to fall asleep in their bed.

And then we don't know when the sleep fairy is going to come because she has a lot of families to visit.

And this keeps the child guessing so that they dive into bed and try to go to sleep because maybe tonight the sleep fairy is going to leave them a prize.

Recommended Sleep For Children

A child’s sleeping habits and number of hours needed for sleep each night can vary depending on where the child is at in the stages of development. Some general pediatric sleep guidelines for amount of sleep needed for children by age range include the following:

0 to 3 months of age need 14 to 17 hours
4 to 12 months of age need 12 to 16 hours
1 to 2 years of age need 11 to 14 hours
3 to 5 years of age need 10 to 13 hours
6 to 12 years of age need 9 to 12 hours
13 to 18 years of age need 8 to 10 hours
18 to 25 years of age need 7 to 9 hours

Source: American Academy of Sleep Medicine

Effects of Sleep on Development

Sleep impacts every aspect of child development, including learning, processing and remembering information. Lack of sleep can also prevent a child from paying attention in school or focusing on learning. Further, a child’s mood and behavior are affected by a lack of sleep.

Other aspects of development impacted by insufficient sleep include growth (i.e., growth hormone is released during sleep for young children), obesity (insufficient sleep causes weight gain) and health. In particular, a child’s immune system can weaken without enough sleep. A weakened immunes system can affect a child’s ability to fight off a cold and stay healthy.

Effects of Sleep on Parents

Often times when a child is not getting enough sleep, the parents are not either. When a child cannot fall asleep or wakes up early, one or both parents are often awake with the child. Lack of sleep for parents can affect their own daytime functioning, including parent mood, performance at work, ability to manage the child’s behavior and ability to drive.

Tension can occur within the family if parents do not agree on a sleeping schedule, or disagree on how to manage a sleeping problem. Family conflict can also have an effect on a child’s sleeping habits.

How Do You Know if Your Child is Getting Enough Sleep?

There are some simple ways to tell if your child is not getting enough sleep at night:

Your child is extremely difficult to wake in the morning. Children who get enough quality sleep should wake easily in the morning, and should be out of bed within 15 minutes.
If your child is sleeping two or more hours on weekends/vacations than on school nights, he/she is trying to catch up on lost sleep during the week.
If you child falls asleep in school or other inappropriate times he/she is not getting enough sleep or quality sleep.
There are noticeable changes to your child’s behavior or mood following nights of increased sleep.