Behavioural Sleep Difficulties in Children

 

Sleep difficulties are a common occurrence for adults and young people alike. However, when it occurs in young children, it can be quite worrying– and inconvenient – for parents. The good news is that sleep difficulties are more likely to be behavioural rather than caused by medical conditions. These behavioural sleep difficulties can be addressed by parents using simple strategies.

Tips for Healthy Sleep

To ensure your child has the best opportunity for to get to sleep, www.healthdirect.gov.au gives the below healthy sleep tips:

Establish a sleep schedule:Make sure your child goes to bed early enough to get the sleep they need. Once you have set an appropriate bed time, stick to it – even at the weekend.

Establish a bedtime routine: Follow the same routine every day: bath or shower, change into pyjamas, brush teeth, read or spend quiet time in their bedroom, lights out and go to sleep.

Help your child wind down:Busy children need some time to relax. Consider playing soft music or reading to them.

Make sure the bedroom is suitable for sleep:Ensure the bedroom is dark and quiet. If your child is anxious or afraid at night, use a night light.

Avoid stimulants:Make sure your child avoids tea, coffee, chocolate or sports drinks, especially in the afternoon.

Turn off technology:Turning off computers, tablets and television 1 hour before bedtime should help your child sleep better.

A Note on Screen Time

Limiting screen time in the evening is very important. Any light, especially blue light emitted from LED-lit devices (eg smartphones, electronic tablets, computer and television screens), can suppress sleep hormones (i.e. melatonin) and hinder sleep onset and quality. These sleep hormones tend to rise two hours prior to sleep onset. Therefore sleep guidelines often recommend limiting exposure to screens for at least one hour before bedtime.

Types of Behavioural Sleep Difficulties

Limit setting difficulties

Limit setting sleep difficulties are predominantly seen in pre-school and school-aged children. This type of sleep difficulty is characterised by:

  • The child goes in and out of the bedroom on multiple occasions before falling sleep
  • The child may make multiple requests to parents (“I want a drink, I want to go to the toilet, I want to talk to you, I’m scared…”) to stall going to bed
  • Parents find it difficult to set limits around these behaviours, known as “curtain calls”

What may help….

Parents can limit the child to 1-2 requests at the start of the night.

The use of the ’bedtime pass’ method can help this i.e. the child gets 1 ‘pass out’ to use at the start of the night and thereafter, needs to stay in their room until they have fallen asleep.

If the child keeps coming out of their bedroom despite having used up their one bedtime pass, parents should return their child to the bedroom with minimal interaction and remind them that they will only get their reward when they use the bedtime pass once

Sleep onset association difficulty

Association difficulties normally affects toddlers through to school age child. This occurs when a child will readily fall asleep if they have a person (e.g. mother or father) or object (e.g. television) with them.

If the child does not have the parent or object then they struggle to get to sleep.

The child typically wakes 1 to 4 times per night wanting the parent or object there in order to re-settle.

What may help……

Identify the sleep association (eg parent) and gradually phase them out of the night settling routine.

This can be done by one of two methods:

  • Checking Methodwhereby the parent settles their child, leaves the room for 1-2 minutes, and promises to return to check on their child briefly after this time.

Parents can then gradually increase the time spent outside the child’s room. Eventually parents return to find that their child has fallen asleep.

  • Camping Out methodwhere parents place a camp bed or chair next to the child’s bed or cot. For the first few nights the parent pats their child to sleep. After a few nights, when the child is settling to sleep readily, the parent sits next to the bed/cot but does not touch the child. The parent then gradually moves their chair/bed away from the child over a period of 7-10 nights. When the child wakes overnight, the parent must return to the bedroom and sit on the chair/bed until the child falls asleep again.

Anxiety-related difficulties

Anxiety is a common cause of difficulties falling asleep. It may present as a sleep-onset association disorder, requiring a parent to be present for the child to fall asleep.

What may help….

In addition to the strategies for sleep-onset association disorder outlined above, older children can try to reduce their anxiety by writing or drawing their worries in a book and then closing the book on their worries for the night, and/or using visual imagery and relaxation techniques around sleep onset. If these simple measures are unsuccessful, consider referring the child to a child psychologist.

Adolescents: Delayed sleep phase

Teenagers will often stay up late at night and then (due to school commitments) rise early the following day. These adolescents appear sleepy and sluggish for most of the morning but will increase energy as the day goes on. Significant sleep losses are normally made up on the weekend, but it does not reduce the daily affect of reduced sleep. Over time, these teenagers who stay up late may find it increasingly difficult to fall asleep at the appropriate time. Delayed Sleep Phase Disorder (DSPD)occurs in 7% of teenagers where their internal body clock moves the timing of sleepiness and they end up staying awake late at night.

What may help…..

If there is more than 30 minutes between bedtime and sleep onset, ‘bedtime fading’ is an effective strategy. This involves temporarily setting the bedtime to when the child or adolescent easily falls asleep (eg 11.00 pm). Bedtime is then moved earlier by approximately 15 minutes every few nights to the desired bedtime (eg 9.00 pm), allowing circadian rhythms to gradually re-adjust. Bedtime fading needs to be supplemented by:

  • consistent early morning wake time
  • elimination of daytime naps to encourage night-time sleepiness
  • avoiding the use of technology with screens before bed
  • increasing natural light exposure in the morning.

Rewards

Consider rewarding the child for being compliant with the chosen method (eg for staying in their room after using the pass out only once). Rewards should be simple and cheap eg stars/stickers for younger children and raffle tickets that can be cashed in for 50 cents for school aged children.

Generally, the novelty of rewards wears off by 2 weeks but the desired behaviour should be established by then.

If rewards do not appear to work, re-think the type of reward given as it may not be enough motivation/reward for the child.

If sleep isn’t adequate

Sleep needs do vary across the lifesan (see Table 1). If your child does not appear to be getting adequate sleep, it is important to speak with a GP or Paediatrician to rule out any other underlying causes. If the cause if behavioural, a Psychologist can support you to implement an appropriate strategy to overcome these difficulties.

AGE RECOMMENDED SLEEP
Newborns 

0-3 months

14 to 17 hours
Infants

4-11 months

12 to 15 hours
Toddlers

1-2 years

11 to 14 hours
Preschoolers   

3 – 5 Years

10 to 13 hours
School-aged Children

6 – 13 years

9 to 11 hours
Teenagers

14 – 17 years

8 to 10 hours
Young Adults

18 – 25 years

7 to 9 hours

 

Table 1: Sleep needs across the lifespan (www.sleephealthfoundation.org.au)