The most common bedtime problems among toddlers and school-aged children are
• Difficulty falling asleep within a reasonable time (e.g., 30-60 minutes) and
• Bedtime “resistance” (i.e., refusing to go to bed when instructed).
Just how common are these problems? According to parent surveys, 20-30% of young children have significant problems going to bed and/or awakening during the night (Mindell et al 2006). Rates may be even higher among school-aged children, because many parents are unaware that their older children are having sleep problems (Gregory et al 2006).
Pediatric sleep specialists often advise parents to tackle sleep problems by putting their children through sleep training. Several training programs have been scientifically tested, and, in general, parents who stick with these programs report improvements in bedtime behaviors.
However, before you try sleep training, it’s important to understand why your child won’t sleep. Kids may resist bedtime for a variety of reasons. Once you identify your child’s personal sleep issues, you’ll find it easier to choose a sleep training program that’s well-suited to your child’s needs.
Just as important, you might discover that you don’t need to try sleep training at all. Some bedtime problems have relatively simple remedies. This article reviews the common causes of bedtime troubles, and suggests practical solutions for coping with them.
The behavioral insomnia of childhood (BIC)
According to researchers, bedtime problems arise in at least two ways.
First, kids may learn to associate falling asleep with certain forms of stimulation—like parental soothing or a particular sleep environment. If they don’t receive these forms of stimulation, these kids have difficulty falling and/or staying asleep (Moore et al 2006).
Second, as kids become more independent, they may begin testing their parents’ limits. Bedtime resistance strategies may run the gamut from charming attempts to stall (“one more hug”) to major tantrums (Moore et al 2007). If bedtime rules are unclear or inconsistently enforced, bedtime resistance becomes a major problem in the family.
In both cases, kids suffer from what sleep experts call the “behavioral insomnia of childhood,” or BIC (American Academy of Sleep Medicine 2005). But there is more to childhood insomnia than sleep associations and poorly-enforced bedtime rules. Kids may have trouble falling asleep for a variety of reasons. Here are some of common triggers of bedtime problems—and ways to cope with them.
Otherwise well-adjusted young children frequently experience anxiety when they are separated from their parents (Jenni et al 2005; Ainsworth et al 1978), and most children also experience nighttime fears. If your child is fearful, he needs your help. Children lack the brain maturation and cognitive skills to cope well with distressing emotions, and there is no evidence that nighttime fears or separation anxiety will diminish as a result of sleep training. In fact, research suggests that ignoring your child’s fears may lead to nightmares and emotional problems.
If you suspect that nighttime fears or separation anxiety are contributing to your child’s bedtime problems, see this article for practical tips on teaching your child how to cope.
As I note in this blog post, recent research suggests that many kids are sending their kids to bed too early, long before they are ready to fall asleep. Their bodies haven't yet produced enough melatonin, a key hormonal regulator of sleep (LeBourgeois et al 2013). Kids who are put too bed too early get understandably bored, and, as they lie awake with nothing to do, these kids may find their minds dwelling on anxieties and fears (Ferber 2006).
Of course, there are two scenarios here. One is that you expect your child to spend to much time in bed. You've simply overestimated how much sleep he needs. To see if this is the cause of your child’s bedtime problems, check out my article on child sleep requirements.
The other scenario is that you are correct about how much time your child needs to sleep. But your child's internal clock is set to a different schedule, one that involves falling asleep later and waking up later than your lifestyle permits. If that's the trouble, you can proceed as if your child has a circadian rhythm sleep disorder (see next).
Circadian rhythm sleep disorders affect the timing of sleep. The individual's internal clock is out of sync with the demands of her work or social schedule. She fails to get drowsy at the preferred bedtime, or has trouble staying awake during the day.
To remedy the problem, you can gradually re-adjust the biological clock with crucial zeitgebers, or environmental cues. Expose her to bright light during the morning and afternoon. After sundown, dim the artificial lights, especially those that radiate blue light, because blue light appears to have a particularly powerful, suppressive effect on the production of melatonin (Wahnschaffe et al 2013). And in the last 2-3 hours before bedtime, take care to avoid stimulating activities (Glaze 2004).
The practice of setting a regular bedtime is by no means universal. In many traditional cultures, the timing of sleep is flexible and opportunistic, with people making up for the occasional "late night" by taking naps in the day (Worthman and Melby 2002). This approach might work for you, too, if you don't have problems meshing your work schedule with your circadian rhythms. But if your lifestyle disallows naps, or you just aren't the type to take naps, then irregular bedtimes can spell trouble. Studies of people living in industrialized countries suggest that young children who lack regular bedtimes have more behavior problems (e.g., Komada 2011; Kelly et al 2013).
Children are tricky when it comes to showing signs of tiredness. Some kids seem to get ever more active as the night wears on—even though they are in desperate need of sleep. When kids become overtired, they may be too stimulated or nervous to fall asleep (Kuhn et al 1999). If this is your child’s problem, review your family’s evening schedule. Is bedtime too late? Do you help your child wind down before bed by leading him through a pleasant, soothing bedtime routine? Do household activities quiet down in the last 2 hours before bedtime? Although you might be tempted to wear your child down with exercise, research suggests that exercise keeps people alert for at least two hours after it’s over.
If your child has trouble falling asleep, she may be experiencing daytime stress. Stress can raise stress hormone levels, and it can fuel nighttime anxieties and fears (above). In one study, children living in homes characterized by marital conflict were more likely to suffer from bedtime problems (El Sheik et al 2006). Similarly, kids may find it hard to settle if they are having conflicts with peers, feeling displaced after the birth of a sibling, or experiencing trouble at school. Even very young children may experience stress in daycare or preschool.
Everybody knows that caffeine is a stimulant that should be avoided in the hours before bedtime. People are often less aware of the relative amounts of caffeine found in everyday consumables. For instance, a 12-ounce “classic” Coke contains about half the caffeine found in a 12-ounce Mountain Dew or 3.5 ounces of dark chocolate. Moreover, some products, like "energy drinks," may contain more caffeine than is indicated on the label, because ingredients listed separately--like guarana, kola nut, yerba mate, or cocoa--are hidden sources of additional caffeine (Seifert et al 2011). For more information about the caffeine content associated with various commercial foods and drugs, see this list put out by the Center for Science in the Public Interest.
Throughout the world, children's sleep problems have been linked with television. For instance, a study of American fourth graders reported that increased television watching (both during the day and at night) was associated with higher rates of bedtime problems, including anxiety, sleep-onset delays, and bedtime resistance (Owens et al 1999). A study of school-aged kids in China reported similar results (Li et al 2007). And in Finland, researchers have uncovered evidence that even passive viewing--being present while parents watch adult programs--can contribute to bedtime problems. Young children (aged 5-6 years) who were exposed to adult programs (like the evening news) slept less overall and experienced more sleep disturbances (Paavonen 2006).
Of course, television is only one type of electronic distraction. Video games, computers, and smart phones may also cause trouble. In a recent study of American school kids, children with three or more devices in their bedrooms got, on average, 45 minutes less sleep each night (Calamaro et al 2012).
Personally, I don’t believe in interfering if a child takes the occasional long nap. If a child sleeps spontaneously, it’s almost always because she really needs to catch up on her sleep. In such cases, a nap doesn’t disrupt the child’s long-term sleep schedule. It puts her back on track. But if your child is routinely taking long naps—particularly naps that end in the later afternoon or evening—this may be contributing to her bedtime problems.
A study of American school-aged children reports that kids with allergies are more likely to suffer from insomnia (Stein et al 2001). They are also more likely to suffer from noisy sleep. If your child has allergies and bedtime problems, consult your physician.
Sleep disordered breathing (SDB) includes snoring, loud breathing, troubled breathing and interrupted breathing (apnea) during sleep. SDB can restrict the oxygen supply to a child’s brain and cause serious health problems. It is also associated with poor sleep quality, frequent night wakings, and daytime sleepiness.
It’s possible that SDB plays a role in bedtime problems, too.
A number of studies have shown a link between SDB and hyperactivity (e.g., Hiscock et al 2006; Shur-Fen Gau 2006). Kids diagnosed with ADHD are more likely to have SDB than are other kids. And when hyperactive kids are treated for SDB, their ADHD symptoms improve. This has led some researchers to speculate that at least some cases of ADHD are caused by SDB. Or, put another way—it’s possible that many kids who have been diagnosed with ADHD are really just suffering from sleep problems.
These findings suggest that sleep-disordered breathing could contribute indirectly to bedtime problems by making SDB sufferers more hyperactive and defiant.
This is a controversial idea that some researchers reject (Sadeh et al 2006). However, given the potential dangers of sleep-disordered breathing (which I discuss in this blog post), it can never hurt to screen and treat an affected child. If you suspect your child suffers from sleep-disordered breathing, consult your physician.
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