BELLEVUE, WASH. – When tired parents complain that their child wakes up frequently at night – and wakes them up – you can offer them a hardball approach or softball approach to dealing with the problem.
The hardball approach is far more effective and more quickly resolves night wakings, but some parents find the idea of it intolerable. For them, there’s the softball approach, Dr. Charles H. Zeanah Jr. said at the annual meeting of the North Pacific Pediatric Society.
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Parents report that 20%-30% of toddlers are night wakers, and most of these will continue to have sleep problems as 6-year-olds if the sleep problem is not addressed, said Dr. Charles H. Zeanah Jr.
The goal of both strategies is to teach the child to fall asleep on his or her own. Waking during the night is normal at age 3-6 months, and 30% of infants are "signalers" who cry and expect someone to respond. By 8 months of age, 60%-70% of infants self-soothe after waking during the night. Parents report that 20%-30% of toddlers are night wakers, and most of these will continue to have sleep problems as 6-year-olds if the sleep problem is not addressed, he said.
"Somewhere between 6 and 9 months of age, I may start to think of it as a disorder or impairment, not just for the child but [also] for the parent," said Dr. Zeanah, professor of clinical pediatrics and psychiatry and director of child and adolescent psychiatry at Tulane University, New Orleans.
First, take a good history of family structure and routines around bedtime, limit-setting behaviors, distress, what tactics the parents have tried, and whether the parents agree on what needs to be done.
"It’s amazing how many people don’t have a bedtime routine," he said. "The key question is, ‘Is the child put down while awake?’ " Learning how to fall asleep at bedtime on his or her own, without "signaling," allows the child to fall back asleep after waking during the night.
Before talking about the hardball or softball approach to teaching a child to fall asleep on his or her own, Dr. Zeanah plays a little "hard to get" with the parents, to assess their commitment to an intervention. He tells them that there’s no evidence that night wakings cause a mental illness or severely damage a child. "I know it’s annoying, but I’m not sure if you want to do something about this" night-waking problem, he says.
Tired parents usually do want to intervene.
The first steps are to create a set bedtime and establish a consistent bedtime routine (such as reading a story) that ends in the child’s room. Finish the routine before the child falls asleep.
Then he explains the hardball approach: If the child cries when you leave, wait 5 minutes, go back and soothe the child without using words (for instance, by patting or rubbing the child’s back), then leave again. If the child cries again, repeat until the child falls asleep. Over the ensuing days, gradually increase the 5-minute interval to longer stretches between soothings.
"The rigidity of this is the key," Dr. Zeanah said, and it works. In 30 years of practice, he has never seen a child last more than a week before learning to fall asleep on his or her own.
Dr. Charles H. Zeanah Jr.
If a parent can’t handle letting the child cry because they fear the child is scared to be alone, he explains the softball approach: When the child cries, go in and sit in a chair next to the child’s bed without interacting with the child, which takes any fear out of the situation. Sit in the chair until the child falls asleep. The next night, move the chair a couple of feet toward the door. Move a little more toward the door each night until the chair is outside the door, but visible to the child when you sit in it. Then pull the chair back so just your knees are visible, and eventually so the parent can’t be seen.
"It’s not as effective" as the hardball approach, but helps in some cases, he said.
With either approach, he asks parents to call him early in the morning after the first night of the intervention to let him know how it went. Check in with parents frequently during the intervention to encourage them and make adjustments, he advised.
With the hardball approach, "by the third night, there’s usually no reason to call," he said.