Solve Your Child's Sleep Problems
Schedules and Sleep Rhythm Disturbances
Schedule Disorders I: Sleep Phase Problems
Now that you understand how sleep rhythms are regulated (see Chapters 2 and 9), we can discuss how schedule factors cause or complicate sleep problems, and we can develop strategies to correct them. As you will see, many of the problems caused by improper schedules are closely related to each other and they can be dealt with by similar strategies.
Why Understanding Sleep Phases Is Important
By now you know that your child’s ability to fall asleep or stay awake varies over the course of the day and night. If you try to put your child to bed during a waking phase, he may seem unwilling to go to sleep, when the truth is he is simply not sleepy. Likewise, if you try to wake him up during a sleep phase, he may seem unwilling or almost unable to get up, when in fact his body is not ready to be awake.
These scheduling issues affect all of us, not just children. Suppose you usually fall asleep easily at 11:30 P.M. and wake fully rested, without an alarm, at 7:30 A.M.—in other words, that your sleep phase runs from 11:30 P.M. to 7:30 A.M. Now consider what will happen if you try to change your schedule:
· If you go to bed early, before the start of your sleep phase—say, at 8:00 P.M.—you will have difficulty falling asleep. Even if you doze, you will certainly not sleep through the night.
· If you try to wake early—say, at 4:00 A.M.—you will have great difficulty getting out of bed. You’ll be very sleepy, and you may feel terrible for several hours, but by 7:30 (when you’re used to waking up) you will start to feel ready to face the day.
· If you go to bed late, after your sleep phase begins—say, at 2:00 A.M.—you will fall asleep easily, but you will wake up close to your normal waking time. You will get less sleep than usual, and you may feel tired during the day.
· If you try to sleep late, into your waking phase—say, until 10:00 A.M.—you will probably find it impossible. At best, you will doze on and off for the last few hours.
Children have similar difficulties if they try to go to sleep or get up at times that do not coincide with the beginning and end of their sleep phase. If your child’s sleep phase does not occur when you want it to, or (for an older child) when he wants it to, then he will tend to fall asleep and wake up too early or too late.
Although the amount of sleep a child needs is determined by his individual biology, the specific times when he sleeps can change to a large extent according to personal preference and social necessity. Some families prefer early schedules, while others prefer later ones. You need only decide where the sleep phase should fall and take the proper steps to move it there. But just as you can’t travel between two time zones every couple of days and expect to keep adjusting, you can’t change sleep phases from day to day. In particular, you cannot have one phase for weekdays and another for the weekends.
If you are comfortable with one end of your child’s sleep phase but not the other, then it probably won’t help to move the sleep phase as a whole. For example, if your child falls asleep at the hour you want but wakes too early, then moving his sleep phase to allow him to sleep later may also cause him to stay awake too late at night. Issues like this one are discussed in the next chapter.
How to Identify Your Child’s Sleep Phase
Before making any decisions about your child’s sleep, you need to know where in the twenty-four-hour day his sleep phase falls. If you do not know when he is capable of sleeping, you cannot establish reasonable rules or make reasonable changes.
Usually, the start of a child’s sleep phase is simply the time at which he falls asleep most nights. That means when he actually falls asleep, not when you want him to go to sleep or when you put him to bed. This time is fairly consistent for most children. If your child’s eight o’clock bedtime is always followed by two hours of struggling, calling for you, and coming out of his room until he finally falls asleep at ten, or even if he just lies awake in bed until then, then ten o’clock is probably the start of his sleep phase. Conversely, if he falls asleep on the sofa every night at 7:30, half an hour before his bedtime, or if you have to fight to keep him awake after that point, then you know that 7:30 is probably the start of his sleep phase.
There are other clues to look for. Suppose your child always resists his eight o’clock bedtime and struggles for two hours until usually falling asleep at ten. If you are out late with him one evening and don’t get to put him to bed until 9:30, he may struggle as before, but now for only for thirty minutes, and he still falls asleep around ten o’clock as usual. If you put him to bed at ten, he falls asleep quickly without much struggle at all, and if you’re out later than that, he falls asleep on the way home. Now you can be sure that ten o’clock is the start of his sleep phase.
Children can keep themselves up past the start of their sleep phase if they need something. Suppose your child falls asleep at ten o’clock, which is also when you go to bed. Is ten really the earliest he can fall asleep, or is he waiting for you? You can easily find out. If he falls asleep by 8:30 whenever you go to bed (or stay with him or take him into your bed) at eight o’clock, then his sleep phase starts no later than 8:30. But if he still stays up playing, talking, and laughing until ten, then ten really is the start.
Even if your child falls asleep at times that vary from night to night, you can probably identify an hour by which he is almost always asleep. Then you know he is able to fall asleep by that time, at least; in other words, his sleep phase starts at or before that time, certainly no later. The important thing is that you have identified a time when you know he is capable of sleep.
Now you need to locate the end of the sleep phase. If your child always wakes for the day spontaneously at seven in the morning, then that is probably the end of his sleep phase. But if you have to wake him every morning at seven, and especially if that is difficult to do, then you know that at seven he isn’t yet ready to wake up “naturally.” At what time does he wake on days when you don’t get him up? That should be the end of his sleep phase.
Here, too, there are more clues. If your child always wakes at seven o’clock, comes to your bed, and goes back to sleep there until eight o’clock, then eight, not seven, is the end of his sleep phase. If that happens sometimes but not consistently, then you at least know that his sleep phase can end no earlier than seven o’clock. The exact time will become clearer as you work to correct his sleep schedule.
Similarly, suppose you regularly wake your eight-year-old for school, with difficulty, at seven in the morning. You’re expecting that on the weekend you’ll be able to see how much later he sleeps when left alone—but on Saturday morning, he wakes by himself at seven o’clock. How his sleeping brain “knows” it is the weekend is uncertain, but for the purpose of identifying his sleep phase, it makes no difference. You need to look at what he does after he gets up. If he slinks into a dark den, turns on cartoons, and curls up under a blanket until eight, when, finally looking “human” and no longer like a zombie, he throws off the blanket and announces that he wants breakfast, then his sleep phase ends at eight o’clock, not seven. He would sleep until eight if there were no cartoons.
Weekends, Vacations, and Naps
You’ve seen the importance of observing your child’s weekend schedule (above and in Chapter 9). It’s equally important to learn about his vacation schedules and naps. This information will help you identify his sleep phase and give you a better idea of his sleep requirement. Once you know when he can sleep, when he actually does sleep, and how much sleep he needs, you can determine how short of sleep he is on weeknights and how much makeup sleep he gets on weekends. You need to have this information before you can decide what the causes are of his poor sleep and what changes you need to make in his schedule to correct them.
When you note your child’s weekend and vacation schedules, always be sure to distinguish between times where the wakings are spontaneous (where he gets all the sleep he wants) and those where he is wakened early, thanks to you, a sibling, or an alarm, for example. On vacation he shouldn’t have any lost sleep to make up, as he might on a weekend, so if he wakes spontaneously every morning, then you can accurately estimate the amount of sleep he needs each night to function normally during the day.
If your child still takes naps, note when they occur, how long they last, and whether or not he wakes on his own. Include all of his daytime sleep, including in the car or stroller or by the television, not just formal naps. Parents often tell me their child “never naps,” without mentioning that he falls asleep two or three times a day in the car on errands.
Naps can follow regular patterns or vary widely. A three-year-old may nap at day care but never at home. He may nap at one o’clock at day care but skip that nap at home, instead falling asleep at four on the sofa or in the car. If the timing and length of your child’s naps show a lot of variation, you may find it helpful to chart them (see the next section, below).
Finally, add up the number of hours of sleep your child usually gets at night, during the day, and over a full twenty-four hours. If he sleeps a different amount or at different times on weekends and vacations, calculate them separately.
Charting Sleep Patterns
It’s a good idea to keep track of your child’s sleep patterns. You can use the chart in Figure 5. If your child’s nighttime sleep habits or daytime naps are irregular, it may be difficult to tell what is happening without a chart. Once you have a record on paper, you may notice, for instance, that he always falls asleep late on nights that follow late-morning wakings—perhaps every Saturday and Sunday. Or you may see that he always has trouble at bedtime if he napped after four in the afternoon. Also, parents tend to remember the worst nights and forget about the better ones, especially if they are sleep deprived themselves, so even if you’re not aware of any great irregularity in your child’s schedule, what the chart reveals may surprise you.
When plotting your child’s “awake” times, count only those times you are certain he is really awake. If he calls to you repeatedly between one and three o’clock in the morning but there are stretches of thirty or forty-five minutes in between when you don’t hear him, don’t assume he was awake for two solid hours (even though it probably feels that way to you).
Finally, it is particularly important to chart sleep patterns while you are working to change them. Only with this record can you look back and actually see the improvements.
Sleep Phase Shifts
It’s important to recognize that there is no such thing as an inherently unhealthy or “bad” sleep phase: the hours we sleep are determined by preference or by scheduling requirements, not by biological necessity. So when we talk about an “early” or “late” sleep phase, we really mean early or late enough to be inconvenient or disruptive.
Early (Advanced) Sleep Phase
Your child is said to have an early sleep phase if he naturally falls asleep and wakes at earlier hours than you (or he) would like (see Figure 11). That is most likely to happen if he is inherently a lark.
Victoria was a nine-month-old girl with this problem. Her parents wanted her to sleep for ten hours a night, from 8:30 P.M. to 6:30 A.M. Victoria did get ten hours of nighttime sleep, but she got them between 7:00 P.M. and 5:00 A.M. Her parents were particularly unhappy about the early-morning wakings. On several occasions they kept Victoria up until 8:30 P.M., with great difficulty; she woke at 5:00 A.M. anyway, unhappy from loss of sleep. Her parents saw no point in continuing that approach.
Victoria obviously had an early sleep phase, but her parents’ attempts to change it by moving only her bedtime had not worked. We needed to look at the rest of her schedule. Since she woke at five every morning, her parents were feeding her at that time. They gave her lunch at eleven and supper at 4:30 in the afternoon. She napped for an hour at eight o’clock in the morning and again at noon, after lunch. In short, her entire schedule was shifted too early, not just her wake-up time. If everything in her daily routine could be moved one or two hours later, the problem would go away. That was what we had to do.
If we had kept trying to move Victoria’s nighttime sleep later without adjusting the rest of her schedule, we would have faced a couple of potential problems. First of all, because she was being fed at five in the morning—not unreasonably, given when she was falling asleep—she had learned to be hungry then. If we only made her bedtime later, she might still wake at five, no longer because she was done sleeping but because she was hungry. So we needed to help her learn not to get hungry until later. Second, her early-morning nap was a possible trouble spot: if we didn’t adjust it along with her bedtime, it could start to function as her last sleep cycle of the night, broken off from the rest of the night by a short period of undesirably early wakefulness. We needed to move that nap later so that it would stay separated from Victoria’s nighttime sleep and allow her to begin sleeping later in the morning.
I explained to Victoria’s parents that moving her bedtime later for one night would not reset her biological clock, which was the main reason she woke up at five even when they had kept her up late the previous night. The schedule shift required gradual and consistent changes. I asked Victoria’s parents to shift all the parts of her schedule that they could control—her first feeding in the morning, lunch and supper times, nap times, and bedtime—moving them fifteen minutes later every day. They could then expect that her morning wakings would gradually move later as well.
This strategy worked effectively. After six days, Victoria’s schedule had been pushed later an hour and a half: now she was sleeping from 8:30 P.M. to 6:30 A.M., as her parents desired. She napped now at ten in the morning and two in the afternoon, and she ate her meals at seven in the morning, noon, and six in the evening.
Changing a child’s entire schedule is not always necessary. For example, if his sleep phase is too early for you, but his feedings and naps do not fall especially early, then you can gradually adjust his bedtime alone. Regardless, if your child is still at the age of napping, he should keep doing so, but don’t let his naps last longer than they did before: as you move his bedtime later, you want him to make up the lost sleep at the end of the night, not in the daytime.
If, despite a later schedule, you are still having trouble getting him to sleep late enough, keep moving his bedtime even later, a little at a time—while being sure you don’t let him extend his naps or have an early-morning nap or feeding. His bedtime may have to be temporarily moved later than you want in order to force his wake-up time later to the desired hour, but at some point it will happen. Once it does, you can begin to gradually move his bedtime earlier again, as long as he continues to wake up when you want.
It may help to provide your child with lots of light in the evening, and to keep his room dark in the morning until the time when you want him to wake. Room-darkening shades and curtains can be useful. Children whose rooms let in bright sunlight early every morning may simply be unable to move their sleep phase later until this light is blocked.
Late (Delayed) Sleep Phase
Your child is said to have a late sleep phase if he naturally falls asleep and wakes later than you (or he) would like (see Figure 11). That is most likely to happen if your child is inherently an owl. But, as explained in Chapter 9, all of our sleep phases tend to drift later due to certain biological drives and exposure to artificial light at night. As a result, a late sleep phase is one of the most common sleep problems to occur at any age.
If your child wakes on his own every morning at the desired hour but seems to have difficulty falling asleep on time, then he may simply not need as much sleep as you think (see “The too-long-in-bed problem” in the next chapter). If he falls asleep easily at the desired bedtime but has difficulty waking in the morning, he may need more sleep than you think, and his bedtime may have to be moved earlier. But if both ends of his sleep phase are too late, so he has trouble falling asleep at the desired bedtime and then either has trouble waking in the morning or sleeps later than you would like, this section will help you.
A late sleep phase can occur alone or in combination with other sleep problems, so many different situations can arise. The examples that follow all share the basic features of a late sleep phase.
Adam was an eighteen-month-old who never went to sleep when his parents wanted to put him to bed, at 7:30 P.M. If they tried to rock him to sleep, he just squirmed and tried to get out of their grasp. They would try again every half hour or so without success, until finally, around ten o’clock, either he would let them rock him to sleep or he would fall asleep on his own on the living room floor; once he was asleep, they would move him to the crib. Once or twice a night he would cry and his parents would have to rock him for a few minutes to get him back to sleep. Adam’s mother got up at 6:30 every morning to take care of the other children, but because Adam always fell asleep so late his parents were reluctant to wake him that early. (In any case, whenever they had to get him up before he woke on his own at eight o’clock, he would wake in a miserable mood.) He ate breakfast soon after getting up at eight, he ate lunch at one in the afternoon, and he took an hour-long nap at three.
FIGURE 11. SLEEP PHASE SHIFTS
Mark, a six-year-old, always resisted his eight o’clock bedtime, saying he wasn’t tired. Bedtime was a struggle, and even the evenings were becoming more and more unpleasant. Mark made continual requests for stories, drinks, trips to the bathroom, and tuck-ins, and he often came out of his room complaining that he didn’t feel well. His parents had been told that they needed to be firmer, so they threatened to take away daytime activities he liked and tried locking his door. These approaches only upset him further; sometimes he lay in bed sobbing, and, if anything, he would fall asleep even later than usual. Most nights he grew quiet at around eleven o’clock, and his parents knew he would be asleep soon. But he had to get up for school at seven in the morning, and waking him was difficult: he cried and begged to go on sleeping. On weekends he was allowed to stay up until nine, and sometimes his parents were less strict than usual about making him stay in his room, but he still fell asleep around eleven. On Saturday and Sunday mornings he woke on his own at eight-thirty, in good spirits.
Lindsey, nine, had no behavior problems and did not complain about her eight o’clock bedtime. But she would never fall asleep until about 10:30, no matter what her parents did, and it was difficult for them to wake her at 6:30 A.M. to catch the school bus. Once put to bed, Lindsey would come out of her room quietly every half hour or so and say she couldn’t sleep. She was not frightened. Her mother would sit with her for a few minutes, rubbing her back, and then leave again; she occasionally gave Lindsey some warm milk, and she told her to “practice thinking pleasant thoughts.”
Lindsey sometimes asked, “What’s wrong with me? Why can’t I fall asleep?” She did not attend sleepovers because she was afraid she would remain awake long after everyone else had fallen asleep. The family doctor prescribed an antihistamine that did seem to help her fall asleep more quickly, but her parents did not want to medicate her every night. Eventually they began allowing her to read in bed, which she often did for hours. On weekends, they usually let her stay up until ten; she would then fall asleep much more easily than on weekdays, and she would wake on her own the next morning around eight o’clock.
Each of these children had a late sleep phase, although each also had different complicating factors.
Adam’s sleep phase ran from 10:00 P.M. to 8:00 A.M.; his nap, at 3:00 P.M., was also late. His parents had inadvertently conditioned him to fall asleep while being rocked (which is why he needed to be rocked again when he woke during the night). It would be easy to break this association with a progressive waiting program, as described in Chapter 4, but if his parents started such a program at the 7:30 P.M. bedtime they were hoping for, they would have to let him cry for two and a half hours before he would even be capable of sleeping. That would be not only unhelpful but cruel.
I told Adam’s parents to set his bedtime at ten o’clock—the usual time when he actually fell asleep—and then (only then) to work on eliminating the rocking. At the same time, they were to wake him fifteen minutes earlier each morning until he was getting up at 6:30 along with his mother and the other children. His nap was to move from 3:00 to 1:30, also in daily fifteen-minute increments. Once he was falling asleep quickly at ten o’clock his parents could also begin moving his bedtime earlier, again in fifteen-minute increments, as long as he continued to fall asleep quickly and as long as he still had to be wakened in the morning. Soon he was sleeping from 8:30 P.M. to 6:30 A.M. and napping for an hour at 1:30 P.M. He was falling asleep on his own without being rocked, he was no longer waking during the night, and he was waking on his own in the morning. Ten hours of sleep at night were plenty for a child his age, and his parents now understood that pushing his bedtime earlier to 7:30 P.M. was unrealistic.
Mark’s nightly struggles would have suggested a limit-setting problem (see Chapter 5), except for the crucial fact that his parents had been trying to get him to fall asleep during his forbidden zone, when he could not sleep at all (see Chapter 9). Shutting him in his room at that time could not and did not help. Indeed, it only made matters worse by leaving everyone upset, tense, and angry. Mark’s sleep phase ran at least from 11:00 P.M. to 8:30 A.M.—nine and a half hours—but he was only getting eight hours of sleep on school nights.
Mark probably expected to dislike any suggestion I made to his parents, thinking it would be punitive. Instead, I told him that there was nothing wrong with him and that he was just going to bed too early. I said I thought he should stay up until eleven o’clock, and I asked if that would be okay with him. A big grin slowly covered his face, although he tried to hold it back, and he looked nervously over at his parents (who, by the way, were not smiling). I asked him if he thought that with the eleven o’clock bedtime he could stay in his room quietly, and he said he could. We encouraged this cooperation with a sticker chart and a chance to earn small rewards (see Chapters 5 and 7). Mark’s parents were initially less than thrilled at the idea of the late bedtime, but they consented when I pointed out that he was not falling asleep before eleven anyway and that the change was only temporary.
Mark’s parents agreed to make themselves available to him in the evening. They would read him a bedtime story at 10:45 P.M. and say good night at eleven. Mark was to be awake and out of bed (dressed and given breakfast, and, most important, exposed to light) at seven o’clock every morning, weekends included, and on weekends he would not be allowed to watch television immediately after getting up. Because he would now be getting up regularly at seven, his parents soon could start moving his bedtime earlier again (probably within a few days, as long as he was falling asleep quickly).
This approach was a success from the first night on. The bedtime struggles vanished, and without them Mark found it hard to stay up until eleven. Evenings became pleasant again. He earned his prizes without difficulty, and his self-esteem improved. His parents gradually moved his bedtime all the way back to nine o’clock, and his total sleep time increased to nine and a half to ten hours every night.
Unlike Adam and Mark, Lindsey presented no behavior problems, but her nights were nevertheless unpleasant, and so was her feeling that there was something wrong with her, that she was “different.” Her sleep phase ran at least from 10:30 P.M. until 8:00 A.M., nine and a half hours, and like Mark she was getting only eight hours of sleep on school nights. It was certainly better for her to read in bed than to lie awake in the dark for hours, but it did little for her sense of failure and it did not get her any more sleep.
I reassured Lindsey that she was completely normal and explained the delayed sleep phase problem to her and her family. I suggested that she should read in the living room in the evening if she wanted, but not for so long in bed. We moved her bedtime to ten o’clock and allowed her to read in bed for half an hour; she was to turn the lights out by 10:30. Her parents would wake her at 6:30 every morning. Lindsey started falling asleep quickly, and we were able to begin moving her bedtime earlier. She ended up sleeping from 9:00 P.M. to 6:30 A.M.—a more realistic bedtime than her original one, eight o’clock, but still early enough to allow her a full nine and a half hours of sleep before she had to get up for school.
All of these children’s sleep phase problems were taken care of without struggles or unnecessary limit setting, threats, demands, or medication. They were resolved simply by fixing their sleep schedules.
Treating a Late Sleep Phase
As the examples above show, the easiest way to treat a child’s late sleep phase is first to put him on a schedule that matches the current setting of his sleep phase—that is, one that fits the current times he is falling asleep and waking up—then to move his bedtime a little earlier each day as you gradually advance his sleep phase by carefully controlling his wake-up time. The key points to remember are:
· Control evening and morning light.
· Start with a late bedtime.
· Adjust (and enforce) morning wake-up times, naps, and mealtimes.
· Gradually move bedtime earlier.
The following detailed guidelines should help you plan your child’s treatment.
· Identify your child’s current sleep phase, as described earlier in this chapter.
· Set his bedtime initially at the start of his current sleep phase, or a little later.
· Allow your child to stay up until the time he normally falls asleep so that, when he does go to bed, he will fall asleep fairly easily. If you are not sure of the correct time, err on the late side. It’s important to reaccustom your child to falling asleep quickly: that way bedtime will become pleasant rather than full of bickering, anxiety, and frustration. If your child is old enough to understand what’s going on, he will be relieved to learn that you are not angry with him, there is nothing wrong with him, and the sleep problem was not his fault.
· Avoid unnecessary bright light in the evening; ensure bright light in the morning.
· What you do next will depend on whether or not your child sleeps as late as he wants on most days or usually has to be wakened.
· If he sleeps late every morning, you can either accept the late sleep phase (but now with a late bedtime as well as a late waking, assuming the late schedule isn’t a problem for either of you), or gradually move his whole sleep phase earlier.
· If you want to move his sleep phase earlier, then once he is falling asleep quickly at his new (later) bedtime—which should happen within a day or two (if it isn’t, you may have to temporarily move the bedtime even later)—begin to gradually shift his wake-up time earlier. Every day, wake him fifteen minutes earlier than you did the day before. Don’t start advancing his bedtime quite yet—you must begin with the morning wake-up time: you cannot make a child fall asleep, but you can make him get up. Once his wake-up time has been moved up by thirty to sixty minutes, so that he is mildly sleep deprived each night, you can then begin moving his bedtime fifteen minutes earlier each night as well. The slight loss of sleep that happens initially (because of the earlier wakings) will help ensure that he still falls asleep quickly at night. Once you have reached the desired morning wake-up time, you may be able to keep advancing his bedtime a little further until he is getting the same amount of sleep that he was getting before you started shifting his schedule.
· If your child must be wakened on weekdays, such as for school or day care, then you must correct his sleep phase while keeping his wake-up time fixed.
· Wake him at the same time every morning, including weekends and vacations. He should get up, get dressed, and have breakfast, and he should be exposed to plenty of morning light. (Don’t let him get up and immediately start watching television.) The early wakings, combined with the later-than-usual bedtime, will leave him mildly sleep deprived, and he will soon be falling asleep quickly at night. Once that happens, begin advancing his bedtime by fifteen minutes a day. You can keep moving his bedtime earlier as long as he continues to fall asleep quickly. If he starts waking on his own at the correct time, then his sleep phase is now where you want it, and he is probably getting all (or almost all) the sleep he needs. About the only way you can push his bedtime much earlier than that is by continuing to move his wake-up time even earlier.
· If your child regularly takes age-appropriate naps, keep letting him nap while you adjust his sleep phase, but don’t let the naps run longer than usual. The sleep you are cutting out in the morning should be made up at the earlier bedtime; it should not be moved to the daytime.
· If, like his sleep at night, your child’s naps and meals are shifted later than they should be for the schedule you are trying to achieve, you may have to move them earlier as well. Advance them at the same rate at which you advance bedtime and waking.
· You must start by setting your child’s bedtime at least as late as the time he regularly falls asleep, even if that is later than you like or later than you yourself want to stay up, and you must be available to take part in your child’s evening activities. It won’t be long before his bedtime has moved to an hour that suits you better.
· If your child has other sleep problems, such as limit-setting difficulties or inappropriate sleep associations, you can correct these problems either while you are working on his sleep schedule or separately. Regardless of your choice, address the other problems only if you are certain that your child is being asked to sleep at times you know he is capable of doing so. If you aren’t yet sure where his sleep phase falls, you would do better to adjust his schedule first and tackle the other problems later.
How a Late Sleep Phase Develops
There are many ways for a child to develop a late sleep phase. In addition to the predisposing biological and environmental factors described in the preceding chapter, anything that interferes with falling asleep—illness, excitement, travel, and fears are typical examples—can result in a sleep phase shift if the child sleeps later than usual the next morning. If he doesn’t sleep later, the sleep phase will not shift. But if he does, and especially if he is allowed to continue sleeping later on the mornings that follow (as may happen in homes where everyone does not have to be up and out by a certain hour), a problem can develop. Even sleeping in just on weekends can be enough to persistently delay a child’s sleep phase—in fact, that is the most common cause of late sleep phases in school-age children.
Although late sleep phases are a frequent cause of problems, they are relatively easy to treat—at least until adolescence—because the schedules of young children are (or should be) entirely under their parents’ control. (Correcting a late sleep phase is much like making the time change from the West Coast to the East Coast.) However, once a child has entered adolescence, the situation becomes more complex (as described in the next section).
Sleep Phase Shifts in the Adolescent
Early (Advanced) Sleep Phase in the Adolescent
Advanced sleep phases in adolescents are almost unheard of. As I explained at the end of the previous chapter, so many forces (biological, academic, and social) push a teenager’s sleep phase later that it is extremely rare to find an adolescent who consistently falls asleep too early and wakes well before he needs to get up for school. Adolescents who have strong lark tendencies may have earlier sleep phases than their peers—they may not like to stay up past eleven or sleep past eight, say—but even their sleep phases are likely to be late-shifted with respect to school hours. Still, these youngsters usually have an easier time than most because they get up for school closer to the end of their sleep phase and are consequently less sleep deprived.
Late (Delayed) Sleep Phase in the Adolescent
Adolescents are particularly likely to have late sleep phases, and their sleep phases are more difficult to correct than those of younger children. Teenagers frequently stay up late on weekend nights and then sleep until noon or later, so their sleep cycles can shift profoundly (as discussed in “Society, Sleep Deprivation, and the Adolescent” in the preceding chapter). As a result, they are often severely sleep deprived during the week, when they most need to be alert.
It is often very difficult for a parent to assume control over an adolescent’s sleep cycle. A teenager may not be willing to maintain a regular sleep schedule even if he understands its importance. Pressure from friends is very strong in these years, and most adolescents love to stay up late watching television, playing on the computer, talking on the phone, or listening to music. Finally, as we saw in the previous chapter, biological factors as well as social ones are working against him: he is now physically able to stay awake very late or even all night, and he probably has to get up earlier for school than he used to. Adolescents may also have an inherent tendency toward late-shifted sleep. All of these factors push teenagers to lose sleep during the week and to sleep later on the weekend, and thus these youngsters tend to develop progressively greater delays of the sleep phase.
Connor, a fifteen-year-old high school junior, had been having trouble falling asleep early and waking for school for many years, but over the summer before I saw him the situation had developed into a major problem. By the time school had started in the fall, he was unable to fall asleep until three or even four o’clock in the morning on weeknights, even though he went to bed at 11:30 the night before. He would pass the time listening to the radio, and occasionally he would get up for a snack. Needless to say, he had great difficulty getting up for school in the morning at 6:30. His parents were becoming angry, and sometimes their attempts to wake him turned into battles. Despite these problems, Connor made it to school most days and usually just on time or a few minutes late. On weekend nights Connor often stayed up very late watching television, and he wouldn’t even get into bed until three or four o’clock. He would sleep through weekend mornings, staying in bed as late as one o’clock in the afternoon, and he did the same on days when he missed school.
Connor was an average student. Although he didn’t particularly like school, he did want to attend and graduate. He was upset by the considerable trouble he had falling asleep at night, and he hated getting up in the morning feeling so tired after only three hours of sleep. He often fell asleep in his morning classes, and even when he was able to stay awake he had a great deal of difficulty paying attention.
Connor was surprised and pleased when I told him that I knew what was wrong and that there was a solution to his problem. He found it reassuring that I sympathized with his difficulties and understood that he wasn’t lazy, and he was particularly relieved when I confirmed that he truly couldn’t fall asleep early (at least, not yet). The problem was that his sleep phase had shifted dramatically, much more so than the sleep phases of the younger children described earlier in this chapter: it was delayed by five or six hours, running from about 3:30 A.M. to 12:30 P.M.
Connor could have corrected his sleep phase by getting up early seven days a week and never napping, even in school, and I did offer this approach. This is the same technique we saw used successfully for the younger children, and the guidelines given above would have applied. But that approach is easiest to use when there is a shift of only one to three hours. For a six-hour shift like the one Connor needed to make, it will be much harder (think of flying from the United States to Europe, or from Hawaii to New York). In practice, teenagers like Connor—who are already having considerable difficulty getting up on time for school and who are already unable to stay awake during the school day—may find it very hard to follow a program that temporarily cuts down even further on their nightly sleep. Until the shift was complete, Connor would be getting much less sleep than he needed, even on Friday and Saturday nights. He would be extremely tired, his motivation likely would flag, and he might be unable to resist occasionally sleeping late, especially on the weekends, or falling asleep during the day, in or after school. If he lapsed in any of those ways, the treatment would not work.
So I also offered a different approach that is sometimes useful with extreme sleep phase delays, namely that he correct his sleep phase by going to bed later each night, until he had gone all the way around the clock to the times he wanted to be sleeping—say, from 11:00 P.M. to 6:30 A.M. After that it would be critical for him to keep getting up early every day, even if he stayed up late on weekends, in order to keep his sleep phase in place. (It would be easier for him to follow through with the plan, and therefore more likely for him to succeed, if he was allowed to stay up late some nights as long as he still got up by 6:30 on weekdays, no later than 7:30 on weekends.)
Regardless of which method he chose, Connor had to agree to assume control over his own bedtime and waking. In particular, he needed to take responsibility for getting up in the morning, like most adults. As things stood, his parents had the task of waking him each morning, while Connor was actually trying to go back to sleep. Instead of working together, he and his parents were working at cross-purposes, and this only led to fights. So Connor bought a clock radio and set it to a loud morning talk show; and, at the other end of the room, he put a backup alarm clock that would not stop ringing until he got up and turned it off.
Connor chose the second option, the one that would move his sleep phase around the clock: his plan was to go to sleep and get up three hours later each day according to the 107 following program:
Connor’s Initial Sleep Schedule 3:30 A.M. to 12:30 P.M.
Connor’s Final Sleep Schedule 11:00 P.M. to 6:30 A.M.
The first day he would go to sleep at 7:00 A.M. and get up at 3:00 P.M. The next day, he would go to bed at 10:00 A.M. and get up at 6:00 P.M., and so on. After six or seven days he would arrive at the schedule he wanted, with all his sleep moved back into the nighttime where it belonged. Oversleeping by an hour or two was acceptable for most of the transition period, since it would push his schedule later and speed up the process, but in the last couple of days he would have to be careful not to sleep past 6:30 A.M. He agreed to chart his sleep patterns so that he and I could follow his progress.
Most teenagers find this adjustment fairly easy to make; as they go through the transition they will be falling asleep quickly, getting enough sleep each night, and waking without difficulty. Hopefully, any unpleasant feelings they have come to associate with lying awake at bedtime will diminish. Besides, this program follows the natural tendency of their circadian rhythms instead of fighting it. Within a week, they should be sleeping and waking at the desired times. From then on, if they keep their morning wakings under control (see “Settling for Improvement in the Adolescent’s Schedule” below), their sleep patterns will remain regular and gradually grow more stable.
During the transition they may have to miss one or two days of school, but absences can be kept to a minimum by starting the program in the early hours of a Saturday morning (as we did with Connor, above). By Tuesday or Wednesday, they won’t be going to sleep until after school. Once their sleep schedule is adjusted, their attendance should be better than it was before.
Certainly, if your teenager’s sleep phase is late-shifted by less than four hours, it makes more sense to try the other approach first, moving an initially late bedtime earlier little by little while keeping the morning wake-up time consistently early seven days a week and avoiding naps. (Even with bigger phase delays, many youngsters choose this option since they already have to get up early five days a week.) This approach involves sleep loss and requires some self-discipline, so you cannot do it for a teenager. You can explain to him the whys and hows, but he must want to make the change, and he must be willing to get himself up each morning. If this approach is not successful, you can always fall back on the around-the-clock approach that shifts bedtime progressively later.
Other Ways to Shift the Clock
There are some other tools available to adolescents to try and counter the forces that push their sleep phases later. Exposure to bright light in the morning, as we have already seen, moves the setting of the biological clock earlier and with it the timing of the sleep phase. Having a teenager get up half an hour early every morning to sit in a brightly lit room, with his eyes open, will definitely help advance his sleep phase, and this method is both safe and effective. (Exposure to bright morning sunlight is ideal, but in the winter adolescents often have to get up before there is much light outside. Ordinary room lighting will help, but not as much as a bank of bright fluorescent lights made especially for this purpose.) However, getting adolescents to give up that extra half hour of sleep every morning is usually not realistic. It makes sense nonetheless to get room lights on and shades up as soon as possible in the morning. Hiding from morning light will only worsen the problem.
Some people find it useful to take the hormone melatonin in the afternoon or evening. Melatonin levels are a marker of the setting of the biological clock, rising at night when the sleep phase starts and dropping in the morning when it ends. Melatonin does not induce sleep directly (at least not very strongly), but it may make falling asleep easier by “tricking” the brain into responding as if the sleep phase had already started. It may also help shift the biological clock earlier in the same way that morning light does. Several studies have shown that these effects may indeed benefit some youngsters. To avoid daily use of this agent, some researchers recommend using melatonin only late on Sunday afternoons, to help counteract any phase delay developing over the weekend. (Several studies suggest that a dose in the afternoon is more effective for adjusting the biological clock than one in the evening.) However, even though it is available over the counter, melatonin is a hormone with a number of different effects (among them effects on sexual function, at least in animals), and there is almost nothing known about its long-term use in adolescents.
Using sleeping pills to induce sleep before the start of the sleep phase generally does not work well, since they do nothing to reset the biological clock, but their use for one to two weeks may help make it easier to start getting up early every day. Other than that, avoid such drugs except for very occasional use since they may be dangerous and can be habit forming. The same goes for using stimulants to help stay awake in the daytime after getting too little sleep the night before. If the underlying sleep phase problem is not corrected, medications will be helpful only briefly, if at all. Discuss any and all such treatments with your physician.
Settling for Improvement in the Adolescent’s Schedule
Whether you fix a sleep phase delay by shifting it forward or pushing it back, the real challenge is to keep it from moving again once fixed. The difficulty is that you may be able only to minimize the problem, not to solve it completely. If a teenager has to be up for school at six in the morning, then to get nine hours of sleep he must be asleep by nine o’clock in the evening. That is simply not practical in our culture. Even a conscientious student who comes home, eats, does his homework, and goes to bed without watching television or talking on the phone is unlikely to get to sleep much before ten or eleven o’clock. But if he can at least fall asleep quickly when he does go to bed, he will still get more sleep than he would with a delayed sleep phase.
While roughly nine hours of sleep at night is an ideal amount for a teenager, getting seven hours is much better than getting four, five, or six—but it is still not quite enough. If a student gets up at the same time seven days a week, he may never get enough sleep, especially if he also goes to sleep later on weekends than during the week, as he probably will. To permit some repayment of his sleep debt, we have to allow for him to sleep later on one or both weekend mornings. We only need to be sure not to let his morning sleep last so long that his sleep phase begins to drift again. If that happens, he will fall asleep even later than before and his sleep debt will only increase. If we must allow teenagers some makeup sleep on weekends, perhaps an hour or so, the trick is that it not be so much that they start to fall asleep later on weeknights. Their weekday and weekend wake-up times will still differ, but by only one or two hours, not four, five, or six.
A “Desired” Late Sleep Phase in the Adolescent
Some teenagers actually want a late sleep phase, although they may not be willing to admit it, even to themselves. It is important that you be able to recognize this problem, because the kinds of schedule change described above will not alleviate it. On the surface, this pattern resembles the sleep phase delays we’ve already discussed, except that the phase delay is long-standing, the child says he cannot wake in the morning, the parents say they are unable to wake him, and his school attendance is very poor. (When he does go to school, he probably gets there quite late.) Actually, in these cases there is usually nothing wrong with the child’s sleep itself. Sleep studies have shown that such youngsters sleep normally and have a normal ability to wake up. In fact, even at home the child can wake in the morning if there is something important that he wants to do—just not for school.
Anna was fourteen years old. Like Connor, she had a very late sleep phase, but with several important differences: rather than just finding her difficult to wake in the morning, her parents often could not wake her at all; unlike Connor’s occasional absence or tardy arrival, she never made it to school on time and usually did not go at all; and instead of falling asleep later and waking later over summer vacation, as children usually do when they are out of school, she fell asleep and woke earlier (during the summer she slept from 1:00 A.M. to 10:00 A.M., but during the school year she usually fell asleep at 5:00A.M. and woke at noon). When her school made special allowances for her to come in at 12:30 P.M. for a half day, she soon became unable to wake before midafternoon or to fall asleep before 7:00 A.M. When I saw Anna, she had missed most of her freshman year. Her parents did try to get her up each morning until they had to leave for work, and Anna usually went back to sleep after they left.
Although Anna’s problem had only become so severe after she started high school, she had always fought going to school and always had a large number of absences. Her family situation was tense, unhappy, and unsupportive; she was depressed, she had no close friends, and she hated school. Being “unable” to wake until the afternoon allowed her to miss a great deal of school and kept her apart from other children her age. That was really what she wanted. Anna had convinced her family—and herself—that she wanted to have a more normal sleep schedule but couldn’t. That was partially true: her sleep phase had genuinely shifted so that she couldn’t fall asleep early, but she also didn’t want to do anything to change it.
The techniques described earlier in this chapter would fail with Anna because she would never cooperate. Just to be sure, we tried moving her schedule progressively later around-the-clock, as we had done with Connor, but she did not follow through at all. Although she had initially complained that she couldn’t fall asleep before five in the morning, now she said she was unable to stay up after five. But she never really tried: before five o’clock even arrived, she would already be in bed with the lights out.
Youngsters like Anna need more than direct treatment of their “sleep problems,” because their sleep isn’t really the problem. A child who really does not want to attend school may be glad to have a plausible reason why he “can’t” go. If the underlying problem is not solved, the child’s sleep schedule will never be corrected. Anna’s real problems were depression, isolation, low self-esteem, and, above all, a dislike of going to school. If she could have given up school altogether and taken on another daily activity instead—one she liked and looked forward to—her sleep problems would largely have corrected themselves.
For children like Anna, I always recommend psychological evaluation and counseling. Often family therapy is useful, because the problems are often connected to the child’s relationships with other family members. It is not unheard of for a child to feel obliged to stay home during the day to care for a parent who is depressed and isolated; here the parent is actually subtly encouraging the child to maintain a late sleep phase. Since in this case neither the parent nor the child really wants anything changed, my recommendation for counseling is often turned down.
Not all children with a “desired” late sleep phase are depressed. Nor do they all dislike school, perform poorly in class, or have major problems at home. Nevertheless, they are all using their sleep “problem” as a way to avoid something else in their life, often at great cost to their ability to get by in school. All of them have underlying problems that must be understood and resolved before they can function normally again.
A “desired” late sleep phase is usually not easy to treat. The longer it has been going on, and the more school the child has missed, the harder it will be to turn things around. However, when the underlying problems have been satisfactorily addressed, the sleep problem may resolve itself. If the youngster is placed in a setting he likes (for example, if he switches from a high school he hates to a vocational program he loves), he may become motivated to get up instead of to stay in bed. In that case, the sleep problem will go away.
At first, Anna and her parents were quite reluctant to accept counseling. After a few months they finally agreed to give it a try, although they found it difficult to discuss their family’s troubles openly. Very gradually, they began to understand many of the problems whose existence they had previously denied. Although many issues remain to be settled, the family has made much progress. Anna still does not like school, but she attends regularly. She is not outgoing, but she has made a few tentative efforts toward making friends and is noticeably happier. Relationships within her family have improved. Although Anna still tends to stay up until about one in the morning, her sleep phase is now much closer to normal.