Solve Your Child's Sleep Problems

Part IV

Interruptions During Sleep

Chapter 16

Head Banging, Body Rocking, and Head Rolling

Some children exhibit rhythmic, seemingly strange behaviors at night. Such a child might rock back and forth, roll his head or bang his head repeatedly against a hard surface such as a headboard or wall. To parents, these behaviors can seem peculiar and even quite worrisome, especially if they do not understand their origin or significance.

Jason, for example, was a healthy and normal two-year-old boy. His parents had first become concerned when he was seven months old, when he began to rock back and forth vigorously on all fours for about twenty minutes every night before falling asleep. Soon this behavior included banging his head against the end of his crib, and he was still doing so each night at age two. Although he still usually stopped within twenty minutes and fell asleep, some episodes lasted as long as an hour. Even worse, he had started banging in the middle of the night as well, once or twice each night for up to forty-five minutes at a time. The rocking and banging often moved the crib across the room. It was constantly being damaged and had had to be replaced twice. Worried that Jason would injure himself, his parents put padding at the end of the crib, but he would either push it aside or find another hard spot where he could bang his head. When his parents moved him to a mattress on the floor, he simply crawled over to the wall and began to bang his head there.

If your child has behaviors like Jason’s, you no doubt share his parents’ concerns. But there is usually little reason to worry. Many young children engage in some sort of repetitious, rhythmic behavior in bed. They rock back and forth, roll their heads from side to side, bang their heads against a hard surface, or repeatedly drop their heads onto their pillows or mattresses. Some children hum rhythmically or make other sounds at the same time.

When Do These Behaviors Occur?

Children who rock or bang in bed usually do so at bedtime, but they may also rock or bang in the morning after waking, before naps, or as they try to return to sleep after nighttime wakings. Some children show these behaviors only after waking during the night. When a child rocks or bangs his head at night, he is usually drowsy, just falling asleep, or in very light sleep, and the behavior generally stops once he is soundly asleep. If the behavior occurs in the morning, it usually stops once the child is wide awake.

Though these instances can seem bizarre, rhythmic behaviors are in fact an entirely normal part of a child’s development. Breathing, sucking, and crying, for example, are rhythmic behaviors all children engage in. In addition, most toddlers at least occasionally rock back and forth for a few minutes during the day, usually sitting up and commonly while listening to music. About one out of five rock on all fours at least once a day, and about half of those children rock in bed before going to sleep. About 5 percent of children exhibit other rhythmic behaviors, particularly head banging and head rolling; these behaviors are most likely to occur at night or at nap time. Head banging appears three times more often in boys than in girls, but body rocking and head rolling are equally common in both.

What Do These Behaviors Look Like?

A child who rocks in bed typically does so on all fours, although some prefer a sitting position (as do most children who rock during the day). Similarly, when the behavior includes head banging, the child usually gets on all fours and rocks back and forth, hitting his forehead or the top of his head on the headboard, wall, or other hard surface, or he sits up in bed and bangs the back of his head repeatedly on the hard surface. Sometimes a child will lie facedown and lift his head, or his head and chest, then drop them back into the pillow or mattress again and again. Less commonly, a child still in the crib may grasp the side rail and hit his head against it, or contort himself so he can rock, bang his head, suck his thumb, and hold on to a stuffed animal all at the same time. A child who head rolls usually lies on his back and moves his head rhythmically from side to side; he may also bang his head or body on the bed rail, wall, or side of the crib in the process.

Some children vocalize while they rock or bang. Usually they produce a loud, continuous humming or chanting sound that waxes and wanes in intensity and pitch in the same rhythm as the body movements:

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For parents who have to listen to these sounds, especially for long periods, it can be torture. The sound of a child’s head repeatedly banging into the wall or headboard can be similarly excruciating. The thud of a child dropping into his mattress or pillow is at least easier to listen to.

Is Head Banging Dangerous?

Although head banging looks dangerous, neurologically normal children do not hurt themselves seriously in the process (unless, perhaps, they have a disorder such as hemophilia that increases the likelihood of bleeding). Although foreheads do occasionally get bruised and, very rarely, there can be a small amount of external bleeding, the banging almost never leads to concussions, fractured skulls, or other head injuries. Any damage is mainly restricted to cribs, beds, and walls.

When Should You Be Concerned?

Rhythmic behaviors generally don’t reflect any underlying emotional difficulty or neurological illness, particularly if they follow the usual pattern, beginning before the age of eighteen months and mostly disappearing by age three or four. Most children with these habits are healthy, with no discernible physical or mental problems and no unusual tensions in their families. It is true that these behaviors occur more frequently in children with certain neurological or psychiatric disorders; in particular, children who are mentally retarded, blind, or autistic are more inclined than other children to rock their bodies or bang their heads (although they tend to do it during the day when they are fully awake). But for many other reasons, major disorders like these are usually quite apparent. So if your child is developing normally in other respects, there is no reason to worry about a significant problem simply because he has begun to engage in rhythmic behaviors.

If such behaviors begin, persist, or recur past age four, they deserve even more attention since in the school-age child such behaviors are more likely to require treatment. Bear in mind, however, that rhythmic behaviors present in the older child are still likely of little concern if they are short lasting and not particularly intense—perhaps brief periods of gentle head rolling or a few minutes of mild thumping into the pillow before sleep. These are probably merely habits the child has learned to associate with falling asleep and are not very important. Although habits of this sort in a school-age child may be slow to resolve completely, they do tend to become progressively briefer and less vigorous over time.

But regardless of your child’s age, you should be concerned if his rhythmic behaviors are intense, last longer than ten or fifteen minutes, or recur repeatedly during the night. In all these cases you should investigate further because such prominent behaviors may have causes that you can identify and should address, as discussed below.

What Causes Rhythmic Behaviors?

Although most of the behaviors described in this chapter can occur in young children as part of their normal development, there are a number of other possible causes to consider. Some of these causes will seem familiar, since they also underlie problems we’ve seen in other chapters, and they require similar treatment here, for the same reasons. For example, your child’s rocking may be a habit associated with falling asleep (as discussed in Chapter 4); his humming and thumping, if they get you to come into his room, may be his way of testing limits or dealing with anxiety (as described in Chapters 5 and 7); or his rocking or banging may be the way he fills up long periods awake caused by an inappropriate schedule (as explained in Chapter 11). Other causes, including neurological problems, familial predispositions, and inherent sleep disturbances, must be handled differently. Also, several causes may be at work in the same child.

Normal Development

Having little ability to keep themselves occupied, infants and young children derive pleasure in whatever ways they can. Children naturally respond to rhythmic stimuli, which is why they like to be rocked or listen to lullabies. The rhythms provide them with a feeling of pleasure and comfort, much like an adult tapping his foot to music. Early in life, infants derive pleasure from rhythmic sucking on a pacifier, thumb, or nipple; later they may find similar comfort in rhythmic rocking or head rolling. (It is less clear how head banging can be soothing, but some children do apparently find the loud rhythmical sounds of the impacts, or even the impacts themselves, comforting.) In the course of normal development, all of these behaviors generally go away as the child develops new abilities to think, listen, attend, and move.

The rhythmic behaviors typically begin very early in life, usually within the first year. On average, body rocking generally starts at around six months of age, head banging and head rolling at about nine months. But there is a wide range of variation. Head rolling and the beginnings of rocking can appear in children as young as a month or two; head banging—if it occurs at all—can begin as early as four months, almost always by the beginning of the second year. Often body rocking or head rolling starts first, and head banging begins weeks or months later. Humming usually does not start before age one.

The behaviors may last only a few weeks or months; they usually disappear within a year and a half of onset. It is uncommon to see them after a child reaches four years of age. Occasionally, rhythmic behaviors that start as normal developmental patterns persist as pre-sleep habits throughout childhood; even in adulthood, some people still roll one or both legs from side to side for a few minutes while falling asleep.

Head banging and rocking often begin at about the same time as teething; when they do, the behaviors—if they are short-lived—might be a response to the temporary discomfort. But too many sleep disorders in infants are ascribed to teething; in any case, it’s unlikely to be the cause of any behavior that persists for more than a few weeks. Temporary head banging or rocking may also appear (or reappear) when a child is facing an important developmental hurdle, such as learning to stand or take his first steps. Perhaps it helps him to release tension he feels during the day, or to return to sleep after waking from stressful dreams. We do not know for sure.

Inappropriate Sleep Schedules

While an inappropriate schedule alone cannot cause rhythmic behaviors, certain schedule problems can allow the behaviors to continue for long periods each night, to persist over months, and to progressively worsen, regardless of the underlying cause. Fixing the child’s schedule is often crucial to successful intervention.

A schedule that has a youngster in bed before he is ready to fall asleep and for more hours than he can sleep will increase the time available to him for rocking or banging, since most such behavior in bed takes place in wakefulness, drowsiness, or transitional light sleep and disappears once the child is sound asleep. As described in Chapter 11, this extra time awake (or drowsy with only brief periods of very light sleep) can appear at bedtime, during the night, or in the morning. As we have seen before (particularly in Chapters 5 and 11), there are a number of ways for a child to pass that time—mainly playing, talking, crying, or repeatedly calling out or leaving his room. Rhythmic activities are another way.

Worse, the more waking time a child has to repeatedly practice a rhythmic behavior, the more that behavior will be reinforced, and the more likely it will be to become a progressively demanding habit.

Habit

Habits that provide comfort and distract us from fantasies or worries are powerfully learned behaviors, and they can become partly automatic. Adults exhibit them much as children do: they tap their feet, stroke their face, or bounce their crossed legs while thinking or in conversation. You can stop those sorts of movements when you’re aware of them, but as soon as your attention drifts, as a child’s does when he becomes drowsy, the movements are likely to begin again.

At the same time, the more such movements are repeated, the more automatic they become and the harder it gets to suppress them. Eventually the child may feel uncomfortable if unable to do them, in the same way that the more a child uses a pacifier, the more he will come to feel uncomfortable without it. If the movements occur while a child is going to sleep, he begins to associate them with falling asleep—just as if he were being rocked to sleep (see Chapter 4), except he is his own rocker. And if a child is used to rocking or banging until he falls asleep at night, he is especially likely to start up again if he has long wakings in the middle of the night, picking up where he left off (though some children do rock or bang only at these wakings and not at bedtime). Eventually the behaviors may become so automatic that, like sucking motions, they continue through drowsiness into light sleep itself.

Emotional Needs

Rhythmic behaviors sometimes occur in response to anxiety. While they cannot overcome severe anxiety, they may help with less intense worries and concerns. We saw in Chapters 7 and 11 that even a child without any significant anxiety could end up scaring himself if his bedtime is too early and he is left alone with his thoughts for too long before he can fall asleep. A child with more anxiety will have still more difficulty tolerating time awake in bed. An older child or an adult can turn to a book or the radio, or to focused activities such as progressive relaxation or pacing, to distract himself until he is sufficiently sleepy. A young child usually turns to his parents for this purpose. But some children try to handle these feelings by themselves, rolling around restlessly or rhythmically. Rocking, banging, and humming require effort and focus and can thus also serve as distractions (all the more so if the behaviors are intense), and the resulting noise can be distracting as well. While a child is engaged in these actions, scary thoughts are less likely to intrude. However, again, with nightly repetition the behaviors may become increasingly habitual until the child begins to feel uncomfortable without them even when he is not anxious or frightened.

Rhythmic behavior can also be a stratagem to get attention from parents, even though there may be no significant underlying anxiety. It will be successful if parents do not limit their responses appropriately. A child who deliberately rocks, hums, or bangs noisily enough to get you to come in can argue truthfully that he is staying in bed and not calling out. If he is rocking or banging to get your attention and you respond by repeatedly going into his room or calling out to him to stop, you may be rewarding the behavior and thus inadvertently reinforcing it.

Jessica was an eight-year-old girl who had gone through a brief period of rocking in bed during her first year but stopped soon thereafter. Six months before her mother brought her to see me, she had begun “thumping”—lying in bed facedown, lifting her head, and letting it fall into her pillow—every night for thirty to sixty minutes before falling asleep. She was healthy and seemed happy enough, if a little withdrawn. But the previous year had been a time of great difficulty for her family. Her parents had separated and were working out the details of a divorce; Jessica and her mother had moved into a smaller apartment, and her mother had returned to work. I learned that Jessica believed she somehow had caused her parents’ separation and thought they might be angry with her over it. She was afraid of causing her mother more unhappiness and losing her love as a result. Apparently, Jessica’s head banging had recurred in response to these emotional struggles, perhaps to help her avoid unpleasant thoughts while she was going to sleep, or to get some extra needed attention. She did not actually need to thump her head to fall asleep: in fact, she stopped whenever someone came into her room, and if they stayed long enough, she fell asleep without any thumping at all. Later in this chapter I explain how our understanding of the cause of Jessica’s head banging allowed us to help her with this problem.

Neurodevelopmental Abnormalities

Children with neurodevelopmental delays, as are present in autism, retardation, and related conditions, often seem to get considerable pleasure out of rhythmic self-stimulation, even after the early years. That may be because, like a normal younger child or infant, their physical, sensory, or cognitive limitations prevent them from finding other ways to distract or comfort themselves; the basic drive that produces these behaviors may be no different from that seen in normal children in the early months and years of life. However, whereas otherwise normal youngsters who head bang do not do so to the point of pain and serious injury, some developmentally handicapped youngsters seem oblivious to pain caused by their intense behaviors, or even take pleasure in it. These children may need to be restrained or otherwise protected to keep them from injuring themselves.

Familial Predisposition

In some families, the tendency to engage in rhythmic behavior in bed is particularly common, occurring in many individuals over several generations. In this situation—one that occurs only infrequently—an inherited trait is evidently involved, but we don’t know what that trait is. (Just as musical aptitude is a trait that may be inherited, perhaps a similar genetic trait makes rhythmic behaviors particularly pleasurable or compelling.) The episodes in inherited cases are usually brief and not particularly intense, provided that the child’s sleep schedule is appropriate. They may be slow to resolve completely, if they ever do, although they do tend to become less intense over time.

Inherent Sleep Disturbance

Rhythmic behaviors rarely persist through drowsiness and light sleep into the deeper stages of sleep; but, occasionally they do, and in some children they occur only in those stages. A child who exhibits this variation will rock or bang in his sleep no matter what the circumstances—in his parents’ bed, at a grandparent’s or friend’s home, or at home with a sitter. If you go into your child’s room when he is rocking and find that he seems unaware of you even when you speak to him, then he is probably asleep; if he responds only after you speak loudly or shake him and then seems briefly confused, then he was certainly asleep. The child, even an older child who finds reports of the behaviors embarrassing, cannot suppress them.

This variant seems to be a truly automatic behavior of sleep, rather than just a habit. Although it might appear that a child whose deep sleep is interrupted by these movements would suffer the effects of sleep deprivation, in fact he does not; usually there are no apparent daytime consequences. This problem may be more difficult to treat than a simple habit associated only with drowsiness, and it may persist longer. Nevertheless, the behavior will likely become less intense over the years, with episodes becoming shorter and shifting to periods of lighter sleep or drowsiness. Eventually it will almost certainly disappear.

If your child bangs or rocks both when awake and when asleep, the wakeful part at least is treatable. But when this is done, you may find that the rhythmic behaviors in sleep decrease as well, since they may have been a result of the waking habits in the first place. Just as habits practiced repetitively can become so automatic that they persist into light sleep (as mentioned above), occasionally they also persist into deep sleep (where there isn’t even the slightest conscious awareness of doing them).

Treating the Problem

Once you have an appreciation of the causes and significance of rhythmic behavior in your child, you can decide what you should do about it. There are a number of choices to consider.

Decide If You Need to Do Anything

In an infant or young toddler, brief rhythmic behaviors that don’t annoy anyone or disrupt the household do not call for intervention. They will likely disappear before long. But (as suggested above), if your child’s rocking or head banging is more severe and lasts more than a few minutes, keeps you up at night or annoys you (or the neighbors), or damages the bed or crib, then you may want to see if these behaviors can be lessened, especially if your child is already of school age. More important, even if your child seems to enjoy the behavior, he shouldn’t have to work so hard just to fall asleep. If he didn’t need to bang, he might be able to fall asleep much faster; thus, the banging may leave him getting less sleep than he would get otherwise.

Adjust the Sleep Schedule

The best way to break any undesirable habits associated with getting to sleep is to have the child practice falling asleep without them, and that is easiest if his schedule is adjusted so that he will be too sleepy at bedtime and nighttime wakings to stay awake for more than a few minutes even if he wants to. If things go well, he will soon be rocking very little, if at all, at bedtime and when he wakes briefly during the night. Before long, he should start to feel comfortable in bed without rocking even when he is less sleepy.

Usually the best starting point is to cut back on the child’s excessive time in bed, just as you would for any other child who takes a long time to fall asleep or lies awake for long periods during the night (see Chapter 11). Add up the amount of time your child spends rocking at night and shorten his time in bed by at least that amount. Do the same for nap periods. If he rocks or bangs a great deal at bedtime, move his bedtime later, at least to the hour he usually stops banging and falls asleep. Don’t let his morning waking drift later to compensate. If he rocks or bangs in the middle of the night for more than a few minutes, you may have to move his bedtime even later, or move his morning waking earlier. If he rocks or bangs in the morning, get up with him as soon as he wakes and before he has had much time to rock or bang. Remember, the goal is to cut out the habitual patterns and get him used to being in bed and going to sleep without rocking or banging.

It may be necessary at first to reduce his time in bed to a period shorter than his actual sleep requirement to make him sleepy enough. Once things are going well and he has had a chance to practice going to sleep without rocking or banging, you can gradually extend his time in bed, as discussed in Chapter 11. Your goal is to reach a permanent schedule that allows him to fall asleep quickly, with little or no nighttime waking, rocking, or banging, spontaneous (or at least easy) morning wakings, and normal daytime functioning.

Address Your Child’s Emotional Needs

In school-age children, vigorous and long-lasting head banging or rocking could be a sign of emotional issues that require your help. As discussed in other chapters, and, of course, depending on the needs of your child, you may have to set consistent limits or provide other emotional support. You should certainly respond to your child’s appropriate needs for attention, but don’t let him demand it through head banging, or you will only reinforce the pattern. Once you have shortened his time in bed as described above, ignore any rocking or banging at night. Instead, spend extra time with him during the day; show him that you enjoy his company. The time before bed is especially important. Rather than waiting for him to demand attention, offer it in the form of an unhurried bedtime routine in his bedroom. It sometimes helps, too, if you offer to stay in a nearby room when you are done, checking in on him until he falls asleep (even if he is perfectly quiet at the time).

If anxiety is a major factor, as it was for Jessica, you will need to address it directly. If your child is concerned about fighting or illness in the family, or about a major issue such as an impending parental divorce, you will probably be aware of it. If you recognize that the behaviors began after the development of concerns or the occurrence of important family changes like these, try to discuss the situation with him openly and encourage him to express his anger or feelings of guilt. If his anxiety is relieved, his need to rock or bang will diminish. If he is too young for such complex discussions, be particularly attentive and loving so that he will know that his world is safe and caring and that he is not responsible for the problems. It is sometimes hard to provide all this support on your own. If your attempts to help meet with little success, or if you cannot determine the source of the problem or how to deal with it, then consider seeking guidance from a psychotherapist. But in the meantime, changing your child’s sleep schedule will still help by eliminating extra time he can spend worrying in bed.

Tackle the Behaviors Directly

There are a few things you can do to make your child’s rhythmic behaviors more difficult to carry out or less enjoyable to do, or to motivate him to stop. If your child is in a crib and rocks forcefully enough to shake the crib or even “walk” it across the floor, you may want to have him sleep on a mattress on the floor. Unfortunately, this approach is less effective with a child who bangs his head into the headboard; even if you set his mattress in the middle of a room, he will probably only crawl over to the wall and bang his head there, at least at bedtime. (On waking in the middle of the night, however, he may settle for rocking instead of banging.)

Some pediatricians recommend putting a loudly ticking clock or metronome in your child’s room. The metronome may be set to beat at the same tempo as the rocking or banging, on the theory that it will fulfill your child’s need for rhythmic stimulation, or you may chose a slightly different rate, just far enough from his typical rhythm to be difficult to match, and close enough to it to be confusing and disruptive if he tries to rock at his usual tempo. I have not had great success with this method, but it is certainly harmless, and you may want to try it.

You may also try to make it more rewarding for your child not to rock or bang by trying to make stopping the goal he is working toward. With a child aged three or older, a good way to do that is through a mutually negotiated sticker chart with prizes for success, like those mentioned in Chapters 5 and 7. To get this program off to a good start, begin with a later bedtime and a shorter night than usual, to help assure initial success.

During the day, meet your young child’s need for rhythmic stimulation by encouraging him to use swings or rocking horses, listen to music, or rock in a chair. With enough of this activity during the day, he may have less need for it at night.

Protection and Medication

Finally, children with autism and mental retardation—especially those with other significant neurological abnormalities—may vigorously bang their heads to the point of actually injuring themselves. Such a child may have to wear a helmet or be restrained, or his sleep surroundings may need to be provided with extra padding. Even for these children, shortening the amount of time they spend in bed can be helpful. Sometimes medication can help if nothing else is working, even though drug treatments for head banging are generally of little use in the normal child. Consult your physician if you think helmets, restraints, or medication might be called for.

Outcomes

How Jason and Jessica Were Helped

Even though Jason was only two years old and his head banging would probably have stopped on its own within a year or so, his episodes of banging were so long, intense, and frequent—up to two and a half hours in total some nights—that we felt it made sense to try to shorten them. I learned that Jason was going to bed at 7:00 P.M., waking at 7:00 A.M., and taking a two-hour nap—fourteen hours in all, two to three more hours than a typical two-year-old is able to sleep. We moved his bedtime to 9:00 P.M., moved his waking time to 6:00 A.M., and limited his nap to ninety minutes. Almost immediately, his head banging decreased markedly, to less than ten minutes at bedtime and ten minutes again once or twice during the night. Over the next few weeks the episodes became even shorter and the head banging became less intense. Some nights his parents heard only a few minutes of banging at bedtime. At that point they gradually lengthened his night to ten hours, 8:30 P.M., to 6:30 A.M., and set his nap back to two hours. Now that he was getting all the sleep he needed without being in bed any more than necessary, the head banging remained brief and occasional and never recurred as a significant problem.

As for Jessica, her mother sought counseling for both of them, at my suggestion, and the tension at home began to ease quickly. She and Jessica spent more time talking, and together they found it easier to discuss feelings related to the divorce. Jessica’s mother was surprised to discover how much Jessica had to say about her father’s leaving, and Jessica admitted that she felt responsible. She hadn’t spoken up before because her mother had always avoided the topic. Now that Jessica could express her feelings, her mother was able to correct her misconceptions and reassure her.

Jessica wanted to stop “thumping,” but breaking any long-standing habit can be very difficult. I recommended that her bedtime be moved temporarily half an hour later, and that together she and her mother should begin to keep a star chart in which she earned rewards for quiet nights. Working on the chart provided them with some special time together during the day, as Jessica added stars and they talked about her success. Jessica’s mother was careful to ignore any thumping at night—she did not call out to Jessica or go into her room—to avoid reinforcing it, and she made it a priority to spend extra time with Jessica during the day.

Now that Jessica and her mother were working together, their daytime relationship improved, and they both felt better. Jessica was proud of her success and worked on earning stars for her chart with real enthusiasm. Her thumping disappeared within four weeks, except for occasional brief episodes in the middle of the night which were of little concern.

Final Points

Rhythmic behaviors at night and at naps are not as strange as they may seem at first. The causes can usually be determined, and the behaviors generally do not imply worrisome underlying conditions. Most often, with understanding and proper planning, these behaviors can be satisfactorily reduced or eliminated using straightforward approaches.