Solve Your Child's Sleep Problems

Part II

The Sleepless Child

Chapter 4

Sleep Associations: A Key Problem

Many infants and toddlers are unable to settle themselves and fall asleep without their parents’ help at night. If your child has this problem, you might have to hold him, rock him, rub his back, or talk to him to get him to fall asleep. He might wake several times during the night, crying, calling out, or (if he sleeps in your bed) reaching for you, and each time you might have to repeat the whole process before he can go back to sleep. You’re tired and frustrated, and you’re probably angry at your child because your own sleep is so badly disrupted. That, in turn, may leave you feeling guilty: you want to do what’s best for your child, and if that means less sleep for you, then perhaps you must learn to accept it. Maybe you’ve been told that his behavior is a normal phase some children go through and that there’s nothing you can do but wait until he outgrows it. Still, you may wonder, “Is it really normal and do I really have to wait it out, and for how long?”

It’s true that this behavior is not abnormal, but neither is it something you have to put up with. You certainly don’t need to wait for it to change on its own: it’s almost always possible to identify the causes of these sleep disturbances and treat them successfully. If your child is not sleeping through the night by three or four months of age, when most full-term infants have “settled,” it may be time to start thinking about what could be causing the problem and, perhaps, to begin to correct it; if more than occasional wakings are still happening when your child reaches five or six months of age, you not only can but probably should take definite steps to address them. If you do nothing, his sleep will eventually improve on its own, but the process could take months or even years. If you can figure out why your child is sleeping poorly and make the necessary changes, he should be sleeping well much sooner—usually within a few days, two weeks at the most.

The root of the problem often lies in your child’s sleep associations. All children learn to connect certain conditions with falling asleep. For most children, that means being in a particular bedroom, lying in a particular crib or bed, and perhaps holding a favorite stuffed animal or a special blanket. When they wake periodically during the night, as all children do between sleep cycles, most will promptly fall back to sleep, because the conditions they associate with falling asleep are still present. But if the conditions have changed, such children may not be able to fall asleep again without help reestablishing them.

As you read this chapter, remember that not all children become dependent enough on particular conditions to cause trouble. If you always rock your child to sleep at night, say, but he sleeps through the night without needing your help to return to sleep after normal brief wakings, then there is no problem and you certainly shouldn’t feel compelled to stop rocking him at bedtime. If he does develop a problem associated with the rocking later, you can treat it then. (See “General Observations” later in this chapter for more discussion on how sleep associations can vary in different locations and at different times.) But if his bedtimes and nighttime wakings are longer and more troublesome, as with the children described in this chapter, you should make changes so he won’t have to deal with nightly surprises.

The same principles apply whether your child has his own bed or crib or sleeps in bed with you, although if you share a bed, you may find it a little harder to refuse to rub his back when he wakes, or to delay or refuse an unneeded nursing. Either way, he should generally go to sleep in the place where he will be spending the rest of the night.

A Typical Sleep Association Problem

Betsy was causing her parents much distress. Although she had started sleeping through the night at the age of three months, soon after that she had begun waking repeatedly during the night. When I saw her, now ten months old, she still fought being put into her crib, and she was still waking several times every night. In the evening, she would not fall asleep without her mother or father rocking her and rubbing her back for around twenty minutes. She seemed to be trying to stay awake, her parents told me: she would begin to doze off, then suddenly she would open her eyes and look around before starting to nod off again. Once she had been fast asleep for fifteen minutes her parents could move her into the crib, but any sooner and she would wake up and start crying again, and they would have to start over. It was difficult to tell when she was sleeping deeply enough to be moved. Sometimes her parents could get away with rubbing her back as she lay in the crib instead of rocking her, but again, if they stopped too soon, she would wake and cry.

Once Betsy was so deeply asleep that she could be placed or left in her crib without waking, she would stay asleep for several hours. Then, several times between midnight and 4:00 A.M., she would wake crying vigorously. She would not settle on her own, but she did not seem to be in pain; when her mother or father began to rock her, she would promptly quiet down and return to sleep. As at bedtime, she had to be deeply asleep before she could be returned to the crib, but at these times that rarely took longer than five minutes. From 4:00 A.M. to 6:00 A.M. she slept well, but she usually woke crying in the morning. She had two daily naps, one in the morning and one in the afternoon, and she had to be rocked to sleep for both, just as at bedtime.

Betsy’s parents had tried everything they could think of. A few times they had let her cry for fifteen or twenty minutes before rocking her to sleep, but it hadn’t helped. Once, at their doctor’s suggestion, they had tried to let her cry until she fell asleep on her own. But Betsy only cried harder and harder and showed no signs of settling down; after an hour and a half her parents decided they were being cruel and couldn’t bear it anymore, so they went in, comforted her, and rocked her to sleep as usual. Finally, they asked the doctor for medication. He prescribed an antihistamine, which Betsy took for a week. During that week she feel asleep a bit more quickly at bedtime, but nighttime wakings and nap time difficulties remained as troublesome as ever.

Problems like Betsy’s are extremely common, and they can be quite frustrating for parents. Yet, once you understand the nature of the problems, they are usually fairly easy to correct. What most parents do not realize is that in most cases the “abnormal” wakings at night are actually quite normal—children always wake from time to time at night, between sleep cycles. In fact, in their attempts to treat their child’s “abnormal” wakings by helping him go back to sleep, the parents are actually causing the disturbances, or at least reinforcing them.

The problem with Betsy was that she was used to falling asleep while being held and rocked and having her back rubbed. During her normal nighttime arousals, she found herself lying in her crib alone with none of these familiar conditions present. She could not simply go back to sleep by herself: she did not know how to. And by giving in and rocking her back to sleep, whether after fifteen minutes or ninety, her parents were unknowingly preventing her from learning how.

For a child like Betsy, normal nighttime arousals are prolonged because the conditions the child associates with falling asleep are no longer present. From the child’s point of view, something is wrong. Instead of going back to sleep, he wakes more fully and begins to cry. The wakings during the night are not the problem; rather, the problem is that the child cannot fall back asleep after these normal wakings, because of his particular associations with falling asleep.

Why Sleep Associations Matter

Sleep associations play a role in the sleep of adults as well as children, and it’s easiest to understand how they can become problems in children by considering the sleep associations we all have. As adults, we take for granted our own associations with falling asleep, but they are very important to us. We all learn to fall asleep under a certain set of conditions: on a certain side of the bed, with a hard or soft pillow, with a heavy or light blanket, or even while watching the news, listening to the radio, or reading. Some of us are more able than others to tolerate changes in our bedtime routines, but we are all affected to some extent.

Recall from Chapter 2 that we spend the first few hours of the night mostly in deep, nondreaming sleep (Stage IV, non-REM), and during the rest of the night we alternate between lighter sleep (Stage II) and dreaming (REM). (Unlike our children, we adults usually don’t sleep long enough to fit in another period of deep sleep near morning.) We all wake briefly from time to time, especially during the transitions between non-REM and REM sleep. During these arousals we change position and briefly check our environment to make sure everything is in order. Typically, we turn over, straighten the blanket, and reposition the pillow. If all is well, we return to sleep promptly, usually without remembering the waking in the morning. But if something feels wrong—if we hear strange noises or smell worrisome odors, for example—we wake more fully to investigate. There doesn’t need to be actual danger: if anything has changed from the way it was when we went to sleep, we may notice the change, feel that something isn’t right, and become fully alert.

Perhaps you’ve had the experience of waking during the night just enough to notice your pillow missing. Most likely, instead of going straight back to sleep, you wakened a little more, enough to find the pillow on the floor and pull it back into bed before returning to sleep. But if you couldn’t find it right away, you probably wouldn’t be able to ignore it and go back to sleep. Instead, you’d become more fully awake so you could look around for it. If you still couldn’t find it, eventually you might turn on the light, get out of bed, and begin searching the room. You might get angry and perhaps curse—showing the same kind of frustration that a child shows by crying.

Even if your pillow falls out of your bed once or twice every night, it will hardly disturb your sleep: retrieving the pillow from the floor doesn’t require you to wake up very much or for very long. But suppose that you are physically unable to get the pillow yourself, and you have to call someone else—perhaps a nurse—to come into the room to replace it whenever you wake up and find it missing. The nurse will soon learn that once you have your pillow back you’ll fall asleep quickly, but your frequent wakings during the night might still seem abnormal to him or her.

To stretch the analogy a bit further, suppose you discover that someone has been sneaking into your room each night and stealing your pillow. Once you know that, you might have trouble falling asleep at bedtime for fear that the pillow will be taken away as soon as you’re asleep. Whenever you catch yourself starting to drop off to sleep, you might wake yourself up again to make sure the pillow is still there.

Now imagine that this person, instead of just taking your pillow, actually moves you from your bed to another room, without waking you. Every night you go to sleep in your bed with everything just as you like it, only to wake after your first sleep cycle on, say, the floor of the living room. Unless you’re an exceptionally tolerant sleeper, you won’t even try to go back to sleep right there; you’ll get up and head back to your bedroom. But now suppose you find your bedroom door locked from the other side. Now there’s nothing you can do but wake someone who can unlock the door for you. Once that’s been done, you can at last get back into bed and get your pillow and blanket arranged properly, thereby reestablishing the conditions that were present at bedtime. Once you calm down, you will fall back asleep—but some ninety minutes later you’ll wake up again, back on the living room floor and again locked out of your bedroom.

If that happens throughout the night every night, you will not be sleeping at all well, and neither will the person who has to keep getting up to unlock your door. Soon you might be resisting sleep in hopes of identifying the person who keeps moving you; in other words, you might have trouble falling asleep even in your own bed because you know that you’ll be moved once you fall asleep. If that happened to you every night, you would not be very happy.

As you have probably recognized, this last scenario describes what actually happens to many children every night. They fall asleep in one place, maybe being held and rocked in the living room with the television and a small light on. But whenever they wake up they find themselves in a different place under different conditions, perhaps alone in their crib in a dark, quiet room, not being held and not being rocked. Someone has stealthily moved them. They cannot reestablish the conditions that were present when they fell asleep, so they must cry and yell until someone comes in and does it for them. They must be picked up, brought back to the rocker, maybe even taken back to the living room and the television; and no sooner are they asleep than someone moves them again. Soon, these children start resisting sleep, and each time they wake they find that the change happened anyway.

Wrong Sleep Associations

This is the situation Betsy was in. She could fall asleep fairly easily when rocked, and if the rocking could continue all night her sleep would be continuous as well (she would stir occasionally at her normal wakings, but she would fall back asleep quickly without crying). It was difficult to place Betsy in the crib without waking her until she was very deeply asleep, because she had learned to be constantly on guard against being moved. Once deeply asleep, she slept well until her first spontaneous waking, when, finding her surroundings “wrong,” she became frustrated and showed that frustration by crying until one of her parents came in and began rocking her, reestablishing the conditions that she associated with falling asleep.

In fact, the last thing Betsy remembered when she fell asleep at night was being held and rocked, and the first thing she noticed when she woke up was that everything had changed. She did not remember being moved to the crib—or being in the crib at all—and she did not remember being asleep. It was as if she had suddenly been transported out of her parent’s arms into her crib, her parent had suddenly disappeared from her room, and the rocking had suddenly stopped. She did not even have to open her eyes to find that out. And since she had learned that her parents did the same thing to her over and over, night after night, as soon as she started to arouse she forced herself to wake fully to check. Of course she became frustrated.

Betsy’s ability to fall asleep quickly in her parents’ arms proved that she had no actual sleep impairment: no inherent abnormality would allow a child to fall asleep quickly in a parent’s arms but not alone in her crib. Betsy’s inability to settle in her crib was due only to her inexperience falling asleep that way; that is, the sleep associations she had learned were different ones.

Most children will sleep well only if there are no surprises, no changes after they are asleep, and no need for them to check where they are and where their parents are every time they stir. In particular, there should be no sneaking about. Sneaking away from a child at night does not foster trust, and a sense of trust is important for good sleep.

Problems like Betsy’s occur most commonly in infants and toddlers because, unlike older children, they have little control over the conditions in which they sleep and are more likely to need your participation. However, similar problems can occur in older children as well. A child of four, five, or six may need to be moved to his own bed each night after falling asleep in the living room or in your bed. Or he can become dependent on other conditions for going to sleep: he may need you sitting in his room, or he may have to have music playing or the television on. When he wakes up, you may have to return and sit with him, lie down with him, or let him into your room; or he may have to turn on the light or the television before returning to sleep.

William’s difficulties were typical. He was a three-and-a-half-year-old who had always had trouble settling at bedtime and during the night. Six months before I saw him he had moved from a crib into a bed, and his bedtime rituals had changed: instead of rocking him to sleep, his parents would lie down with him for a while. He usually fell asleep fairly quickly, although if his parents tried to leave his bed too soon he would wake up. Once he was deeply asleep, they could quietly sneak away. William would sleep for three or four hours, then wake up and call for his parents. He sometimes complained about being scared or seeing monsters, but he never seemed truly frightened. If his parents didn’t answer his calls, he grew more demanding; sometimes he went to their room and refused to return to his bed. William’s parents, concerned about what they interpreted as nighttime anxiety, always took him back to his bed and lay down with him, knowing he would go back to sleep in five or ten minutes and then they could sneak away again. Usually he would wake up one or two more times and repeat the whole routine. But occasionally one of the parents fell asleep in William’s bed, and when that happened, William slept through the rest of the night without difficulty.

William’s problem, like Betsy’s, was not abnormal wakings but inappropriate associations: he could not fall asleep unless one of his parents was lying down with him. And that was a problem for William’s parents, because they wanted to sleep by themselves, in their own bed.

Not all problems with sleep associations involve a parent’s actions. Alexa was a sixteen-month-old girl who slept in bed with her parents. They liked having her there, but the situation presented some difficulties. Alexa went to sleep at 8:00 P.M., but only if her mother was in bed with her (her mother had to be there, but she didn’t have to do anything). Usually her mother could slip away once Alexa was asleep, but she would have to hurry back if Alexa wakened before her parents had come to bed for the night. Since they all shared one bed, that particular problem didn’t come up when Alexa woke later in the night. But Alexa also liked to fall asleep lying across the bed with her head resting on her mother and her feet against her father. Her mother found that position physically uncomfortable, and it usually kept her awake much of the night. If she tried to move Alexa, or if they tried to get Alexa to rest her head on her father instead, Alexa would cry. Alexa’s father, who also found this arrangement uncomfortable and was annoyed at being physically separated from his wife, often ended up sleeping in another room.

Still, Alexa’s parents liked keeping Alexa in their bed and didn’t want to move her to a separate room. Fortunately, Alexa’s disruptive patterns could be corrected without giving up co-sleeping. She just needed to learn to fall asleep lying in a normal position instead of across the bed, with her head on the mattress rather than on her mother, and without depending on either parent to be there with her.

Sam, age two, was another child who had always had trouble going to sleep and staying asleep. His parents took the path of least resistance, letting him fall asleep on the couch in the living room while they watched television. When they followed this routine, the bedtime struggles seemed to disappear. Sam could then be moved into his bed at his parents’ convenience, usually without waking him. However, he would wake up several hours later, call out, and point toward the living room. If his parents lay down with him or took him into their bed, he stayed awake, insistently repeating, “TV, TV!” He did not seem to be afraid, but he was demanding. Most nights his parents gave in, taking him back to the living room, placing him on the sofa, and putting on a video. He hardly seemed to care whether or not they stayed with him. Soon he would fall back asleep on the couch, where he would sleep through until morning.

Sam had certainly developed poor associations with falling asleep, even though they did not include any special need to be close to his parents. Furthermore, although he needed the lights and television on to go to sleep, the constant light, and the frequent speech and music changes, also stimulated him and tended to keep him awake. He would be better off learning to associate falling asleep with a dark, quiet environment.

Even children who always fall asleep under nonstimulating conditions—perhaps alone in their own beds in a dark, quiet room—can form associations that interfere with falling asleep. Jacob, for example, was an eight-month-old who always fell asleep with a pacifier in his mouth. He would get drowsy, start to fall asleep, and stop sucking. But when the sucking motions stopped, he would wake—just as Betsy did when her parents stopped rocking her too soon—and start sucking again. Usually that pattern repeated until he fell asleep deeply enough not to notice when he had stopped. But occasionally his pacifier would fall out of his mouth before he was completely asleep, and he would wake fully and cry until one of his parents replaced it. Whether he fell asleep quickly at bedtime or not, he would still wake three or four times later in the night, find his pacifier missing, and cry until it was replaced.

(Actually, Jacob’s parents learned to race into his room and replace the pacifier at the first sign that he was waking, because when they didn’t, he often got so upset that he couldn’t go back to sleep for a while even after the pacifier had been replaced. At one point, at a friend’s suggestion, they tried what I refer to as the “sprinkle technique”: they sprinkled ten pacifiers around the crib in hopes that Jacob would randomly find one of them whenever he started to wake. This approach, although creative, almost never works. By the time Jacob was awake enough to find and retrieve one of the pacifiers, it was too late for him to slip quickly and easily back into the next sleep cycle.)

Kaitlyn was very similar to Jacob: at eighteen months of age she still fell asleep at bedtime sucking on a bottle. She, too, woke several times each night, but she always went back to sleep after she was given another bottle. Since her parents could simply hand her a bottle and leave the room, the problem was not an expectation that her parents be in the room or holding her. That she didn’t need to be held during the feedings made it clear that her association was only with the bottle. That she drank only an ounce or two each time made it clear that her middle-of-the-night association with the bottle was only as a pacifier, not as a source of food. She certainly was not being fed excessively, as discussed in Chapter 6.

What Jacob and Kaitlyn had in common was that, although they both fell asleep alone in their own beds, they were still dependent on conditions that they could not reestablish by themselves (unlike a child who depends only on sucking his thumb, say). Someone else had to get up, come in, and replace the pacifier or bottle.

How to Solve the Problem:
The Progressive-Waiting Approach

The goal of this approach is to help your child learn a new and more appropriate set of associations with falling asleep so that when he wakes in the middle of the night he will find himself still in the same conditions that were present at bedtime, conditions that he already is used to falling asleep under. But, to do this, you must first identify the pattern of associations that is currently interfering with his sleep (and yours) and which he must unlearn. Almost anything can become associated with falling asleep. Feeding, sucking on something, and being rocked to sleep or given a back rub are common examples; others include being patted, walked, or driven around in a car (or even just being in a car seat); lullabies; videos; music; and fans or white-noise generators. Even simple tuck-ins and good-night kisses can become a poblem if they need to be carried out repeatedly at bedtime and again during the night. Fortunately, it doesn’t take most children very long to learn to give up old habits and take on new and better ones.

If you have a child like Betsy who is still in a crib, treatment of improper sleep associations is fairly simple and the improvement will be quite rapid. However, the problems can be solved regardless of the sleep setting. Programs for treatment are described below. Variations for children no longer in a crib will also be explained.

As you help your child learn a new set of sleep associations, you will need to be understanding, patient, and consistent until he adapts. Since you will be changing some familiar patterns, at first you will not always be doing what your child wants. Anytime you have to say no to a child, there will probably be protests and there may be some crying, but you can keep them to a minimum. A young child’s sleep will show marked improvement, usually within a few days to a week.

Think again about having to sleep without your pillow. If you had to start sleeping without it regularly, for health reasons perhaps, you would probably find it difficult at first. You would be uncomfortable at bedtime; you’d thrash around, searching for a satisfactory position. You might be angry at your doctor, even if you understood why it was important to make the change. Even after you finally fell asleep, you would still find it hard to return to sleep after nighttime arousals for a while. The only way you could learn to fall asleep easily without your pillow would be by actually doing it—over and over. If you kept going to sleep with the pillow and had someone sneak it out from under you after you were asleep, you would never get used to the change. But if you persisted in trying to get to sleep without the pillow, each time it would be easier, until at last it would begin to feel normal and familiar. At this point your nighttime wakings would also cease to be a problem. So it is with the children I treat.

The program I used with Betsy and her family usually works well. Together we first identified the troublesome sleep associations that Betsy needed to unlearn—namely, being rocked by her parents at bedtime and after nighttime wakings. Then we decided upon the new associations that Betsy’s parents felt she needed to learn to replace them—namely, being alone and in her own crib; that is, Betsy had to learn to fall asleep at bedtime under the same conditions that would be present when she woke spontaneously during the night.

I used a “progressive-waiting” approach, which is very effective and which I will explain in detail here. The chart (Figure 4) will help you to understand this method.

Once Betsy’s parents understood her problem, we were ready to begin treatment. Each night, at bedtime and after nighttime wakings, Betsy’s parents were to make sure that she fell asleep alone, without them in her room. They would allow her to cry for gradually longer periods before briefly returning to her, but they would always leave while she was still awake. They would repeat this process until she finally fell asleep. Each night they would begin with a longer waiting period than they’d started with the night before.

FIGURE 4. HELPING YOUR CHILD LEARN TO FALL ASLEEP WITH THE PROPER ASSOCIATIONS: THE PROGRESSIVE-WAITING APPROACHM

NUMBER OF MINUTES TO WAIT BEFORE RESPONDING TO YOUR CHILD

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For simplicity, most of the following instructions assume your child sleeps in a crib or bed in his own room. However, variations of the same program are also described in case your child sleeps in your bed, or in his own bed or crib in your room (see below).

1.   Pick a starting bedtime no earlier than the time your child usually falls asleep, even if that is later than his usual bedtime. In fact, you may find that making bedtime even thirty to sixty minutes later than usual for the first several nights will help him fall asleep more quickly and speed up the learning process. However, his morning waking should not be moved later, and his naps should be kept to their normal length.

2.   Put your child into the crib or bed awake, in the place you want him to be sleeping for the night. Let him fall asleep under the same circumstances that will be present when he wakes normally during the night (in his crib or bed, not being held or rocked). Let him fall back asleep the same way after nighttime wakings.

3.   If he cries or calls for you at bedtime or upon waking at night, check him briefly at increasing intervals. This chart suggests the number of minutes to wait before going in to him. (Most families find the waiting intervals shown on the chart to be workable. If the intervals seem too long for you, start with intervals you feel you can manage—for instance, one, three, and five minutes the first day. Any schedule will work, as long as the waiting periods increase progressively, and as long as you continue the process long enough for your child to get practice falling asleep under the desired conditions.)

4.   When you reach the maximum number of minutes to wait for a particular night, continue to leave the room for the same interval—no longer—until your child finally falls asleep while you are out of the room.

5.   By the third or fourth day your child will most likely be sleeping very well. If further work is still necessary after that, continue following the chart down to day 7; if at that point the problem is improving but is still not fully resolved, continue to add a few minutes to each interval on successive days. But if things are not improving or are getting worse, you may have to rethink your approach (see “If Things Are Not Getting Better” later in this chapter).

6.   Each time you go to your child, spend no more than one or two minutes with him. Remember, your job is to reassure him (and yourself), not necessarily to help him stop crying, and certainly not to help him fall asleep: the goal is for him to learn to fall asleep on his own. (Even if he does start to calm down when you are in the room, the crying will probably intensify when you leave again.) You may replace a fallen or lost blanket or doll, but if he throws them out of the crib or bed, you should not replace them again until the next time you come in.

7.   If your child wakes during the night, restart the schedule with the minimum waiting time for that night and work up to the maximum again from there.

8.   Continue this routine after each waking until a time in the morning (usually 5:00 A.M. to 6:00 A.M.) after which it is unlikely that your child will fall back asleep, even if it is earlier than he has usually been waking. If he wakes at that time or later, or if he is still awake then after waking earlier, get him up and begin the morning routine. Do not let him go right back to sleep in another room—the entire night’s sleep should be in one place. If he is still asleep at his usual waking time in the morning, wake him up then even if he was awake part of the night.

9.   If your child sleeps in a bed in his own room but will not stay there, put a gate on his doorway (effectively making his entire room a crib) and return to the gate at the increasing intervals, as above. It is not a problem if he falls asleep on the floor for a few nights. If a single gate is not sufficient, you may need to use two gates or temporarily close the door as described for limit-setting problems in Chapter 5.

10. If your child sleeps in a crib in your room, you should put him into the crib at bedtime and then either speak to him briefly at the scheduled intervals from your bed, or—if your presence in the room is too stimulating, or if you prefer it—leave the room and come back in to check him at those intervals, as you would if he were in his own bedroom. (If he learns to fall asleep with you out of the room, you will have more freedom in the evening. You can accomplish the same thing even if you stay in the room as long as he doesn’t know you’re there—for example, if he can’t see you from his crib, or if it is fairly dark and you are quiet.) When he wakes at night, do the same.

11. If your child sleeps in his own bed in your room, use the same approach unless he refuses to stay in his bed and either follows you out of the room or tries to get into your bed. In either of these cases you will need a gate at your doorway (as described in Chapter 5). Leave the room and close the gate behind you for progressively longer intervals until he stays in his own bed.

12. If your child sleeps in your bed, you may be able to lie still and withhold your responses to him for the appropriate intervals. If that isn’t possible, you may have to get out of bed and check from a chair in the room. You may even have to leave and check from outside the room, and as above, a gate may be helpful in that case.

13. Use the same waiting schedule for naps, but if your child has not fallen asleep after half an hour, or if he is awake again and calling or crying vigorously after even a short period of sleep, end that nap time. He may fall asleep on his own later in another room, which is fine, at least initially, as long as he does it by himself, without the associations you are trying to break. However, the amount of time he spends napping should not be allowed to increase—that is, he should not be making up in the daytime any sleep he lost the night before. Also, don’t allow naps to run so late (past 4:00 P.M., perhaps) that they will interfere with falling asleep at night.

14. Be sure to follow your schedule carefully, and chart your child’s sleep patterns daily (Figure 5,) so you can monitor his progress accurately.

15. Additional information on enforcing desired sleep habits when your child sleeps in your room is discussed below (“Co-sleeping and Related Considerations”) and in Chapter 5 (“Setting Limits When Your Child Shares Your Bedroom”).

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FIGURE 5. SLEEP CHART FOR PARENTS TO USE

I asked them how long they felt they could listen to Betsy cry before feeling they had to do something. Although they thought they could probably tolerate up to fifteen minutes of crying, we decided to begin with three. I find that three to five minutes is usually a good starting point, but, as noted in Figure 4, if that seems too long you can even start with one minute.

On the first night of the treatment program, we agreed, Betsy’s parents would get her ready for bed half an hour later than usual, play quietly and talk with her for a little while, then put her in her crib awake, without rocking her or rubbing her back. Then they would leave the room, returning after three minutes if she was still crying vigorously, to reassure her that they were still there to care for her (and also to reassure themselves that Betsy was all right despite the crying). They would stay in the room for one or two minutes, but they would not pick her up or begin rocking her: they were not there to help her fall asleep. It was crucial that she fall asleep by herself, in the crib with her parents out of the room. Her parents agreed that they would speak to her briefly and replace her blanket if necessary, but then they would leave again, whether or not she was still crying and even if she cried harder when they left.

If Betsy continued to cry for five more minutes, her parents would return to reassure her briefly in the same way. If she was still crying ten minutes after that, they would return again. Ten minutes was the maximum wait for the first night: after that point they would return to Betsy every ten minutes as long as she continued crying, until she finally fell asleep while they were out of her room. At any point, if she stopped crying or subsided to mild whimpering between checks, they were not to go back in: the one thing they did not want to do was to interrupt Betsy as she was starting to learn how to fall asleep on her own.

If later in the night Betsy woke up and began crying hard again, they would restart the same pattern as at bedtime, waiting for three minutes, then five minutes, and working back up to ten minutes. They would continue this program over the rest of the night until an hour before her usual waking time: since Betsy usually woke at 7:00 A.M., that meant that if Betsy woke after 6:00 A.M., they were to get her up for the morning (by that time she was unlikely to get any more sleep no matter what). If Betsy was still asleep at 7:00 A.M., they would get her up no matter how much she’d been awake during the night.

At nap times, Betsy’s parents would use the same routine. But if after half an hour Betsy had either cried the whole time or had fallen asleep and wakened again, they would end that nap period. If she fell asleep later on the floor or in the playpen, that would be all right. The important thing was that she was falling asleep alone, without being rocked. As long as she had to spend time in her crib every day, she would eventually start to nap there once she had begun to associate that environment with falling asleep.

On the second day of the program, Betsy’s parents were to start with a five-minute wait and work up to a maximum wait of twelve minutes. Each night after that the waiting times would become a little longer, as shown in Figure 4.

I told them to expect the first night or two to be difficult—though only rarely will a child cry for several hours—but by the third or fourth night things should be going fairly well. I also told them that if things were not improving markedly over the first few days, or at any time that they decided that the amount of crying was more than they were willing or able to accept, that we would consider shifting to an even more gradual multistep approach (as described in the next section).

Her parents braced themselves for the worst and found that things went much better than they had expected. The first night was difficult, but Betsy did fall asleep during the third ten-minute episode of crying. She woke three times during the night, but each time she went back to sleep more rapidly. On the second night, Betsy fell asleep at bedtime after only one visit, and when she woke during the night she fell back asleep on her own so quickly that no checking was needed. On the third night, Betsy fell asleep on her own before even the first visit, and again she went back to sleep quickly on her own when she woke during the night. By the end of the first week, hardly any nighttime wakings were still apparent. Over the months that followed, her sleep remained excellent. Her naps improved just as quickly: there were difficulties the first two days—during her first nap time on the first day, she did not sleep at all—but by the third day she was doing fine (see Figure 6).

Betsy’s response was typical. Her parents also reported that as Betsy found it easier to fall asleep on her own at bedtime, they heard shorter and shorter episodes of whimpering when she woke during the night before returning to sleep on her own. Within a week she did not cry at all during these wakings. Of course, she continued to wake periodically during the night, as all people do, but she returned to sleep so rapidly and uneventfully that to be aware of these wakings one would have had to observe her closely all night.

For Jacob and Kaitlyn, who needed a pacifier or a bottle used as a pacifier to fall asleep, we used a routine similar to the one we used with Betsy: the parents would check on them at gradually increasing intervals, without giving Kaitlyn a bottle or replacing Jacob’s pacifier. In each case, I recommended that the parents not stay with their child while he or she learned to fall asleep without the bottle or pacifier, since that would only produce new associations that would then have to be broken, too. Like most children who already know how to fall asleep in bed alone, Jacob and Kaitlyn needed only a few opportunities to practice falling asleep without the bottle or pacifier.

Because the parents were permitted to go in to see their children while they were crying or calling, rather than leaving them alone all night, they could see that although they were unhappy they were otherwise fine. This gradual approach is better for your child, and easier on you, than going “cold turkey.” Such a drastic approach—putting your child in the crib at bedtime, shutting the door, letting him cry, and not returning until morning—would probably work eventually if you never gave in, but it is far from ideal. It would be unnecessarily painful for you and difficult for your child, and you would surely be tempted to quit. If, like Betsy, your child has always fallen asleep in your arms, and if you have always gone to him quickly when he wakes, then to stop this behavior all at once would mean going directly from one extreme to the other. Such an abrupt change would be very confusing to your child. He has learned to expect your prompt appearance when he cries. What is he to think if you don’t come in? Where are you? Will you ever come back?

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FIGURE 6. BETSY’S SLEEP CHART

When parents say to me, “If you’re going to suggest I let my baby cry, forget it; we already tried that and it didn’t work,” often what they really tried is this cold-turkey approach. If you’ve tried that technique, you likely found—quite understandably—that you couldn’t stand to listen to your child cry alone in a room for an hour or more night after night without being able to check on him. Although a child under one year old can sometimes make the transition under these conditions with only a little crying, even on the first night, an older child is more likely to cry constantly or intermittently for hours for a night or two. The longer your child cries, the more likely you are to give up and go in to console him, reinforcing the very habits you are trying to break. It is easier to maintain your resolve, and easier for your child, if you can periodically look in and check on him. Remember, as I told Betsy’s parents, if even that proves to be too much for you or your child, you can switch to a more gradual approach (see below).

You may also have misunderstood the thinking behind a cold-turkey approach. Parents are sometimes told that they’re “spoiling” their child by not letting him cry, implying that the crying itself should lead to better sleep. That is untrue: better sleep comes only when your child learns to fall asleep and return to sleep without your intervention, and that happens only when he gets practice at it. Crying does not help children develop appropriate sleep associations; for that reason, as well as out of compassion, we should try to keep crying to a minimum. When parents tell me they have tried helping their child by “letting him cry for several nights,” usually that’s exactly what they did: they let him cry, but they did not let him fall asleep on his own. They may have let him cry for a few minutes or for an hour or more, at bedtime or nighttime wakings or both, but in the end they always went in eventually to do whatever was necessary to help him go to sleep. In effect, then, all that crying was for nothing; their child only learned that he must cry longer to get what he wants. It is not practice in crying but practice in falling asleep under new conditions that a child needs to learn. If you are going to rock your baby to sleep in the end, you would do better to rock him at once and skip the crying altogether.

The gradual approach accomplishes the same goal in a much more compassionate way. Your child has to learn some new rules, but he will not understand them at first. He should know that you are still nearby and taking care of him, and he can learn that only through experience. If you abruptly began staying out of his room all night, he would still learn that you always come back eventually and that you aren’t abandoning him, but the lesson would be unnecessarily harsh. By waiting only a short time before going in to check him, you put him through much less uncertainty. He will begin to see after only a few wakings that you are still around and responsive to him. He may be angry that you are not rocking him, but since you keep returning, he will not be frightened by your apparent disappearance. As you increase the waiting times, he’ll learn to anticipate that as well. Eventually he will simply find it preferable to go back to sleep than to cry for fifteen or twenty minutes knowing he won’t be rewarded with rocking, holding, or nursing. At the same time, he is learning to fall asleep, and feel comfortable, alone in the crib or bed.

Making the Changes in One Step or Several

Habits associated with falling asleep can be changed all at once (as we did with Betsy, Jacob, and Kaitlyn) or little by little. Several different associations, such as back rubbing and pacifier use, can be changed at the same time or consecutively. Even a single habit, such as being rocked, can be broken into components, and then the components can be addressed one at a time—first eliminating the actual rocking motions, then being held, then having the parent in the room at all, for instance. Similarly, nighttime feedings can be tapered gradually rather than stopped suddenly (see Chapter 6).

Most families choose to correct their children’s sleep associations in a single step. However, you can choose to teach your child new associations in two steps or even more if you think it will be better or easier for you or for him. But bear in mind that at each stage you will have to start the learning process over again. How long that takes depends on how many steps are involved. It might sound easier for your child to learn new sleep habits in a few small steps rather than in one big one, but that is only occasionally the case.

Children are very quick learners. A child who has always fallen asleep one way can learn to fall asleep a new way after just a few nights’ practice. (It’s their slower-learning parents who may take a month or more to master new sleep habits.) That is both good news and bad news: sleep problems can develop over just a few days, but they can be solved just as quickly. Even if your nine-month-old has been sleeping fine on his own for months, if he gets an ear infection that keeps you up with him for a few nights, afterward he may suddenly have trouble getting to sleep, or back to sleep, without being held. (Events like this probably account for the increase in nighttime difficulties that many children experience in their second six months of life.) On the other hand, even if you have been rocking your nine-month-old to sleep all his life, he can learn to fall asleep without rocking in the same few days.

Because children learn so quickly, it often doesn’t matter how many changes they have to master at once, so it can be better to go through the process just once and be finished with it as quickly as possible. However, in certain situations it makes more sense to solve the problem one step at a time. Thus, for a child who always gets very anxious when apart from his parents, or a child first learning to sleep in a room by himself, you might chose to work on certain of your child’s habits first, such as dependence on a pacifier or being rocked or sleeping in a new bed or room, and leave the separation problem for last. (Techniques for managing the anxious child are further discussed in Chapter 7.) However, if your child is not reassured by your presence in the room—for instance, if he only gets angry at you for being there but refusing to pick him up—then leaving the room from the start may actually make the change in sleep habits easier. If you are unsure whether to try a one-step or multistep approach, you can start with either one and, if it isn’t working well, switch to the other.

Similarly, while spacing out nighttime feedings in an effort to reduce or eliminate them, as discussed in Chapter 6, many parents initially prefer to respond to their child whenever he calls and in whatever way will comfort him (other than feedings). In one or two weeks, after the nighttime feedings have been phased out, the parents can change the child’s other associations as a second step.

Finally, children with special needs may require changes to be made in very small steps with very gradual changes, sometimes for the parents’ sake as much as the child’s. It is very hard to refrain from responding to a child who is blind or has cancer, and a child with major neurological abnormalities may simply be unable to master the changes except in small steps, with long learning periods at each step. In some cases all the desired changes may not be possible.

Associations to the Breast,
Bottle, or Pacifier

It is not necessary to wean your child in order to break the association of nursing with falling asleep. Nor, probably, will you have to give up the bedtime feeding, which is usually the last feeding to be phased out, anyway. You may try to eliminate nursing during the night (as described in Chapter 6) while still allowing your child to feed at bedtime, even if he falls asleep at the breast or with a bottle. If you are trying that approach, continue the bedtime feeding as usual, completing the feeding and then moving the baby to the crib. You don’t have to wait until he is deeply asleep to move him; in fact, it’s better if he knows he is being moved so there will be no surprises when he wakes up. If he is still awake or wakes during the transfer, respond to his cries at progressively longer intervals, as usual, until he does fall asleep. Since you have already fed him, you should not bring him back to the breast then or try to restart bottle feeding.

But if you find that your child has trouble giving up feedings during the night as long as he continues to fall asleep while feeding at bedtime, then you should consider separating the last feeding of the day from bedtime. Move the feeding a little earlier in the evening; if your child starts to fall asleep, stop the feeding, wake the child enough that he will be aware he’s being moved, and put him in his crib or bed to continue falling asleep. You may need to do the same at nap times. Many parents choose to take this step even before they know whether it will be necessary, since it makes the bedtime process go more quickly and easily and frees a nursing mother from being the only one who can put the child to bed.

If your child is consuming large amounts of liquid at night, his sleep may be disturbed for reasons other than sleep associations (such as hunger signals, altered body rhythms, and increased wetting, as discussed in Chapter 6). But a sudden end to nursing at night would be hard on both you and your child; it’s better to gradually reduce the number and frequency of feedings. (How to solve problems caused by these excessive feedings is also discussed in Chapter 6.)

If your child uses a pacifier only when going to sleep, then once he has learned how to fall asleep without it, he will no longer use it at all. But if he has a pacifier in his mouth most of the day, it will be harder to stop its use at night. In that case, I suggest that you first work to cut down on his use of the pacifier during the day. Decide on certain periods in the morning and afternoon when you will not let him use the pacifier; then increase the length of those periods gradually day by day. During those times, give him extra attention and divert him so that he will have an easier time getting used to the pacifier’s absence. You may have to listen to some protests as he learns to feel comfortable without the pacifier during the day, just as you may when he learns to give it up at night. Once he is using the pacifier mainly at sleeping and resting times, you can eliminate it and begin a progressive program like the one we used for Jacob. By now he will be quite used to being without the pacifier and will only have to learn to fall asleep without it.

Stopping the pacifier at night is easier than most people realize, particularly for a child between four months and twelve months old. It isn’t that hard to stop later, either, but the older the child, the harder it seems to be (because he can protest more verbally and stay awake longer). There is no good way to eliminate nighttime use of the pacifier gradually; limiting the minutes it can be used during the night is too frustrating and confusing to work. This part you must do “cold turkey.” But even if your child has the pacifier with him all night, he probably doesn’t suck on it more than ten or twenty minutes total, since most sucking takes place in short intervals as he is going to sleep. Often, falling asleep just once or twice without the pacifier is enough for a child to master sleeping without it. If he is very sleepy at bedtime, the learning will be even easier, so starting with a later-than-usual bedtime the first two nights will help. Sleeping without the pacifier should certainly be routine after one or two days.

The 2005 recommendation of the American Academy of Pediatrics to let babies fall asleep with a pacifier in their mouth to decrease the risk of SIDS and related conditions—possibly by disrupting sleep and causing more wakings—was discussed in Chapter 3. Still, if this guideline is strictly followed, and dropped pacifiers are never replaced to aid return to sleep later in the night, the child likely will learn to sleep both ways (especially if pacifier use during the day is limited). If the baby continues to have difficulty falling back asleep without it at five to six months—when the likelihood of SIDS has become small—then stopping the pacifier even at times of falling asleep would pose little risk, even if these recommendations prove to be well grounded.

Co-sleeping and Related Considerations

Proponents of co-sleeping often suggest that you can avoid the problems discussed in this chapter simply by having your child sleep in bed with you. It is true that sleeping together does avoid some problems. Parent-child separation is not an issue, at least if you are prepared to be in the bedroom as soon as your child goes to bed. If it is physical closeness with you that he wants and expects, then being in bed with you should make him happy and able to sleep. But inappropriate or undesirable habits and associations can develop wherever the child is sleeping. That he is in your bed does not mean that he won’t expect to have his back rubbed or be fed or nursed repeatedly; he may still need a pacifier replaced, or you may still have to rock him each time he wakes. If he just needs a few pats on his back during the night it may not be difficult for you, but if he needs long periods of patting at bedtime and again several times during the night, you have a problem. If you have to move to the rocking chair to get him back to sleep every time he wakes up, he may just as well be in his own room, except that you don’t have to walk as far. Finally, if your child uses you as a soothing object, instead of an appropriate transitional object for that purpose (as discussed in Chapter 3), the situation may be even worse. If you are a nursing mother, he might use your breast as a pacifier every time he stirs, easily ten times or more during the night. Or, like Alexa, he may insist on falling asleep in a way that he likes but that is uncomfortable for you, such as on top of you or sideways in the bed, or he may demand to stroke your face while he sucks his fingers or nurses.

If your child sleeps in a crib in your room, the basic situation is mostly the same as if the crib were in his own room. However, the reassurance of simply being able to see you immediately whenever he wakes may not be enough to let him fall back to sleep quickly. Instead, seeing you may be a temptation that is difficult to ignore and that may actually make it harder for him to get back to sleep without your help (in the same way that a child may have a harder time being with a sitter when he can hear his mother’s voice in the next room than once she’s left completely). Bringing him into your bed at these times will allow you to get back to sleep as fast as possible, and that’s fine if you’re happy with those sleeping arrangements; but if you’re not, then you may still need to make changes.

Even if your child sleeps in your room or bed, his sleep association problems can be solved. If he is in a crib in your bedroom, treat the sleep problems exactly as if the crib were elsewhere: put him down at bedtime, leave the room, and return for brief visits at increasing intervals. He will learn to fall asleep in the room alone and without rocking or patting, allowing you more freedom in the evening. If he wakes at night, you can try lying quietly in bed, responding to him at timed intervals as before. (You can do the same at bedtime if you don’t mind always having to be in the room when he falls asleep.) But if your presence is too stimulating, you may have to leave and make your visits from outside the room. Once he gets used to falling asleep without your intervention, you should be able to stay in the room. Some parents prefer to sleep in another room for a few nights, until the child has mastered the new patterns. You may also be able to make a “room within a room” with an accordion-style room divider or by hanging a sheet or blanket from the ceiling—if your child cannot see you in bed, you can limit your responses to him without having to leave the room yourself. The inside of the divider could be decorated for him.

If your child sleeps in your bed, or if you stay in his while he falls asleep, undesirable habits can still be dealt with as discussed below and in Chapters 5 and 6. If your child sleeps in your bed, then it is easiest if there are two parents working together to solve the problems, although a single parent can do it all if necessary. There is no need to let your child use your body in a way you find unpleasant, and there is no need to rock, pat, or walk him during the night, either. You must simply refuse to go along with these demands and let him fall asleep anyway. If he uses you but not the other parent as an object for soothing himself, turn away or move to a chair until he returns to sleep. If he is big enough to pull at you or follow you out of the bed, you may have to leave the room and temporarily close the door or gate. (You can even sleep in another room for up to a week until the problem is resolved. The other parent can usually stay in the room.) Come back at increasing intervals, and each time you return, get back in bed and stay as long as your child does not make the objectionable demands. If he does, leave again for a longer time. The choice you present to your child should be “me on my terms or nothing,” where the terms are those you have decided are best for his—and your—sleep. Your child should find this an easy decision.

Alexa’s parents used this method to deal with her preference for sleeping positions that interfered with their own sleep. Her mother left the bed every time Alexa tried to lie on her; each time she left for a longer period, while Alexa and her father stayed in bed. Whenever Alexa tried to turn sideways and force her parents apart, her parents placed her on a blanket on the floor, again for a longer period each time. The positions she favored were no longer associated with anything pleasant. Soon both behaviors stopped.

Even if your child does not co-sleep with you in your bedroom, he still may be used to having you come into his room, at bedtime and after nighttime wakings, and lie with him until he falls asleep. You can break that association as well. If your child is old enough to understand, explain to him that you can no longer lie down with him while he falls asleep. Make sure you have an appropriate and pleasant bedtime ritual (see Chapter 3). When you finish your story, game, or quiet talk, tuck your child in and leave the room, but leave the door open. Some children will call out or cry; others will get out of bed. If your child only calls out, he can be handled in the usual manner by progressively increasing the interval between your responses. You can go back into the room when it’s time to respond, but do not lie down with him, and always make sure you are out of the room when he falls asleep.

But if your child will not stay in his room when you leave, then you need to use a boundary of some sort, such as a gate or the door, as discussed earlier and in Chapter 5. If he is old enough, usually three or three and a half, you may want to try a reward system to help speed the initial phase of relearning. If the rewards are especially successful, you may not even need a boundary. Otherwise, you can still use them along with a boundary and appropriate limit setting. You can set up a chart like the one described in Chapters 5 and 7, letting him earn stars or stickers and occasional small prizes for going to sleep without getting out of bed. The chart will help motivate him to try to fall asleep without having you there, and he will feel that you are working together to solve the problem. When the novelty of the rewards wears off, he may begin to make more demands at bedtime again. If that happens, be especially careful not to give in, or the old problems may reappear. Since he has already learned to fall asleep on his own, it is no longer a matter of teaching him how to do it, but simply of enforcing the rules. Be firm, and use a boundary at the doorway if necessary: the good sleep patterns will return quickly.

Because William, the three-year-old who needed his parents in bed with him, and Sam, the two-year-old who fell asleep on the sofa with the television on, were old enough to get out of bed on their own, the progressive-waiting approach had to be applied using the option of a boundary. William’s parents put up a gate to help keep him safely in his room. He put up major struggles over the first few days. His parents got little sleep and began to wonder if the plan would work. But they persevered, and by the middle of the first week William was beginning to sleep much better. By the end of the week, he was protesting only mildly when his parents left the room, and before long he was sleeping continuously through the night.

Although Sam did not need his parents present when he fell asleep (he only needed the television), the need to learn to fall asleep alone in his bedroom was similar to William’s—and so was the treatment. Unfortunately for Sam, however, his existing associations with falling asleep did not even include his own bedroom. He had no formal bedtime ritual at all, and when he awakened in the night, he could re-create the conditions he associated with falling asleep only by going to the living room and playing while the television was on.

His parents instituted a pleasant bedtime ritual ending with a fifteen-minute period of story reading that Sam enjoyed. Still, at first, he did not like being told to stay in his room, and he tried to come out until his parents, too, put up a gate. Like William, Sam struggled valiantly over the first few days to maintain the status quo, but by the start of the second week he, too, was sleeping normally.

A consistent, progressive program for learning new routines can be difficult to enforce initially, but it works remarkably well in a variety of situations. If your child’s problem is similar to those of the children described in this chapter, your approach to solving it can be very similar as well. Younger children are usually easier to deal with but, at least after the first three months of life, children of all ages with these problems will respond well to the program if their parents are willing to stick to it.

If Things Are Not Getting Better

The program of progressive waiting is designed to treat only one specific sleep problem: the situation where your child has come to inappropriately associate something you do, or allow him to do, with the process of falling asleep. If this is indeed your child’s problem, and it is the only problem, you should have no more than a few difficult nights as he adapts to the new patterns. By the third or fourth night, certainly within a week, everything should be much better. If it isn’t, you should be looking for a reason.

If a week or so has gone by without improvement—or, even worse, if your child’s periods of crying have grown longer and more intense—then don’t continue the program. Stop and review the situation. There are a number of possibilities to consider before you decide what to do next. You may have made the wrong diagnosis; you may have made the right diagnosis but be treating only one part of a complex problem; or you may somehow be treating the problem inappropriately.

Procedural Considerations

Something you are doing, or not doing, could be interfering with your progress. Some parents have trouble following the program strictly and consistently. Common errors include letting your child fall asleep on his own at bedtime, but then rocking him during the night; staying with him until he falls asleep at bedtime but insisting that he fall back asleep alone later in the night; letting him fall asleep alone at bedtime and early in the night, but moving him into your bed when he wakes near morning; handling his pleas or crying differently from night to night, or responding differently when you think he is making enough noise to wake his siblings; and, in two-parent families, having each parent enforce the program in his or her own way. If you do any of these things, matters may not improve.

If you stay out of your child’s room for a certain length of time as planned but then, after checking him, you end up staying in his room until he falls asleep, you will not make much progress: remember, it is having him finally fall asleep the new way that matters, not the waiting. If you start with short waiting intervals and don’t increase their length, your child may come to expect several visits from you before he goes back to sleep. The reason for increasing the times is to reach a point where he is alone long enough to fuss for a while and then settle himself before you have had to go in even once. The best thing you can do for your child at night is to give him a clear and definite understanding of what is to happen. Enforcing routines inconsistently will only make problems worse.

Similarly, if you can’t enforce consistent, clear rules, you may not see progress (see Chapter 5). Perhaps you insist that your child start falling asleep alone, but you still have to put him back into his room over and over after he runs out. (For him, it may be a game.) Or you may be unable to insist that he stay in bed all night because he quietly sneaks into your bedroom without waking you. Or you may have stopped allowing him to watch television at bedtime, but he still watches in the middle of the night because there is a television in his room or because he can sneak into the den. In setting new routines, you will succeed only if you enforce them completely and throughout the entire night.

Schedule Considerations

The treatment can be undermined if the plan does not take into account your child’s daily schedule and biological rhythms (see Chapters 9 through 12). The progressive-waiting program assumes that your child is sleepy and capable of sleep at the times when you are using it. If he isn’t sleepy, no program—regardless of how strictly and consistently it is applied—can help him fall asleep. If your child has been falling asleep at 9:00 P.M. and you set his bedtime at 7:00 P.M., he will have about two hours to complain before he even begins to get sleepy. That is why I suggest you start with a bedtime no earlier, and probably a little later, than the usual time he falls asleep. If you are not sure what time to start with, remember that it is better to err on the late side at first than to put your child to bed when he is still wide awake. You can always move his bedtime earlier again after a few days.

Similarly, if your child is usually awake for an hour or two in the middle of the night, but he is happy as long as you are there playing with him, then you may simply be keeping him in bed longer than he can sleep. In that case he will have an hour or two to fill in the middle of every night before he is capable of falling back asleep. As will be explained in Chapter 11, you will need to cut back the length of time he spends in bed accordingly before you try to teach him a new pattern of associations.

If your child loses sleep while you are teaching him new patterns because he is up crying during the night, don’t let him sleep later than usual or take more naps or longer ones the next day. If you let him make up in the day the sleep lost at night, you will only succeed in shifting some of his sleep from the nighttime to the daytime, ensuring that he will be awake and crying more the next night. If he ends up short on sleep one night, that’s okay: it will actually work to your advantage the next night.

If you are not sure when your child is even capable of sleeping, perhaps because his schedule and hours of sleep vary so much from day to day, work on developing a consistent schedule that works for him. You should find a schedule in which he falls asleep quickly at bedtime (even if he needs help to do so) and falls back to sleep quickly after waking during the night (again, even if he needs help) before you start enforcing a program of changes.

Anxiety

Your child may be frightened. If he shows signs of separation anxiety in the daytime, he may not be able to tolerate separation at night. Leaving him alone in his room for longer and longer periods will not help—in fact, it may make matters worse. If that seems to be happening, then choose a multistep approach: as described earlier and in Chapter 7, you should work on all other associations first and deal with the separation problems later. You may need to sleep in the same room as him all night, but even then you can still insist on sleeping on a separate bed or mattress, refuse to hold or rock him, or eliminate a pacifier. If he keeps pulling at you or getting into your bed, you can still leave the room for increasing periods of time, except that when you return you should agree to stay as long as the undesirable behavior does not resume.

Confusional versus Habitual Wakings

When you think your child is awake at night, is he really awake? When you go to him, does he respond appropriately, calm down quickly, and let you know what he wants, or does he push you away and keep thrashing and kicking? Children experiencing a confusional arousal or sleep terror are not awake enough even to realize that you are there, much less to learn new patterns of associations. How to recognize and treat these partial arousals is discussed in Chapter 13.

Medical Considerations

It is quite uncommon for pain to be the cause of frequent or nightly wakings in children, but you may need to rule out the possibility. A child who is in pain at night can usually be distinguished from one who is simply unhappy. The child who wakes because of pain may be somewhat comforted by being held, but the pain will not go away: he will still show signs of being in pain, and he will not return to sleep quickly. He will probably experience similar periods of pain in the daytime as well. On the other hand, if your child is happy if you hold him, give him his pacifier, or allow him to play, or if he sleeps well when you let him sleep in your bed, then you can be sure that he is not in pain. Pain and other medical situations are discussed further in Chapter 8.

General Observations

There are some general points that are useful to keep in mind as you try to determine the cause of your child’s sleep problem and try to correct it.

1. Changes you need to make to correct a problem of inappropriate sleep associations are not being made solely for your own benefit—more important is that they are also to benefit your child.Being able to fall asleep easily, and trusting that things won’t change once he does, is a better way for your child to go through the night.

2. Ideally, the conditions associated with falling asleep should not be stimulating, like television, and they should not involve continuous activities such as sucking on a bottle or pacifier. It’s best for children to learn to fall asleep in a crib or bed in a room that is fairly dark and quiet (no lullaby tapes, CDs, television, or sound machines). After their first few months, children should not need to be held, rocked, or patted, or need to be soothed with a bottle or pacifier or at the breast, just to fall asleep. (Bedtime feedings are fine even after the early months as long as the child doesn’t come to depend on them to fall asleep throughout the night.)

3. When children wake during the night, they should be where they were when they fell asleep, with the same people there (or not there): they should be able to trust that no changes were made after they fell asleep. They should not have any jobs to do—checking, calling, sucking, eating, watching, listening, pleading, or demanding—before falling back asleep. All they should need is to find a comfortable position and continue quickly into the next sleep cycle.

4. If your child wakes crying at night but quiets rapidly and returns to sleep promptly once you reestablish the conditions that were present at bedtime—such as rocking him in your arms—then you can be certain that he has merely learned to associate the wrong conditions with falling asleep. There is no inherent abnormality in his ability to sleep. The physiological systems that control sleep in a child cannot prevent him from sleeping well only when he is not being held or rocked. If these systems were not working properly, your child would not sleep well under any conditions. So you can be sure that the cause of his sleep disturbance is not a neurological abnormality, a dietary imbalance or food sensitivity, or significant discomfort.

5. Don’t start too young. Parents frequently ask at what age they should start a progressive-waiting approach. It is difficult to give a precise answer to this question, but there are some guidelines. Most children start to sleep through the night on their own within three or four months after birth. (Note that all figures here are based on the due date, so they will be later for children born prematurely.) Newborns do not sleep through the night, and you should not try to make them. Sleep (particularly REM sleep) in the newborn is broken by many wakings. At these times, and during the periods of change from one sleep state to another, an infant’s sleep patterns are particularly vulnerable to disruption. Your newborn should not have to negotiate these periods without comforting and help. At any rate, a full night is too long for a newborn to go between feedings.

By the time a child is around three months old, significant developmental changes have taken place. Now most sleep should be occurring at night, and the pattern of sleep stage cycling should be fairly mature (see Chapter 2). A baby’s sleep patterns often improve markedly around this time, so unless you are having unusually severe problems, it is a good idea to wait until your child is three or four months old before you institute major changes. If at that point you only need to get up briefly once or twice a night to settle your child, you might want to wait a few weeks and see what happens; often, such sleep patterns continue to improve on their own.

But even a two-month-old should not be up more than two or three times during the night. If your baby is up more than that and always goes right back to sleep when you help, you might see if he starts to do better if you do not always respond immediately. (Remember, the methods in this chapter are designed to help you treat habits, not other sleep problems.) If his sleep does not improve over a few days, you should probably give him the benefit of the doubt and wait a few weeks before trying again. (Similarly, as discussed in Chapter 6, you should not have to feed a healthy two-month-old hourly across the night, and it is fine to start spacing out the feedings then, but it is too early to aim at eliminating them altogether.)

If a marked problem persists at three or four months, you can then consider a real effort to make changes. By the time the baby is five months old, you can consider making changes even if his sleep problems are relatively minor.

6. Your child’s sleep associations at one time (say, bedtime) may not always affect what happens at other times (such as later in the night or at nap times). Rocking your child to sleep or patting his back is not necessarily wrong, or even certain to cause trouble. If your child falls asleep rapidly, is easy to move to his crib or bed, and sleeps through the night (i.e., puts himself back to sleep quickly after normal wakings), and if you are happy with this routine, then there is no problem at all. For example, even if you rock your child for five minutes at bedtime or nurse him to sleep over ten minutes, you may be able to transfer him easily into his crib or off you onto the mattress, and he may resettle himself quickly and then sleep through the night. You would have reason to change the routine only if problems emerged—if, for instance, the bedtime routine becomes prolonged, as it was with Betsy, or if your child begins waking most nights and requires your presence each time.

To take another example, your child may fall asleep alone at bedtime and nap time but need to be rocked after nighttime wakings. Or perhaps he falls asleep easily at day care, even though his sleep associations there differ completely from those he has at home. Children with sleep patterns like these have learned to associate different conditions with falling asleep at different times or in different places. This is no more or less normal than needing the same conditions each time one falls asleep.

7. If your child falls asleep by himself at nap time but needs you at night, then you can expect the relearning to go very quickly. He already knows how to fall asleep on his own; he simply has to learn to associate that behavior with the nighttime as well as with nap times.

8. The amount of help a child needs to settle during the night may vary depending upon the time. A child who wakes frequently at night may sleep well for several hours before his first nighttime waking and after his last one. For example, he may sleep soundly from 7:00 to 10:00 P.M. and from 4:00 to 7:00 A.M. but be restless, waking frequently, between 10:00 P.M. and 4:00 A.M. This variation is only a reflection of his normal pattern of sleep state cycling. As you learned in Chapter 2, children spend the first few hours of the night in deep sleep and often return to that same state near morning. During the period of lighter sleep in between, they are more subject to wakings.

9. If you have been going in to your child during the night to help him fall back asleep, you may have been told that you were “spoiling” him. That is not true. Spoiling a child means giving in to his demands regardless of what is best for him. If you are comforting him at night, it is probably because you feel that it is the right thing to do for him, not because you cannot say no or are incapable of discipline.

Repeatedly going in to comfort him, however, is often not the best thing to do. By doing so, you may only be strengthening a habit, not responding to a real need. In the daytime, you may find it easier to distinguish your child’s wants from his needs, and you can deny him any inappropriate requests without difficulty, even if he cries. But if he wakes and cries at night and only settles when he is nursed or rocked, you may mistakenly believe that he is hungry and needs to be fed or that he is in pain. You could also jump to the conclusion that he has some inherent problem that makes it impossible for him to go back to sleep without gentle rocking. You know that a colicky baby of two months might need to be walked; you might imagine that by the same token it is appropriate to walk a sleepless, crying child of six, eighteen, or thirty-six months. The real problem here is not that you are spoiling him, but that you do not yet know enough about sleep and sleep associations to distinguish his wants from his needs. Once you understand that what he needs is to learn a new way to fall asleep—whether or not it is what he wants—you will find it easier to see that this need is met.

10. The process of learning new sleep associations will not hurt your child. Parents want their children to feel safe and cared for. When they realize they will have to let a child do some crying, they often fear that the experience will be traumatic, causing permanent psychological harm. While this concern is understandable, long experience has shown that there is nothing to worry about. Allowing some crying while you help your child learn to improve his sleep will never cause psychological damage. It will probably be harder on you than on your baby. Even the most worried parents I have worked with have told me afterward that their concerns about the relearning process proved groundless and that, if anything, once the child’s sleep improved, both they and the child were happier.

A young child cannot yet understand what is best for him, and he may cry if he does not get what he wants. As his parents, you have to be the judge of what he can and cannot have or do. You want to do what is best for him, and that should include helping him form good sleep patterns. If he wanted to play with a sharp knife, you would not give it to him no matter how hard he cried, and you would not feel guilty or worry about psychological consequences. Poor sleep patterns are also harmful for your child and it is your job to correct them. Doing so is a sign of caring, not of selfishness.

Of course, if your child does not get enough love and attention overall, then he may well develop psychological problems. But if you consistently show your love and provide warmth and care, then a little extra crying for a week or so—no matter how upset or angry it sounds—will not hurt him in the least. Even when children become more “clingy” for a day or two, as sometimes happens, the parents are invariably convinced by the rapidity with which this behavior resolves and the child’s sleep improves that they have done the right thing. In fact, with respect to possible psychological effects, your family situation can only improve when your child sleeps better at night. He will feel better and be less irritable during the day. If there are no changes or surprises during the night, he will be more trusting. Because of these changes, and because you yourself will be more rested and have less to be angry about, you will enjoy your child’s company more, and your interactions with him will improve as well.

11. Since it is important that you follow through on your program consistently, wait for a convenient time to begin. Don’t start at a time when you cannot afford to lose sleep yourself, such as before an important meeting or a job interview, or when someone is coming to visit. You may want to wait until a Friday night to begin, so that you have the weekend to catch up on any missed sleep.

12. In most cases, once you decide on a waiting schedule, follow it closely (or at least don’t go in too soon). Know ahead of time how long you are supposed to wait and keep track of the time. Ten minutes can seem like an hour in the middle of the night. Sometimes, too, it may be better not to go in to your crying child even when the time is up. If you can tell that he is beginning to calm down, you may only interrupt the calming process and make things worse if you go in and leave again. If you sense that waiting a bit longer will actually be easier on him, then wait and see if he continues to calm down on his own. Remember, you can always go in if he becomes more upset.

13. In two-parent households, parents should share the responsibilities, if possible, so that the same adult does not have to handle all bedtime and waking interactions during the relearning period.Your child should feel comfortable with either parent at bedtime and after wakings, so it is better if both parents participate.. You do not have to alternate strictly; just pick a schedule that suits you. One parent may find it easier to get up in the first half of the night and the other parent may prefer the second. Or work demands may call for one parent to do more on weekends and the other on weekdays. If one parent has handled all the bedtimes and wakings until now, the other parent may have better luck breaking the old associations.

When a child cries and one of the parents responds, it is probably best if that parent continues to be the one who responds until the child falls asleep, so that the child won’t sense that he can control who comes in by crying enough. For similar reasons, it is good advice not to let your child insist “I want Mommy” or “I want Daddy.” Decide who will handle each night’s bedtime routines, and stick to it. You will do more to convince your child of your love by staying than by giving in to his demands for the other parent. Once he learns that you really mean that you want to be the one to care for him at that time, he will look forward to it (if it is part of the usual bedtime ritual), and he will be more reassured. The same applies to your responses at nighttime wakings.

14. Occasionally, as parents increase the time they wait before responding, their child cries so hard that he throws up. If that happens, go in even though the time isn’t up yet. Clean your child up and change the sheets and pajamas as needed. But do so quickly and matter-of-factly, and then leave again. If you reward him for throwing up by giving him too much attention, he will only learn that vomiting is a good way for him to get what he wants. Occasional vomiting will not hurt your child, so don’t feel guilty that it happened. Like the crying, it will soon stop.

15. If you have other children, especially young children, you may be concerned that they will be kept awake by the noise of crying during the relearning period. You probably don’t need to worry too much. If the other children wake, tend to them as necessary, but don’t let your fear of their being wakened interfere with your ability to stick to the program. Remember, even if their sleep is disturbed for a few nights, it will return to normal quickly. They will probably sleep through most of the fuss anyway. If a child who shares a room with the one doing the relearning complains about the noise, or if it seems to be disturbing him greatly, let him sleep in another room for a few nights. Generally the child with the sleep problem wants his brother or sister back, and that provides further motivation for him to cooperate. If the child you are helping sleeps in a crib, you can instead move the crib (rather than the sibling) to another room for the few days necessary.

16. When you are considering a program that involves some crying or screaming at night, it may seem that it would only be practical if your family lived alone on a deserted island. If you live in an apartment building, you may have to contend with neighbors and your landlord. Explain to your neighbors what you are doing and tell them the problem should only last a few nights. Start the program on the weekend if they prefer. If they are not willing to go along, perhaps you can wait until they will be away for a few days. Or you may have to use a very gradual approach in which you stay in the room initially to keep crying to a minimum.

17. During the relearning process, it is better not to use a sitter. But if it becomes necessary for a night or two, let the sitter put your child to bed in whatever way is easiest. It is not fair to ask a sitter (especially a grandparent) to follow your program, and letting a sitter put your child to bed differently will not really affect what he is coming to expect from you. Nothing will be lost; just be sure to restart the program the next day. Once the new routines are well established, however, you might ask your sitter to try them.

If your child is left with a sitter most days, the sitter will know your child well and he or she can participate in the relearning program for nap times. When a sitter or day care provider handles nap times differently from the way you handle bedtimes, there are usually fewer problems than there would be if you handled both yourself but did so inconsistently. If it is not possible to involve the sitter, or if it seems inadvisable (because the sitter is very young, perhaps), then you may have to institute the program only at night. It will still work.

18. Once your child has learned to fall asleep by himself with the proper associations, he will probably continue to sleep well, but there may be occasional disruptions. If you are visiting friends or relatives, your child may have to share your room, and you may want to respond to his whimpering quickly so that it doesn’t disturb your hosts. Or your child may be sick, perhaps in pain, so you sit with him or take him into your bed. When you get home or the illness passes, he may want to continue going to sleep under these “new” conditions. If you give in, the temporary change may well develop into an ongoing sleep disturbance. This is a common problem, especially during the second six months of life. Making changes on a trip or during an illness is necessary and reasonable. But if these changes lead to new associations that cause your child’s sleep to remain disrupted after he is back home or recovered, then all you need to do is go back to the progressive program described in this chapter for several days to reestablish the proper patterns.

Since it is not difficult to reestablish good sleep habits, you should not hesitate to take care of your child in any way he needs if he is ill or frightened or while traveling. In fact, it is important to show him you are available when he truly needs you. That trust makes it easier for him to handle other times by himself. It’s best, however, to make as few temporary changes as possible. If you have to spend some extra time in his room, you may not have to stay all night. He may want a cup of water, but you probably won’t have to restart feedings or bottles. Do only what is necessary, so he will have less to relearn later.