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Behavioral “Insomnia” in the Child
Skep Disorders
0193-953X/87 $0.00+ .20
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Behavioral "Insomnia" in the Child Richard A. Ferber, M.D.*
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There are many causes of sleeplessness in the child. In the infant and toddler, the term insomnia seems inappropriate, because there is never a complaint from the patient about an inability to sleep. Such a complaint usually does not appear before latency, and even then it may be more common to find a child trying to stay awake than unsuccessfully attempting to go to sleep. Thus, the clinician is faced with a complaint from parents (or other caretakers) that the child is not going to sleep easily, is not staying asleep, is not sleeping late or long enough, or is not napping appropriately. The child complains only about having to go to bed and to leave their bedroom or living room and television. Although parents usually have an honest concern about their child's welfare, their dissatisfaction with their youngster's sleep is usually proportional to the degree that they themselves are affected by their own sleep loss. Even if their child is happy, functions fine, and does not seem sleepy during the day, and even if the total number of minutes of sleep per 24hour day are appropriate, they, as parents, may be faced with an enormous problem: getting up 4 to 6 times each night to coax their wakeful child back to sleep. In some families, even a single nightly waking requiring the briefest of interventions represents a significant problem because one or both of the parents finds great difficulty returning to sleep; so, even if the child's sleep disturbance is minimal, the parents' loss of sleep may be great. In such a setting, tensions rise. Anger toward the youngster is felt and, even if not directly expressed, certainly may affect the quality of the parentchild relationship. This is complicated by the parents' irritability due to their own lack of sleep. And, if parents do not deal with this problem with cooperation and mutual consideration, that is, if the nighttime responsibilities fall all on one parent or if parents disagree on how the wakings should be handled, then marital tensions may increase above the level simply related to sleep loss. Now, with these tensions present, with angry outbursts at child or spouse followed by guilt mixed with confusion and concern, the stage is set for increasingly severe sleep disturbances as anxiety increases and nurturance decreases. *Director, Center for Pediatric Sleep Disorders, The Children's Hospital; Instructor in Neurology, Harvard Medical School, Boston, Massachusetts
Psychiatric Clinics of North America-Vol. 10, No . 4, December 1987
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ily, it is reassuring to discover that the causes of most of the problems can be easily recognized and, once diagnosed, rapidly treated using only behavioral types of intervention. 4• 6· 8 · 9· 18 · 20• 35• 38 These will be addressed in this article. Although the sleeplessness associated with certain medical and psychiatric disorders (chronic illness, pain, depression, anxiety, and psychosis) may be treated in part by behavioral approaches utilizing motivational, relaxation, and desensitization techniques, such disorders will not be considered "behavioral" in this discussion. In these cases, behavioral factors are not responsible for the sleeplessness even though behavioral alterations may lead to improvement. However, relevant "behavioral" factors may also complicate medical and psychiatric disorders secondarily as parents try, or fail to try, to deal appropriately with a sick or emotionally disturbed youngster. These factors then may become partly or completely responsible for the subsequent sleep difficulties, and these secondary problems may be responsive to the interventions outlined here. These must be recognized because if these secondary issues are not dealt with satisfactorily, there may be persistence of sleep difficulties even when the original medical and psychiatric problems have resolved. Of the disorders discussed here as "behavorial," those most "pure" are ones that can occur in emotionally normal children with completely normal physiologic functioning. Problems caused by simple habits, associations, and normal-for-age limit testing would fit into this category. But, because the spectrum of normality merges imperceptibly into the abnormal, the concept of "pure" becomes quickly muddied. It may be difficult to draw the line between a normal but difficult and strong-willed child who always tests limits to the fullest and an emotionally compromised child with similar behavior. Similarly, a normal but shy and somewhat nervous child may be very close to a mildly anxious and somewhat phobic one. There is even a spectrum within the range of normal sleep ability itself with the best sleepers being least likely to fall into poor habitual patterns, complain of nighttime fears, or try to stay up late. The sleep-wake schedule (or chronophysiologic) disorders are discussed in part here as well, at least those particular disorders not involving true circadian system pathology (of the type seen in a blind or otherwise neurologically damaged youngster with abnormal hypothalamic function) . Here the basic underlying circadian physiology is intact but function of multiple physiologic systems may be altered because of external factors, namely sleep-wake and eating schedules. Thus there may be physiologic alteration but no true medical abnormality, and although the treatment is, in strict terms, chronophysiologic, it may also be considered behavioral in the sense that only the alteration of routines is required for correction. Individual variation here too is very important as certain "chronobiologic types" tend to become symptomatic more quickly than do others.
DEVELOPMENT OF NORMAL SLEEP PATTERNS Babies do not come into this world with the ability to sleep through the night and the ability to maintain wakefulness throughout the day. In
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fact, initially there is little day-night differentiation. Instead, sleep periods last 20 minutes to 6 hours, sleep occurs 6 to 8 times per day, and feedings take place every 1 to 6 hours in an irregular pattern. 9 · 11 · 26 Sleep itself, however, does show some organization with alteration of REM and NREM sleep occurring with approximately a I-hour cycle length. REM is usually the first state entered at sleep onset. NREM is not yet divided into the four polygraphic substages typical of the older individual. NREM in a full-term infant is characterized by a "trace alternant" pattern with bursts of irregular electroencephalographic activity interrupting a slow background. But matters change rapidly. Within the first few weeks of life, the trace alternant pattern is lost and the electroencephalogram (EEG) in NREM becomes fairly continuous; and, by 1 month, sleep spindles start to appear. 7 • 9• 11 · 22· 23 • 26 · 32 By 3 to 6 months of age, NREM sleep becomes divisible into four substages and the characteristic spindle and K-complex patterns are fully developed. Sleep onset is into NREM instead of REM. And, diurnal sleep organization has matured considerably. Most of the 14 to 15 hours of sleep time and the longest sustained period of sleep has taken its place in the night with daytime sleep being divided into about three naps. 3. 1. 9, 10, 11, 19, 21, 22, 21. 31 By 6 months of age, total sleep time should be about 14 hours with three of them in the day divided into two naps. The brief night-time wakings that were present for feeding or handling, should have disappeared as the infant "settled," that is, began to sleep through the night. Sleep time gradually decreases across childhood as sleep's diurnal organization increases. By 1 to 1112 years, a child will get about 11 1/2 hours at night and 2 hours in a single daytime nap. By age 5, a child requires about 11 hours, 10 hours by age 9, and 9 hours by age 14. The final nap is typically abandoned at age three, but this is variable between age 2 and 4, and sometimes is stopped as early as age 1 or as late as age 5. Much depends on the environment; thus, a child may continue to nap daily at daycare until the start of kindergarten but stop napping at home at age 2. 9 · H. 36 Variations certainly occur, mostly reflecting inherent individual differences. Still, by 6 months, if not sooner, children should be able to fall asleep quickly at a regular bedtime and sleep through the night without repeated parental intervention. If they are not, then the causes should be identified and treated. The most common are "behavioral. " 1• 9· 13 · 24 SLEEP TRANSITION AND ASSOCIATED CONDITIONS Although a neonate already is capable of establishing several distinct psychophysiologic states in waking as well as in sleep, these are somewhat unstable. 37 The ability to change smoothly from one state to another is not yet mature as can be seen clearly in the infant's difficulty calming himself. The full transition from activity through calm to sleep is even more difficult. State maintenance is not all that stable either, and the ability to maintain sleep is also somewhat shaky. This is more true about REM than NRE M;--and-waking-s-from-this-state-are-cummon-:-1 In the early weeks, parents are important in helping an infant calm, fall asleep, and fall back asleep after waking. Soothing techniques that may
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heip iuciude rocking, patting, nursing, and use of G. pac:iTier . But, the iufant' s abilities to soothe himself mature rapidly and from 3 to 6 months he should be able to take on this task more and more. If he still seems to "require" such help at 5 or 6 months, this does not mean such skills have not developed. Rather it may simply mean that he has not learned how to apply them, at least to the sleep transition process. The patterns used at sleep transitions, patterns requiring parental participation, have become habits more than needs. 5 · 6• 9· 29• 30 Similar habits or associations are part of the sleep transition process throughout life. They may be complex or simple, rigid, or flexible, but they are present in everyone from infancy through senility. A person may become accustomed to fall asleep on three thick pillows in a semi-sitting position on a very soft mattress, in a dark quiet room. He may be used to drifting off while lying flat on one thin pillow on a extra-firm mattress or even a water bed while listening to the radio with the lights on. For the infant or toddler these associations may include being rocked or having his back rubbed, listening to a music box playing or a parent singing, or sucking on a bottle, breast or pacifier. Often the associations involve settings other than the bedroom: for example the living room and the television, or the car seat and the automobile. For the adult, these associations are usually set by the individual himself. They generally remain present throughout the night and this allows rapid return to sleep after normal night-time wakings. These nighttime wakings are part of the normal process of sleep cycling across the night, and even though the ability to maintain sleep may stabilize after early infancy (and remain quite stable until adulthood), such brief wakings persist. 1• 11 · 36 If the associations associated with sleep onset are altered during the initial sleep transition itself (for example if the radio turns off), there may be waking. And, if these associated conditions are not present at times of night-time wakings , there may be difficulty returning to sleep quickly (and the radio may have to be turned back on). Even then, the individual himself can re-establish the conditions associated with sleep without involving someone else. For the infant and toddler, the associations that cause the most problems are ones that are not under his own control. Thus, he may seem unable to fall asleep by himself but must be rocked. He may not be transferred to the crib without waking until he is deeply asleep. And, he may be unable to go back to sleep after waking during the night unless he is rocked again (or nursed, patted, handed the pacifier, or taken back out for a ride in the car). Such a child may be perceived as having a problem going to sleep (depending on how long the initial sleep transition takes and how difficult transition to crib is), but he almost certainly will be seen as having a problem staying asleep. In reality, however, these are not separate problems. Because the night-time wakings are normal, the problem is not one of sleep maintenance per se, it is one of sleep initiation. Specifically, it is a lack of individual control over the conditions associated with sleep initiation. It is a problem because a parent must get up, go to the child, and do something
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that the child cannot or will not do for himself to get him to go back to sleep. And that something is to re-establish the conditions that the child associates with falling asleep. 5 · 9· 14• 29 From the parents' point of view, this misinterpretation of events is easy to understand. Maturation is a gradual phenomenon and it is not obvious to a caretaker when there has been a change from the inherent transitional difficulties of the neonate and young infant to the difficulties of the older infant and toddler now based only on habit and association. Phenomenologically the presentations may be similar. Furthermore, if normal sleep physiology is not understood (and parents are rarely taught what to expect), then it is reasonable to perceive the wakings as abnormal rather than normal. Once this assumption has been made, it becomes the duty of the parents to deal with these "abnormalities." And, if their interventions work, that is if it gets their children back to sleep, then it seems to be a reasonable response. So, if the child wakes and cries and will not go back to sleep unless rocked, and if rocking gets him back to sleep quickly, why assume that rocking is the inappropriate response, much less the cause of the problem? On the other hand, once the nature of normal sleep cycling (including the existence of normal night-time wakings) is understood along with the concept of sleep onset associations, parents may quickly grasp the inappropriateness of their night-time interactions. This understanding is crucial to helping them change the current situation. What they have to do to improve matters is difficult, and it may be almost impossible if the parents do not really understand the rationale behind the alterations in their nighttime responses that will be necessary. The behavioral treatment of this condition is to gradually help the child learn to fall asleep, both at bedtime and after night-time wakings, by himself. He must learn a set of associations to the sleep transition process that will not require parents' participation repeatedly throughout the night. We and others have had the most success using some variation of the following routine: 5 · 6 · 9 · 14· 18· 20· 30· 34 The child is readied for bed. Then there is a bedtime ritual appropriate for age (song, story) and the child is put down into the crib or tucked into bed. The parents leave while the child is still awake. If he keeps calling or crying they may come back after a few minutes but only for brief reassurance. Then they should leave again. This time they should wait longer before returning, and longer again the next time. This should continue until the child finally falls asleep during one of their stays out of the room. This may be viewed as a practice session; that is, the child had practice falling asleep in the desired setting, the same settii:;; that will be present when he wakes at night. When he does wake at night and cry or call, the parents should respond in the same progressive manner as at bedtime, waiting longer and longer intervals between brief visits until sleep occurs. The subsequent nights should be handled in the same manner as the first, except that the starting times each night should be longer than the night before. It is important to increase these times until the child can wake and call, fuss , or cry but go back to sleep without the parents having
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to return at ali. From thi~ puiut u11, re~ului.iv11 i~ u~uctliy 1itp~J.. I 11 fii..:t gci!erally by the third or fourth night, sleep is vastly improved if not completely normal. The night-time wakings continue, but the child is able to put himself back to sleep quickly, without requiring help from the parents. Once he becomes so adept at this that vocalizations at wakings cease, parents will describe the night-time sleep as continuous. The parents will have the greatest chance of success if they have support during the early days of this program. Thus, the health care provider should be available by phone to discuss problems or questions if they should occur. The schedule of minutes to wait at each arousal should be negotiated with the family and written down in a concrete and tabular manner. And, the parents should be asked to chart the youngster's sleep until the next visit. Such use of a sleep chart is not only helpful to the person treating the family, but it is of direct therapeutic value to the family helping them stick to routines and providing them with a sense of reality of actual progress. 1
ABSENCE OF LIMITS A child is not apt to go to sleep very well if he will not stay in bed. He is not likely to go to sleep if the parents keep going back into his room to carry out his endless requests. 5• 9 As obvious as this may seem, such is the scenario that takes place in many homes. The child is usually at least of toddler age and either already in a bed or capable of climbing out of the crib. The nightly patterns seen are variations on a theme. The child is put to bed but he fights this immediately, simply comes out later, or keeps calling. A variety of excuses and requests are the rule such as needing to be tucked in again, to go to the bathroom again, or to have another drink of water. The child may complain that he "can't sleep" (after all of one minute of trying) or he may describe being "afraid" of monsters or robbers (but in this case his matter-of-fact manner of expression and his calm appearance should make his pleas unconvincing). Such a litany of requests may continue until the child is successful. Thus, parents may refuse to tuck their child in a third time but be reluctant to refuse permission for another trip to the bathroom. And, if the child does manage to void (even in very small amounts), they may become convinced that the need was real. Parents may refuse all requests until there is a complaint of fear or pain. Children learn quickly, and whatever will work will be used repeatedly. Sometimes the requests are trivial ("pull the sheets b ack up, " "give me another tissue") but still the parent or parents give in. Sometimes there is not even a pretense of setting limits. Although ostensibly there is a bedtime, if the child refuses, he is simply allowed to stay up watching television with the parents until he falls asleep in the living room. There are many reasons that limits may not be set appropriately. Parents may not appreciate the importance of limit setting and feel that they are being better parents by acceding to the child's demands. They do not
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understand that this only increases anxiety and insecurity. Allowing the child to force his way into the parents' bed against their desires is a good example of this. Or, the parents may not know how to set limits. If their 2-year-old decides to come out of the bedroom, they do not know how to respond in a manner that will prevent this. Parents may not really want to set limits. The child being up at night may provide secondary gains for them. A single parent may enjoy the company. A couple in the midst of marital strife may find that the child's presence refocuses their own attentions away from their interpersonal difficulties or they may find the setting of limits too painful. This may relate to their own childhood experiences, or it can reflect feelings of guilt because they both work or because the child has certain physical or mental handicaps. Psychosocial issues are also important. Parental illness, depression, alcoholism, and marital tensions are some of the conditions that will certainly interfere with the desire and ability to be firm and consistent. The correct type of help for the family should depend on the cause of the limit setting problem. Educating them as to the importance of limit setting for the well being of the youngster is important, but this must be followed by the development of a concrete program of firm and consistent limits that the parents can carry out. This must be one that allows firmness and nurturance to be shown together. Threats, physical punishment, and other signs of loss of control by the caretaker will not bring the desired response. Limits must be set, preferably using a passive device such as a gate at the doorway or even door closure for progressively increasing amounts of time (starting at very short times such as 30 seconds), in such a way that warm encouragement from the parents can be offered simultaneously. And, the parents must be taught that saying "No," even to another request to use the bathroom, is doing their child a service, not the opposite. If guilt is significant, for example if the child is deaf, leaving the youngster behind a closed door may be too abrupt Gradual withdrawal is still possible. Instead of lying down with the child, the parent may agree to sit in the room until sleep occurs. If the child makes too many demands, the parent may leave, close the door briefly, and then return to try again. If necessary this can be repeated, leaving for progressively longer times. Once this is accepted, the parent may move the chair closer to the door, next outside the door, then down the hall, and so forth. When psychosocial issues are paramount, limit setting may not only be impossible but may be contraindicated. A child who receives no nurturance during the day should not be closed behind a door at night. Instead, efforts on helping the family with the relevant issues should come first by psychotherapy, family counseling, and appropriate use of social agencies.
CIRCADIAN FACTORS The issues of sleep-wake schedule disorders are not addressed in this may-differ somewhat from that seen in the adolescent and adult. arlicle~eir presen.tation.in....ead~ncLmilchchildhood,--how-tWer,
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Nighttime F eedings This particular problem actually fits partly under several different headings. An infant or young toddler being fed repeatedly at night may have a very severe sleep disturbance. 9• 12• 29· 33 Wakings may occur up to 7 or 8 times per night, sometimes almost hourly. With each of these the child seems to want to feed, either from a bottle or at the breast. The amount taken at each feeding may vary but is usually at least several ounces. (If only one ounce is taken each time, the intake of nutriments is probably not that relevant, only the association of sucking with the sleep transition.) A total of 16 to 48 ounces may be consumed across the night. Several factors likely underlie this sleep disturbance although their relative importance is difficult to measure. First there is the association of sucking with sleep onset (just like the baby going to sleep with a pacifier). But when associations are the only problem, there are usually only one to three wakings at night, and these wakings all seem to be part of the normal sleep cycle pattern. Second, the increased intake means increased wetting and the associcated discomfort may cause extra wakings. Third is the factor of hunger. The baby often seems truly hungry during at least some of the nighttime feedings. Certainly in a healthy normally growing infant of 6 months of age or more (if not considerably earlier), there should be the ability to go through the night without eating and without feeling hungry. 5• 16 Thus, this hunger, although real, is not nutritionally based. It is chronobiologically based. That is, the infant has come to expect (in a physiologic sense) feedings during the night. Anyone, at any age, fed at certain times during the day or night will "learn" to be hungry at those times. This hunger may well be a stimulus to increased wakings. Finally, it is likely that other systems under circadian control are adversely affected by this nocturnal gastronomic extravaganza. Intake of proteins and carbohydrates stimulates digestive responses, and the absorption of food products into the blood stream stimulates endocrine responses. This causes a cascade of alterations of physiologic systems away from the state that should be present if the principal sleep period is consolidated into the night and food intake relegated to the day, a cascade that would be expected to reach the hypothalamus. When such is the case, the regulation and control of sleep onset, offset, and cycling will likely suffer. Such a child will continue to show an immature circadian pattern like that of a neonate in which sleep is broken into multiple segments and meals are distributed across the day and night. This being the case, treatment is straightforward. If the night-time feedings seem to be causing a significant sleep problem, then the sleep problem may be improved by decreasing the amount of feeding at night and cured by stopping them altogether. This too can be done progressively. Each night the amount of juice or milk per bottle or the number of minutes taken to the breast at bedtime and at each nighttime waking is reduced. Simultaneously, the minimum time between feedings is progressively increased regardless of when the baby wakes. By so doing, the night-time feedings can be eliminated easily over 1 to 2 weeks. Along with this is usually a very rapid resolution of the sleep problem.
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A breastfeeding mother may be reluctant to eliminate the night-time feedings. Still, improvement is possible. If the bedtime feeding is continued but all nighttime feedings gradually eliminated, sleep may still consolidate. Even if the amount and frequency of feedings is substantially reduced, with responses to the child when he wakes at "nonfeeding" times being managed by progressively postponing the parents' responses as in the treatment of inappropriate sleep-onset associations, sleep will improve substantially. By so doing, one should be able to reach a compromise that is acceptable to the mother. "Insisting" that she stop nursing altogether is far too intrusive and ignores her important maternal feelings. It is fair to discuss with her that complete elimination of nighttime feedings will be more likely to bring total resolution than will partial elimination, and that if some feedings are still present any gains made must be viewed as tenuous. This is fine because if partial nocturnal weaning brings results that are unsatisfactory to the mother or be followed by unsatisfactory relapse, a more complete process can be carried out at anytime in accordance with her wishes. Sleep Phase Delays or Advances
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The sleep phase of the daily sleep-wake cycle is the time from physiologic readiness for sleep to the point of spontaneous natural waking. In the age group under discussion here, a delay or advance of a sleep phase refers to placement of the sleep phase either later (delay) or earlier (advance) in the day than desired by the parents. When there is a phase advance, the child usually is ready to go to sleep early at night, perhaps at 5:00 or 6:00 P.M . If he is kept up later, he becomes cranky and irritable. The parents' complaint, however, is generally the associated early morning waking, often before 6:00 A .M. Typically, naps and mealtimes are shifted early as well. 9 · 10 Treatment is only necessary if a later wake-up time is desired. Then, bedtime should be gradually made later, readjusting naps and mealtimes, if necessary, in the same direction. 9 • 10 A phase delay is much more common, as this reflects the natural tendency to operate closer to a 25 than a 24-hour day. 25 Children with a phase delay of one to several hours generally present with bedtime problems only. If there are night-time wakings, then this would require a second diagnosis. The struggles at bedtime may resemble those seen in a child for whom limits are not set; but, in this case, the child will not fall asleep early regardless of the degree of parental firmness. Some children show a remarkable ability to remain in their room for up to several hours, even in the dark, with only occasional complaints, but most children cannot do this. Thus, various bedtime struggles develop. Sometimes there may even be the appearance of significant night-time fears as the child, lying in a dark room unable to sleep, starts to fantasize, eventually to the point of scaring himself. As in the older person, the hallmarks of this syndrome are a difficult bedtime, a time of sleep onset that is fairly independent of bedtime (that is, the later the bedtime, the shorter the sleep latency), and late sleep in the morning either everx.._day_or at_leasLon weekends_wi.th difficu.l.ty..-bfilng wakened earlier.
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Although treatment employing a progressive phase deiay- that is, going around the clock moving bedtime and waking several hours later each day- has been the standard therapy for this syndrome as it appears in adolescents and adults (at least when the phase shift is several hours or more), in infants, toddlers, and young children, this is not necessary. Instead, starting with a bedtime close to the time the child usually falls asleep will eliminate the bedtime struggles and break the tensions and bad habits associated with the bedtime routines. If the child has been allowed to sleep late every morning, then the time of waking should be advanced progressively, perhaps 15 minutes a day. If he only sleeps late on weekends but gets up early during the week for daycare or school, then that same early waking must be enforced on weekends too. Once adjustment has started in the morning, bedtime may be gradually advanced to an earlier hour as well. Regular But Inappropriate Schedules Without Phase Shifts
If the length of the sleep phase is shorter than expected or desired by the parents (even though it may be completely normal for age), they may be unhappy about the timing of its start or finish. Take the case of a 9-yearold who requires 10 hours of sleep. He may be put to bed at 7:00 P.M., at the same "convenient" (to the parents) time as his 4-year-old sister. Bedtime may be no problem but the parents are unhappy about his 5:00 A. M. waking. Or, he may not wake until 7:00 A.M., but the parents are displeased about the 2 hours of struggle each night until he finally falls asleep at 9:00 P.M. In both cases, the parents are happy about one end of the sleep phase but not the other. However, they cannot have it both ways. The timing of the child's sleep can be moved about but his sleep requirement cannot be changed. For both of these conditions, the parents must choose which 10 hours they want their child to sleep, and bedtime or morning waking (enforced if necessary) should be adjusted accordingly. For the child with the bedtime struggles, the parents should make bedtime 9:00 P.M. and the problem will be solved. If they want him in bed early but do not mind getting up early, then they should still start with a 9:00 P.M . bedtime and gradually move waking and bedtime 1 to 2 hours earlier. The parents of the other child, wanting the morning waking to move 2 hours later from 5:00 to 7:00 A . M., must gradually move his bedtime from 7:00 to 9:00 P.M. Not only the night-time schedule can cause problems. A late afternoon nap every day can interfere with bedtime. And, an early morning nap (7:00 or 8:00 A . M . ) can reinforce an early morning waking. Early feedings at the time of early wakings can do the same. Thus, a child fed at 5:00 A.M. "because" he wakes then may be waking at that hour because he has become conditioned to be hungry at that time. Gradually delaying naps and feedings to more appropriate hours may be curative. Irregular Schedules An infant's ability to stablize circadian functioning into a regular, predictable, and stable pattern is fairly well established by 3 or 4 months of age. So, by this age it becomes increasingly important to watch for signs of emerging rhythms and to reinforce them with increasingly regular signals
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from the environment. Thus, meal and sleep times should become progressively less "on demand" and more "on schedule." The infant will adapt, and his own daily rhythms will become progressively stable. If no regular schedules are provided, the infant may not be able to stabilize all by himself. Thus, if meal and sleep times remain scattered across the day and night, sleep may suffer. Consolidation of sleep into a regular prolonged period during the night with predictable shorter naps during the day may not occur. Some naps may be 4 hours, others 30 minutes. And night-time sleep may be broken in several segments, some more resembling naps than prolonged sleep. Helping the family to set appropriate schedules and to follow them may be all that is required to convert a very disorganized sleep pattern into one that is quite normal.
CONFUSED PARTIAL AROUSALS ("SLEEP TERRORS")
Sleep terrors and sleepwalking are described elsewhere in this volume. However, it is important for the practitioner to be aware that in young children, the clinical manifestations of a partial arousal from the deepest stages of NREM sleep often differ considerably from those described as "classical" somnambulistic or sleep terror episodes. These may be misinterpreted as nightmares, seizures, or as behavioral (that is, with full awareness) events. The "behavioral" misinterpretation is of interest here because if these children are described by their parents simply as "waking" at night and if treatments thus employed are to interrupt inappropriate association patterns or to increase limits, then little beneficial effect is to be expected. And, the parents will remain upset, worried, possibly frightened, and confused. In infants (certainly of 6 months of age and older), toddlers, and older children up to age 5 or 6, confusional partial arousals are fairly common. 13 They usually begin with a moaning or soft crying that rapidly increases in intensity. The child begins to roll about and thrash, possibly kicking into the bed rails or walls. He may remain lying or get to a sitting posture. Eyes may be open or closed. Speech, if present, is difficult to understand and usually includes little except a call for "Mommy" or "Daddy" or nonspecific phrases such as "No, no, get away!" Generally a look of "terror" is not described. More often parents describe their child as looking very upset and confused, possibly with the appearance of pain or discomfort. The child may stare at or "right through" the parents despite continuing to call for them, acting as if oblivious to their physical proximity and contact. The children not only fail to recognize and be comforted by the parents, they usually react negatively to the parents attempts to soothe and calm them. When the parents try to hold, restrain, or wake them, they only squirm, arch, and push away, and the thrashing and crying may actually intensity. 9 Although these episodes may last only a few minutes, they frequently continue for 10 to 15 minutes and can persist for nearly an hour. Calming finally comes almost suddenly, the child then wakes briefly without recollection of the precedi.!!g events, and he_jllit....wants_to return to_ sleep. Generally, only one episode happens on a given night, but several may
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occur. And, as in oider chiidren and aJults, they tend to happen early in the night, within the first 4 hours of sleep. But, in young children these arousals may also occur in the second half of the night, although rarely near morning. And, they may begin during naps. These events are quite common, buttheir true frequency is unknown; many occasional or mild events are simply dismissed as "bad dreams." In young children, they are generally felt to be of "developmental" origin, because the affected children are usually otherwise healthy and because the events tend to disappear by the start of school. Very possibly it is the fact that the stage 4 sleep of children is so deep (that is, that the arousal threshold from that state is so high), that they have difficulty passing smoothly through the normal phases of partial arousal that occur at the termination of each stage 4 epoch. For this reason, insufficient or irregular sleep-wake schedules (which decrease arousability or disrupt the timing of normal arousals) may seem to increase the frequency and intensity of events. And, correction of these problems may be all that is necessary to eliminate or partially ameliorate this disturbance. 9
REFERENCES 1. Anders TF: Night-waking in infants during the first year of life. Pediatrics 63:860--864, 1979 2. Anders TF: Biological rhythms in development. Psychosom Med 44:61- 72, 1982 3. Coons S, Guilleminault C: Development of consolidated sleep and wakeful periods in relation to the day/night cycle in infancy. Dev Med Child Neurol 26:169-176, 1984 4. Cuthbertson J, Schevill S: Helping your Child Sleep Through the Night. Garden City, New York, Doubleday & Co, 1985 5. Douglas J, Richman N: Sleep Management Manual. Great Ormond Street Children's Hospital In-House Publication, 1982 6. Douglas J, Richman N: My Child Won't Sleep. Hammondsworth, Middlesex, England, Penguin Books, 1984 7. Ellingson RJ: Ontogenesis of sleep in the human. In Lairy CC, Salzarulo R (eds): Experimental Study of Human Sleep: Methodical Problems. Amsterdam, Elsevier, 1975, pp 120-140 8. F erber RA: Sleep disorders in infants and children. In Riley T (ed): Sleep Disorders for the Clinician. London, Butterworths, 1985, pp 113-157 9. Ferber RA: Solve Your Child's Sleep Problem. New York, Simon and Schuster, 1985 10. Ferber R: Circadian and schedule disturbances. In: Guilleminault C (ed): Sleep and its Disorders in Children. New York, Raven Press, 1987, pp 165-175 11. Ferber R: The sleepless child. In Guilleminault C (ed): Sleep and its Disorders in Children. New York, Raven Press, 1987:141-163 12. Fe rber R, Boyle MP: Nocturnal fluid intake: A cause of, not treatment for, sleep disruption in infants and toddlers. Sleep Res 12:243, 1983 13. Ferber R, Boyle MP: Six-year experience of a Pediatric Sleep Disorders Center. Sleep Res 15:120, 1986 14. Ferber R, Boyle MP: Sleeplessness in infants and toddlers: Sleep initiation difficulty masquerading as a sleep maintenance insomnia. Sleep Res 12:240, 1983 15. Illingworth R: The child who won't sleep and whose parents won't let him. Mims Magazine, November 1976, pp 71-77 16. Illingworth RS: Sleep problems in the first three years. Br Med J 1:722-728, 1951 17. Jackson H, Rawlins MD: The sleepless child. Br Med J 2:509, 1979 18. Jones DPH, Verduyn CM : Behavioral management of sleep problems. Arch Dis Child 58:442-444, 1983
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19. Kleitman N: Sleep and wakefulness. Chicago, University of Chicago Press, 1939 20. Largo RH, Hunziker UA: A developmental approach to the management of children with sleep disturbances in the first three years of life. Eur J Pediatr 142:170--173, 1984 21. Lenard HG: Sleep studies in infancy. Acta Paediatr Scand 59:572-581, 1970 22. Metcalf D, Mondale J, Butler F: Ontogenesis of spontaneous K-complexes. Psychophysiology 8:340-347, 1971 23. Metcalf D: Sleep spindle ontogenesis in normal children. In Smith W (ed): Drugs, Development, and Cerebral Function. Springfield, Illinois, Charles C Thomas, 1972, pp 125-144 24. Moore T, Ucko LE: Nightwaking in early infancy: Part l. Arch Dis Child 32:333-342, 1957 25. Moore-Ede MC, Sulzman FM, Fuller CA: The clocks that time us. Cambridge, Massachusetts, Harvard University Press, 1982 26. Parmelee AH: Ontogeny of sleep patterns and associated periodicities in infants. In Faulkner E, Kretchmer N, Ross E (eds): Pre- and postnatal development of the human brain. Basel, S. Karger, 1974, pp 298-311 27. Parmelee AH, Wenner WH, Schulz HR: Infant sleep patterns from birth to 16 weeks of age. J Pediatr 65:576-582, 1964 28. Ragins N, Schachter S: A study of sleeping behavior in 2-year old children. J Am Acad Child Psychiatry 10:464--480, 1971 29. Richman N: A community survey of characteristics of one-to-two-year-olds with sleep disruptions. J Am Acad Child Psychiatry 20:281-291, 1981 30. Richman N: Sleep problems in young children. Arch Dis Child 56:491-493, 1984 31. Stem E, Parmelee AH, Akiyama Y, et al: Sleep cycle characteristics in infants. Pediatrics 43:65-70, 1969 32. Stem E, Parmelee AH, Harris MA: Sleep state periodicity in prematures and young infants. Dev Psychobiol 6:357-365, 1973 33. Van Tassel, EB: The relative influence of child and environmental characteristics on sleep disturbances in the first and second year of life. JDBP 6:81--86, 1985 34. Valman HB: Sleep problems. Br Med J 283:422-423, 1981 35. Weissbluth M. Healthy sleep habits, happy child. New York, Fawcett Columbine, 1987 36. Williams RL, Karacan I, Hursch CJ: EEG of human sleep. New York, John Wiley & Sons, 1974 37. Wolff PH: The causes, controls, and organization of behavior in the neonate. Psychological Issues Monograph Series V, No. l. New York, International Universities Press, 1966, p 105 38. Younger JB. The management of night waking in older infants. Pediatr Nurs 8:155-158, 1982 Children's Hospital 300 Longwood Avenue Boston, Massachusetts 02l15
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Behavioral "Insomnia" in the Child Richard A. Ferber, M.D.*
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There are many causes of sleeplessness in the child. In the infant and toddler, the term insomnia seems inappropriate, because there is never a complaint from the patient about an inability to sleep. Such a complaint usually does not appear before latency, and even then it may be more common to find a child trying to stay awake than unsuccessfully attempting to go to sleep. Thus, the clinician is faced with a complaint from parents (or other caretakers) that the child is not going to sleep easily, is not staying asleep, is not sleeping late or long enough, or is not napping appropriately. The child complains only about having to go to bed and to leave their bedroom or living room and television. Although parents usually have an honest concern about their child's welfare, their dissatisfaction with their youngster's sleep is usually proportional to the degree that they themselves are affected by their own sleep loss. Even if their child is happy, functions fine, and does not seem sleepy during the day, and even if the total number of minutes of sleep per 24hour day are appropriate, they, as parents, may be faced with an enormous problem: getting up 4 to 6 times each night to coax their wakeful child back to sleep. In some families, even a single nightly waking requiring the briefest of interventions represents a significant problem because one or both of the parents finds great difficulty returning to sleep; so, even if the child's sleep disturbance is minimal, the parents' loss of sleep may be great. In such a setting, tensions rise. Anger toward the youngster is felt and, even if not directly expressed, certainly may affect the quality of the parentchild relationship. This is complicated by the parents' irritability due to their own lack of sleep. And, if parents do not deal with this problem with cooperation and mutual consideration, that is, if the nighttime responsibilities fall all on one parent or if parents disagree on how the wakings should be handled, then marital tensions may increase above the level simply related to sleep loss. Now, with these tensions present, with angry outbursts at child or spouse followed by guilt mixed with confusion and concern, the stage is set for increasingly severe sleep disturbances as anxiety increases and nurturance decreases. *Director, Center for Pediatric Sleep Disorders, The Children's Hospital; Instructor in Neurology, Harvard Medical School, Boston, Massachusetts
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ily, it is reassuring to discover that the causes of most of the problems can be easily recognized and, once diagnosed, rapidly treated using only behavioral types of intervention. 4• 6· 8 · 9· 18 · 20• 35• 38 These will be addressed in this article. Although the sleeplessness associated with certain medical and psychiatric disorders (chronic illness, pain, depression, anxiety, and psychosis) may be treated in part by behavioral approaches utilizing motivational, relaxation, and desensitization techniques, such disorders will not be considered "behavioral" in this discussion. In these cases, behavioral factors are not responsible for the sleeplessness even though behavioral alterations may lead to improvement. However, relevant "behavioral" factors may also complicate medical and psychiatric disorders secondarily as parents try, or fail to try, to deal appropriately with a sick or emotionally disturbed youngster. These factors then may become partly or completely responsible for the subsequent sleep difficulties, and these secondary problems may be responsive to the interventions outlined here. These must be recognized because if these secondary issues are not dealt with satisfactorily, there may be persistence of sleep difficulties even when the original medical and psychiatric problems have resolved. Of the disorders discussed here as "behavorial," those most "pure" are ones that can occur in emotionally normal children with completely normal physiologic functioning. Problems caused by simple habits, associations, and normal-for-age limit testing would fit into this category. But, because the spectrum of normality merges imperceptibly into the abnormal, the concept of "pure" becomes quickly muddied. It may be difficult to draw the line between a normal but difficult and strong-willed child who always tests limits to the fullest and an emotionally compromised child with similar behavior. Similarly, a normal but shy and somewhat nervous child may be very close to a mildly anxious and somewhat phobic one. There is even a spectrum within the range of normal sleep ability itself with the best sleepers being least likely to fall into poor habitual patterns, complain of nighttime fears, or try to stay up late. The sleep-wake schedule (or chronophysiologic) disorders are discussed in part here as well, at least those particular disorders not involving true circadian system pathology (of the type seen in a blind or otherwise neurologically damaged youngster with abnormal hypothalamic function) . Here the basic underlying circadian physiology is intact but function of multiple physiologic systems may be altered because of external factors, namely sleep-wake and eating schedules. Thus there may be physiologic alteration but no true medical abnormality, and although the treatment is, in strict terms, chronophysiologic, it may also be considered behavioral in the sense that only the alteration of routines is required for correction. Individual variation here too is very important as certain "chronobiologic types" tend to become symptomatic more quickly than do others.
DEVELOPMENT OF NORMAL SLEEP PATTERNS Babies do not come into this world with the ability to sleep through the night and the ability to maintain wakefulness throughout the day. In
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fact, initially there is little day-night differentiation. Instead, sleep periods last 20 minutes to 6 hours, sleep occurs 6 to 8 times per day, and feedings take place every 1 to 6 hours in an irregular pattern. 9 · 11 · 26 Sleep itself, however, does show some organization with alteration of REM and NREM sleep occurring with approximately a I-hour cycle length. REM is usually the first state entered at sleep onset. NREM is not yet divided into the four polygraphic substages typical of the older individual. NREM in a full-term infant is characterized by a "trace alternant" pattern with bursts of irregular electroencephalographic activity interrupting a slow background. But matters change rapidly. Within the first few weeks of life, the trace alternant pattern is lost and the electroencephalogram (EEG) in NREM becomes fairly continuous; and, by 1 month, sleep spindles start to appear. 7 • 9• 11 · 22· 23 • 26 · 32 By 3 to 6 months of age, NREM sleep becomes divisible into four substages and the characteristic spindle and K-complex patterns are fully developed. Sleep onset is into NREM instead of REM. And, diurnal sleep organization has matured considerably. Most of the 14 to 15 hours of sleep time and the longest sustained period of sleep has taken its place in the night with daytime sleep being divided into about three naps. 3. 1. 9, 10, 11, 19, 21, 22, 21. 31 By 6 months of age, total sleep time should be about 14 hours with three of them in the day divided into two naps. The brief night-time wakings that were present for feeding or handling, should have disappeared as the infant "settled," that is, began to sleep through the night. Sleep time gradually decreases across childhood as sleep's diurnal organization increases. By 1 to 1112 years, a child will get about 11 1/2 hours at night and 2 hours in a single daytime nap. By age 5, a child requires about 11 hours, 10 hours by age 9, and 9 hours by age 14. The final nap is typically abandoned at age three, but this is variable between age 2 and 4, and sometimes is stopped as early as age 1 or as late as age 5. Much depends on the environment; thus, a child may continue to nap daily at daycare until the start of kindergarten but stop napping at home at age 2. 9 · H. 36 Variations certainly occur, mostly reflecting inherent individual differences. Still, by 6 months, if not sooner, children should be able to fall asleep quickly at a regular bedtime and sleep through the night without repeated parental intervention. If they are not, then the causes should be identified and treated. The most common are "behavioral. " 1• 9· 13 · 24 SLEEP TRANSITION AND ASSOCIATED CONDITIONS Although a neonate already is capable of establishing several distinct psychophysiologic states in waking as well as in sleep, these are somewhat unstable. 37 The ability to change smoothly from one state to another is not yet mature as can be seen clearly in the infant's difficulty calming himself. The full transition from activity through calm to sleep is even more difficult. State maintenance is not all that stable either, and the ability to maintain sleep is also somewhat shaky. This is more true about REM than NRE M;--and-waking-s-from-this-state-are-cummon-:-1 In the early weeks, parents are important in helping an infant calm, fall asleep, and fall back asleep after waking. Soothing techniques that may
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heip iuciude rocking, patting, nursing, and use of G. pac:iTier . But, the iufant' s abilities to soothe himself mature rapidly and from 3 to 6 months he should be able to take on this task more and more. If he still seems to "require" such help at 5 or 6 months, this does not mean such skills have not developed. Rather it may simply mean that he has not learned how to apply them, at least to the sleep transition process. The patterns used at sleep transitions, patterns requiring parental participation, have become habits more than needs. 5 · 6• 9· 29• 30 Similar habits or associations are part of the sleep transition process throughout life. They may be complex or simple, rigid, or flexible, but they are present in everyone from infancy through senility. A person may become accustomed to fall asleep on three thick pillows in a semi-sitting position on a very soft mattress, in a dark quiet room. He may be used to drifting off while lying flat on one thin pillow on a extra-firm mattress or even a water bed while listening to the radio with the lights on. For the infant or toddler these associations may include being rocked or having his back rubbed, listening to a music box playing or a parent singing, or sucking on a bottle, breast or pacifier. Often the associations involve settings other than the bedroom: for example the living room and the television, or the car seat and the automobile. For the adult, these associations are usually set by the individual himself. They generally remain present throughout the night and this allows rapid return to sleep after normal night-time wakings. These nighttime wakings are part of the normal process of sleep cycling across the night, and even though the ability to maintain sleep may stabilize after early infancy (and remain quite stable until adulthood), such brief wakings persist. 1• 11 · 36 If the associations associated with sleep onset are altered during the initial sleep transition itself (for example if the radio turns off), there may be waking. And, if these associated conditions are not present at times of night-time wakings , there may be difficulty returning to sleep quickly (and the radio may have to be turned back on). Even then, the individual himself can re-establish the conditions associated with sleep without involving someone else. For the infant and toddler, the associations that cause the most problems are ones that are not under his own control. Thus, he may seem unable to fall asleep by himself but must be rocked. He may not be transferred to the crib without waking until he is deeply asleep. And, he may be unable to go back to sleep after waking during the night unless he is rocked again (or nursed, patted, handed the pacifier, or taken back out for a ride in the car). Such a child may be perceived as having a problem going to sleep (depending on how long the initial sleep transition takes and how difficult transition to crib is), but he almost certainly will be seen as having a problem staying asleep. In reality, however, these are not separate problems. Because the night-time wakings are normal, the problem is not one of sleep maintenance per se, it is one of sleep initiation. Specifically, it is a lack of individual control over the conditions associated with sleep initiation. It is a problem because a parent must get up, go to the child, and do something
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that the child cannot or will not do for himself to get him to go back to sleep. And that something is to re-establish the conditions that the child associates with falling asleep. 5 · 9· 14• 29 From the parents' point of view, this misinterpretation of events is easy to understand. Maturation is a gradual phenomenon and it is not obvious to a caretaker when there has been a change from the inherent transitional difficulties of the neonate and young infant to the difficulties of the older infant and toddler now based only on habit and association. Phenomenologically the presentations may be similar. Furthermore, if normal sleep physiology is not understood (and parents are rarely taught what to expect), then it is reasonable to perceive the wakings as abnormal rather than normal. Once this assumption has been made, it becomes the duty of the parents to deal with these "abnormalities." And, if their interventions work, that is if it gets their children back to sleep, then it seems to be a reasonable response. So, if the child wakes and cries and will not go back to sleep unless rocked, and if rocking gets him back to sleep quickly, why assume that rocking is the inappropriate response, much less the cause of the problem? On the other hand, once the nature of normal sleep cycling (including the existence of normal night-time wakings) is understood along with the concept of sleep onset associations, parents may quickly grasp the inappropriateness of their night-time interactions. This understanding is crucial to helping them change the current situation. What they have to do to improve matters is difficult, and it may be almost impossible if the parents do not really understand the rationale behind the alterations in their nighttime responses that will be necessary. The behavioral treatment of this condition is to gradually help the child learn to fall asleep, both at bedtime and after night-time wakings, by himself. He must learn a set of associations to the sleep transition process that will not require parents' participation repeatedly throughout the night. We and others have had the most success using some variation of the following routine: 5 · 6 · 9 · 14· 18· 20· 30· 34 The child is readied for bed. Then there is a bedtime ritual appropriate for age (song, story) and the child is put down into the crib or tucked into bed. The parents leave while the child is still awake. If he keeps calling or crying they may come back after a few minutes but only for brief reassurance. Then they should leave again. This time they should wait longer before returning, and longer again the next time. This should continue until the child finally falls asleep during one of their stays out of the room. This may be viewed as a practice session; that is, the child had practice falling asleep in the desired setting, the same settii:;; that will be present when he wakes at night. When he does wake at night and cry or call, the parents should respond in the same progressive manner as at bedtime, waiting longer and longer intervals between brief visits until sleep occurs. The subsequent nights should be handled in the same manner as the first, except that the starting times each night should be longer than the night before. It is important to increase these times until the child can wake and call, fuss , or cry but go back to sleep without the parents having
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to return at ali. From thi~ puiut u11, re~ului.iv11 i~ u~uctliy 1itp~J.. I 11 fii..:t gci!erally by the third or fourth night, sleep is vastly improved if not completely normal. The night-time wakings continue, but the child is able to put himself back to sleep quickly, without requiring help from the parents. Once he becomes so adept at this that vocalizations at wakings cease, parents will describe the night-time sleep as continuous. The parents will have the greatest chance of success if they have support during the early days of this program. Thus, the health care provider should be available by phone to discuss problems or questions if they should occur. The schedule of minutes to wait at each arousal should be negotiated with the family and written down in a concrete and tabular manner. And, the parents should be asked to chart the youngster's sleep until the next visit. Such use of a sleep chart is not only helpful to the person treating the family, but it is of direct therapeutic value to the family helping them stick to routines and providing them with a sense of reality of actual progress. 1
ABSENCE OF LIMITS A child is not apt to go to sleep very well if he will not stay in bed. He is not likely to go to sleep if the parents keep going back into his room to carry out his endless requests. 5• 9 As obvious as this may seem, such is the scenario that takes place in many homes. The child is usually at least of toddler age and either already in a bed or capable of climbing out of the crib. The nightly patterns seen are variations on a theme. The child is put to bed but he fights this immediately, simply comes out later, or keeps calling. A variety of excuses and requests are the rule such as needing to be tucked in again, to go to the bathroom again, or to have another drink of water. The child may complain that he "can't sleep" (after all of one minute of trying) or he may describe being "afraid" of monsters or robbers (but in this case his matter-of-fact manner of expression and his calm appearance should make his pleas unconvincing). Such a litany of requests may continue until the child is successful. Thus, parents may refuse to tuck their child in a third time but be reluctant to refuse permission for another trip to the bathroom. And, if the child does manage to void (even in very small amounts), they may become convinced that the need was real. Parents may refuse all requests until there is a complaint of fear or pain. Children learn quickly, and whatever will work will be used repeatedly. Sometimes the requests are trivial ("pull the sheets b ack up, " "give me another tissue") but still the parent or parents give in. Sometimes there is not even a pretense of setting limits. Although ostensibly there is a bedtime, if the child refuses, he is simply allowed to stay up watching television with the parents until he falls asleep in the living room. There are many reasons that limits may not be set appropriately. Parents may not appreciate the importance of limit setting and feel that they are being better parents by acceding to the child's demands. They do not
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understand that this only increases anxiety and insecurity. Allowing the child to force his way into the parents' bed against their desires is a good example of this. Or, the parents may not know how to set limits. If their 2-year-old decides to come out of the bedroom, they do not know how to respond in a manner that will prevent this. Parents may not really want to set limits. The child being up at night may provide secondary gains for them. A single parent may enjoy the company. A couple in the midst of marital strife may find that the child's presence refocuses their own attentions away from their interpersonal difficulties or they may find the setting of limits too painful. This may relate to their own childhood experiences, or it can reflect feelings of guilt because they both work or because the child has certain physical or mental handicaps. Psychosocial issues are also important. Parental illness, depression, alcoholism, and marital tensions are some of the conditions that will certainly interfere with the desire and ability to be firm and consistent. The correct type of help for the family should depend on the cause of the limit setting problem. Educating them as to the importance of limit setting for the well being of the youngster is important, but this must be followed by the development of a concrete program of firm and consistent limits that the parents can carry out. This must be one that allows firmness and nurturance to be shown together. Threats, physical punishment, and other signs of loss of control by the caretaker will not bring the desired response. Limits must be set, preferably using a passive device such as a gate at the doorway or even door closure for progressively increasing amounts of time (starting at very short times such as 30 seconds), in such a way that warm encouragement from the parents can be offered simultaneously. And, the parents must be taught that saying "No," even to another request to use the bathroom, is doing their child a service, not the opposite. If guilt is significant, for example if the child is deaf, leaving the youngster behind a closed door may be too abrupt Gradual withdrawal is still possible. Instead of lying down with the child, the parent may agree to sit in the room until sleep occurs. If the child makes too many demands, the parent may leave, close the door briefly, and then return to try again. If necessary this can be repeated, leaving for progressively longer times. Once this is accepted, the parent may move the chair closer to the door, next outside the door, then down the hall, and so forth. When psychosocial issues are paramount, limit setting may not only be impossible but may be contraindicated. A child who receives no nurturance during the day should not be closed behind a door at night. Instead, efforts on helping the family with the relevant issues should come first by psychotherapy, family counseling, and appropriate use of social agencies.
CIRCADIAN FACTORS The issues of sleep-wake schedule disorders are not addressed in this may-differ somewhat from that seen in the adolescent and adult. arlicle~eir presen.tation.in....ead~ncLmilchchildhood,--how-tWer,
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Nighttime F eedings This particular problem actually fits partly under several different headings. An infant or young toddler being fed repeatedly at night may have a very severe sleep disturbance. 9• 12• 29· 33 Wakings may occur up to 7 or 8 times per night, sometimes almost hourly. With each of these the child seems to want to feed, either from a bottle or at the breast. The amount taken at each feeding may vary but is usually at least several ounces. (If only one ounce is taken each time, the intake of nutriments is probably not that relevant, only the association of sucking with the sleep transition.) A total of 16 to 48 ounces may be consumed across the night. Several factors likely underlie this sleep disturbance although their relative importance is difficult to measure. First there is the association of sucking with sleep onset (just like the baby going to sleep with a pacifier). But when associations are the only problem, there are usually only one to three wakings at night, and these wakings all seem to be part of the normal sleep cycle pattern. Second, the increased intake means increased wetting and the associcated discomfort may cause extra wakings. Third is the factor of hunger. The baby often seems truly hungry during at least some of the nighttime feedings. Certainly in a healthy normally growing infant of 6 months of age or more (if not considerably earlier), there should be the ability to go through the night without eating and without feeling hungry. 5• 16 Thus, this hunger, although real, is not nutritionally based. It is chronobiologically based. That is, the infant has come to expect (in a physiologic sense) feedings during the night. Anyone, at any age, fed at certain times during the day or night will "learn" to be hungry at those times. This hunger may well be a stimulus to increased wakings. Finally, it is likely that other systems under circadian control are adversely affected by this nocturnal gastronomic extravaganza. Intake of proteins and carbohydrates stimulates digestive responses, and the absorption of food products into the blood stream stimulates endocrine responses. This causes a cascade of alterations of physiologic systems away from the state that should be present if the principal sleep period is consolidated into the night and food intake relegated to the day, a cascade that would be expected to reach the hypothalamus. When such is the case, the regulation and control of sleep onset, offset, and cycling will likely suffer. Such a child will continue to show an immature circadian pattern like that of a neonate in which sleep is broken into multiple segments and meals are distributed across the day and night. This being the case, treatment is straightforward. If the night-time feedings seem to be causing a significant sleep problem, then the sleep problem may be improved by decreasing the amount of feeding at night and cured by stopping them altogether. This too can be done progressively. Each night the amount of juice or milk per bottle or the number of minutes taken to the breast at bedtime and at each nighttime waking is reduced. Simultaneously, the minimum time between feedings is progressively increased regardless of when the baby wakes. By so doing, the night-time feedings can be eliminated easily over 1 to 2 weeks. Along with this is usually a very rapid resolution of the sleep problem.
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A breastfeeding mother may be reluctant to eliminate the night-time feedings. Still, improvement is possible. If the bedtime feeding is continued but all nighttime feedings gradually eliminated, sleep may still consolidate. Even if the amount and frequency of feedings is substantially reduced, with responses to the child when he wakes at "nonfeeding" times being managed by progressively postponing the parents' responses as in the treatment of inappropriate sleep-onset associations, sleep will improve substantially. By so doing, one should be able to reach a compromise that is acceptable to the mother. "Insisting" that she stop nursing altogether is far too intrusive and ignores her important maternal feelings. It is fair to discuss with her that complete elimination of nighttime feedings will be more likely to bring total resolution than will partial elimination, and that if some feedings are still present any gains made must be viewed as tenuous. This is fine because if partial nocturnal weaning brings results that are unsatisfactory to the mother or be followed by unsatisfactory relapse, a more complete process can be carried out at anytime in accordance with her wishes. Sleep Phase Delays or Advances
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The sleep phase of the daily sleep-wake cycle is the time from physiologic readiness for sleep to the point of spontaneous natural waking. In the age group under discussion here, a delay or advance of a sleep phase refers to placement of the sleep phase either later (delay) or earlier (advance) in the day than desired by the parents. When there is a phase advance, the child usually is ready to go to sleep early at night, perhaps at 5:00 or 6:00 P.M . If he is kept up later, he becomes cranky and irritable. The parents' complaint, however, is generally the associated early morning waking, often before 6:00 A .M. Typically, naps and mealtimes are shifted early as well. 9 · 10 Treatment is only necessary if a later wake-up time is desired. Then, bedtime should be gradually made later, readjusting naps and mealtimes, if necessary, in the same direction. 9 • 10 A phase delay is much more common, as this reflects the natural tendency to operate closer to a 25 than a 24-hour day. 25 Children with a phase delay of one to several hours generally present with bedtime problems only. If there are night-time wakings, then this would require a second diagnosis. The struggles at bedtime may resemble those seen in a child for whom limits are not set; but, in this case, the child will not fall asleep early regardless of the degree of parental firmness. Some children show a remarkable ability to remain in their room for up to several hours, even in the dark, with only occasional complaints, but most children cannot do this. Thus, various bedtime struggles develop. Sometimes there may even be the appearance of significant night-time fears as the child, lying in a dark room unable to sleep, starts to fantasize, eventually to the point of scaring himself. As in the older person, the hallmarks of this syndrome are a difficult bedtime, a time of sleep onset that is fairly independent of bedtime (that is, the later the bedtime, the shorter the sleep latency), and late sleep in the morning either everx.._day_or at_leasLon weekends_wi.th difficu.l.ty..-bfilng wakened earlier.
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Although treatment employing a progressive phase deiay- that is, going around the clock moving bedtime and waking several hours later each day- has been the standard therapy for this syndrome as it appears in adolescents and adults (at least when the phase shift is several hours or more), in infants, toddlers, and young children, this is not necessary. Instead, starting with a bedtime close to the time the child usually falls asleep will eliminate the bedtime struggles and break the tensions and bad habits associated with the bedtime routines. If the child has been allowed to sleep late every morning, then the time of waking should be advanced progressively, perhaps 15 minutes a day. If he only sleeps late on weekends but gets up early during the week for daycare or school, then that same early waking must be enforced on weekends too. Once adjustment has started in the morning, bedtime may be gradually advanced to an earlier hour as well. Regular But Inappropriate Schedules Without Phase Shifts
If the length of the sleep phase is shorter than expected or desired by the parents (even though it may be completely normal for age), they may be unhappy about the timing of its start or finish. Take the case of a 9-yearold who requires 10 hours of sleep. He may be put to bed at 7:00 P.M., at the same "convenient" (to the parents) time as his 4-year-old sister. Bedtime may be no problem but the parents are unhappy about his 5:00 A. M. waking. Or, he may not wake until 7:00 A.M., but the parents are displeased about the 2 hours of struggle each night until he finally falls asleep at 9:00 P.M. In both cases, the parents are happy about one end of the sleep phase but not the other. However, they cannot have it both ways. The timing of the child's sleep can be moved about but his sleep requirement cannot be changed. For both of these conditions, the parents must choose which 10 hours they want their child to sleep, and bedtime or morning waking (enforced if necessary) should be adjusted accordingly. For the child with the bedtime struggles, the parents should make bedtime 9:00 P.M. and the problem will be solved. If they want him in bed early but do not mind getting up early, then they should still start with a 9:00 P.M . bedtime and gradually move waking and bedtime 1 to 2 hours earlier. The parents of the other child, wanting the morning waking to move 2 hours later from 5:00 to 7:00 A . M., must gradually move his bedtime from 7:00 to 9:00 P.M. Not only the night-time schedule can cause problems. A late afternoon nap every day can interfere with bedtime. And, an early morning nap (7:00 or 8:00 A . M . ) can reinforce an early morning waking. Early feedings at the time of early wakings can do the same. Thus, a child fed at 5:00 A.M. "because" he wakes then may be waking at that hour because he has become conditioned to be hungry at that time. Gradually delaying naps and feedings to more appropriate hours may be curative. Irregular Schedules An infant's ability to stablize circadian functioning into a regular, predictable, and stable pattern is fairly well established by 3 or 4 months of age. So, by this age it becomes increasingly important to watch for signs of emerging rhythms and to reinforce them with increasingly regular signals
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from the environment. Thus, meal and sleep times should become progressively less "on demand" and more "on schedule." The infant will adapt, and his own daily rhythms will become progressively stable. If no regular schedules are provided, the infant may not be able to stabilize all by himself. Thus, if meal and sleep times remain scattered across the day and night, sleep may suffer. Consolidation of sleep into a regular prolonged period during the night with predictable shorter naps during the day may not occur. Some naps may be 4 hours, others 30 minutes. And night-time sleep may be broken in several segments, some more resembling naps than prolonged sleep. Helping the family to set appropriate schedules and to follow them may be all that is required to convert a very disorganized sleep pattern into one that is quite normal.
CONFUSED PARTIAL AROUSALS ("SLEEP TERRORS")
Sleep terrors and sleepwalking are described elsewhere in this volume. However, it is important for the practitioner to be aware that in young children, the clinical manifestations of a partial arousal from the deepest stages of NREM sleep often differ considerably from those described as "classical" somnambulistic or sleep terror episodes. These may be misinterpreted as nightmares, seizures, or as behavioral (that is, with full awareness) events. The "behavioral" misinterpretation is of interest here because if these children are described by their parents simply as "waking" at night and if treatments thus employed are to interrupt inappropriate association patterns or to increase limits, then little beneficial effect is to be expected. And, the parents will remain upset, worried, possibly frightened, and confused. In infants (certainly of 6 months of age and older), toddlers, and older children up to age 5 or 6, confusional partial arousals are fairly common. 13 They usually begin with a moaning or soft crying that rapidly increases in intensity. The child begins to roll about and thrash, possibly kicking into the bed rails or walls. He may remain lying or get to a sitting posture. Eyes may be open or closed. Speech, if present, is difficult to understand and usually includes little except a call for "Mommy" or "Daddy" or nonspecific phrases such as "No, no, get away!" Generally a look of "terror" is not described. More often parents describe their child as looking very upset and confused, possibly with the appearance of pain or discomfort. The child may stare at or "right through" the parents despite continuing to call for them, acting as if oblivious to their physical proximity and contact. The children not only fail to recognize and be comforted by the parents, they usually react negatively to the parents attempts to soothe and calm them. When the parents try to hold, restrain, or wake them, they only squirm, arch, and push away, and the thrashing and crying may actually intensity. 9 Although these episodes may last only a few minutes, they frequently continue for 10 to 15 minutes and can persist for nearly an hour. Calming finally comes almost suddenly, the child then wakes briefly without recollection of the precedi.!!g events, and he_jllit....wants_to return to_ sleep. Generally, only one episode happens on a given night, but several may
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occur. And, as in oider chiidren and aJults, they tend to happen early in the night, within the first 4 hours of sleep. But, in young children these arousals may also occur in the second half of the night, although rarely near morning. And, they may begin during naps. These events are quite common, buttheir true frequency is unknown; many occasional or mild events are simply dismissed as "bad dreams." In young children, they are generally felt to be of "developmental" origin, because the affected children are usually otherwise healthy and because the events tend to disappear by the start of school. Very possibly it is the fact that the stage 4 sleep of children is so deep (that is, that the arousal threshold from that state is so high), that they have difficulty passing smoothly through the normal phases of partial arousal that occur at the termination of each stage 4 epoch. For this reason, insufficient or irregular sleep-wake schedules (which decrease arousability or disrupt the timing of normal arousals) may seem to increase the frequency and intensity of events. And, correction of these problems may be all that is necessary to eliminate or partially ameliorate this disturbance. 9
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