Bedtime problems in children:

Solutions for the science-minded parent

© 2008 Gwen Dewar, Ph.D., all rights reserved

The most common bedtime problems among preschool and school-aged children are

• Difficulty falling asleep within a reasonable time (e.g., 30-60 minutes) and

• Bedtime “resistance” (i.e., refusing to go to bed when instructed).

Just how common are these problems? According to parent surveys, 20-30% of young children have significant problems going to bed and/or awakening during the night (Mindell et al 2006). Rates may be even higher among school-aged children, because many parents are unaware that their older children are having sleep problems (Gregory et al 2006).

Pediatric sleep specialists often advise parents to tackle sleep problems by putting their children through sleep training. Several training programs have been scientifically tested, and, in general, parents who stick with these programs report improvements in bedtime behaviors.

However, before you try sleep training, it’s important to understand why your child won’t sleep. Kids may resist bedtime for a variety of reasons. Once you identify your child’s personal sleep issues, you’ll find it easier to choose a sleep training program that’s well-suited to your child’s needs.

Just as important, you might discover that you don’t need to try sleep training at all. Some bedtime problems have relatively simple remedies. This article reviews the common causes of bedtime troubles, and suggests practical solutions for coping with them.

Understanding your child’s bedtime problems:

The behavioral insomnia of childhood (BIC)

According to researchers, bedtime problems arise in at least two ways.

First, kids may learn to associate falling asleep with certain forms of stimulation—like parental soothing or a particular sleep environment. If they don’t receive these forms of stimulation, these kids have difficulty falling and/or staying asleep (Moore et al 2006).

Second, as kids become more independent, they may begin testing their parents’ limits. Bedtime resistance strategies may run the gamut from charming attempts to stall (“one more hug”) to major tantrums (Moore et al 2007). If bedtime rules are unclear or inconsistently enforced, bedtime resistance becomes a major problem in the family.

In both cases, kids suffer from what sleep experts call the “behavioral insomnia of childhood,” or BIC (American Academy of Sleep Medicine 2005). But there is more to childhood insomnia than sleep associations and poorly-enforced bedtime rules. Kids may have trouble falling asleep for a variety of reasons. Here are some of common triggers of bedtime problems—and ways to cope with them:

Separation anxiety and nighttime fears

Otherwise well-adjusted young children frequently experience anxiety when they are separated from their parents (Jenni et al 2005; Ainsworth et al 1978), and most children also experience nighttime fears. If your child is fearful, he needs your help. Children lack the brain maturation and cognitive skills to cope well with distressing emotions, and there is no evidence that nighttime fears or separation anxiety will diminish as a result of sleep training. In fact, research suggests that ignoring your child’s fears may lead to nightmares and emotional problems. If you suspect that nighttime fears or separation anxiety are contributing to your child’s bedtime problems, see this article for practical tips on teaching your child how to cope.

The wrong bedtime

Sometimes parents are simply mistaken about how much sleep their children need. As a result, they set bedtime too early—long before their child is ready to fall asleep. Kids who are put too bed too early get understandably bored. And—as they lie awake with nothing to do—these kids may find their minds dwelling on anxieties and fears (Ferber 2006). To see if this is the cause of your child’s bedtime problems, check out my articles on child sleep requirements and the signs of sleep deprivation. They will help you develop realistic estimates of your child’s personal sleep needs.

Overtiredness

Children are notoriously tricky when it comes to signs of tiredness. Some kids seem to get ever more active as the night wears on—even though they are in desperate need of sleep. When kids become overtired, they may be too stimulated or nervous to fall asleep (Kuhn et al 1999). If this is your child’s problem, review your family’s evening schedule. Is bedtime too late? Do you help your child wind down before bed by leading him through a pleasant, soothing bedtime routine? Do household activities quiet down in the last 2 hours before bedtime? Although you might be tempted to wear your child down with exercise, research shows that exercise keeps people alert for at least two hours after it’s over.

Circadian rhythm sleep disorders

You might have set a reasonable bedtime, but if your child’s internal clock is out of sync with the 24-hour day, she might not be sleepy when bedtime comes along. Circadian rhythm disorders are usually caused by light—getting insufficient light during the day and/or getting too much artificial light at night. If your child has trouble getting started in the morning, and shows other signs of being a late-night owl, make sure she’s getting the right circadian cues. Expose her to bright light during the morning and afternoon. After sundown, dim the lights and insist on calm, quiet activities in the last 2-3 hours before bedtime (Glaze 2004).

Stress

If your child has trouble falling asleep, she may be experiencing daytime stress. Stress can raise stress hormone levels, and it can fuel nighttime anxieties and fears (see below). One study of 8-9 year olds reports that bedtime problems were associated with higher rates of marital conflict at home (El Sheik et al 2006). Other sources of stress may include traumatic events (like earthquakes), the birth of a sibling, school problems, and conflicts with peers. Even very young children may experience stress in daycare or preschool.

Caffeine

Avoid caffeine in the hours before bedtime, and remember that caffeine is found in other consumables besides colas, teas and coffee. Also, keep in mind that popular beliefs about the worst offenders are often wrong. For instance, a 12-ounce “classic” Coke contains about half the caffeine found in a 12-ounce Mountain Dew or 3.5 ounces of dark chocolate. For more information about the caffeine content associated with various commercial foods and drugs, see this list put out by the Center for Science in the Public Interest.

Television

International research reports a link between TV-watching and sleep problems. A study of American fourth graders reported that increased television watching—-both during the day and at night—-was associated with higher rates of bedtime problems, including anxiety, sleep-onset delays, and bedtime resistance (Owens et al 1999). A more recent study of school-aged kids in China reported similar results (Li et al 2007). And kids don’t have to deliberately watch TV to be affected. Passive viewing—-being present when parents watch adult programs—-can also contribute to bedtime problems. A Finnish study reports that 5-6 year olds exposed to adult programs—including the evening news—-slept less overall and experienced more sleep disturbances (Paavonen 2006).

Poorly-timed naps

Personally, I don’t believe in interfering if a child takes the occasional long nap. If a child passes out spontaneously, it’s almost always because she really needs to catch up on her sleep. In such cases, a nap doesn’t disrupt the child’s long-term sleep schedule. It puts her back on track. But if your child is routinely taking long naps—or naps that end in the later afternoon or evening—this may be contributing to her bedtime problems.

Allergies

A study of American school-aged children reports that kids with allergies are more likely to suffer from insomnia (Stein et al 2001). They are also more likely to suffer from noisy sleep. If your child has allergies and bedtime problems, consult your physician.

Snoring and other forms of sleep-disordered breathing

Sleep disordered breathing (SDB) includes snoring, loud breathing, troubled breathing and interrupted breathing (apnea) during sleep. SDB can restrict the oxygen supply to a child’s brain and cause serious health problems. It is also associated with poor sleep quality, frequent night wakings, and daytime sleepiness.

It’s possible that SDB plays a role in bedtime problems, too.

A number of studies have shown a link between SDB and hyperactivity (e.g., Hiscock et al 2006; Shur-Fen Gau 2006). Kids diagnosed with ADHD are more likely to have SDB than are other kids. And when hyperactive kids are treated for SDB, their ADHD symptoms improve. This has led some researchers to speculate that at least some cases of ADHD are caused by SDB. Or, put another way—it’s possible that many kids who have been diagnosed with ADHD are really just suffering from sleep problems.

These findings suggest that sleep-disordered breathing could contribute indirectly to bedtime problems by making SDB sufferers more hyperactive and defiant.

This is a controversial idea that some researchers reject (Sadeh et al 2006). However, given the potential dangers of sleep-disordered breathing, it can never hurt to screen and treat an affected child. If you suspect your child suffers from sleep-disordered breathing, consult your physician.

References: Bedtime problems

Ainsworth MDS, Blehar MC, Waters E, and Wall S. 1978. Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.

American Academy of Sleep Medicine. 2005. International classification of sleep disorders: diagnostic and coding manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine.

El-Sheikh M, Buckhalt JA, Mize J, and Acebo C. 2006. Marital conflict and disruption of children's sleep. Child Dev. 77(1):31-43.

Ferber R. 2006. Solving your child’s sleep problems: New, revised, and expanded edition. New York: Fireside.

Glaze DG. 2004. Childhood insomnia: why Chris can’t sleep. Pediatrics Clinics of North America 51: 33-50.

Gregory, AM, Frühling, VR, and Eley, TC. 2006. A Twin-Study of Sleep Difficulties in School-Aged Children Child Development. Vol. 77 (6): 1668–1679.

Jenni OG, Fuhrer HZ, Iglowstein I, Molinari L, Largo RH. 2005. A longitudinal study of bed sharing and sleep problems among Swiss children in the first 10 years of life. Pediatrics 115(1 Suppl):233-40.

Kuhn BR, Mayfield JW and Kuhn RH. 1999. Clinical assessment of child and adolescent sleep disturbance. Journal of Counseling and Dev 77: 359-368.

Li S, Jin X, Wu S, Jiang F, Yan C, and Shen X. 2007. The impact of media use on sleep patterns and sleep disorders among school-aged children in China. Sleep 30(3):361-7.

Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A and the American Academy of Sleep Medicine. 2006. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 29: 1263-1281.

Moore M, Allison A, and Rosen CL. 2006. A review of pediatric nonrespiratory sleep disorders. Chest 130(4): 1252-1262.

Moore M, Meltzer LJ, and Mindell JA. 2007. Bedtime problems and night wakings in children. Sleep Med Clin 2: 377-385.

Owens JA, Spirito A, McGuinn M, and Nobile C. 2000. Sleep habits and sleep disturbance in elementary school-aged children. J Dev Behav Pediatr 21: 27-36.

Paavonen EJ, Pennonen M, Roine M, Valkonen S and Lahikainen AR. 2006. TV exposure associated with sleep disturbances in 5-to 6-year-old children. J Sleep Research 15: 154-161.

Petit D, Touchette E, Tremblay RE, Bolvin M, and Montplaiser J. 2006. Dyssomnias and parasomnias in early childhood. Pediatrics 119: e1016-e1025.

Sadeh A. L. Pergamin, Y. Bar-Haim2006. Sleep in children with attention-deficit hyperactivity disorder: A meta-analysis of polysomnographic studies. Sleep Medicine Reviews, Volume 10, Issue 6, Pages 381-398.

Zarowski M, Młodzikowska-Albrecht J, Steinborn B. 2007. The sleep habits and sleep disorders in children with headache. Adv Med Sci. 2007;52 Suppl 1:194-6.

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