I am very excited to have Dr. Craig Canapari here on My Two Hats this week as the blog’s first guest. Dr. Canapari is a board certified pediatric pulmonologist and sleep specialist at Massachusetts General Hospital for Children, where he cares for children with sleep and breathing problems. He is here today with great advice regarding bedtime resistance in toddlers. I think his thoughts will prove very helpful for many families, as they did for us. So, check out the post, and then head over to his great blog for more fantastic tips about sleep and children.
Our little guy, now 29 months old, has been a pretty great sleeper for a long while now. It didn’t start out that way, and we’ve had our blips and bumps along the way, but for the past year or so we can pretty much count on sleeping through the night and a good nap.
A couple weeks ago this changed a bit as, all of a sudden, bedtime became a prolonged affair. Our son usually would fall asleep about 20 minutes after lying down in his crib. Now, he is often falling asleep 1.5-2 hours after the desired bedtime of 8pm. He has found various and sundry ways to delay going to sleep. He would like a drink of water. He needs his blanket fixed. He wants to rock. He has a story to tell or a song to sing. Many of these are actually very endearing, but nonetheless I worry about him not getting enough sleep and admittedly become a little frustrated. On a particularly trying night, I made the mistake of bringing him into our bed to see if he would fall asleep. Fall asleep he did, but he now refuses to go to sleep any other way. Of course.
After consulting Dr. Canapari’s blog, I realize that we have a case of the “behavioral insomnia (limit setting type).” But now, what to do about it? Given that my husband and I are both sleep softies I don’t think that we’ll be able to just put him down in his crib and walk away. So, what options are out there for a couple of sleep softies and a very creative little insomniac who need to get some rest?
Dr. Canapari’s Advice:
I have a couple of thoughts on this. First, I wonder what prompted the change in your son’s sleep habits. Some causes can be new incipient developmental milestones (I think of walking and toilet training as being two milestones associated with sleep disruption). Any disruption in routine such as vacation, moving, or starting a new school can result in these issues. Sometimes, it is unclear what prompts the change. Everyone (even a child) is entitled to a bad night of sleep. In some children, a single off night with some unexpected but welcome parental accommodation can lead to sleep problems, which is what I suspect happened with your little boy.
The most likely cause of your son’s difficulties are behavioral insomnia of childhood, limit setting type, given the frequent curtain calls, lack of nocturnal awakenings, and lack of leg complaints to suggest a restless leg component. Fortunately, this is not terribly difficult to treat. Now, taking into account that you and your husband are self professed softies, I would make a couple of recommendations as I would if we were discussing this in clinic.
1.You need to pick a convenient date to address this issue, preferably when you don’t have a big work presentation, vacation, or grandparent visit planned in the next week or so. If a vacation is imminent I usually recommend deferring this to after returning from your trip.
2. Prior to starting spend some time playing with your son in his room, especially in his crib or bed. Frequently kids become averse to the sleep environment. Make it fun again.
3. Bedtime in this context should be brief (30 minutes), predictable, and goal directed e.g. don’t make multiple trips downstairs if the bedroom is upstairs.
4.Two major reasons that parents fail are inconsistency, and failing to push through an extinction burst, which is a brief escalation in sleep difficulties during training.
5. An important part of minimizing fussing with training is bedtime fading. This means moving your son’s bedtime later than is typical for a few days to increase sleep drive at bedtime. If your desired bedtime is 8 PM, 9 is okay, but may need to be later if he consistently falling asleep later. The keys to successful bedtime fading include not letting your child sleep later than usual in the morning, and avoiding sneaky sleep in the late afternoon either in the car, stroller or other venue. Once your child is falling asleep within 15-30 minutes you can move this earlier by 15 minutes a day to the desired bedtime.
6. I would absolutely avoid taking him into your bed as doing so drastically worsened your issues.
7. Now here is the hard part. Your son needs to relearn falling asleep on his own, in his room. You could either go straight to an extinction approach (at the later bedtime, expecting him to fall asleep on his own and ignoring his cries) or a more gradual process (having him fall asleep with you in the room nearby x 1-2 nights, then by the door for 1-2 nights, then outside the door for 1-2 nights). Unfortunately, given his age, you are likely to have some tears either way, so I as a parent have generally chosen the shorter approach.
8. In a 29 month old, rewards e.g. via a sticker chart, may be helpful.
9. Avoid working on sleep if you are working on another major milestone such as potty training.
10. Stay the course. Once you start the process, see it through. Otherwise any tears (yours or your son’s) will have been in vain, and you will have to do it all again later.
I have more about the scientific rationale for these techniques here.
I’m happy to report that about one week after implementing a number of these strategies our little guy is falling asleep in his own bed after a much shorter bedtime routine. And, with very few tears from anybody at our house. Thanks, Dr. Canapari!