Concerned about your child’s sleep? You’re not alone!

My interest in sleep research began when my own son was two. He had been a pretty good sleeper as an infant, but the transition from crib to toddler bed, transitioning away from a pacifier, AND a time change away from daylight savings time really threw us for a loop! I remember keeping a careful sleep diary, charting his nighttime and naptime sleep and found that he was getting WAY less sleep than was recommended for his age.

As a pediatric occupational therapist, I know how vital sleep is for developing brains as well as helping to keep those toddler tantrums at bay. In addition to my personal interest in sleep, in my work I have listened to many parents share their sleep concerns. Believe me, if a member of your family is struggling to get enough sleep, you’re not alone!

All occupations can be impacted by sleep in one way or another. A child’s occupation, developing coordination, practicing social skills, learning to eat, write, and learn, etc. is greatly impacted by sleep. In fact, mental, emotional, and physical challenges are easier for all of us, adults and children alike, when we are well rested.

Disclaimer

This blog is intended to assist families. It is NOT intended to dictate lifestyles or change parenting philosophies. If a family has a sleep routine that is working… GREAT! Leave it as is.

Getting enough sleep

The ultimate goal for any sleeping routine/environment is for ALL members of the family (parents AND kids) to get adequate amounts of quality sleep. It does not matter if everyone shares a bed, stays up late, has a TV in the bedroom, etc., as long as everyone is getting enough sleep. However, many families find themselves in sleep situations that are NOT working for either the parent or the child. This blog is intended to provide tips compiled from multiple sources to help assist the whole family, from infants to adults, in obtaining the appropriate quantity and quality of sleep each day.

How much sleep do children actually need?

The American Academy of Pediatrics (AAP) recommends the following amount of sleep based on a child’s age:
• Infants 4-12 months = 12-16 hours of sleep per day including naps
• Children 1-2 years = 11-14 hours of sleep per day including naps
• Children 3-5 years = 10-13 hours of sleep per day including naps
• Children 6-12 years = 9-12 hours of sleep per day
• Teenagers 13-18 = 8-10 hours of sleep per day

Naps

As reported by the AAP, a portion of a child’s overall sleep quantity in a 24-hour period is obtained through napping. Infants tend to take frequent naps between each feeding. Older babies and toddlers tend to take 1-2 longer naps of 30 minutes to 2 hours, while older toddlers and preschool children tend to rely on a single nap in the afternoon.

In an article written for the New York Times, A Child’s Nap is More Complicated Than It Looks, Perri Klass, M.D., drew on her experience as a pediatrician in compiling a thorough report on napping research. She noted that very young children take naps because so-called “sleep pressure” builds rapidly in their brains. In other words, the need for sleep accumulates so quickly during waking hours that a nap becomes a biological necessity.

When children do not have access to naps, they are not able to cope with day-to-day challenges in their own worlds. They demonstrate more negativity and decreased cognitive engagement.

When do children actually stop napping? Age ranges vary widely. The ability to tolerate wakefulness (and therefore, be able to give up the afternoon nap) is an indication that the brain is maturing. By age 5 years, 80% of children have given up naps, but this still means that 1 in 5 children will continue to need their afternoon nap.

Sleep Rules

The American Psychological Association (APA) reports that a quarter of young children experience some kind of sleep problem that can significantly affect their functioning and well-being. They add that 30-40% of these sleep problems in children are behavior-related. This is actually good news! This means that in many cases, parents can make modifications to environment and routine to help their children receive a proper amount of sleep. Here are some tips I regularly offer parents who share their sleep concerns with me. 

1. Keep a structured bedtime routine 

The longer and more consistent the routine the better. A simple hug and a kiss as a routine will not cut it. The entire routine could take up to several hours. Therefore, it is important to start the bedtime routine early enough so that “lights out” is not too late for the child to obtain an adequate amount of sleep.

The AAP has adopted a “Brush, Book, Bed” campaign to promote a regular bedtime routine which includes turning off all screens 60 minutes before bedtime. An example of an appropriate bedtime routine might be is as follows:

5:30 pm  Dinner
6:00 pm  Play
7:00 pm Bath, PJ’s, Brush teeth
7:30 pm  Books
8:00 pm  Lights out/Bed time

2. Keep bedtime the same EVERY NIGHT

Yes, it is tempting to have a later bedtime on the weekend, and it is OK to allow a tiny bit of flexibility. For example, an 8:30 pm bedtime on the weekend rather than 8:00 pm. However, the more bedtime fluctuates, the harder it will be for the child to get back on schedule during the week, which ultimately means less sleep for parents.

3. Follow a day schedule

If a child naps, make the nap(s) the same time every day. If the child needs to wake up early on some days for school, but not on other days, keep the wake up time similar for all days. Yes, it is very hard to wake a sleeping child, but if a nap runs too long, the remainder of the day/night sleep schedule may get off. An obvious exception to this rule is “sick days.” On these days, a child will generally need to sleep in and take longer/more frequent naps.

If the child does get “off” of the nap schedule, allow the child to sleep for 30 minutes to an hour, then wake her up. A good rule of thumb is to not allow for any napping after 5pm so that the child can fall asleep at the appropriate bedtime.

4. Make the bed environment a SLEEP environment

This means minimize or even eliminate toys, TV, games, etc., from the bedroom. Yes, this means no TV in the bedroom. A favorite stuffed animal or blanket is great. However, the child should only have access to items that are calming/boring and will help lull the child to sleep. This idea also applies to adults, who should not eat, watch TV, or use a laptop/tablet/phone in bed for the same reason.

One great item to have in the bed area is a glowworm or a soft music/light radio with an automatic shut off. Many of these are found in the baby section and look like aquariums. These allow the child to drift off to sleep with soft music/lights if they are not quite ready to fall asleep the moment you put them down. These soft music/light toys also give the child an element of control in their own sleep environment. In addition, they make various clock radios with soothing lights and music/sounds for older children and adults to help the older crowd fall asleep without the aid of screens.

5. Teach children to fall asleep the right way

The environment the child falls asleep in needs to be the same environment for the entire night. This means that if the parent doesn’t intend on sleeping with the child the entire night, then the parent should NOT be there when the child falls asleep.

If the parent allows the child to always fall asleep with them in the room, this teaches the child that the only “safe” way to sleep is when the parent is there. Therefore, when the child wakes in the night, she will automatically seek out the safety of a parent.

This rule additionally applies to letting a child fall asleep in the parent’s bed or on the couch. Everyone has periods of wakefulness in the middle of the night, but if the child awakes in a different environment than where she fell asleep, this gives her new information to process and will likely cause her to fully wake up and seek comfort. The child can get sleepy and snuggly in another environment, but the final drifting off to sleep needs to be in the same environment in which she will wake up at different times during the night.

6. Create a space with appropriate lighting

Some people prefer total darkness. Most children do best with some light. Generally, for children, parents should aim for the amount of light from a full moon. This is enough light so that the child can see that she is in a safe environment, but not too much so that she wants to get up and play. Parents can create this lighting by turning on a closet light, night lights, “Twilight Turtle” and other soft light toys, etc.

7. Create a separate space for each child (away from parents)

This is not an absolute rule, and is not necessarily possible for every household environment. However, this will greatly improve the chances of sleep success. Some parents prefer the child to sleep in the parents’ bedroom. However, this can be tricky because (1) parents are generally not in bed the entire time a child is in bed because adults simply need less sleep, and (2) because children will wake up in the middle of the night and want the parent’s attention.

Some children feel a “safety in numbers” effect, and want to share a room with a sibling. This technique works best if each child has his/her own bed to help squelch late night/midnight interactions. Many kids just do best in their own private space. Parents can get creative and use large closets, hallways, room dividers, etc., to create a separate sleeping space for each child. This is one of the “Sleep Rules” that has many variations depending on the needs of the child and the home environment.

8. Create a “Sleep Drive”

If a child is lying around all day and doesn’t play outside in the sunshine, she will be less sleepy at night. Make sure the child gets plenty of exercise and mental stimulation throughout the day before you start your bedtime routine.

9. Cut out caffeine

This seems obvious, but young children should not have caffeine unless prescribed by a doctor. If an older child does enjoy an occasional Coke, limit it to NO caffeine after 2-3 pm, and ideally no caffeine after lunch. This rule applies to the parents’ coffee/tea/soda consumption as well.

10. Know your child

Some children are more flexible and can handle you letting them sleep with parents when there is a storm, slight illness, bad dream, family vacation, etc., and they know that the general routine is for the child to sleep in his own bed most of the time. However, children who have more sleep difficulties overall tend to be less flexible in this area and require additional structure. Therefore, even when extenuating circumstances arise, it is generally better to stick to the already familiar sleep routine as much as possible.

11. Limit screen time

This one is SO important that it is listed multiple times in my “sleep rules.” (Reminder, AAP recommends NO screen time for children under 2 years, and no more than 1 hour per day for children 2-5 years). Again, the AAP recommends that all screens be turned off at least 60 minutes before bedtime. This additionally means that there should be no televisions in the bedrooms, and that tablets/phones for older children should be charged outside of the bedroom in order to help children resist the temptation to engage with screens when they should be sleeping.

12. Avoid over scheduling

As mentioned in my blog, The Overextended Child, the pressure to schedule children and teens in multiple after school activities is intense. While activities often work to build gross motor coordination, sportsmanship, artistic expression, more expansive social networks, etc., they also can impact sleep. Many extracurricular activities require numerous hours per week. If a child has more than one interest area, these hours of extracurricular activities can add up to very late bedtime routines.

It is important for parents to encourage their children to explore their interests, but it is also important for parents to help children balance these interests with obtaining adequate amounts of sleep.

Building sleep skills

All of these rules are helpful in getting a child to fall asleep on her own at night, but how do you get a child to stay asleep throughout the night? The APA notes that once a child has a solid sleep routine and learns to fall asleep on their own at the beginning of the night, then the skill of being able to fall back asleep on their own will usually be generalized.

Items to discuss with your doctor

Sometimes, parents have tried all of the above for several weeks with no success. This is when parents can talk their child’s doctor about the possible need for medical interventions to assist with the child’s insomnia. Sometimes children can have underlying sleep conditions that interfere with their quality or quantity of sleep.

According to the AAP, sleep apnea is a common problem that affects an estimated 2% of all children, including many who are undiagnosed. Sleep apnea is defined as periods of disrupted breathing during sleep. Symptoms of sleep apnea in children include frequent snoring, sleepiness during the day, inattention, and behavior problems. If a child is exhibiting many of these symptoms, her physician may prescribe an overnight sleep study (polysomnography) to determine if the child has sleep apnea and the best treatment options to correct this.

As I have mentioned, the symptoms of sleep deprivation in children closely mimic the symptoms of ADHD. While adults tend to be sluggish when tired, children tend to compensate for their fatigue by becoming overly active. Tired children also tend to be more impulsive, interruptive, and inattentive. On the reverse, children with ADHD also frequently experience insomnia. Therefore, it is important for parents to work with their child’s doctor to help tease out if a child’s sleep patterns are the underlying cause for the ADHD, rather than simply trying medication for attention as a standard first line of treatment.

In a sleep study done at the University of Michigan, Symptoms of sleep disorders, inattention, and hyperactivity in children, researchers concluded that, “25% of all children with ADHD could have their ADHD eliminated if their habitual snoring and any sleep-related breathing disorders were effectively treated.”

Common surgeries such as the removal of tonsils and/or adenoids are often the appropriate and effective treatment plan for correcting sleep-related breathing disorders. In these cases, giving a child medication for poor sleep would absolutely not solve the underlying problem, and may cause unnecessary side effects. Again, this is why parents should always address medical interventions for sleep concerns with their child’s physician.

Sleep Medications

The AAP AND American Academy of Child and Adolescent Psychiatry (AACAP) strongly recommend that behavior and environmental modification techniques, such as the ‘sleep rules’ I proposed, be used FIRST. If these techniques prove unsuccessful on their own, then medications in conjunction with a comprehensive treatment plan may help.

In the study, Trends in Medication Prescribing for Pediatric Sleep Difficulties in US Outpatient Settings, researchers found that 81% of insomnia-related visits conclude with a prescription for a medication.

The purpose of the following list is to provide information for parents so they can have an informed discussion with their child’s physician before any mediation is prescribed. Parents should further ask the physician about the latest research on any possible side effects of medication. In addition, the child’s pharmacist is also a tremendous resource for further information regarding the medications listed below.

1. Melatonin

This is a hormone naturally occurring in the body. Melatonin supplements can be found in natural foods stores, pharmacies, or grocery stores. Research has shown that it is effective in children with ADHD, autism spectrum disorders, blindness, and various developmental delays. It is also utilized by shift-workers and for jet lag. Melatonin works to help regulate the body’s sleep/wake cycle.

This supplement tends to be somewhat short acting in that it helps the child to fall asleep, but does not help with maintaining sleep through the night. Though melatonin generally has fewer side effects than other medications, possible side effects include nightmares, headache, and irritability. It should be noted that melatonin is a “supplement” rather than a “medication” and therefore is not regulated by the FDA.

2. Benadryl (Diphenhydramine)

This is an over-the-counter (OTC) antihistamine used to treat allergy symptoms which has mixed literature as to its effectiveness with inducing sleep in children. It makes some children sleepy, while other children become more hyperactive. As with all OTC medications, it is important to discuss dosage with the child’s pediatrician. Possible side effects include drowsiness, dizziness, weakness, headache, and dry mouth.

3. Atarax (hydroxyzine)

This is a stronger antihistamine used to help aid sleep. While this medication is helpful with allergies, it also has the side effect of aiding with anxiety and producing a sleepy/relaxed state before bed. Possible side effects include drowsiness, dizziness, weakness, headache, and dry mouth.

4. Blood pressure medications (Clonidine, Kapvay, Catapres)

Blood pressure medications act to aid sleep by preventing the body from getting too “hyped up.” These medications should only be started and stopped under the direction of the physician to prevent possible blood pressure side effects. Possible side effects include dry mouth, dizziness, fatigue, and constipation.

5. Benzodiazepines (Restoril/Temazepam)

This type of benzodiazepine helps individuals fall asleep faster and stay asleep longer through the night, as well as lessens night time wakefulness. It also acts on the brain to produce a calming effect. This medication should only be started and stopped under the direction of the physician to prevent withdrawal reactions. There is a risk of addiction with taking benzodiazepines, as well as possible side effects of short-term memory loss, dizziness, depression, sleepwalking, and daytime sleepiness.

6. Antidepressants (Desyrel)

This medication is used to help reduce anxiety and depression in order to decrease insomnia as well. This medication should only be started and stopped under the direction of the physician to prevent possible withdrawal reactions. Possible side effects include nausea, diarrhea, dizziness, daytime tiredness, weight changes, dry mouth, and constipation.

In all, antihistamines are most often prescribed (33% of visits), followed by blood pressure drugs (26%), benzodiazepines (15%), antidepressants (6%), and finally nonbenzodiazepine drugs such as the sleeping pills Ambian and Sonata (1%).

Why is adequate sleep so important?

The APA reports that deficient or disrupted sleep in children has been linked to a number of emotional and cognitive consequences such as difficulties with concentration and learning, inattention, impulsivity, poor emotional regulation, increased risk-taking (more accidents), and an increased risk for depression. This is especially true for teens who may experience increased risk of self-harm and suicidal thoughts when they regularly miss out on sleep.

For all children and adolescents, a lack of adequate sleep can also lead to negative physical health outcomes including high blood pressure, high cholesterol, insulin resistance/diabetes, and obesity. In addition, sleep difficulties in children often have a significant negative impact on parental sleep, as would be expected, which in turn, affects parental daytime functioning, mood, marital quality, family functioning, work performance, and general parenting skills.

The APA reports that children with more than one diagnosed disorder, neurodevelopmental condition, or other medical conditions have even more sleep related difficulties than their healthy, typically developing peers. I have observed over the years that the vast majority of children I work with have some type of sleep difficulty. It is so common that I always ask parents about a child’s sleep quality/quantity on initial evaluation. All of the best intervention in the clinic is less effective if a child is not getting adequate amounts of sleep.

The relationship between sleep and other medical/psychiatric disorders is very complex, as disturbances with sleep are often considered both a symptom of the primary illness as well as a primary factor. For example, does a child exhibit ADHD because she has difficulty sleeping at night? OR, does the child have difficulty sleeping at night because she has ADHD?

Research shows that it is important to establish good sleep habits early. A 2017 Harvard study found that children who did not routinely receive adequate amounts of sleep in the preschool and early school-age years scored worse on behavior rating scales completed by both mothers and teachers when the child reached 7 years of age, compared to peers who regularly achieved recommended amounts of sleep. Examples of deficits found on these behavior rating scales included difficulties with: attention, emotional control, executive functioning (working memory and problem solving skills), and peer relationships. These deficits in cognitive and behavior problems persisted even once the researchers adjusted for several factors that could have influenced these results.

An adequate amount of sleep is vital for a child’s overall mental, emotional, and physical development. Struggles with insomnia are common in children and can result from a variety of medical and/or behavioral causes. It is imperative for children to have a healthy sleep environment and bedtime routine. If initial interventions do not help a child achieve an appropriate amount of sleep, it is important for parents to problem solve these concerns with their child’s doctor.

About the author

Melissa Foster is a Nationally Board Certified Occupational Therapist who received her Masters in Occupational Therapy from University of Central Arkansas in 2004. She came to Children’s Therapy T.E.A.M. in 2013 with a wealth of treatment experience in settings that range from clinical experience in Northwest Arkansas (NWA) to Kansas to New York. Her primary interests are treatment of children on the Autism Spectrum, treatment of children with ADHD and treatment of children with sensory processing and behavioral disorders. Melissa is an active public speaker in the NWA community on topics related to Autism and Sensory Processing Disorder. She has authored several resource materials for parents on topics such as picky eating and toys to promote development. Her blogs address topics of interest to parents and have become a popular resource for families. Melissa loves spending time with her husband and their two children. On warm summer days she enjoys sitting on her patio with a good book and a glass of iced tea.

Sources:
The Importance of Sleep for Kids, Johns Hopkins All Children’s Hospital (March 12, 2018)

American Academy of Pediatrics Supports Childhood Sleep Guidelines, AAP.org (June 13, 2016) 

Healthy Sleep Habits: How Many Hours Does Your Child Need? Healthychildren.org (July 2, 2018) 

SleepEducation.org. Rate of ADHD diagnosis in children is rising, American Academy of Sleep Medicine (January 22, 2013) 

Sleep Apnea Detection, Healthychildren.org (November 26, 2012). 

Brush, Book, Bead: How to Structure Your Child’s Bedtime Routine, Healthychildren.org (June 7, 2014) 

A child’s Nap is More Complicated Than It Looks, New York Times (September 11, 2011)

Sleep, baby, sleep, American Psychological Association (February 2004)

Symptom of sleep disorders, inattention, and hyperactivity in children, Sleep (December 1997)

Making Sleep a Priority in Pediatric Primary Care, American Psychological Association (Downloaded May 2019) 

Study flags later risks for sleep-deprived kids, The Harvard Gazette (March 10, 2017)

Sleep Drugs Often Prescribed for Kids, WebMD (August 1, 2007)

Sleep Pills for Children – Medication Doses, Risks, and alternatives, Countingsheep.net (December 2018) 

Further Reading:
Healthy Sleep Habits, Happy Child by Dr. Marc Weissbluth, MD
Solve Your Child’s Sleep Problems by Dr. Richard Ferber, MD
The Big Book of Parenting Solutions: 101 Answers to Your Everyday Challenges and Wildest
Worries by Dr. Michele Borba, Ph. D
Sleeping through the Night: How Infants, Toddlers, and their Parents Can Get a Good Night’s
Sleep by Dr. Jodi Mindell, PhD

The American Academy of Child and Adolescent Psychiatry at www.aacap.org