Medical Examiner

The Get-Out-of-Bed-Free Card

New and old strategies for children who won’t sleep.

Kids who don’t or won’t sleep are one of the most daunting and unwelcome challenges of parenting. If children sleep poorly, their parents are likely to do the same, and the result is irritability, grumpiness, and general misery, if memory serves me. A new study suggests the stakes might be even higher. Its authors found a clear association between the bad sleep of babies and children and the poor health of parents—physical and sometimes mental.

What can desperately tired parents do about this? Another new piece of research proposes a sensible-seeming answer I haven’t heard before. And I’ll tell you the sleep advice I give to parents of infants and toddlers. But first let’s sort out the link between kids’ poor sleep and parents’ poor health.

The new study involved 5,000 Australian children followed from infancy by a team led by Melissa Wake and Harriet Hiscock at the University of Melbourne, and an additional 5,000 children who enrolled in the study as preschoolers. The children’s parents were asked whether their child’s sleep was a problem. Possible answers: “no,” “mild,” “moderate,” and  “severe.” About 15 percent characterized their infants and preschoolers as having moderate or severe sleep problems.  This number seemed low to me—based on previous research, I would have expected about twice as many. But the difference probably results from the researchers’ decision to look beyond mild sleep difficulties.

When Wake and Hiscock compared the children’s sleep history with parents’ medical histories, looking at general health, mental-health problems, and severe psychological distress, they found an association. Both fathers and mothers of infants with sleep problems reported poor general health for themselves. Alas, the researchers didn’t ask whether these problems preceded the babies’ bad sleep, or—as I suspect—it was the babies’ sleep patterns that led to their parents’ health troubles. 

The relationship is clearer for mental health. The researchers asked mothers whether they had a previous history of depression, and they found that sleepless infants put mothers with no past history of depression at risk for developing mental-health problems. (If they already had such a history, their babies’ sleeplessness didn’t make their prognosis any worse than it already was.) By contrast, infants who sleep poorly seem to have little effect on the distress levels of their fathers. Also, preschoolers’ sleep problems were associated with milder negative effects, physical and mental, on both parents.

Why is there such a strong association between poor sleep in infants and poor physical health for both parents?  I can only speculate that the stress of chronic sleep interruption may have greater physical consequences than we have previously appreciated. Surely, this question calls out for more research. Also, I should point out that the state of physical health comes from the parents’ self-reporting rather than an examination of their health records.  It’s possible that their physical health isn’t objectively poorer—it’s just that they feel much worse.

As for the mental-health findings, they come as no surprise. Poor sleep in infants is likely to lead to poor sleep in mothers, and sleep deprivation in adults is bad for their mental health.  I would have thought that fathers would be similarly blighted, and the findings about their poor overall health suggest they aren’t snoozing away while their wives tear their hair out. But maybe the sleep deprivation affects fathers differently, for some reason.

It’s a relief to learn that badly sleeping preschoolers don’t have the same deleterious impact. That’s probably because they’re just not as all-demanding as the awake-all-night infant. But if you’ve got one of those still-plaguing kids, here’s a strategy backed by evidence, from new research by Brei Moore and Patrick Friman and their associates at the University of Nevada and the University of Nebraska. The method they test is simple: Put children to bed with a card they can exchange for one “free pass” to leave the bedroom to get a drink or a parental hug. (Not on the list is permission to stay up later.) Once the child enjoys his free pass, he has to turn in it in for the night, and his parents must ignore all subsequent bids for attention. 

Moore and Friman tracked 19 normally developing children between the ages of 3 and 6 who strongly resisted bedtime by crying, calling out, escaping from their bedrooms—as I like to think of it, the usual stuff. They divided the kids into two groups. About half of them got the “free pass.” The parents of the children in the comparison group did nothing special.

Remarkably, to me at least, the free pass was quite successful. After just four days, the kids in the experimental group showed substantial improvement by crying and calling out less often, making fewer flight attempts, and quieting down much faster. Their parents reported that they were very satisfied with the results—only 7 percent said the strategy made them uncomfortable, and none thought that their child experienced discomfort. Follow-up studies after three months showed sustained gains.

How does the free pass differ from other “extinction” methods, in which parents forcefully (and consistently) stop tolerating the bedtime resistance? The literature suggests that those methods also work but at a certain cost. Along the way, there is a difficult period of “extinction burst,” when the sleep battles dramatically worsen. Friman and Moore’s families didn’t report this. A note of caution: This is a small study that needs to be replicated on a larger scale before we leap to follow its lead. And more cautions from the researchers: They say their method is intended for normally developing children ages 3 to 10, because younger children generally won’t have the cognitive tools needed to make it work. 

So, what to do about those infuriating little ones? My advice to parents in my practice is based on my sense that children wake in the middle of the night seeking the reward of the warmth and affection they have come to expect. In 25 years practicing as a pediatrician, I’ve found that mothers in particular are often as reluctant as children to give up the nighttime cuddle. It is, after all, a time of pure and intense pleasure with a child, free of worries about hurting someone else’s feelings or the need to put breakfast on the table or to answer the phone. The problem, of course, is that eventually the early-hours pleasure makes mothers miserable in the morning. When you get to that point—and if your baby is at least 4 months old—it may be time to decrease the child’s reward for waking so as to make it not worth the trouble.

I start by recommending that parents ignore fussing for at least five minutes every time a child wakes. Give the kids a chance to settle down on their own. (Though, contra Ferber, don’t wait more than 10 minutes or they’re likely to become so anxious that you’ll never get them back to sleep.) If this step fails, go to the child but keep it very low-key and unrewarding. Talk as little as possible. Don’t turn on the light. Don’t look the child in the eye. Pick her up slightly awkwardly, so she’s not sure you have a good grip. If it’s a cold night, let her tush collect a few icicles. Above all, don’t hug or kiss her or tell her how wonderful she is. Also, don’t nurse or give formula. A bottle of plain water will reduce the return for waking (and encourage the development of a good pitching arm).

This strategy takes time to work. Initially, you’ll have to come back several times, your sleep will be trashed, and you’ll hate me. But almost every child will succumb in 10 days, at most.

Additional tips: Kids hate bars. Starting at about 18 months, springing a toddler from the crib to a low bed often leads to better bedtimes. Children inclined to wander (unwanted) into the parental bed can often be satisfied with the explanation that while you sympathize, parents need some privacy, too. Try putting a mattress just outside your own bedroom door (a hook-and-eye on the inside will remind them that you really don’t want them to come in). A bed tent, stuffed with every fuzzy the child owns, and a flashlight or two besides, is another source of sleep-time security.

Consistency is pretty important, so don’t start down the sleep-or-die road until you’re sure you’re ready to stick it out. Also, honesty compels me to admit that there are some kids who are too tough for my tricks. Including at least one of my grandchildren.