Aristotle's Child

Risk, resiliency and the parent/child relationship

Sleep Problems in the Alcohol- or Drug-exposed Child

Why would we let a child cry herself to sleep?

Two events this past week were the genesis for this column.

The first occurred while I was flipping through the New York Times and came upon the bestseller list. (This is a rather masochistic activity since I long ago gave up all fantasies that my books would land there.) I was astounded when I read the title of the number one nonfiction bestseller in the country: Go the F*** to Sleep. Visions of a sleep-deprived, out-of-control new parent standing before his infant's crib and screaming at her immediately came to mind. Not a pretty picture. When I actually read the book, I found that the title is a parody, meant for parents, not for their children. It urges parents to get some sleep and not yell at their children.  Perhaps the title was designed to assure new parents that we are all in the same boat. Maybe it was constructed to sell books. What I do know is the image is a very disturbing one, even if in jest.

The second was an interesting email I received from a mother. Here is her direct quote with only identifying information changed:

 "I am an adoptive mother of a drug-exposed child ... age 2 years and ... exposed to meth and PCP.  My child has been diagnosed with Abnormal Limb Movement Sleep Disorder.  I have been trying to find any information on the prevalence of sleep disorders in drug-exposed children and can't find anything. I have worked with many drug-exposed children that appear to be ADHD, and I am starting to wonder how many of them actually have a sleep disorder instead.  A tired toddler looks very much like an ADHD child with a regulation disorder."

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This foster mother is absolutely correct. Children who have been exposed prenatally to alcohol and illicit drugs have trouble regulating themselves-whether it's their behaviors, their emotions, or their sleep patterns. In general, prenatally exposed children have trouble figuring out how to interpret all the busyness in the world around them. A good example of this is the difficulty the newborn or young infant has in habituating (blocking out) visual and auditory stimulation. An infant who is unable to filter out unimportant sounds-such as the buzz of an air conditioner-can become overwhelmed easily and appear irritable and disorganized. Children like this are unable to fall asleep easily and maintain a good sleep state. Thus, they do not get enough quality rest, which can affect mood and hamper the ability of these children to regulate behavior and attention. This makes a child prenatally exposed to alcohol and illicit drugs appear very much like a child who has attention deficit hyperactivity disorder (ADHD). Of course, as the child's behavior becomes more and more dysregulated, sleep becomes more dysregulated, and the cycle spirals downward. More sleepless nights. More tired and bewildered parents.

Infant sleep difficulties can be particularly trying to parents, especially when their concerns are dismissed by the pediatrician or other professionals as a variant of normal: "She's just a fussy baby." In truth, it's more complicated than that. If your child was drug or alcohol exposed and then removed from her family, she is coming into your foster or adoptive home with two significant risk factors: the biological effects of the drugs or alcohol on her developing brain and the emotional trauma of being separated from her birth mother (even if the separation occurred right at birth). The answer is not to let the baby "cry it out." Remember-there is a reason for every behavior you see, including crying. In the first year, the most important lesson you can teach your child is that you always will be there for her. She should sleep in her own room, but you should stay close as she goes to sleep and go to her immediately in the middle of the night if she cries. This is a key time for your child's developing a sense of trust in a trusting world. 

If the baby is fussy and not able to calm, move in and help her learn to self-soothe. Here are some easy steps to try with your infant:

1.   Swaddle her in a blanket with arms and legs flexed. Place her on her back in her crib.

2.   Give her a pacifier. Step back and take a deep, calming breath. Watch her as she begins to calm.

3.   When she does calm a bit (which she will do in time), pick her up and hold her at arm's length. Don't talk and don't make eye contact. Just let her get used to your touch.

4.   Begin to talk to her softly in a low, monotonous, loving voice.

5.   As she gets used to your voice bring her around to face you. Don't rush it.  If she starts getting fussy, move her back out to arm's length or hold her facing away from you. Once she calms bring her back in a face-to-face position.

6.   If she keeps looking away from your eyes (this is called "gaze aversion") turn her so she is facing out, looking away from you. 

7.   Keep repeating steps 5 and 6 until she can accept your gaze and voice. Then, bring her in to cuddle in your arms against your chest.

8.   Rock slowly and gently back and forth (not side to side).

She will go to sleep ... just be patient.

I know, I know. Easier said than done. But if you can manage to go through these steps on a regular and consistent basis, the baby will learn self-soothing skills that will help her go to sleep and stay asleep.

As the child gets older, there are a variety of other issues that will come up related to sleep. In a future blog, I'll talk about some things you can do with the older child to help address these sleep problems. In the meantime, try these eight steps with your infant. You will enhance the bond between you and your baby, and you'll feel a lot better about yourself after competently managing a nighttime crisis.  Importantly, when the child sleeps at night you will get some sleep, which will make you a better parent during the child's waking hours.  And it sure beats yelling the "F word" at your baby.

 

Ira J. Chasnoff, M.D., is a Professor of Clinical Pediatrics at the University of Illinois College of Medicine in Chicago. His most recent work is The Mystery of Risk.

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