A reader writes:
My 6 year old step-daughter wakes up several nights a week. When she stays over at other people's houses (cousin, for instance), she does the same thing. She usually comes in, goes to her dad's side of the bed, starts crying, and then wants to be tucked back in. She had sleep apnea as a toddler and had her adenoids removed when she was 3 but still didn't actually sleep through the night once till she was about 4. Her usual complaints are that she woke up and can't get back to sleep or that she just can't sleep period. We have tried telling her that she needs to just relax in bed and not come in our room but that doesn't work. I have told her that if our door is closed, she can't come in unless it's an emergency (sick, nightmare, etc.) but that doesn't work either; she will just cry in her own room or at our door until my husband gets out of bed. My 3 year old has been sleeping through the night since she was a very small baby and now wakes up only once every couple of months, usually due to a nightmare or an accident. We are expecting a baby in just 3 weeks and I am really worried about my step-daughter coming in our room crying & waking up the baby. I want to teach her to stay in her own room but she refuses. How else can I get her to stay asleep more often? My husband says that she has always had sleep problems but just brushes it off as it being "the way she is." Is there anything we can do or do we have to just wait for her to eventually outgrow it? Would it help if we closed our door and didn't come to her rescue when she cries? As a baby, her parents never did the "let them cry it out" method; they came to her side whenever she woke up. I'm not sure if this has stuck with her and might be part of the reason she has a hard time getting back to sleep on her own.
If I was seeing this child and her parents in clinic, I would ask for more information:
• How does she fall asleep in the evening? On her own, or with someone holding/stroking/lying next to her until she falls asleep?
• When awakening at night, does she seem anxious, or does she calm down as soon as her father gets up to tuck her back in?
• What happens if her father is away? When she sleeps over at other people's homes (without her parents being present)? When her parents are away and someone else is staying over to care for her and her sister? Does she wake up and seek out someone else to tuck her back to sleep, or is she able to sleep through the night without assistance?
• How much time is she in bed for? Is it an age appropriate amount (10-10 ½ hours), or is she in bed for more than she needs to be, which might be leading her to wake up spontaneously during the night?
• What is her sleep environment like? Is her bedroom quiet and dark, or are there lights on/music playing/cats that jump on her bed which could be waking her up?
If she is in bed for an age-appropriate amount of time, her sleep environment is conducive to sleep, she is able to fall asleep on her own without requiring the physical presence of someone next to her, she does not appear overly anxious upon awakening, and especially if the pattern you describe is only present when her father or parents are present, this behavior pattern would be most consistent with what is known as "limit setting disorder", one of the two main forms of behavioral insomnia of childhood.
There are clearly many different ways of dealing with this, but the first and most important step is for both parents to agree that there is even a problem which needs to be addressed. If one parent find this behavior disturbing, but the other does not, and they cannot agree on what they would like their child to do when she awakens at night, it will be very difficult to transmit a consistent message to her about how she should behave. If the parents do agree on the need for behavior modification, at this age it is often helpful to enlist her help and active participation in solving the problem. One very effective way is to enlist the use of a reward system in which the child gains points for adopting the new behavior (positive reinforcement). This can be done with a sticker chart hung prominently in the child's room, so that she has a graphic reminder of what she needs to be doing (and how well she is doing at it), with the child receiving stickers based upon an agreed upon system (for example: 3 stickers for sleeping through the night, 2 for calling out but staying in her room, 1 for coming to the parents' bedroom but going back to bed on her own), which in turn credit her towards an agreed upon reward, such as going out for a slice of pizza or a movie on the weekend, a small toy, or a book.
In this specific example, it might be helpful to think about implementing the changes in the nighttime behavior before the baby is born, so that she does not perceive it as a sign that the baby is loved more than her (especially as the plan seems to be to have the baby sleep in the parents' room), but instead as something that she and her parents can work at together for mutual benefit and satisfaction.
Dennis Rosen, M.D.
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