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What to do with a preschooler who won't stay in bed

By Dennis Rosen M.D.
Special To Boston.com / September 21, 2011

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September 21, 2001—Adam Mansbach's new children's book for adults, Go the F**k to Sleep has generated a lot of buzz since coming out in June, resonating powerfully with almost everyone with kids who has read it. It describes the frustration and angst many parents experience while trying to convince, cajole, bribe or threaten their young child to go to bed at an acceptable hour and to stay there until it's time to get up in the morning. While meant to be humorous, the book's huge success demonstrates just how big a problem this really is.

Between 20 to 30% of children suffer from sleep disturbances at some point in their childhood, though fewer than a quarter are seen by a medical professional because of this. Some sleep disorders, such as obstructive sleep apnea, can cause high blood pressure, heart disease, behavioral changes and decreased school performance. Others, such as behavioral insomnia of childhood, have more of an effect on the parents than on the child, leading to frayed nerves, marital tension and chronic (parental) sleep deprivation.

One of the two forms of behavioral insomnia of childhood, limit setting type, seen mainly in preschool age children, develops when parents are unwilling or unable to set firm rules for their children about when and how they should sleep. While difficulties setting limits can extend to all areas of child rearing, not defining clear boundaries about what is and is not acceptable with regards to sleep can have particularly nerve-wracking consequences for the parents of a child who simply will not stay in bed. Limit setting type behavioral insomnia of childhood can develop when parents are unsure of themselves and their own authority; try to allow their children to take a participatory role in decisions they are developmentally incapable of making; or simply feel guilty about refusing their child just "one more hug" after spending a long day at work.

Here is what limit setting type behavioral insomnia of childhood can look like. After eating dinner, taking a bath, getting into pajamas, brushing her teeth, and listening to a bedtime story or two, a three year old is tucked into bed and kissed good night by her father, who turns the lights off as he leaves the bedroom, fully expecting (and hoping!) that his daughter will soon be fast asleep. A few minutes later, though, she reappears in the living room to ask for one more cuddle, one more story, another drink of water, or to tell her parents something really, REALLY important that absolutely CANNOT wait until the morning. Request fulfilled, she is returned to bed, but comes back out again just a few minutes later asking for something else. After more than an hour of back and forth, rising tones and tears, she finally falls asleep... only to show up in the parents' bed at 2 AM. Knowing that they will need to wake up four hours later to go to work, they choose the path of least resistance, allowing her to burrow in between them, and awakening frequently from the kicks and elbows sent their way as she rolls back and forth for the remainder of the night.

In most families, this doesn't happen too often. And when it does, it's usually not because of poorly defined limits, but because the child really is thirsty, or scared about something or sick and in need of some extra comfort from the parents. And that's totally fine, of course. That's why they're kids, and we're their parents. In some families, though, a battle of nerves plays out nightly between children who don't want to settle into and sleep in their own beds, and are willing to go to great lengths not to, and their parents, who are torn between wanting to do the right thing for their kids and their own needs for some adult-only time and undisturbed sleep.

As a pediatric sleep specialist, I see quite a number of kids with limit setting type of behavioral insomnia of childhood. By the time they arrive in my clinic, the parents are ready for a change. Many intuitively understand what the problem is, but want reassurance that they won't cause their child harm by insisting that he or she obey their rules.

The first step in treating limit setting type of behavioral insomnia of childhood involves understanding exactly what outcomes BOTH parents are interested in reaching. Without agreement about whether or not it is acceptable for their child to sleep in the parents' bed at night, for example, they will be unable to deliver a consistent message to the child about what is permissible and what is not, and the likelihood of successfully altering the child's behavior is very small.

The next step involves making sure the child is on a regular and age appropriate sleep schedule. It is very important to make sure that the parents do not expect the child to sleep more than she needs to, and are not putting the child into bed two hours before she starts getting sleepy. For example, expecting a three year old to sleep for twelve hours at night in addition to the two hour nap she takes at daycare is unreasonable, and it should therefore come as no surprise when the very awake (and bored!) child starts wandering out of her bedroom looking for someone to play with. Adhering to a relatively fixed schedule with regular wake-up and bed times enables the body's internal clock to synchronize with the external clock, and for sleepiness to set in at more or less the same time every day, which will make the child less resistant to staying in bed and falling asleep.

Some preschoolers will respond to the consistent message to stay in their own bed without too much argument once they realize that this is what is expected of them and that it isn't going to change. Many respond favorably to the use of sticker charts, with which they collect stickers for each night they stay in their own bed and redeem them for a small reward after doing so for a number of nights.

However, some will be unable or unwilling to cooperate with the new bedtime rules. In these cases, putting up a gate (or two, if the child is a climber) at the bedroom door effectively creates a room-size crib from which the child cannot leave. While this may initially be met with frustration, carrying on and even tantrums, as long as the child understands that his parents haven't abandoned him by their coming to the bedroom door at regular intervals (though not actually entering the bedroom itself) to tell the child that it is time for him to go to sleep in his own bed, and as long the parents don't give in, within a few days almost all children adapt to the new rules, and the weeks and months of bed-time battles are soon forgotten.

Dennis Rosen M.D. is a pediatric sleep and lung specialist practicing in Boston.

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