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Improving sleep patterns in young children

Alison Deakin
RGN CertHV DipCouns MSc
Family Support Coordinator
Sure Start Teesdale
Durham
E:alideakin@homecross.fsnet.co.uk

Maura Appleby
BSc RGN RHV
Practice Development and Evaluation Worker
Sure Start Adswood and Bridgehall
Stockport
E:maura.appleby@stockport-pct.nhs.uk

A total of 22% of nine-month-old babies have difficulty getting off to sleep, and 42% are reported to wake during the night.(3) This article describes an approach to resolving sleep problems in young children that has been used successfully over a number of years at the Stockport Sleep Clinic. Both sleep rhythms and attachment issues are taken into consideration in what we have termed the "Attention to Sleep Rhythms" approach. The article includes background information on the sleep clinic, the relationship between sleep rhythms and waking children, and a description of the approach used by some parents attending the clinic. A case study is included to illustrate how the approach was used with one family.

Background
The sleep clinic has been a part of the health visiting service in Stockport since 1984 and is staffed by health visitors with a special interest. The families attending the clinic are seen individually, building on a known strength of health visiting, the individual client relationship.(4) Before the first appointment, parents are asked to complete a sleep diary. This is used during the first appointment to assist in carrying out an assessment, which normally takes about an hour and  follows the principles of "motivational interviewing".(5) Further appointments are arranged according to individual need. Where possible, the family are seen by the same health visitor at each appointment to ensure continuity. The interaction with the parents focuses on improving relationships within the family and on raising the self-esteem of both the parents and the child. The use of skilled listening, observing and reflecting on what is being said, together with the use of open-ended questioning, encourages the parents to discuss their current situation.
 
Theory
There are two main schools of thought on causes of sleep disturbance in children, and as a result there are two schools of thought on how these problems might be resolved. The psychotherapeutic approach suggests that the sleep disturbance is caused by a disturbance in the attachment process, as described by John Bowlby.(6) The attachment of mother to child and child to mother is considered significant when viewed in terms of putting the child down to sleep, thus demanding a separation between the two and causing anxiety.(7)
The behavioural school of thought believes that the development of sleep routines and the use of comforters is learnt behaviour.(8) Sleep disruption, if unresolved, can therefore become habitual. Behavioural approaches to sleep problems are thus commonly used and incorporate such strategies as leaving the child to cry and checking in on the child every five minutes, or using a graduated approach where the parents progressively withdraw their input at the child's bedtime and when they wake in the night.(9)
At our clinic we have found that many of the parents attending are unable to carry out these behavioural approaches due to the level of their exhaustion and anxiety. In the majority of cases, a sleepless child causes significant stress to the parents, and if not obtaining sufficient sleep, can have a detrimental effect on parents' physical and emotional wellbeing.(1) The staff at the Stockport Sleep Clinic have developed an approach to sleep problems that gives consideration to the level of exhaustion and anxiety the parents feel. The approach used in the clinic embraces psychotherapeutic theories while still using some behavioural strategies concerning sleep rhythms.

Sleep rhythms
We have within us many biological clocks or biorhythms. One of these rhythms, the ultradian rhythm, relates to the waking pattern of children. When asleep, the rhythm is demonstrated by periods of rapid eye movement (REM), alternating with non-REM. The ultradian rhythm in adults runs at about 100 minutes; in children it is more variable as children spend more time in REM sleep than adults. During each 100-minute cycle, or one ultradian rhythm, approximately 80 minutes will be spent in non-REM and approximately 20 minutes will be spent in REM sleep.(10) The ultradian rhythm becomes evident when studying the sleep diary completed by the parents before the first appointment. Many sleep diaries reveal that children wake from every hour to every two hours throughout the night, which appears to link to the ultradian rhythm. In our experience, parents' understanding of the sleep cycle and the rationale for the "Attention to Sleep Rhythms" approach enhances their confidence.

The "Attention to Sleep Rhythms" approach
One of the most important factors for a successful outcome to resolving sleep problems is that the parents offer a consistent approach each time the child wakes. Taking the child into the parents' bed is an approach that even the most exhausted parents can carry out. Parents should be reassured that this does not mean that their child will be sleeping with them for years! Bed sharing allows the parents to offer a consistent approach (as for many parents taking the child into their own bed is often already used as the last resort), while getting some slight improvement in their own sleep pattern. The parents are also "modelling" the behaviour they want from their child, as the child sees the parents sleeping during the night.(11) This is combined with the reassurance of the parents' presence, thus addressing issues of attachment that improve the sleep pattern. This approach can be comforting for both parents and child. The parents should allow the child to sleep in their bed until the child has been sleeping through the night for several weeks. This allows the biological clock or biorhythm to readjust. When the child is moved back into his or her own room, the "reset" biological clock continues and the child does not return to the previous waking behaviour. This approach establishes a sound sleeping pattern for the child.
It has been noted that young infants who "sleep through the night" have developed the ability to self-soothe when they rouse. Those children who are not able to self-soothe are most likely to have difficulty establishing a settled sleep routine.(12) It is this group for which the approach described is most helpful.

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Conclusion
The "Attention to Sleep Rhythms" approach works particularly well for children aged 8 months to 2 years. Recent research regarding bed sharing and sudden infant death syndrome may cause concern,(13) but with the "Attention to Sleep Rhythms" approach it need not, because the children involved are older than the most vulnerable age for sudden infant death. This approach facilitates the ability of parents to use a consistent, confident approach and benefits the parent-child relationship. Establishing a habit of sleeping through the night with their parents is the first step towards a child sleeping without a parent present. The "Attention to Sleep Rhythms" approach encourages the development of a regular sleep pattern. As Daws states,(7) "Closeness facilitates eventual separation."

References

  1. Kerr S, Jowett S, Smith L. Preventing sleep problems in infants: a randomised control trial. J Adv Nurs 1996;24:938-42.
  2. Galbraith L, Hewitt K, Pritchard L. Behavioural treatment for sleep ­disturbance. Health Visitor J 1993;66:169-71.
  3. Morris S, St James-Roberts I, Sleep J, Gillham P. Economic evaluation of strategies for managing crying and sleeping problems. Arch Dis Child 2001;84:15-9.
  4. De La Cuesta C. Relationships in health visiting: enabling and mediating. Int J Nurs Stud 1994;31:451-9.
  5. Rollnick S. Motivational interviewing; preparing people for change. Guildford: Guildford Press; 2002.
  6. Bowlby J. Attachment and loss. Vol 1: attachment. New York: Basic Books; 1969.
  7. Daws D. Through the night: helping parents and sleepless infants. London: Free Association Books; 1989.
  8. Skinner BF. Science and human behaviour. New York: Macmillan; 1953.
  9. Douglas J, Richman N. My child won't sleep. London: Penguin Books; 1984.
  10. Oswald I, Adam K. Getting a better night's sleep. London: Macdonald Optima; 1990.
  11. Bandura A. Principles of behaviour modification. New York: Rinehart and Winston; 1969.
  12. Deakin A. Children's choice of comforters and their effects on sleep. Br J Community Nurs 2004;9:126-30.
  13. Scheers NJ, Rutherford GW, Kemp JS. Where should infants sleep? A comparison of risk for suffocation of infants sleeping in cribs, adult beds and other sleeping locations. Pediatrics 2003;112:883-9.

Resources
BBC Parenting pages - sleep problems
W:www.bbc.co.uk/parenting/your_kids/toddlers_sleeping1.shtml

British Sleep Society
W:www.sleeping.org.uk

Further ­reading
Birth to Five: Your Complete Guide to Parenthood and the First Five Years of Your Child's Life London: Department of Health; 2004.Available in hard copy or online at  W:www.­publications.doh.gov.uk/birthtofive

Through the Night: Helping Parents and Sleepless Infants Daws D. Free Association Books; 1989.

The Enchanted World of Sleep Lavie P. New Haven and London: Yale University Press; 1996