The more you know about sleeping, the better equipped you can be to sleep well!

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Waking-up, getting-going, settling down, and falling asleep:
Solving problems with day-night transitions and sleep-wake cycles
“The existence of twilight does not obscure the difference between day and night.”
-Samuel Johnson
Why fix the night?
For many living in the industrialized world, cultural and technological revolutions have
created a perpetual twilight. Increased work and school pressures, combined with
electronic lights and cybermedia, have virtually eliminated the natural difference between
night and day.
Meanwhile, many parents ask, “How much sleep is really enough?” In general, sleep
needs gradually decrease with age, averaging: up to 18 hours in infancy, 12-14 hours by
two years, 10-11 hours by twelve years, and 7 hours by fifty years. The day nap of early
life is reclaimed after middle-age. Despite these general patterns, individual sleep needs
vary tremendously. What is enough sleep for some is not enough for others. Sleep phases
vary too. Some people are “larks”; early to bed and early to rise. Others are “owls”; late
down and late up. As discussed below, many children and parents have
neurodevelopmental-biological difficulties with sleep-wake cycle regulation. These
individual differences and cultural factors have combined to create an epidemic of sleep
deprivation. The consequences are significant.
Whether the effects are short-term and obvious or more cumulative and subtle, sleep
deprivation impairs learning, behavior, mood and health – big time! Consequently,
children have difficulties in school, on the playground, and at home. Parents struggle at
work, in their marriages, and with their children. Without sleep, everybody is at their
worst. Despite cultural pressures and individual differences, parents should not be
confused. Samuel Johnson (see above) was right! That people need their sleep is as clear
as the difference between night and day.
Why fix the day?
First things first: Trouble “turning-off” mind and body at night is often associated with
trouble “turning-on” mind and body in the morning. Irregular wake times can cause
irregular sleep times (and visa-versa). Circadian biorhythms can not be established
without predictable “good mornings” and “good nights”. Many children have difficulties
with sleep-wake cycle regulation secondary to more general problems with self-
regulation. For example, most children with ADHD and mood disorders have sleep-wake
problems as part of the package. Whatever the source of the difficulty, parents will have
D A N I E L G . S H A P I R O , M . D .
D E V E L O P M E N T A L A N D B E H A V I O R A L P E D I A T R I C S

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more success fixing sleep problems if they first regulate their child’s morning and
structure up the rest of the day.
Starting the day off right: Too many families begin the day in chaos. The morning routine
does not go smoothly. Frustration mounts. Tempers flare. Battles ensue. Everyone is
angry - and late. Whether or not there is an associated sleep problem, parents and
children want to move through the morning routine pleasantly and efficiently. The
morning environment should be relaxed; free from tension and conflict. This positive
start can set the tone for the rest of the day.
Teaching responsibility and independence: Of course, infants and younger children need
help with various aspects of the morning and daytime routine. However, many parents
find themselves continuing to provide assistance beyond when their children could have
learned to do some things for themselves. At the earliest possible age, parents should give
their children the opportunity to learn important self-care skills; morning and night,
waking and settling. Earlier is easier but it’s never too late.
From whence twilight? What causes problems with sleep-wake cycles and day-night
transitions?
Delays in the development of self-regulation and self-help often result from a
combination of child and parent factors. Understanding the sources of learned
dependence relieves blame and guilt. Such explanation then guides “custom-design” of
strategies to promote healthy day-night routines.
• Child factors
o Temperament
§ Activity level
§ Impulsivity
§ Distractibility
§ Intensity of reaction
§ Adaptability/ flexibility
§ Sensory reactivity
§ Mood
o Neuropsychiatric/ neurodevelopmental disorder
§ Anxiety
§ Depression
§ Bipolar illness/ Severe Mood Dysregulation
§ ADHD
§ Executive Dysfunctions
§ Learning Disability
§ Motor coordination disorders
§ Autism Spectrum
o Sleep disorder
§ Delayed or advanced sleep phase

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• “Owls”: resist bedtime/ delayed sleep phase
• “Larks”: early morning-wakers
§ Night terrors and nightmares
§ Sleepwalking and sleep talking
§ Periodic limb movements
§ Bedwetting (as sleep disorder, arousal failure)
§ Teeth grinding
§ Rhythmic movements/rocking
o Medical illness
§ Apnea/ upper airway obstruction
§ Allergy
§ Seizures
§ Gastroesophageal Reflux (“heartburn”)
§ Any illness; acute or chronic; ranging from ear infection to cardiac
disease
o Chemicals
§ Any medication: for asthma, seizures, allergy, ADHD, sleep, etc.
§ Rebound from medication withdrawal
§ Alcohol
§ Caffeine
§ Passive smoking
• Parent/ environmental factors
o Primary trained dependence: “trained crying”/ “trained night-waking”/
“trained helplessness”
o Secondary reinforcement of child factors; “vulnerable child syndrome”
o Chronic success deprivation: school, social; resulting in avoidance
behaviors
o Child abuse: sexual or physical
o Exposure to violence; real or media; Post-Traumatic Stress Disorder
o Family/ marital stresses
o “Poor sleep hygiene”/ lack of effective morning, day and evening routines
(see below).
Assessment
• Sleep-wake diary: Assessment of problems with sleep-wake regulation and
morning-evening transitions should begin with a sleep-wake diary. For 1-2 typical
weeks, parents should chart times to bed, to sleep, night-waking, and morning
waking, including daytime naps. They should also log their child’s behavior and
their response to that behavior at bedtime, at night-wakings, and at morning-
waking.
• Day-night routines checklist: Parents should analyze their child’s day, from
waking in the morning to falling asleep at night. What works? What doesn’t?

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Especially at transition times, is there sufficient structure and routine? (See
below).
• Medical evaluations: The Pediatrician should perform a screening history and
physical exam. Referral to specialists should be made only if there is a specific
indication.
o ENT: If there is noisy or irregular breathing, an Ear, Nose and Throat
doctor can evaluate for upper airway obstruction. Treatment may include
removal of tonsils and/or adenoids.
o Allergy: If there is chronic congestion, cough, wheeze, or itch, an allergist
may be able to help identify the cause. Treatment may include
environmental control, medication, and or desensitization.
o GI: If there is unexplained irritability or abdominal distress, especially at
night or associated with meals, a Gastroenterologist may be consulted for
the possibility of acid reflux. Treatment includes restrictions on night
feedings, elevation of the head during sleep, and antacids.
o Neurology: If there are abrupt and unexplained changes in mood, behavior
or learning, or an observed seizure, a Neurologist should be consulted for
possible epilepsy; perhaps including a 24 hour sleep EEG. Treatment is
with anticonvulsant medication.
o Psychiatry/ Psychology: If there is anxiety, irritability, or depression, a
Child Psychiatrist or Clinical Psychologist can assess. Treatment is
cognitive-behavioral therapy and/ or medication.
o Developmental Pediatrician, Pediatric Neurologist, Pediatric
Neuropsychologist, or Pediatric Physiatrist: If a parent or teacher suspects
developmental delays or disabilities, early evaluation can guide early
intervention. Treatment includes individualized accommodations and
therapies.
o Laboratory: Blood sample or sleep laboratory investigation is not usually
necessary in pediatrics but may be indicated for mysterious night waking
or excessive daytime sleepiness.
General principles
There is not one best behavioral strategy for all children with sleep-wake transition
problems. However, there are some generally useful principles. (See sessions 1-10,
“Raising Your Challenging Child” for more detailed discussion.)
• Expecting too much: Knowing their child and knowing themselves, parents
should choose an approach that has the best chance of working. Sometimes, this
requires parents to separate their child’s needs from their own. Just because “a
child that age should be able to do such and such” does not mean that they can.
Parents need to be realistic. They should meet their child at his or her current
functional level - whatever that is - and provide necessary supports.
• Expecting too little: Although some children have legitimate difficulties, this does
not mean that they can not learn. “I need help!” is a call for “teaching how”, not

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“doing for”. Realistic goals can be set, one step up from the child’s current
functional level. Difficult tasks should be broken down into manageable steps. If
necessary, parents should provide explicit instruction, demonstration, and then
guided practice. Incremental progress is better than none. Patience can lead to
surprising success. Parents may have their own limitations and restrictions;
personal or circumstantial. If so, they should neither “beat themselves up” nor
assume that they are trapped. With help, most parents can develop effective
strategies that take their own challenges into account.
• Have good reasons, give good reasons: The establishment of healthy habits need
not result in power struggles. “Because I said so,” is never a good reason and it
invites oppositional reaction. Parents should teach their children about the
importance of sleep and routine. Children should understand the reasons for
structure and schedules. They should be given the chance to consider the facts and
come up with their own solutions.
• Do not reinforce noncompliance and dependence: Sometimes, parents are causing
the problem. “Helicopter” or “micromanager” parents should simply back off and
let their children learn to take care of themselves. If such parents are just too
anxious to disentangle, this is not their fault, but they should seek supportive
counseling and coaching. More often, parents do not cause their child’s sleep/
wake problem but they may over-react and unintentionally reinforce poor self-
regulation.
• Have reactive strategies ready: Parents should avoid power struggles. For non-
compliance, they should have a rehearsed response. As children get older, it is
appropriate to respond empathically and engage in collaborative problem solving.
For younger or immature children, parents should ignore inappropriate requests,
demands, “curtain calls”, dawdling, over-reporting, exaggerated fears, or other
attention-seeking or avoidance behaviors. Time-out should be used only for very
significant harm. Whether using ignoring or time-out, parents should watch their
technique; that is, “immediate, non-verbal, and non-emotional”.
• Be proactive: In the heat of the moment, plans should be implemented, not
debated. Advance planning is always more thoughtful and effective than reactive
improvisation. Preemptive strategies can be discussed and rehearsed.
Expectations and responsibilities can be clarified. Fortunately, most sleep-wake
transition problems occur with aggravating regularity. This predictability makes it
easy for families to anticipate trouble and head it off.
• Use external prompts and cues: Despite all the explanation and rehearsal in the
world, some children still have trouble remembering. Parents should not
underestimate the importance of visual schedules, check-lists, cue cards, timers,
alarms, and programmable electronic reminders. Children should be shown how
to refer to these aids, frequently, before and during the performance of their
routines. Learning to depend on these time management tools prevents learned
dependence on parents. These aids should be modified over time but not
necessarily withdrawn. After all, adults need ways to track what to do and when
to do it.
• Not too long, not too short: Everybody transitions in and out of sleep at different
rates. Some children need more time to complete their morning and evening

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routines; others need less. Parents should think about how long it takes for their
child to rev up and settle down. They should schedule accordingly.
• Motivation
o Natural consequences: In parenting, sometimes less is best. By stepping
back, parents allow children to learn the natural consequences of their
actions. For the child who is late getting up and getting going, the natural
consequence will be late arrival for school or other preferred activities. For
the child who is late to sleep, the natural consequence will be fatigue.
Parents should not allow natural consequences that are serious and long-
term. However, letting a child experience minor time-limited setbacks
may be instructive and self-motivating.
o Logical and effective sequences: The morning and evening routines should
be sequenced such that less desirable activities precede favored activities.
Parents should identify what parts of the routines the child enjoys least and
most - then save the best for last. Logical sequences should be carved in
stone: first this, then - and only then - that. For example, if a child likes
breakfast but does poorly getting dressed, then no breakfast until all the
clothes are on. If he or she likes story time but resists brushing teeth, no
reading until brushing is done. More applications of this very effective
strategy are discussed below. (See “day-night routines”.)
o Sufficient positive attention, gradually faded: All too often, parents pay
attention only in reaction to their child’s non-compliance, or they withhold
praise until multi-step tasks have been completed. But as children begin to
comply, parents should take note and not wait to communicate their
appreciation. During the morning and evening routines, it is crucial to
give frequent and immediate positive attention at each point of
performance. Parents should be ready to praise their children at each and
every step. Praise should be tailored to the child’s profile; verbal vs. non-
verbal, overt vs. subtle. Only after successful routines are well established,
parents can space their positive feedback, promoting independence by
fading their support gradually and incrementally.
o Rewards systems: Despite good routines and positive attention, some
children need greater incentive. When other strategies are not motivating
enough, supplementary reward systems can effectively target specific
“breakdown points”.
• Beware “too many chefs in the kitchen”: During difficult transitions, parents
should be focused on the child, not each other. Children quickly learn to play
parents (or other caretakers) off against each other. One adult should manage the
morning or evening routine, preferably the one who is less likely to get drawn into
verbal or emotional interactions. Often, scheduling realities determine who’s in
charge. Others should clear out. Literally. The designated non-manager should
take advantage of this time to run some errands, get some exercise, do some work,
read; or do something (well enough away) with the other kids.
• Beware too many kids: When possible, parents should divide and conquer.
Different children have different needs. If day-night transitional choreography is
complicated enough with one child, then adding another to the dance turns a tango

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into a mosh-pit. Instead of focusing effectively on one child’s needs, parents can
find themselves struggling to manage the dynamic between the children. By
separating children, parents eliminate disruptive back and forth talking, playing,
irritating, distracting, stirring-up, and partying. For children who have sleep
problems, separate rooms are always best. If this is not feasible, then stagger bed
times. Single parents with more than one child need to become skillful in parallel
scheduling, assigning specific activities to other children while giving necessary
attention to one.
• Keep the faith: Parents should never assume that things can not be better. There is
always something new to try. Strategies that failed before might work better now.
Even minor technique tune-ups can make a big difference. Once a strategy is
selected, parents need to demonstrate self-control and resolve. They need to
support each other, consistently implementing the agreed upon plan, especially if
it does not work right away. Perseverance usually pays off.
• But faith should not be blind: In general, new behavioral interventions should
show some signs of working within one week of proper initiation. If there is no
progress, parents should review their technique or consider modifying their plan.
Professional consultation can be helpful.
Day-night routines
Let’s apply the general principles discussed above to specific strategies for waking up,
getting going, settling down, and falling asleep. Parents should not try to implement all
these changes at once. Rather, start with the morning routine, then structure up the
daytime routine, evening routine, and finally sleep. This dawn-to-dusk approach usually
works best.
• Regular morning routine
o Setting a wake-up time.
§ Make it regular: Set a specific wake-up time for weekdays and, if
there are no scheduled activities, an approximate wake-up time for
weekends. For children with sleep-wake cycle regulation
problems, the weekday and weekend wake-up times should not be
much more than an hour different; otherwise it’s like traveling
between time zones several times each week! Irregular start times
and perpetual jet-lag are very disruptive to the establishment of
regular sleep-wake cycles.
§ Not too late: Some children need a long time to “get the sleep out
of their eyes” and gradually power-up. They might need an earlier
wake-up time. Deliberately postponing morning preparations by
allowing extra lounging time can make things go more smoothly. It
is easier to start a motor if it has had a chance to warm up.
§ Not too early: Some children wake up much too early. They have
too much time before it’s time to get ready. Others blaze through
their morning routine. They have too much time before it’s time to

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go. If the child has a sleep phase disorder (“lark”), try gradually
resetting their sleep clock. (See chronotherapy below.) If attempts
to set a more appropriate wake-up time fail, then schedule very
specific non-disruptive activities to fill the gap. Until the family’s
wake-up time, the child should quietly entertain him or herself
without any attention from parents.
§ Promote independence: Children should be taught how to wake
themselves up and when to refrain from waking others. From an
early age, they should learn to refer to the presence or absence of
sunlight. As they get older, they should learn to use simple alarm
clocks. For late-wakers, parents may first have to couple the alarm
with their own direct assistance. Once conditioned to wake to the
alarm, children should be expected to wake without needing their
parents. For deep sleepers, there are all sorts of very loud alarms;
some even flash lights off and on. Some people use two alarm
clocks, one right by the bed, another across the room. Pity the
freshman college student who has never learned how and when to
wake-up.
§ Bed wetting as “arousal failure”: Most bedwetters do not have a
bladder problem per se. They just sleep too deeply, right through
bladder-to-brain wake-up calls. Conditioning such a child to stay
dry means “outsourcing” the signaling system. Parents should not
carry or drag a minimally conscious child back and forth to the
bathroom. This may keep the bed dry but it does not solve the
problem. Bedwetters can be taught to set an alarm clock to wake
and void just before they would have otherwise wet the bed. On
hearing the alarm, the child should be coached to go to the
bathroom and back to bed, gradually moving the void time closer
to their bedtime and requiring less assistance. Or they can wear one
of the commercially available electronic wetness alarms in their
pajamas. Such external signaling techniques require a motivated
child, parent and child training. Initial parent support is gradually
faded as brain-bladder signaling, self-arousal, and self-help is
successfully conditioned.
o Anticipation: The evening routine should include a preview of tomorrow’s
schedule and advance preparation of necessary items. (See evening routine
below.) Don’t put off for morning what can be done the night before.
o Logical and effective sequences: Structure the morning so that the child
has something to work towards. For example, Tommy’s parents have
come up with the following morning routine: go to the bathroom, wash
hands then face, get dressed, eat breakfast, brush teeth, get back pack,
then leave for school. This works for Tommy because he is motivated to
reach two strategically sequenced (italicized) points: he likes breakfast and
he hates being late for school. Before he gets either, he has to do the
preceding steps in the sequence.

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o “I’m ready when you are”: To help their child through the morning
routine, parents should position themselves ahead and wait rather than
pushing from behind. For example, instead of staying upstairs nagging
Tommy to get dressed, parents should go downstairs and prepare
breakfast, withholding it temporarily if he comes down before getting
dressed. Instead of repeating requests to hurry up and get in the car,
Tommy’s parent could simply get in the car (relaxing with a cup of coffee
and the newspaper) and wait for him to come out. If he walks to the bus or
rides with a carpool, his parent could wait outside or stand silently at the
door. Parents should never threaten to leave. By eliminating power
struggles and waiting ahead, they can take advantage of the fact that most
children do not like being last or even temporarily alone.
o Eliminate distractions: During difficult transitions, TV, video games, toys,
- any extraneous activity - even books should be made unavailable or
strictly prohibited. If an easily side-tracked child does not follow the rules,
parents may have to take charge. Sometimes this means toy lock-ups or
high-tech controls (e.g. TVallowance.com, Net Nanny, and Cyber Sitter).
Siblings are another common source of distraction. Parents might have to
stagger sibs’ morning schedules or physically separate them.
• Regular daytime routines
o Regular meal, work, play and study times: Erratic days lead to erratic
nights. Schedule up to avoid a vicious cycle.
o Regular chemistry: For children taking medication, doses should be
administered at approximately the same times each day; 7 days per week.
Irregular dosing can contribute to irregular sleep-wake rhythms.
o Regular exercise times: At least 30 minutes of aerobic exercise every
afternoon promotes the development of good sleep/ wake cycles; plus, of
course, general physical and emotional well-being. Exercising after dinner
can interfere with settling down to sleep.
o Regular stay-awake times: It is important to build up “sleep debt” by
deliberately limiting or eliminating naps. Sleeping too much or sleeping
too late during the day makes it much harder to sleep at night.
• Regular evening/ bedtime/ sleep time routines
o Set a specific dinnertime, bedtime, and sleep time:
§ Top priority: the “3 Rs” - Regularity, Ritual and Routine. Parents
should not underestimate the importance of a regular family dinner
and evening routine. Environmental predictability relieves stress
and fosters resilience. Rehearsal and repetition promotes
efficiency, prevents conflict, and makes for smoother transitions.
Familiarity can be emotionally grounding; even spiritually
centering.
§ Allow enough sleep for normal daytime functioning and enough
transition time to relax and unwind. Remember, needs vary from
person to person.

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§ Avoid large weekday/ weekend discrepancies. Remember, constant
jet-lag is tough.
o Sequence the routine from less calming to more calming. As bedtime
approaches:
§ Avoid exercise, rough-housing, or very active play.
§ Avoid emotional or intellectual activation. In general, reading may
be relaxing, but not if the book is a murder mystery. Listening to
music may be soothing, but not if it’s “heavy metal”. Playing a
card game of “solitaire” may be quieting, but hard to stop. Also
remember: what is activating for one person may be calming for
another.
§ Avoid conflict and stress. Serious discussions should be held very
early in the evening or deferred until the next day. Contrary to
common practice, parents should respond to bedtime anxieties with
brief reassurance, reserving more prolonged discussion for the
light of day.
§ Avoid chemicals. For six hours prior to bedtime, no caffeine, no
alcohol, no illicit drugs, and no cigarette smoke.
§ Move into a calming environment. Custom design in advance.
Bedtime is not the time to re-negotiate predetermined
accommodations; such as the following:
• To control noise (e.g. TV, street, other awake people); use
earplugs, white noise, calming music.
• To control light (e.g. sun light, TV/ video/ computer
screens); use effective window blinds, sleep masks,
electronic screens off, barriers.
• To control climate (e.g. 65-72 degrees); use thermostats,
blankets, space heaters, humidifiers/ vaporizers, fans.
§ Beds are for sleeping: One type of conditioned association
involves the use of the bed for work, eating, or play. It is harder to
fall asleep if the bed is regularly associated with activities that
require wakefulness.
o Sequence the routine from less desirable to more desirable. Just like the
morning routine, pleasant activities (italicized in the following example)
should be strategically ordered to motivate completion of preceding tasks;
e.g. clear the table, do homework, screen time; prepare for tomorrow,
quiet play with parent; brush teeth, bath or shower, pajamas, toilet, read
or listen to music in bedroom with parent then read or listen to calming
music in bed without parent, then lights out. Before you can do this
(desirable), you have to finish that (not so desirable).
o Preparing for tomorrow includes:
§ make lunch (or at least help/ discuss)
§ organize back pack and set in designated place
§ consult tomorrow’s schedule and the weather report
§ choose and lay out clothes with shoes

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o Screen time includes: TV, video games, computer/ internet. Rules
regarding time and content should be clearly stated and enforced. Rule
violations result in loss of electronic privileges for 24 hours. Electronic
parent controls (software and external devices) simplify enforcement.
• Regular sleep routine.
o Avoid learned dependence: It is very important to separate bedtime
(parents on duty) from sleep time (parents off duty). Especially at
younger ages, parents can be involved in bedtime, helping to create a
relaxed environment and a routine conducive to falling asleep. They can
also give positive attention for compliance with the evening routine.
However, even during infancy, parents should not assume any
responsibility for the actual transition into sleep. If parents make it their
job to get the child asleep, the child becomes either more resistant or more
dependent. “No-no’s” such as rocking to sleep, feeding to sleep, lying
down with to sleep, family beds, back-rubbing to sleep, singing to sleep,
reading or telling stories to sleep all deny the child important opportunities
to learn self-settling. On occasion, when circumstances are compelling,
parents can lend their presence to sleep time. But as a rule, parents should
say a simple good night and leave their child, sleepy but awake, to make
the wake-sleep transition independently. Children need to learn how to fall
asleep on their own.
o Avoid problematic learned associations: In order to shift from wake to
sleep, children not only learn to depend upon the presence of specific
people (a parent, sibling, grandparent or pet); they may also be
conditioned to need certain objects or routines.
§ Oral: First transition objects often include oral comforters; such as,
pacifiers, breasts, bottles, thumbs, cups; any food or drink.
§ Scripts: Transition rituals might include inflexible adherence to a
specific order of events, songs, stories, or prayers.
§ Favorite things: Common transition objects can become too
essential; such as, blanket, pillow, stuffed animal, or toy.
Increasingly, electronic devices (TVs, computers, and I-pods), are
becoming comforters of choice.
§ Space/ place: Many children develop very specific environmental
preferences regarding lighting, music, white noise, temperature,
fans, etc. Some children learn to fall asleep only on their parents’
bed, their siblings’ bed, or on the living room sofa.
§ So what? Not all these learned sleep-onset associations are bad.
However, some are unhealthy, undesirable, and inconvenient.
Some are problematic only because they turn normal cycles of
light sleep into full-blown craving arousals, disrupting the sleep of
others upon whom the child depends to provide the necessary fix.
Without the transition object or routine, it may be impossible for
the child to fall asleep at the beginning of the night or fall back
asleep upon waking in the middle of the night.

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§ Avoiding bad habits: Children should be given the opportunity to
learn addiction-free self-settling. Understandably, loving parents
may have some difficulty separating their own needs from their
child’s needs. At the earliest ages, children should fall asleep in
their own beds without their parents and without unhealthy learned
associations. For example, infants should not be rocked or fed to
sleep; they should be put down sleepy but awake.
§ Breaking bad habits: Although it’s easier to break these habits
before they become too firmly established, it is never too late.
Parents should decide whether to wean gradually or simply remove
“cold-turkey”. Like breaking any habit, this takes persistence.
Motivation comes from remembering the importance of
eliminating objects and routines that interfere with the
development of self-calming.
Sleep strategies
Realistic goal #1: Getting your child to sleep? Not! Rather, “Learn to get yourself
asleep.”
• Teach self-calming: For some children, daytime stresses make it hard to fall
asleep. For others, insomnia actually stems from anxiety about not being able to
fall asleep. Many children have difficulty turning off their minds and bodies; “I
just can’t fall asleep!” Whatever the source of the trouble, parents should not
assume responsibility for solving the child’s sleep problem. There should be no
extended stories on demand, no food or drink, and no overindulgence regarding
reported anxieties or fears. Parents and children should not ruminate about the
problem. “Just try to fall asleep,” is not helpful advice. Instead, the child should
be prepared to use self-calming techniques. During the day, he or she should be
introduced to a “menu” of age-appropriate strategies. After some instruction,
practice and a trial, they can choose to continue strategies that work best. Specific
techniques might work well for some children, but not for others. At the earliest
possible age, the responsibility for solving the sleep problem should shift from the
parent to the child. Whatever techniques are taught, it is crucial that the child
learns to use the technique independently. See “Teaching Your Child How to
Manage Their Own Anxiety” for a thorough discussion of self-calming
techniques; including the following:
o Cognitive techniques
§ positive self-talk, power of positive suggestion, “magic”
§ positive imagery: “my favorite place”, pleasant or interesting
distractions
§ paradoxical suggestion: “I will not fall asleep, I will not fall
asleep.”
§ meditation
§ self-hypnosis

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o Neuromuscular techniques:
§ progressive muscle relaxation
§ yoga
§ biofeedback
§ olfactory techniques: lavender scented eye-pillow
o Substitution of calming activities (note: what is calming for some can be
activating for others)
§ music
§ reading
§ drawing/ crafts
§ solitaire
• Graduated extinction/ “spacing”: With this strategy, parents check-in briefly.
Without interacting, they progressively shorten their time in the bedroom and
lengthen the time between check-ins - no matter what! Tolerating (ignoring)
crying may break a cycle of learned behavior. If the child leaves the room, he or
she should be returned immediately; in doing so, parents should not show any
emotion, they should not interact at all, and they should not say a single word. If
the child leaves again, then the child should be returned in the same manner and
the door should be locked. (See session on “time-out”.) If there is no progress
within one week, re-evaluate.
• Parent fading: Children need to learn how to fall asleep on their own and in their
own beds. But with this softer approach, parents first lend their presence and then
gradually fade. Until sleep, the parent stays in a chair near – not on or in - the
child’s bed. The child stays in their bed. There should be no parent-child
interaction. If the child talks or cries, the parent immediately leaves the room
without saying a word. After a few minutes the parent can return saying only, “I’ll
stay quietly in my chair if you stay quietly in your bed.” If the child is non-
compliant, then the parent should leave again and shift to the graduated extinction
strategy described above. If the child is quiet, then the parent can very gradually
increase the distance between their chair and the child’s bed while decreasing the
time spent in the child’s bedroom. If the child has been falling asleep in his or her
parent’s bed, a temporary transition maneuver may be necessary; that is, the child
can be moved to a mattress on the parents’ bedroom floor before relocation to his
or her own bed.
• “Bed-time pass”: Parents give their child a Bed-time Pass, a card he or she can
exchange for one parental visit. The pass can be used to satisfy one acceptable
request; e.g. a drink of water, a hug, etc. Afterward, the child gives up the pass
and parents ignore any further requests or attention-seeking behaviors.
• Bedtime/ sleep phase shifting or “chronotherapy”:
o “One big step back; then one little step earlier, then another, then another”:
First, parents should keep their child up until one half-hour past the natural
bedtime; that is, the time when he or she would finally run out of steam
and fall asleep without difficulty. Then, very gradually (week by week)
and incrementally (5-15 minutes earlier), this delayed bedtime can be
shifted closer to the desired bedtime. Taking advantage of natural
exhaustion can mean less crying but a more gradual process.

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o “Later and later and later and later equals earlier”: With this radical (rarely
used) approach, parents keep the child awake, later and later and later and
later; pushing the bedtime back every 1-2 nights, all the way around the
clock, until the actual sleep time matches the desired sleep time.
• For “relapse” secondary to illness, trips or other disruptions: Parents should
quickly reclaim ground previously gained; that is, reestablish the desired sleep
routine ASAP. If necessary, they may have to repeat behavioral strategies that
worked before.
Realistic goal #2: Staying asleep? Not! Rather, “Learn to get yourself back to sleep.”
• Normal night waking: As children cycle through the different phases of sleep, a
certain amount of night waking, partial or complete, is perfectly normal. Some
people are especially light sleepers. Others wake-up for all sorts of reasons.
Although parents can not order their child to stay asleep, they can expect their
child to settle him or herself back to sleep when they do wake up. Of course,
parents should help their children through major distress but children need to
learn to help themselves through minor illness and discomfort. That expectation
should be clearly communicated.
• “Don’t wake us up”: If children are led to believe that it is ok to wake up their
Mom or Dad, they will not have the opportunity to learn self-settling, their
dependence will be reinforced by parental attention, and they will not be
compelled to consider the needs of others. (Parents have needs too.) Once again,
although parents can not order their child to sleep through the night, they can -
and should - request uninterrupted sleep for themselves.
• First things first: Before a child can self-settle back to sleep (after waking in the
middle of the night), her or she must be able to self-settle into sleep (at the
beginning of the night). Therefore, parents should fix the front end of the evening
first, using one of the sleep initiation strategies described above. Once a child has
learned to fall asleep on his or her own, night-waking problems become much
more manageable, sometimes even disappearing.
• Wait to respond: If parents hear their child wake in the middle of the night, they
should not rush right in. Sometimes the child is only half awake. Given a few
minutes, some night-wakers will fall back asleep entirely on their own. Even if he
or she needs some parental reassurance or assistance, deliberate delay sends a
clear message: in the middle of the night, do not expect us to instantly materialize.
After pausing, if parents have to respond, they should do so briefly and with
minimal interaction, resorting to the graduated extinction strategy described
above.
• Sleep restriction: Sometimes, less is more. Some children pay off their “sleep
debt” too early and wake in the wee hours. Parents can increase the child’s sleep
debt by limiting day naps, delaying night bedtimes, and/or waking the child
earlier in the morning. These maneuvers might lead to a more solid block of night
sleep.

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• Scheduled preemptive waking: This strategy can work well if the child has
disruptive or dangerous behaviors which occur at approximately the same time
each night. Such timed “dyssomnias” include night terrors, nightmares, sleep-
walking, sleep-talking, teeth grinding, rocking, and head-banging. Because these
behaviors are often linked to specific phases in the sleep cycle, resetting the sleep
cycle may work. Parents can wake their child very briefly, one half-hour before
the earliest regular disruption, and then let him or her fall right back to sleep.
Medications for sleep-wake cycles and day-night transitions
Although medication is never the whole answer, it can be a helpful part of an
effective management plan. Medicine can be used short-term to break an insomnia
cycle or longer-term for more “hard-wired” sleep disorders. These medications work
best if given on a regular basis, not as needed; that is, in anticipation of sleep
problems rather in response to trouble falling asleep. The timing of the dose should
depend upon the observed “kick-in” time. The size of the dose should be increased or
decreased to maximize effectiveness and minimize side effects. The most common
side effect is morning grogginess. All sleep medications have the potential for
tolerance; that is, they may lose their effectiveness over time. However, when used in
combination with behavioral strategies, medications may be weaned before tolerance
develops. Valium-like barbiturates have addictive potential and are not recommended
for children. With medical consultation, parents can consider the following options on
a trial basis:
• Benadryl (diphenhydramine): This short-acting antihistamine can back-fire in a
small percentage of children who have “paradoxical hyperexcitability”. However,
for most children, it is reliable, safe and effective. A good first-line old stand-by.
Fringe benefit if allergies coexist. No prescription needed.
• Melatonin: A “natural” human hormone that regulates sleep-wake cycles. Used
by international travelers to treat jet-lag. Two mechanisms of action: (1)
“hypnotic” sedative effect, 30 minutes after administration and (2)
“chronobiologic” sleep-clock-setting effect, 4-5 hours after administration.
Consequently, some children do best taking melatonin 30-60 minutes before
bedtime; others, at dinner time or before. Dose for younger children, 1-3 mg; for
older children and adults, 3-6 mg. No prescription needed.
• Remeron, Tofranil (imipramine), or Trazadone: One of these prescription
antidepressants could be considered if a child has trouble with sleep initiation or
sleep maintenance, especially if associated with poor appetite, anxiety or
depression. In particular, Remeron can stimulate appetite. For some, this is a
blessing; for others, a curse (requiring discontinuation). Other side effects are
those associated with any antidepressant, the most common being decreased
inhibition/ over-activation.
• SSRIs such as Prozac, Zoloft and Lexapro: If sleep or transition problems are
obviously secondary to anxiety or Obsessive-Compulsive Disorder, this family of
medicines can supplement cognitive-behavioral strategies.

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• Neuroleptics and mood stabilizers: Only for sleep disorders associated with
severe disorders of mood regulation. These are serious medicines for serious
problems.
• Clonidine: Originally used for the treatment of hypertension, then as a second line
medication for ADHD and tic disorders/ Tourette’s Syndrome. Clonidine is not a
great daytime medication (for anything) because of its common side effect:
sleepiness! A long-time favorite in the treatment of insomnia associated with
either untreated or treated ADHD.
• Ritalin and other stimulants used to treat ADHD!
o Everybody knows that these medications can cause insomnia. However,
many children with ADHD have trouble falling asleep before they receive
any treatment. Why wouldn’t impulsivity, hyperactivity and distractibility
interfere with sleep onset? Contrary to common assumptions, treatment of
these symptoms in the evening with a short acting stimulant can actually
help some children settle down. Caution: Late afternoon or evening
stimulants certainly can make things worse. If this strategy is selected, the
first trial should be on a Friday or Saturday night with nothing important
planned for the next day and a good movie on hand for late night viewing-
just in case!
o If behavioral strategies are insufficient in the management of morning
distractibility and lack of mental energy, options include;
§ rapid onset stimulants such as Ritalin on waking or 30 minutes
before
§ Strattera the night before
§ Daytrana patch ineffective unless applied very early
• Ambien and Lunesta: These popular adult sleep aids are tempting but parents and
pediatricians should exercise restraint (for now) because of lack of research in
children.
• Light therapy: Commercially available white or blue light boxes have been shown
to help with morning mood and energy.
References:
1. Baker and Brightman, Steps to Independence, Teaching Everyday Skills to
Children with Special Needs
2. T. Barry Brazelton, Touchpoints
3. Howard Bennett, Waking Up Dry
4. Richard Ferber, Solve Your Child’s Sleep Problems
5. Mark Durand, Sleep Better, A Guide to Improving Sleep for Children with
Special needs
6. McClannahan and Krantz, Activity Schedules for Children with Autism, Teaching
Independent Behavior
11705 MAGRUDER LANE • ROCKVILLE, MARYLAND • 20852
PHONE: 301-881-6855 • FAX: 301-881-9849

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