At various stages of childhood, children may wake up in the middle of the night and request assistance from their parents to help them go back to sleep. There can be many reasons why a child might wake up during the night, and a sensible and informed approach on the part of parents will do much to reduce or even eliminate any stress that might arise as a result of these occurrences.

The prevalence of unusual night wakings is difficult to calculate without information on the child’s daily routine and an accurate measure of his dietary and emotional stresses. One study found that twenty-five of sixty children (42 percent) had sleep disturbances, as reported by their parents.’ The most common problem was night waking, which (22 percent) of the children experienced, according to their parents. Thirteen percent of the children in this study were reported to resist bedtime, and 7 percent experienced both night waking and bedtime struggles.

Although we can guess that the vast majority of these “problems” were a result of avoidable stresses, misaligned internal clocks, and lack of healthy bedtime rituals, the authors of this study noted that persistent sleep disturbances were significantly related to an increased frequency of stress factors in the environment. Additionally, 20 percent of the mothers at initial interview and 30 percent at three-year follow-up perceived their child’s sleep disturbances as stressful to them and to their family life.

In other words, sleep disturbances probably lead to a vicious cycle, wherein the stress that causes sleep disturbances leads to more stress, which leads to more sleep disturbances, and so forth.

On a similar note, one very troublesome study found that infants who woke up and required parental care during the night were rated as significantly more “difficult” by fathers than by mothers. I think that this study reflects the problem that many fathers in our culture face: a feeling of alienation from parenthood.

Both mothers and fathers may think of night wakings as a sign that their baby is “difficult” if no one has shown them how to bond effectively with their baby Fathers in our culture have traditionally been discouraged from forming supportive, nurturing, emotionally healthy, and mutually beneficial bonds with their children.Thankfully, this is changing.

In general, though, we should remember that a child is more likely to wake up during the night and require assistance if he has been subjected to disruptive substances and influences during the day Whatever the cause, when faced with a night-waking situation, parents need good advice on how to handle it intelligently and compassionately

In approaching night wakings, the first thing I tell parents is that the reason why a child awakens in the night is usually related to the child’s age and stage of emotional development. Consequently the approach that parents take should reflect this fact.

Using music to help you relax is one of the easiest ways to de-stress. Music feeds your brain as well as your emotional well-being. Mozart’s music, for example, has been shown to resonate at deeper levels of consciousness; the sound of a crystal or Tibetan bowl, when struck, will fill your whole being.

Relaxing music and sounds can also lower brain waves and heart rate (listening to Albinoni’s Adagio is one of the most famous examples of this phenomenon). A nice thing to know, too, is that if a piece of music seems relaxing to you, it is. For me, for example, it’s Gregorian chant.

Don’t forget that the opposite is also true. Wailing dolphins may be music to some people’s ears, but will leave others wondering what all the fuss is about. Today there is a whole industry devoted to soothing relaxing music specifically to help promote sleep. Until I developed insomnia I would never have thought of using them.

Now, I’m a convert. Playing them before you go to bed, and in bed, can also make you feel safe and secure. So much so that silence during the night now seems uncomfortably quiet. Just remember you need a CD player which switches off silently, or has a repeat button. Another tip is to play the music softly: the aim is to create a soothing environment, not recreate the Albert Hall

For some people, certain voices or radio programmed have the game calming effect as music – Radio Test Cricket coverage is one well-known example. Many people who have difficulty sleeping sleep with their radio permanently on, burbling away softly in the background. I have one insomniac friend who plays story tapes in the small hours.

Hypnosis tapes quickly become reliable dummies as well. Scientists and music are merging fast. Spanish geneticists have recently produced a CD tape of “DNA music” maybe a serotonin and melatonin adagio is the miracle cure we need.

I have prepared a great “Natural Sound Remedies Program” for you. Is limited to certain time only.

Commentary: Free of side effects, inexpensive, and known to promote relaxation, reduce agitation and even pain, we can now add insomnia to the list of benefits of music. Hopefully, it won’t keep the neighbors up.

The best treatment for insomnia depends on what is causing the problem. For example, if the problem is a result of depression or anxiety, then the best treatment is psychotherapy or medication, such as an antidepressant or anti anxiety drug. In addition, it is important to determine whether another sleep disorder, such as sleep apnea or restless legs syndrome, is causing you to have problems falling asleep. What feels like insomnia to you may actually be another problem. If this is the case, treating the actual sleep disorder will cure the problem.

If your insomnia is not caused by depression, anxiety, or another sleep disorder but involves some other disturbance of your normal sleep routine, there are two primary options.

MEDICATION. Many people try medication for insomnia. Some of the more common ones are Ambien and Sonata. A newer choice is Estorra, with several other sleeping medications about to be sold in the United States. These medications have been found to have few negative effects, and recent studies indicate little tolerance over long periods, whereas in the past, it was recommended that sleeping medications not be taken for more than two to three weeks. Drugs to help you sleep at night may not always be a good long-term solution, however drugs are not always the answer.

STANDARD TREATMENT FOR INSOMNIA. Research has shown that standard cognitive-behavior therapy is the most effective treatment for insomnia. Study after study has shown that if you diligently follow the seven rules outlined in the box below, you can successfully fall sleep and stay asleep.

In addition, there are other things that you can try to help you sleep better.

• Relaxation. Research has shown that relaxation training is effective in 45 percent of cases. You can learn to relax using a number of different techniques, including progressive muscle relaxation, guided imagery, and meditation. Several methods are covered in Chapter 9. There are also several good books available to teach you ways to relax.
• Hot bath. A twenty-minute hot bath taken an hour or two before bedtime can often help you to sleep. The hot bath affects body temperature, which makes you tired and helps to prolong deeper natural sleep. Be careful about hot baths if you have any circulatory disorders. If this is the case, consult your physician first.
• Keep a strict sleep schedule. It is best to maintain a strict sleep schedule in which you go to bed at the same time every night and wake up at the same time every morning.
• Don’t stay in bed too long. One problem that people often have is staying in bed too long. Don’t stay in bed nine or ten hours if you need only eight hours of sleep. It is better to be in bed only the exact number of hours that you need sleep. This is called sleep restriction. It will consolidate your sleep, especially if you have long periods of being awake in the middle of the night or wake too early in the morning. To do this, you will need to keep a sleep diary to determine how much you actually sleep. Many people believe that they, sleep less than they actually do. By keeping a sleep diary for two weeks you can figure out the average amount of time you sleep per night. Then for the first five to seven days limit the time you are in bed each night to the average number of hours that you actually slept for the past two weeks. Once you are sleeping the entire time that you are in bed, gradually increase the amount of time that you allow yourself to sleep. Increase this time by small amounts, anywhere from fifteen to thirty minutes. This method will help consolidate your sleep and will help you associate your bed with sleep. This process can take from a few days to several months to accomplish. The one side effect that you need to be aware of is that you may be sleepy during the day from the initial sleep deprivation.
• Reduce alcohol and drug use. Alcohol and drugs interfere with sleep. For someone with a drug or alcohol problem, withdrawal can occur in the middle of the night, causing the person to wake. Reducing or eliminating alcohol and drug use is beneficial to combating insomnia.
• Watch the clock and stay up as long as possible. Some people get caught in a vicious cycle of trying without success to fall asleep and then becoming frantic. Being frantic does not help falling asleep. If this is true for you, simply watching the clock and trying to stay awake as long as possible will break this pattern. Do this for a few nights in a row, and you will learn that you can still function the next day with less sleep than you would want. You will also decrease the worry when you can’t fall asleep on other nights. This suggestion, while it seems to counter all the other advice provided in this book, can be helpful for some, but it may not work for all.

Insomnia usually begins during a person’s late twenties or early thirties. Many people suffer for years before seeking help, and many simply treat themselves by using drugs or alcohol to help them sleep at night and by drinking a great deal of caffeine during the day to combat their sleepiness.

There are two primary symptoms of insomnia:

• Difficulty sleeping. People with insomnia have problems sleeping: trouble falling asleep at night, waking in the middle of the night, or waking up too early in the morning and not being able to return to sleep.
• Daytime fatigue. The result of not getting a good night’s sleep is being tired during the day. This can lead to a significant impact on daytime functioning at home, on the job, and socially. Although people with insomnia often feel fatigued, they usually are not excessively sleepy.

Other symptoms include:

• Effects on mood. Many people with insomnia feel depressed or anxious. They may be irritable and have little energy.
• Decreased attention and concentration. As a result of the sleep deprivation caused by insomnia, some people will have problems with concentration at work or at school, especially when listening to a lecture or in a meeting.

What Causes Insomnia?

Insomnia can have many different causes, which makes it different from the other sleep disorders discussed. Again, it is important to understand that not all people who have problems sleeping actually have insomnia. Many other sleep disorders, such as sleep apnea and restless legs syndrome, interfere with a person’s ability to fall asleep and thus are experienced as insomnia. For those who do have insomnia that is not the result of another sleep disorder, it can be the result of many factors.

For example, some people have insomnia as the result of anxiety or depression. However, most people’s insomnia is learned. Something happens that interferes with a person’s sleep, whether it is the birth of a baby, illness, pain, or shift work. Once the sleep becomes disturbed, it continues to be problematic because there is a continued association between sleeplessness and situations and behaviors that are associated with sleep, such as lying in bed.

Then lying in bed where you just spent several sleepless nights will cause you to feel tense and frustrated. These feelings will make it even more difficult to fall asleep. Once the pattern is established it can continue for months or years. Also, poor sleep habits often develop, such as spending too much time in bed, not keeping to a consistent bedtime and wake time, and napping during the day.

An additional problem can be negative thoughts about sleep and being unable to fall asleep. This is experienced by many insomniacs and also leads to a vicious cycle: the more you try to sleep, the more agitated you will become, and the less likely you will be able to fall asleep. Trying too hard to fall asleep can simply add to the problem. Also, thoughts such as “I will never be able to fall asleep” contribute to the problem.

A number of factors put children at risk for sleep apnea. These include:

• Tonsils and adenoids. As mentioned earlier, most children with sleep apnea have enlarged tonsils and/or adenoids. Once the muscles in the neck relax during sleep, the big tonsils or adenoids block the airway and impede breathing.
• Illness. Children with frequent ear infections, sore throats, and tonsillitis are more likely to have sleep apnea. Allergies and asthma also can contribute to sleep apnea.
• Weight. Sleep apnea is more common in children who are overweight, as the extra weight around their necks can make their airways smaller. Not all children with sleep apnea are overweight, however. Many children of normal weight have sleep apnea, and children with sleep apnea can even be underweight.
• Physical structure. Other children who are at high risk for sleep apnea include those with abnormal bone structure in the jaw area. For instance, children who have a receding chin may have a smaller airway. Another potential cause may be a cleft palate, particularly if it has been repaired.
• Decreased muscle tone. Children with decreased muscle tone, as a result of such conditions as cerebral palsy or muscular dystrophy, are at risk for sleep apnea.
• Down syndrome. Children with Down syndrome are at risk for sleep apnea because they are often slightly overweight and because they often have an enlarged tongue that can block the airway during sleep. Studies have shown that almost half of all children with Down syndrome have sleep apnea.

Causes of Sleep Apnea In Children

The most common cause of obstructive sleep apnea in children is enlargement of the adenoids and tonsils. During sleep there is a considerable drop in muscle tone, which affects the airway and breathing. Many of these children have little difficulty breathing when awake; however, with decreased muscle tone during sleep, the airway becomes smaller, making the flow of air more difficult and the work of breathing harder.

An analogy can be made to breathing through a small, flimsy straw with the straw occasionally collapsing and obstructing airflow. These obstructions result in frequent brief arousals from sleep. Many of the short pauses (lasting only a few to twenty seconds or so) cause a brief arousal that increases muscle tone, opens the airway, and allows the child to resume breathing. Although the actual number of minutes of arousal during the night may be small, the repeated, chronic, but brief disruptions in sleep can lead to significant daytime symptoms in children.

A comparable image is being poked in the arm every few minutes throughout the night. The child is usually unaware of waking up, and the parent often describes the child as having very restless sleep but not necessarily waking up completely.

The most common cause of obstructive sleep apnea in children is enlargement of the adenoids and tonsils. During sleep there is a considerable drop in muscle tone, which affects the airway and breathing. Many of these children have little difficulty breathing when awake; however, with decreased muscle tone during sleep, the airway becomes smaller, making the flow of air more difficult and the work of breathing harder.

An analogy can be made to breathing through a small, flimsy straw with the straw occasionally collapsing and obstructing airflow. These obstructions result in frequent brief arousal from sleep. Many of the short pauses (lasting only a few to twenty seconds or so) cause a brief arousal that increases muscle tone, opens the airway, and allows the child to resume breathing. Although the actual number of minutes of arousal during the night may be small, the repeated, chronic, but brief disruptions in sleep can lead to significant daytime symptoms in children.

A comparable image is being poked in the arm every few minutes throughout the night. The child is usually unaware of waking up, and the parent often describes the child as having very restless sleep but not necessarily waking up completely.

Daytime Symptoms Often Associated With Sleep Apnea In Children

• Appearing sleepy during the day. Children with sleep apnea are not getting enough sleep because their nighttime sleep is interrupted so frequently. Thus, your child may be sleepy during the day. He may be difficult to get up in the morning and may fall asleep in school or at other unusual times (such as during meals). Younger children may nap longer or take more naps than others their age.
• Appearing hyperactive during the day. Many children who do not get enough sleep do not look and act sleepy. Instead, they become wired and hyperactive. This is common. Don’t fool yourself by saying that your child is never tired because he is in constant motion. This may actually be a sign that he is overtired.
  Daytime behavior problems. Some children may have daytime behavior problems. For example, some children with sleep apnea are irritable, cranky, or easily frustrated. Others may have difficulty focusing their attention.
• Behavior has changed significantly. If your child’s behavior has changed significantly during the day, such as appearing more cranky, irritable, or sleepy, and if he also has other symptoms that are discussed above, the problem may be associated with sleep apnea.
• Falling asleep at inappropriate times or at times other than naptime. Your child may not be getting enough sleep if he is falling asleep at inappropriate times. For ex-ample, does he always fall asleep while riding in the car, whether for a two-minute or twenty-minute drive? Does he fall asleep at mealtimes?
• Health problems. Many children with sleep apnea have a history of chronic problems with tonsils, adenoids, and/or ear infections.
• Difficulty eating. Some children with sleep apnea are noisy eaters, probably because they have difficulty breathing solely through their nose while chewing. Other children with sleep apnea are slow eaters, and some even have problems swallowing, especially if they have very large tonsils.
• Slow growth. Sleep apnea may cause growth impairment, as growth hormone gets released during sleep. Children with growth impairment are usually impaired because of sleep apnea, she may have a sudden growth spurt when the sleep apnea is treated and catch up to other children her age.

Additional Symptoms Associated With Sleep Apnea In Older Children (Ages Six and Up)

• Bed-wetting. Older children with sleep apnea often continue to wet their beds beyond when you would expect them to stay dry all night. If your older child is continuing to wet his bed, check to make sure that he doesn’t have any of the symptoms listed above.
• Morning headache. Some children with sleep apnea will complain of having a headache in the morning. The headache is caused by the decrease in oxygen to the brain during the night. This diminished oxygen is unlikely to be harmful, although it sounds scary. This symptom may also occur in infants and toddlers, although it is difficult to know whether they have a headache.
• Difficulty in school. In older children the effects of sleep apnea may result in poor performance in school. These children may be labeled slow or lazy and may have difficulty focusing their attention on their schoolwork.

What Is Sleep Apnea?

Sleep apnea, also known as obstructive sleep apnea, is a serious disorder in which there are pauses in breathing during sleep. Sleep apnea is generally thought of as a disorder that occurs in adults, but children often experience it. For some children, like Stevie, apnea is serious, and the parents, while aware of the problem, don’t know where to turn for help. In many instances, however, the parents aren’t even aware that their child has sleep apnea and do not seek medical help.

There are a number of symptoms to look for that is common in children with sleep apnea. Some children will have most of these symptoms, whereas others may have only one or two.

• Snoring. Almost all children and adults who have sleep apnea snore. However, it is important to realize that not all children who snore have sleep apnea. Children with sleep apnea usually snore loudly, and most of the time (not just when they have a cold).
• Breathing pauses. Breathing pauses are the hallmark of sleep apnea. Rather than breathing in an even and consistent manner, your child may stop breathing for a few moments and then start breathing again. If you observe this behavior, it is almost certain that your child has sleep apnea.
• Difficulty breathing while sleeping. Rather than observing breathing pauses, you may notice that your child seems to have difficulty breathing while asleep. His breathing may not appear regular and even, or he may be a noisy breather.
• Mouth breathing. Most children with obstructive sleep apnea breathe through their mouths at night and often during the day as well.
• Coughing or choking. If your child frequently starts coughing or choking in his sleep, this may be a sign of a breathing problem.
• Restless sleep. Many children with sleep apnea are rest-less sleepers. Each time they have a breathing pause they will arouse and move.
• Sleeping in unusual positions. Some children with sleep apnea sleep in an unusual position, for example, with their head hanging over the side of the bed or with their head raised on several pillows or on stuffed animals. They do this unconsciously to try to keep their airway open to help them breathe while asleep.
• Sweating. Many children with sleep apnea sweat profusely while they sleep. The reasons for this are unclear, but it may be because the body has to work hard to breathe during sleep.
• Nightmares or sleep terrors. Children with sleep apnea may be more prone to these two sleep problems. The next chapter discusses both nightmares and sleep terrors.
• Night wakings. Frequent night wakings in infants and toddlers are usually related to sleep associations, as discussed in earlier chapters. However, some children’s night wakings are caused by sleep apnea. If your child has other symptoms discussed in this chapter and awakens at night, it is worth considering whether or not your child has sleep apnea. Remember, though, that although his waking may be caused by the sleep apnea, he should be able to fall back to sleep on his own. If he does not, be sure also to consider a sleep association problem.