How to Help Kids Who Have Trouble Sleeping

Countless parents have experienced the frustration of trying to get kids to go to sleep and stay asleep. The coronavirus hasn’t helped matters. A lot of kids, even those who had no significant sleep issues before the pandemic, are having trouble now. And those who had struggled in the past may have regressed.

Confusing changes in routine and increased anxiety — older kids may be worrying, while younger children may be sensing their parents’ anxiety — are causing behavioral issues across the board. Sleep is no exception.

Fortunately, there are well-tested strategies for helping kids learn to fall asleep in their own beds and stay asleep. A form of behavioral therapy called CBT-I (cognitive behavioral therapy for insomnia) has been shown to be more effective than medication for treating kids with insomnia, explains Wendy Nash, MD, a child and adolescent psychiatrist. And for children with less severe problems, parents can use CBT strategies to change sleep habits.

So what’s a parent to do? First, you want to identify the issue. Then you can seek out solutions. The same guidelines can also be applied to naps, which are more invaluable than ever, given how many parents are working from home.

Just chatting with a child about the issues surrounding sleep is a good jumping-off point. Anna Loiterstein, PsyD, a clinical psychologist, says parents should first try to understand what’s going on with their child. Let’s say they’re anxious. Before the coronavirus, it might have been school, conflicts with friends or separating from their parents. Now, is it the crisis itself? A fear that they or their parents will get sick? Knowing these things will help you assist your kids.

Dr. Loiterstein says the idea is to empathize and validate the child’s fear. Start by saying, “I understand you’re feeling scared and that’s a really hard feeling,” and then encourage bravery. So, a parent could tell their child they understand it can feel really frightening to sleep in one’s own room, and then explain they’re going to practice going to sleep in steps to overcome this worry.  Let them know you are very confident that they can do it.

Once you know what’s going on with your sleep-challenged child, you can use behavioral techniques to help them move towards sleeping independently.

We aren’t talking about the “cry-it-out” form of sleep training used with infants, but rather one for older children that involves gradually moving farther away from the child.

“Again,” says Dr. Loiterstein, “we want the child to learn that they have the self-soothing skills to manage whatever it is that’s distressing them. Otherwise, they become too reliant on the parent for their presence or reassurance.”

She cautions parents to remember this will take time and patience. “You’re not going to go from one night sleeping in your child’s room to them sleeping independently the next,” she says.

There are systematic steps to work up to that. As an example, if you are lying in bed with your child, the first thing to do is to move to a chair next to them, just holding hands. The next thing could be to move the chair farther away, followed by sitting outside the door to get more distance away from the bed. Individual steps you might take would depend on the specific case.

Ultimately, your goal is to get to the place where you can come in and say good night and leave the room. It’s fine to have a sleep routine where the parent comes in, say, to read a story to a younger child or hug an older one, but the child shouldn’t be reliant on you to be there for them to fall asleep.

A posted sleep schedule with a consistent, predictable routine will help everyone, parents and kids alike, stay on track, from brushing teeth to lights out, as well as wakeup time. As the child accomplishes each step, they can be reinforced by that chart, which allows them to see their progress, earning them rewards for doing brave steps like staying in their room after their parents leave.

The parents can also be using charts to track progress and notice any patterns. “If it seems to a parent, ‘Oh, my child’s having a harder time on a Sunday than they are on a Friday,’ that tells us something,” Dr. Loiterstein says. “So tracking this type of information can really help to target certain interventions.”

Some kids get into the habit of falling asleep fine on their own but wake up in the middle of the night and go to their parents’ bedroom.

“They like to have these interactions with their parents,” Dr. Loiterstein says. “It’s their comfort zone.” She says the best thing when that happens is to bring them back to their own bed as soon as possible.

“We don’t want to reinforce this interaction and make it more likely that the kid is going to want to come in every night,” she says. “We want to minimize the reward they’re getting from their parents’ bedroom.” A reward system for their bravery can be used here, as well.

In addition to behavioral techniques, there are ways to create an environment that’s conducive to sleep. The idea is to train our bodies to go to bed and wake up at the same time each day. Some methods to get into that rhythm:

•  A calming, warm bath. “It can be helpful to have a hot bath one to two hours before bedtime,” Dr. Loiterstein says, “because it raises your body temperature, causing you to feel sleepy.”
• Meditation and relaxation techniques. Dr. Nash recommends meditation apps specifically for sleep, created for different ages. With calming music and a guiding voice, apps help kids relax, from a “body scan,” during which you relax your body starting with your toes, to breathing and visualization. All are meant to reduce anxiety and guide kids toward relaxing enough to fall asleep.
• Noise-canceling headphones. Some kids may tolerate the soft devices.
• Eye masks and room-darkening curtains. These can help create a dark, “cave-like” environment.
• A cool room. Adding a fan also provides soothing white noise.
• A weighted blanket. There is anecdotal evidence a weighted blanket can help kids. Just be sure it’s not too heavy or hot.
• No exercise right before bed. Exercising raises body temperature, speeds up heart rate and stimulates the nervous system, none of which are good for sleep.
• Make the bed for sleep only. Use the bed only for sleeping, not as a place for homework, eating or watching TV. “We really want to train our bodies to know that bed is associated with sleep and bedtime,” Dr. Loiterstein says.

Dr. Nash says if these measures fail and there’s real, chronic insomnia, it’s time to talk to your pediatrician. “Make sure any underlying issue is being addressed,” she says. These could include asthma or sleep apnea; medication side effects might also be the reason.

If a child needs a sleep study, she adds, there are ones that can be done at home.

If none of the above is at play, it’s time for parents to check for any underlying psychiatric conditions with an evaluation, which can now be done via telehealth.

Disorders such as anxiety, depression, bipolar, ADHD, autism and OCD can all interfere with sleep, as can phobias and media stressors, says Dr. Nash. For instance, children and teens with autism may be kept up by sensory issues while separation anxiety might lead to clinginess.

If a child has persistent trouble sleeping, cognitive behavioral therapy for insomnia, or CBT-I, can be effective. CBT-I teaches children how to manage their own anxiety, now and in the future, and supports parents in helping their children get better. Dr. Nash says that CBT-I has been shown to be more effective than medication in treating insomnia.

Medications are the last resort. “We don’t have any FDA-approved medication for sleep in children,” Dr. Nash says. “I’d say the most commonly used is melatonin, for sleep initiation, but kids could wake up after four hours. Some parents try the timed-release XR but then you risk them being groggy in the morning.” The idea is to start with a low dose.

Dr. Nash notes that there have been anecdotally variable results with the blood-pressure medication clonidine; while she’s used it with some patients, it may not get them a full night’s rest.

Two more medications that are used off-label for sleep are the antidepressants Trazodone and Remeron. Dr. Nash notes that Trazodone’s side effects can include grogginess, so again, she recommends starting at a low dose. “I’d probably only use in teenagers with really severe cases,” she says.  As for Remeron, when used at low doses, it works like an antihistamine. It also increases appetite, so it tends to be good for kids who are on stimulants and anxious and have insomnia. For these reasons, she will usually try Remeron before Trazodone.

Parents may have heard of Gabapentin, an anti-epileptic drug also used to treat nerve pain in adults. But it can be sedating and cause nausea.

What about the antihistamine diphenhydramine, best known as Benadryl, some parents’ go-to when they want their child to sleep? Dr. Nash doesn’t recommend regular use because of side effects including tolerance and weight gain.