How to help children with anxiety sleep better

I recently recorded a new episode of The Sleep Edit where Arielle and I interviewed Dr. Danielle Garay (which will come out in a month or so. In preparation, I reread Breaking Free of Child Anxiety and OCD by Eli Lebowitz. It’s a terrific book if you have a child who struggles with these issues. It’s also a wonderful parenting book in general, because it gets into the concept of parental accommodations. Understanding this idea is key to addressing sleep issues in older children.

Many children who struggle with sleep are anxious about separating from their parents, or are rigid about behaviors around sleep. Before the pandemic, up to 10% of children suffered from anxiety; now the prevalence may be as high as in 20% of children.

True story, both my children have suffered from anxiety at various times in their childhood, my older boy especially when he was little. This would manifest as prolonged tantrums when things did not go according to plan. When he got older, it would manifest as excessive questioning about our plans. Where are we going? Who were we going to see? What would we eat there?

Parental accommodations, or how I inadvertently ended up strengthening The Cheese Touch

Parental accommodations are simply behaviors you make to help you child cope. Sometimes they can be very helpful and useful. Let’s say that your child is struggling with reading. You work with the reading specialist at their school who teaches you a special way to read with her to help her learn. That’s a positive accommodation which is helping your child with her reading.

In the context of anxiety, however, parents often are bending over backwards to keep their child from suffering. This is going to sound funny, but my older boy practically had a phobia around cheese. I wonder if “the cheese touch” in Diary of a Wimpy Kid had anything to do with this (he loved those books). At the beginning of that book,

it is revealed that the Cheese Touch originated from a piece of moldy Swiss cheese that lay on the basketball court for months. The first person to have the cheese touch was Darren Walsh, who touched it with his finger. Greg Heffley says that Cheese Touch works like the cooties: you have it until you pass it on to someone else. Greg says that the only way to protect yourself from the Cheese Touch is by crossing your fingers, and Greg ended up taping his fingers together (he got a D in handwriting as a result, but felt that it was worth it) (Source)

Now, both my wife and I are Italian. We consume a fair amount of pizza and pasta. And it’s not a proud moment to go pick up a pizza with no cheese at your local pizzeria. You lose face. We would often have to make him special plates of food with no cheese. He was worried about eating food even adjacent to cheese so we would have to segregate his food.

These changes we were making were also accommodations, but they were disruptive. Fortunately, they weren’t that disruptive for us, but often parents ARE making more and more elaborate accommodations to avoid conflict. that they are making are disruptive. Often, parents resent them. And (most importantly) they are making their child less likely to cope.

Accommodations around sleep are really common

I see a lot of parenting behaviors around sleep that perpetuate sleep difficulties in children.

Performing rituals around bedtime. Items need to be arranged a certain way. Certain songs and books need to be read. Any deviations result in tantrums or anger.
Allowing their child into their bed every night when the child wake up
Avoiding nights out as their child will not fall asleep for a baby sitter. (A key violation of The Canapari Rule: If your child is awake when you come home, you shouldn’t have to pay the babysitter).
Avoiding trips or vacations where the sleep routine may not be obeyed
Staying in the room until the child is absolutely asleep.
Answering obsessive questions about bedtime, sleeping, or night time fears.

Almost always, these accommodations seem innocuous at first. However, with time, they become more baroque and burdensome. I had one patient who was very fearful about thunderstorms at night. Her parents started showing her the weather forcast, so she started them asking them multiple times per day to show her the weather application.

Here’s an an example of parental accommodations gone awry:

Ted has a ten year old son named Ethan. Every night, Ethan insists that Ted lie his bed until he falls asleep. If Ted gets up too soon, Ethan will wake up and Ted has to lay there even longer. Ted’s partner Mike cannot put Ethan down to bed unless Ted is out of town. In this scenario, bedtime goes relatively smoothly. Laying down at bedtime wasn’t too annoying to Ted when Ethan was little, as he fell sleep quickly, but now that Ethan is older and bigger, it is uncomfortable for Ted to lie on the edge of the bed, and he is often there for an hour or more, which results in stress as he has to fold the laundry and do the dishes when he gets out of bed. Also Ethan has been asked to go to a sleep over but has turned down the request because he is worried that he will not be able to fall asleep.

In this example, a ritual that was pleasant and sweet at first became burdensome over time.

How to know if you need to make a change?

The first (and most important question is): is your behavior helping your child to become more confident and independent? Ordering a pizza without cheese not that big a deal— some people like pepperoni, other people (horribly misguided people) like Hawaiian pizza. Everyone is entitled to a preference. However, being interrogating by our son about the cheese content of food or needing to make a show of segregating cheese was wearing thin and not helping him to be go out to a friend’s house for dinner. In the example above, Charlie is not making progress towards sleeping away from home, which he would like to do.

The second question is, is it unduly burdensome to you or other family members. Do you resent it? Would you prefer to be doing something else with your time? Does indulging your child’s paranoia about cheese interfer with family gatherings with your elderly Italian relatives? Is your back in agony because you spend 90 minutes lying half off of a twin mattress you bought at Ikea for $30?

How do you change your child’s behaviors?

Behavior change is hard, especially if you are addressing long-standing patterns— say, a seven year old who needs his dad to fall asleep every night. The good news is, these ARE fixable, and the solution lies with you, not your child.

In our situation, we stopped answering questions about cheese. We honored our son’s preferences (e.g. we did not serve him food with cheese in it) but we refused to be interrogated about the contents of everything prepared for him.

In the scenario above, Ethan is unlikely to make a change anytime soon, He is perfectly comfortable with the current state of affairs. Ted has more power than he thinks however. If Ted changes his own behavior, Ethan’s behavior will change.

How to change your own behavior

The first step is recognizing the accommodations that you make. I would start by making a list things that YOU do to avoid conflict around bedtime or the middle of the night. Then you pick ONE accommodation to change. Here’s the criteria that will help you pick.

1. Pick something that you can control. In the example above, Ted can choose not to get into bed. He cannot choose, say, to have Ethan not argue about this.

2. Pick something that happens frequently. If your child has a tantrum every time they have to fall asleep in a new place unless you lay down with them when you go on vacation once a year, this will be hard to address and is probably easier just to go along with your child’s requests.

3. Pick something that annoys you. Many nursing mothers may elect to continue to nurse their child once per night even when their return to work and they enjoy this closeness. There’s no NEED to change if you don’t want to.

Ted’s plan

There are several different ways to address a problem like this. Mike could become the point person for bedtime. Ted could elect to stay in the room in a chair and gradually move out at bedtime [(the “camping out method”)].

Ted decided it would go more smoothly if he was not in the room at bedtime, as he thought that it would be harder for him to set limits. So he and Mike presented the following plan to Ethan:

1. Ted would do the bedtime routine (helping Ethan get ready for bed, reading a story, say goodnight, and leave the room).

2. Mike would sit in a chair in the room for one week.

Ted explained it by saying, “Ethan, you are such a big boy now! It’s uncomfortable for me to lie in bed with you until you fall asleep, and I have some chores I have to do at night, so I can’t stay in your room anymore even though I love you very much. Dad (Mike) is going to stay with you for a week to help you get used to this.”

Success is purely defined by Ted’s actions. If he said goodnight and left the room successfully, that was success, whether Ethan cried, had a tantrum, or just went along with it. Note that it may be fairly common in situations like this for there to be some crying or even aggression for a short period of time.

In this case, Ethan got angry when the plan was presented.

Dr. Lebowitz has a great analogy about how to respond if your child is trying to argue about a planned change:

Here's a little trick you can use to help you stay out of an argument with your child. (This works for other arguments too-not just those about anxiety and accommodation.) Imagine that your child is trying to play ping-pong with you, but you don't want to play. Your child picks up the ball and hits it toward you. You don't want to play so you throw the ball back and say, "I'm not playing."

Your child hits it to you again, and you pick it up, maybe a little angrily now, and throw it right back to her. Your child hits it to you once more and again you throw it back. Do you see what is happening? You don't want to play, so you keep throwing the ball back.

But as long as you keep throwing it back, your child is just going to hit to you again. You're saying you don't want to play ping-pong, but that's exactly what you're doing. It's as if by trying not to play you actually are playing. If you really don't want to play, what can you do? The best thing is to ignore the ball completely. Let it bounce off and roll to the floor. Your child might pick it up and hit it to you again, but if you keep letting it bounce and roll, she is not going of you to keep it up forever. The ball is like your child's arguments, when you don't want to argue. If you keep throwing the argument back to her, she probably won't stop. Tell yourself, "I'm not playing. I'm just going to let it bounce and roll," and you'll see how much faster the arguments stop.

Other techniques to ensure success

Some children benefit from rehearsal. What this would look like in this situation would be explaining the situation to Ethan, but allowing him to “practice” for a week by doing a pretend bedtime during the day a few times during the day prior to starting.

Rewards can also help. In this scenario, you could offer a small reward for both a successful reward, and being in bed at night with a calm body at bedtime.

I would also recommend that you don’t spend a lot of time explaining and re-explaining your plan. If your child keeps asking you about it, it’s not because she didn’t understand. Continuing to explain it is like a yellow light at an intersection— it’s suppose to make people slow down, but it actually makes them speed up. As Dr. Lebowitz explains,

Consider something as commonplace as a traffic light, which has a very simple job. Traffic lights tell drivers when to go, when to stop, and when to slow down because the signal is about to change. We know that red means "stop," and green means "go," but what about yellow? If you are approaching an intersection and the light is yellow, the message is supposed to be, "Slow down, because you won't make it through." But have you ever noticed that this is not what drivers do when they see a yellow light? It's typical to see drivers speed up when the light is yellow, and this is exactly the opposite of what the light is signaling (and frequently results in running a red light)! Sometimes, you may think you are giving your child one message while, in fact, she hears the opposite. Your continued responses can be like that yellow light. If your child is having a tough time accepting that you are not providing an accommodation, then repeatedly telling her you are not going to accommodate or doing other things that are intended to help her feel better, can actually make the process longer and harder because your child interprets your responses as a signal to continue, and she speeds up rather than slowing down.

So what happened?

On the first night, Ethan was very angry and yelled at his fathers. When Ted tried to say goodnight, he refused to talk to his father. Mike sat quietly in his room and Ted went elsewhere in the house folding laundry. Ethan kept trying to discuss the plan and why it was unfair and Mike said, “I’m not going to discuss this with you right now”. Ethan stayed up late reading his book. The next night he still refused to say goodnight to Ted, but the nights after that he said good night without comment. At the end of the week Mike said he would no longer stay in the room but would be available down the hall. In a few months, Ethan was confident enough to go on his first sleepover.

And, importantly for me, my older son now eats cheese on his pizza.

What accommodations are you making?

If you are struggling with your child’s sleep, ask yourself— what accommodations are you making which are allowing your child to continue to struggle? Are you making any accommodations? If so what do you want to change? What barriers do you have to doing so? If you are struggling with getting your child out of your room at night, I have detailed plans here, event for older children with separation anxiety. Leave a comment or reply to this email.

Craig

Craig Canapari MD