My Child Won't Go to Sleep: Limit-setting Type Disorder

by Eli Hendel, M.D. Medical Reviewer

In the last sharepost, we talked about children who have problems staying asleep and suffer with multiple awakenings throughout the night. I discussed how these symptoms may become a disorder, and recommended strategies to help parents deal with this normal development in the child.

But as a child ages, are there other stages in the normal sleep development process that may require some adjustments? One such condition children may encounter is known as Behavioral Insomnia of Childhood, or Limit-setting Type Disorder.

What is Behavioral Insomnia of Childhood?

This problem typically occurs in children ages 2 to 6, and is characterized by a stalling behavior at the time of sleep. It will typically start as plain refusal to go to go to bed. Then, the child will often make multiple requests - all of a sudden the child is hungry, thirsty, wants another story, or wants to play another game. The multitude of requests can be creative and endless.

"It’s important for parents to understand that this is not as simple as the child misbehaving."

Is this a limited and unique problem?

Of course, many parents believe that they are alone in dealing with this problem (I know my wife and I felt that way when our daughter was classically behaving this way.) Most of us assume that this is simple a case of having a stubborn child. The reaction of the parents will often vary from trying implementation of very strict rules and threats to acquiescing. However, the choices parents make will have a direct effect on the child’s behavior.

What is really going on?

It’s important for parents to understand that this is not as simple as the child misbehaving. The truth is that the child is really unaware of his behavior or the consequences of delaying sleep.

The theory behind this behavior is that their brain and circadian rhythm are still in development, and there is still no clear-cut difference between being asleep and awake for these children. Children do not have the insight of how much sleep they need and don’t understand the consequences of not getting enough sleep. Unlike adults with sleep deprivation who are sleepy and unable to keep their eyes open, these children are actuallyperactive and restless.

The disorder may be prolonged by the child’s environment. Permissive parents who allow the child to stay up past a healthy bedtime reinforce the disorder]( If left un-supervised, these children are unlikely to follow a regular sleep schedule and this will further delay the maturation of the circadian rhythm. A very typical situation is when the child is aware of older siblings who get to stay up later and quite frequently the child will engage in stimulating activities such as watching TV before bed time or playing video games.

How can parents limit or prevent this disorder from becoming a long term problem?

  • Avoid stimulating activities an hour to 90 minutes before bedtime.

  • Let the child understand that they are younger and their sleep needs are different than their older brothers and sisters.

  • Avoid feedings close to bedtime.

Consider following the sleep measures described as Positive Bedtime Routines:

  • Aim to achieve a regular bedtime schedule. Be consistent so the child understands the expectations.

  • Enforce the same daily bedtime, even on weekends. When there is a variation of the norm on a special occasion, the child must understand that this is a unique situation and not the norm.

  • In the 20 to 30 minutes prior to bedtime, create a quiet transition activity such as reading a story, playing soft music, dimming the lights gradually.

  • Establish a consistent routine of washing up, brushing teeth and getting into pajamas.

  • Create a pleasant association with sleep time so the normal response of the child to sleep is reinforced.

  • Avoid a loud environment outside the bedroom and avoid excessive light (light suppresses melatonin).

  • Unreasonable demands during the period after bedtime should not be met by the parent.

What if my child is still resistant to these techniques?

For very resistant cases there is a technique that’s been developed called Bedtime Fading. This involves delaying the child’s bedtime to try to approximate his individual wake-sleep limit and the timing of natural sleep onset. Parents should then slowly advance the bedtime to this new time, making sure that the child is still meeting age-appropriate total sleep hours.

When you use this technique be careful to remember the recommendations for sleep needs for the child’s age.Children ages three to five need 11 to 12 hours of sleep, and usually daytime napping should stop by school age. The payoff for parents and the child

Establishing good sleep habits at this young age are not only valuable, but help to avoid negative consequences later on. With the teen age years coming up sooner than you think, not creating good sleep hygiene will likely lead to teens who want to delay sleep on a regular basis. It’s already built into the nature of teens!!

School and other routines of life will only become more complicated for the child who can’t follow natural and healthy sleep patterns. Avoid this disadvantage by resolving Limit-setting Type Disorder.

Eli Hendel, M.D.
Meet Our Writer
Eli Hendel, M.D.

Eli Hendel, M.D., is a board-certified internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Playing jazz music.