Anxiety and Sleep

It often happens that mothers burst out in tears during our first, introductory call. They have done their very best to make their child sleep well, yet they are exhausted.

This time I talk to a mother of a 4-years old boy. Tears are rolling down on her cheek, as she tells me that she gave up trying alone — she admits that she needs help because this problem has grown over her. From what I hear she has done so far a fantastic job: stable routine for all the children, tender love and care, healthy sleeping habits. Where is the problem?

The 4-year old boy requires parental presence at his bedside for hours long, so the mother doesn’t have time for her other children, for her husband let alone for herself. The mother cries because she is exhausted, lost hope and the failure hurts her.

But there are other emotions coming up, too: anger, for example, because she would expect a certain level of collaboration from a 4-year old. After all, the younger siblings sleep well, and they don’t even get the chance to have long bedtime with mom as the little boy steals the show every night. “I don’t want that he gets to be the center point of the whole family, others need attention, too”, she says. She is right and her anger is understandable.

According to Judith A Owens, MD, the Director of Sleep Medicine in the Boston Children’s Hospital:

Behavioral sleep problems (behavioral insomnia) in children include bedtime refusal or resistance, delayed sleep onset, and prolonged night awakenings requiring parental intervention. All of these issues are common in the pediatric population and often adversely affect the quality of life of both children and caregivers. While most children experience occasional transient insomnia, more persistent insomnia carries an increased risk of mood and behavior problems, academic failure, and even worsened health-related conditions

This mom knows what it’s like to feel anxious, and she doesn’t want her son to go through the same thing. She talks about not feeling super close to her own mom when she was growing up. So, she really wants to be a better parent to her son. As she realizes that her own anxiety might be because of her past experiences, she wants to do things better for her son and make sure he feels safe and loved. Her main goal is to a genuine aspiration to break the cycle and provide him with a more secure and nurturing environment.

The problem is that she is being pushed in between strong emotions and it’s difficult for her to set clear bounderies with her son. In her heart, she’s a fortress of love, yearning to embrace her son with affection. Yet, there’s a tender anxiety that lingers, as the bedtime hours stretch long and emotions sway like huge waves. Bedtime might not be a problem with the other children, but this one son is particularly sensitive to the mother’s feelings. Here are some possible scenarios and their consequences:

1. Kids sense when Mom is unsure. In this case the child might act out to see what he can get away with. If Mom gives in and stays longer, it reinforces this behavior.
2. Some nights, the child can sense when Mom is worried. The child wants to make Mom feel better, and Mom stays because the child is trying to bring her comfort.
3. Some nights, the child might feel worried and have trouble falling asleep, especially after a long nap during the day. He might toss and turn before finally falling asleep, causing both the child and Mom to spiral down in sleep-related anxiety.

In this case the hours-long bedtime routine has lead to a negative outcome: the child associates independent sleep with uncertainty, when it should be a natural, fearless process.

As Sára Víg, child psichologist says:

Many people misunderstand the concept of secure attachment and associate it with a permanent, close symbiosis, whereas it also involves a gradual, age-related separation and becoming independent. Falling asleep, restful sleep, is an essential part of this process.

While I am not a psychologist to treat anxiety, I certainly know about the importance of winding down before bedtime. Relaxing techniques can help and there are playful ways in which we can do this with toddlers. The problem with behavioural insomnia many times is the additional anxiety attached to sleep.

Judith A Owens explains that:

Psychophysiologic (also sometimes termed “conditioned”) insomnia may interfere with sleep onset or maintenance in the pediatric population, primarily in older children and adolescents. It is characterized by anxiety specifically about falling or staying asleep due to heightened physiologic and emotional arousal related to sleep and the sleep environment. Affected children often have maladaptive cognitions about the consequences of their sleep problems that further compromise their ability to sleep.

This type of insomnia frequently arises from a combination of predisposing factors that may include genetic vulnerability, medical disorders, or psychiatric conditions. Precipitating factors may include acute stress, and perpetuating factors may include poor sleep habits, caffeine use, or inappropriate daytime napping

At this point it’s not enough to set parental boundaries and give the child the confidence in falling asleep independently, but we need to reduce the anxiety, too. In the case of a child older than 2 years of age we are able to utilize the power of bedtime stories to transform their perception of sleep. Through the enchantment of fairy tales, it becomes possible to reshape their perspective and alleviate long-term anxiety surrounding sleep.

Of course, a single story alone doesn’t make magic. We take a closer and strategic look at daytime nap, so that we make sure that the boy goes to bed when he is sleepy enough and he can fall asleep smoothly. Also we aim to reduce mom’s anxiety around bedtime because if she can manage her anxiety to a certain level, she can maintain healthy boundaries around bedtime.

It’s all about breaking that wicked cycle at one point. Once we get a foot in the door, we can start building up new sleep habits that’ll stick around for the long haul. When those habits start to take hold, it’s a game-changer for the whole family. Sustainable sleep, is what we’re aiming for.