I hope you all find it helpful
Paulette
Sleep and Adoption
BY JULIAN DAVIES, MD
ABOUT THE AUTHOR
Julian Davies, MD is a clinical professor of pediatrics at the
University of Washington, where he co-directs the Center for Adoption Medicine
and works at the longest-running FAS clinic in the country. His interest in foster
care, adoption, and FASD started in Russia, where he started a summer arts and
clown camp for Russian orphans. He now has a pediatric practice where 2/3 of
his patients were fostered or adopted. Dr. Davies created an online resource
for pediatrics and adoption (www.adoptmed.org), has hosted “Raising Resilient
Rascals” conferences, and presents on a variety of topics at regional and
national venues.
The Problem
Dr. Sears: “Thou shalt co-sleep, unless you don’t really
want that special bond we like to call attachment.”
Dr. Ferber: “Thou shalt let them cry, unless you don’t
really want that thing we like to call a good night’s sleep.”
Dr. Dobson: “Good night’s sleep? Have you considered a
good night’s spanking?”
Dr. Weissbluth: “If you don’t sleep train them now, there’s a
92% chance they’ll be huffing paint behind the Quik-E-Mart by age 16.”
That neighbor whose kid would have slept well even if raised
by wolves: “Really?
Our precious Tyler slept through the night since he was 2 months old...”
Attachment therapist: “Never let their feet touch the ground.”
Movement therapist: “But if she doesn’t learn to crawl soon, her
left brain will never talk to her right brain!”
Mother-in-law: “You’re spoiling that child — she needs to
cry it out.”
APmom on your 4am chat group: “Cherish these
magical middle-of the-night bonding opportunities — her little feeties in your
face all night long is a glorious gift!”
Dad: “Honey, the baby’s crying.”
Mom: “Honey, why don’t you go cherish this magical moment?” Too
many experts, not enough left brains talking to right brains. Too many opinions,
not enough research. Too much crying, not enough sleeping.
What’s an adoptive parent to do? Read on, my sleepless
friend, as we tiptoe through the too-often tendentious topic of SLEEP.
What is this Thing You Call Sleep?
So much depends on adequate, restful sleep. We’ve got
important work to do at night, from physical growth (80% of growth hormone is
secreted while we sleep), to mental growth (integrating themes and memories of the
day), to recharging cellular batteries, and other functions that we just don’t
understand yet.
We all sleep in cycles, but children have unique sleep
patterns. As infants, they have many sleep periods through a day, and a greater
proportion of active (REM) sleep — about 50% — with the other half being “quiet
sleep,” a precursor to more developed Stages 1-4 of non-REM sleep. By 3-4 months,
melatonin turns on, and infants organize their sleep into more of a day/night
pattern. This is why it’s silly to expect children to sleep through the night
before 4 months.
By 6 months, the full cycle of non-REM and REM sleep
is happening, but infants can get into Stages 3 and 4 (deep sleep) much faster
than adults, and still spend more time in REM sleep. Deep non-REM sleep is
important, since it’s the most restorative phase of sleep, and is also when
growth hormone is released. REM sleep seems to process and organize new
memories and events, and is crucial to mental wellbeing.
By 3-4 years of age, children’s sleep finally
resembles adult sleep in quality, with 4-6 sleep cycles. The first half of the
night has more non-REM sleep, with more REM sleep in the second half. You’d think with something this important
we’d be born good at it…but we’re not. Not even close. Just like walking and
talking, the ability to fall asleep and stay asleep is something that is
learned at developmentally appropriate times. How and when to help your child
learn is the hard part. Why bother?
Sleep deprivation is being increasingly linked to emotional and behavioral
problems, poor concentration, impulsivity, ADHD misdiagnoses, impaired learning,
reduced physical performance, poor growth, headaches and bellyaches, and
decreased immune function, not to mention family stress.
Sleeping Through the night?
As for “sleeping through the night”…nobody does. We all wake up to
some degree several times a night, often when our sleep cycles from deep to lighter
sleep. Arousals after REM sleep also occur, and tend to leave you more awake and alert. You may not be up long enough to
remember it (that takes 3-5 minutes), but you do wake up, even without the
“help” of your less sleep-skilled child. Our goal, thus, is not to “sleep
through the night,” but to promote healthy sleep associations and self-soothing
skills so that your kids will fall back asleep when they wake five times every
night.
How common are night wakings that you’ll notice? By
4-6 months, babies are physiologically capable of sleeping through without
feeding, but according to this 2004 Sleep in America poll, 70% of
these infants still wake up and need help or attention, with 47% of toddlers,
36% of preschoolers, and 14% of school-age children also with notable
wakenings.
The numbers seem considerably higher in new adoptees,
for reasons we’ll address below. As far as other sleep difficulties go, the
same poll revealed that 69% of all children experience one or more sleep
problems, including stalling, bedtime resistance, and daytime sleepiness.
How Much Sleep Does My Child Need?
The following table is based on sleep surveys and recommendations from the National Sleep Foundation:
While each child is unique, it’s rare for kids to need
much less sleep than these recommendations. However, there does seem to be
individual variation in amount of needed sleep, as well as “night owl” versus
“early bird” variation;
these patterns are present from early childhood and are fairly stable. As for
the naps, children who nap
are happier, have better attention spans, may learn better, and arrive at
bedtime without being overly tired.
Good naps lead to good night-time sleep, and vice-versa. “Sleep
begets sleep.” Just try to keep naps from lasting into the later afternoon.
Special Concerns in New Adoptees
Sleep disturbances are far and away the biggest
initial concern for the new adoptive families that come to our clinic. Most new
international adoptees sleep well enough on the trip home — quite possibly
because they’re thoroughly overwhelmed and emotionally exhausted by this
transition. When you arrive home, 1-2 days of jet lag per time zone crossed is
typical, but children often recover before grownups.
Learning as much as possible about the prior
sleep environment and bedtime routines can be very helpful. But since
orphanages can have unnaturally long naps and early bedtimes (often aided by
medication, sadly), you may not want to follow their timetable precisely.
Remember that children from orphanages may never have been alone in a room, and
will need a prolonged transition to sleeping by themselves. Children in foster
care may have quite evolved bedtime routines, transitional objects, and sleep
habits such as co-sleeping, which is common in Korea and many other countries.
Even the clothes they came in have reassuring smells and associations, so keep
them around.
If the “cry-it-out” methods work as advertised, then
why do kids from orphanages who’ve unfortunately been trying-it-out their whole
lives sleep so poorly at first? Well, since almost every aspect of bedtime and your
child’s new sleep environment is different and thus “wrong” at first, it’s
natural that new adoptees have difficulty falling asleep and falling back
asleep during night arousals. Your child’s grief at the loss of familiar caregivers
may erupt at night, and when you come to console them they may be expecting
someone else.
New adoptees are usually so overstimulated (we call it
“Disneyland syndrome”) that they may blow right through sleepytime into an
adrenaline-addled second or third wind. Also, your child is experiencing
dramatically more love and stimulation and having rapid catchup development,
and we know that children working on new skills often obsessively practice or
at least cogitate upon these new milestones. Nighttime is no exception, and
it’s not unusual to find children happily or unhappily attempting new feats in
the crib.
Children experiencing parental love and attention for
the first time are understandably reluctant to give it up because someone says
it’s “bedtime.” The early stages of a new attachment have an insecure, “velcro”
quality, so it’s normal for new adoptees to be anxious and insecure around
bedtime. If they won’t even let you have a bathroom break, how are they supposed
to handle the big kahuna of daily separations — bedtime in their own crib? Add
to that the fact that it’s developmentally normal for kids to have a flare-up
of separation anxiety at around 18 months, and you got quite an anxious child
on your hands.
It’s
natural that new adoptees have difficulty falling asleep
and
falling back asleep
Plus it’s scary in the dark for many kids. On top of
that, think of all the negative associations with nighttime your adoptive child
may have had. Being cold, soaked through the rags that served as diapers, in a
hard metal crib, with no one answering your cries, and waking up to a different
shift of caregivers is not a good memory. Neither is hearing your first parents
yell and hurt each other late at night.
Finally, children with histories of prematurity,
prenatal substance exposures, lack of early responsive, regulating caregiving,
and stressful/traumatic experiences can literally be wired differently, with
real neurologic differences in sensory processing and self-regulation. Children
with over sensitivities to sound, light, or touch are more likely have
difficulty filtering these inputs out at night. Children with poor emotional
and self-regulation experience their emotions more intensely, and have
difficulty self-soothing. The process of “attunement” (a powerful emotional
connection in which the caregiver recognizes, connects with, and shares the
child’s inner states) with a responsive caregiver is necessary to help your
child identify, organize, and work through their emotions. That attunement,
more than “crying-it-out,” is what will rewire your child so that they develop
genuine self-soothing skills. Try to see initial nighttime wakenings with
empathy for where they’re coming from and what they’re now experiencing.
For all of these reasons, most
adoption professionals do not recommend sleep training that involves prolonged
crying in the first few months home. You may have brought home an
18-month-old, but he or she may be emotionally younger in many ways, and your
relationship itself is a bouncing brand new baby…one that will keep you up more
than you might like in the first few months. Plan on being more emotionally and
physically available at night, and try to think of these nighttime interactions
as an opportunity for bonding, and a way to repeatedly show your new arrival
that she is loved, safe, and well-cared for. But keep your eyes on the prize —
restful restorative sleep for all. It’s never too early to set up good sleep
habits, and help build self-soothing skills. You’ll probably want to have both
a transitional sleeping plan, and a long-term plan. Get one of the “sleep
training” books (Sleeping
Through the Night is my favorite, but see
our list of recommended Sleep Books), and get down to learning and
soul-searching about what’s going to work for your family in the short and long
term. The National Sleep Foundation’s Children’s Sleep Diary can help
analyze a school-age child’s sleep patterns (or use this simpler
sleep log for younger kids).
Try
to see initial nighttime wakenings with empathy for where they’re coming from
and what they’re now experiencing.
While the transitional plan should probably involve
some parental presence during sleep onset and night wakings, the long-term plan
is up to you. If you are loving, attentive, and attuned to your child during
the day, and have been responsive to transitional sleep issues in the first
months home, you can move into some modified, “gentle” sleep training if that’s
what you need to do. You also have my blessing to co-sleep until the cows come home,
as long as you’re all co-sleeping and not co-sleepless.
Bottom
line — know thyself, and know thy children. If they have histories of
trauma or neglect, you don’t want to reinforce those stress-forged neuro-endocrine
pathways by re-traumatizing them. If a method feels like torture, or involves
prolonged hysterical crying, or just isn’t helping your child, then try
something else. Sleep training is not a one-size-fits-all solution; some
children may settle quickly after a brief fuss that blows off some of the
stresses of the day. Some will cry for hours and devolve into a sweaty,
snot-smeared, how-dare-you-do-this-to-me, too-frantic-to-sleep zombie. And
they’ll do this every time the routine gets off and you have to “re-sleep-train.”
Weigh the risks and benefits for your family. What’s worse, lonely frantic crying
and loss of loving, attuned care at night, or having a dangerously sleep-deprived,
depressed, not-so-attuned parent during the day? There’s no right answer to
that question; you need to trust your instincts here.
That said, I do think Mary Sheedy Kurcinka’s Sleepless
in America is the closest I’ve read to “the right answer,” since she
skillfully walks you down the path of what underlies your child’s sleep issues,
and helps you adjust your approach to your child’s temperament.
After all this sleep theory, I know that you want to
get practical, so let’s get practical.
Zeitgebers
Zeitgebers are the “time-givers,” the
environmental cues that set or reset our biological clocks. Because we run on a
25-hour clock, and the world runs on a 24-hour clock, we need daily cues to
continually set our circadian rhythms. And trust me, you need these right now,
especially if you just got off the plane.
•• Light is the major zeitgeber — keep
things dim in the hour before bedtime, dark at night except for a dim
nightlight if necessary, and brightly lit through the day. A sunny breakfast
first thing in the morning is ideal.
•• Physical handling and eye contact are potent stimuli
that can boost adrenaline levels. Keep the physical play and long intense gazes
for daytime. Soothing contact, like rocking and gentle backrubs, work well at
night.
•• Food routines can help maintain circadian rhythms, so
try for consistency in your meal/snack/bottle schedule.
•• Vigorous physical activity during the afternoon can
make a big difference at night as well. Go for a big hike or playground session
—your new arrival may have more energy than you think.
Bedtime Routines
Even if you’re a free spontaneous spirit, your child
will need a bedtime routine. Young children thrive on predictability and
routine, and that goes double for post-institutionalized children. How long
should it be? How about 30-40 minutes? Sound too long? Well, how long does your
child take to actually fall asleep after you “put them to bed”? Either you’ve
just found some time that could be better spent on a cozy, bonding bedtime ritual,
or you’ve won the sleep jackpot (don’t tell the other parents). When things are
going well, it makes sense to trim it back to 20 minutes or so.
Here are some ideas for your bedtime routine:
•• The hour before bedtime should be free of TV, computer
games, vigorous play, or other stimulating activities.
•• Preempt the “I’m still hungry” calls with a healthy
and even sleep inducing bedtime snack. Complex carbohydrates, as well as
turkey, peanut butter, bananas, soy and dairy products (which all contain tryptophan)
can help you get your sleep on. Best eaten half an hour before bed.
•• Review a pictorial sleep routine story that you
wrote/drew together to reinforce the pre-bed ritual, and to confidently
anticipate sleep successes. These sorts of personalized picture stories can
really help in any anxious situation.
•• Baths. Who doesn’t love a bath? Well, the kids who got
stuck under a cold faucet during diaper changes don’t love the bath so much at
first, but usually quickly warm up to the concept. Try not to make it a wet‘n
wild play session, though.
•• Brush their teeth. Battery-powered toothbrushes are
fun. So are tasty toothpastes. “Should I brush your teeth…or your bellybutton?”
Riff on your routine with absurd suggestions — they like it, and it builds language
in the younger child or new English speaker. My niece likes to “teach the cat
how to brush.”
•• Change into PJs. And don’t forget to change out of PJs
in the morning— helps them become a more powerful sleep association.
•• Bedtime bottle? The dentists just can’t seem to win on
this one…but certainly no caloric beverages in the crib/bed, and it’s nice to
finish feeding 15 minutes before sleep to let saliva wash out some of those sugars,
and to avoid setting up drinking as a sleep association that won’t be there in
the night. Milk, formula, and breastmilk are all soporific!
•• Take a tour of the room, saying goodnight to all the
favorite toys. Doubles as a language lesson for the English learners.
•• A bedtime prayer is part of many people’s bedtime
rituals.
•• Put your child in his bed or crib and take up your
station next to him. Oh look, was there a nice little not-too-stimulating
surprise waiting in bed? Maybe a sticker? Or a new book? Isn’t going to bed
dandy?
••Do consider a gentle, soothing back massage or foot
rub. Massage can work magic at bedtime, unless your child is overly sensitive
to touch or ticklish.
•• Read books. Let your child choose 2-3 books. The
lights should be dim by now, so it’s not about the pictures, it’s about your
soothing voice. If your voice needs a rest, try a tape of you reading, or an
audiobook.
•• “Goodnight, you princes of Maine, you Kings of New
England...” What words will you leave your child with each night?
Bedtime Itself
It’s earlier than you think. In fact, the ideal
toddler bedtime is often somewhere between 6:30 and 8pm.
••Use your sleep logs to keep track of when your child
shows signs of sleepiness, and when he actually falls asleep.
•• If you miss it, poof goes the
easy sleepy bedtime — tired cranky adrenaline-addled children don’t fall asleep
well.
•• If you get home from work late, you may need to
rejigger that or make early mornings your quality time.
•• If you’re having sleep issues, you’re well advised to
keep sleep schedules the same 7 days a week. Which
means keeping the bedtimes the same, but also not letting them sleep in much
past their usual/appropriate wakeup time (ouch).
•• That said, sometimes your child’s current circadian
rhythms has him going to bed later than you think. Try letting the bedtime
start out later, but inch it backwards by 10-15 minutes per night.
Falling Asleep
This here is the key. The associations your child has
with that golden moment of falling asleep will be the ones she needs each time
she wakes in the middle of the night. Do everything in your power to let that
moment be on her own. No feeding, no rocking at that moment, if you can. Stay in
the room at first, by all means; stay next to the bed or even in it if you must
— you can wean that later if you want. Falling asleep is hard to do if you are
anxious and having difficulty letting go. Here are some ideas to help with the
weaning process, which may take weeks to months.
•• Does your child have a “lovey,” or transitional
object, that can represent the emotional security she’s building with you? If
she didn’t arrive with one, have an array of dolls, stuffed animals, and
blankies around for a few days and see if she gravitates to one. When she
settles on one, experienced parents keep backup loveys on hand, and even rotate
them so they’re equally worn and stinky.
••Maybe there are a few nonsense “errands” you need to
do, in the room or out of it? But you’ll be right back.
•• In fact, you can set a silent timer like an hourglass
egg timer or visual timer and tell her that you’ll be back in 3 minutes when
the timer is done. Come back, check on her briefly, and repeat. Make sure you
do come back.
•• Even if you’re not doing the timer, coming back in for
brief check-ins when your child is not screaming
for you is reassuring and rewards good bedtime behavior.
•• Successes with independent falling asleep are often
followed by fewer night wakings in 1-2 weeks.
Night Wakings
Remember the sleep study statistics — 70% of infants,
47% of toddlers, 36% of preschoolers, and 14% of school-age children wake and
need help at least once per night.
••What’s going on? Illness, teething, soaked diapers,
recent stresses, new developmental milestones, night fears, night terrors,
nightmares?
•• Again, be more responsive at first than you might
eventually plan to be…
•• But be as brief, boring, and minimalist in your
interventions as possible.
•• And give brief fussing a chance to subside on its own
— your child may be having one of those night arousals that doesn’t involve
fully waking up.
•• Before you approach your
wide-awake-and-screaming-at-4:00am child, take several slow, deep breaths, in
through nose, out through mouth, focusing on a happier parenting moment or
image of your child. Then go in.
•• Keep the “deep cleansing breath/find your happiness”
visualization going while you’re in there. Seriously — breathing and a calm, affectionate
approach is SO helpful, day or night.
•• Review your child’s sleep associations — is there
anything he falls asleep to that isn’t there in the night?
•• Is there something your child could do for himself
that’s self-soothing? Some of my older adoptees have cassette/CD players in bed
with calming stories or music. If you played music at bedtime, can your child
turn it back on easily?
•• Elizabeth Pantley has several great suggestions —
giving your older child one or two Get-Out-Of-Bed-Free cards, a “Sleep Fairy”
that leaves stickers under the pillow when children have had a successful night
(depending on what they’re working on - reward incremental successes), and even
wrapped prizes in the morning for kids that have a good quiet night.
•• If you suspect night terrors, do
less. They’re more distressing for you than your child, and sleep
experts discourage waking a child while they’re having one. I’ve also heard
that limiting fluids before bed may help, as a full bladder might provoke night
terrors.
Cozy Sleep Nooks
•• First things first — if there’s a TV or computer in
your child’s room, banish it forthwith. They are the anti-sleep.
•• Ideally the sleep area is for sleeping and quiet
resting ONLY, and perhaps even separated by curtains or other dividers from the
rest of the room.
•• Lots of stuffed animal friends can be reassuring, as
are pictures of loved ones.
•• Climb in and spend some time in it yourself. Is the
mattress comfortable enough? Audible household or outdoor noises? Lights shining
in from the hallway or street?
•• Is there a place for you? Because that’s the ultimate
safe, secure, “cozy sleep nook,” at first. I think the ideal transitional
solution is with one parent sacked out next to the child, since that will
maintain a consistent sleep environment for the child when you eventually wean the
parental presence.
•• If you’re not there during the night, something that
explicitly reminds her of you is also very important — since smell is one of
the most powerful shortcuts to our primitive brain, where our senses of anxiety
and security come from, perhaps an aromatic worn t-shirt or pillowcase of
yours? And some photographs of you together in a loving, calm moment can be
reassuring in the night.
••Other options are having the crib (or, for an older
child, a futon) next to your bed.
•• Co-sleeping is also a popular option at first. Some
adoptive parents report that their child was easily weaned after a few months
to their “big kid bed,” but in general, once you start co-sleeping it’s the hardest
habit to wean.
Light
•• The summer can be brutal for sleep. Try creative
window treatments like “blackout curtains,” cardboard, aluminum foil (also adds
a certain “blocking the alien mind control rays” touch to your decor), or whatever
it takes to get that room dark.
•• If you do use a nightlight, keep it as dim as possible.
Sound
••White noise can be a godsend for sleep, and is one of
the first things I recommend for light sleepers.
•• A fan or aquarium pump running all night long can help
drown out other intrusive noises.
••Ocean wave noise generators, machines that make “womb
noises,” and heartbeat lullabies are other favorites.
Smell
•• That lovey smells funky for a reason. Wash it at your
peril.
•• Something that smells like you can be soothing too.
•• Aromatherapy — lavender and chamomile scents are felt
to be relaxing as well.
Touch
•• Being wet in the night is trouble, so limit fluids in
the 1-2 hours before bed, use diaper doublers, and consider a nice layer of
protective diaper paste before bedtime.
•• For children that seem to crave that
snug-as-a-bug-in-a-rug sensation, often winding up wedged in the corner,
perhaps a smallish sleeping bag or sleep sack would feel good. Tucking in the
sheets extra-tight may help at first, but they come undone; some parents have
used a lycra sleeve around the mattress that the child slips into. Weighted blankets
are available for older children with sensory issues as well.
••Many orphanage-raised children will have pronounced
self-stim/self-soothing habits like rocking, head-shaking or -banging, ear
fiddling, or sucking on lips or fingers. These do fade with time, but may still
show up in times of stress.
Temperature
•• The body tends to cool off at night, and people sleep
better in a cooler environment.
••Warm baths followed by cool bedroom may help this
process along.
Does My Child Have a Sleep Disorder?
Courtesy of Dr. Mindell, the following list of sleep
problems may indicate that your child has a sleep disorder. If these issues are
present, if sleep issues are getting worse and not better, or if you’re at the
end of your rope, please talk to your health care provider.
1. Loud
snoring, noisy breathing, or breathing pauses while sleeping
2. Breathing through his mouth while
sleeping
3. Appearing confused or looking
terrified when he awakens during the night
4. Frequent sleepwalking
5. Rocking to sleep or head-banging
when falling asleep or during the night (ed: actually
very common in orphanage-raised
children, and thus only a problem if severe or persistent)
6. Complaining of leg pains,
“growing pains,” or restless legs when trying to fall asleep at night
7. Kicking
his legs in a rhythmic fashion while sleeping
8. Sleeping
restlessly
9. Frequent
difficulty falling asleep or staying asleep
10. Sleep
difficulties leading to daytime behavior problems or irritability
Acknowledgements
Thanks to New Hope Child and Family Agency for the impetus, Elizabeth Pantley for many fab ideas, Drs. Mindell and Weissbluth for others, Dr. Greene for the zeitgebers, and our sleepless families for the inspiration.
Editor’s Note: This article by Dr. Julian Davies was originally published at www.adoptmed.org by the Center for Adoption Medicine at the University of Washington. Reprinted with permission.
http://adoptioncouncil.org/publications/2015/04/adoption-advocate-no-82
