How Many Hours of Sleep Should a 17-year Old Get?

Case Study: A mother of a 17-year old high-school senior contacted me . She was concerned that the young man wasn’t getting enough sleep. He played a sport every season, and got decent grades. He had friends and did not demonstrate any evidence of behavior or mood changes. The problem was that he appeared to sleep until the afternoon every Saturday. How many hours of sleep should a 17-year old get?

How many hours of sleep should a 17-year old get?

The answer to the question is fairly easy: it is 9 1/2 hours, according to most sleep experts. When I told this to the high schooler who is the subject of this case study, he gave a fairly typical reply:

“Ha. Ha-ha. Ha-HA-ha.”

I get that a lot.

The sarcasm, not meant to be rude, was his way of expressing that there was not a chance in hell he’d be able to get that much sleep. There simply were not enough hours in the day for him to get everything done and to sleep 9 1/2 hours!

Let’s call him “Nate”. A typical weekday ran as follows: Nate’s alarm would go off at 7:30 am. He’d take approximately 10 minutes to get out of bed and stumble to the bathroom. Breakfast for Nate consisted of a protein smoothie. He told me this had been his breakfast of choice for as long as he could remember. Nate never had been much of a big breakfast eater.

The most important meal of the day

That wasn’t a bad choice. I was glad to hear he got some protein in before school. Nate is 5 feet, 8 inches, 140 lbs. He’s a long-distance track athlete. Nate probably wouldn’t have made it to lunch block without something in his system.

How many hours of sleep should a 17-year old get 2
How many hours of sleep should a 17-year old get? Risk-taking requires rest!

Good diet is one of the three legs upon which all of health stands. The others are exercise and sleep(!). Some experts add stress reduction as a fourth leg.

Nate’s school is 1.1 miles from his home. He almost never walked or rode his bike. His mother drove him. This gave Nate a time cushion to help him get out of the house. Nate is lucky in this regard. Teenagers who need to catch a bus have tighter time constraints. If they miss the bus, they are sore out of luck, so they have to work harder at going out of the house.

If the teenager is old enough to drive, I hope they got enough sleep the night prior. It is well known that teen sleepiness is associated with accidents during the morning drive.

First block in Nate’s day starts at 8:30 am, one hour after he wakes up.

Nate Hits the Road

School lets out at 2:20 pm. Nate changes into running shorts and runs with his friends to track practice. He will not be home until 6:00 pm. Noah eats before showering, much to the chagrin of his mother and his younger brother. This particular issue is beyond the scope of our consult!

By the time Nate has eaten and showered, it is 7:oo pm and time for homework. The average high school student has 3.5 hours of homework per night. Nate is no different.

How many hours of sleep should a 17-year old get 4
How many hours of sleep should a 17-year old get? This kid may need a lot!

At 10:30 pm, homework done, Nate is finally able to text his girlfriend, which he will do for about one hour (or at least, that is how time he will admit to!)

Nate’s home is one where phones are permitted in the bedroom. Both Nate, his brother, and his mother, all keep their phones by the bedside. Here’s a possible area where I can intervene. Technology in the bedroom is associated with reduced sleep and increased daytime sleepiness in teens.

By my calculation, the maximum amount of sleep Nate would get in a typical night would be 8 hours, 1 1/2 hours less than the recommended amount. My suspicion is that the real number is probably closer to 7 1/2, given that Nate likes to watch YouTube videos and spends a fair amount of time on Facebook.

By the weekend, Nate has accumulated a sleep debt. Naturally, if he does not need to wake up for school, he will stay in bed. It is not unusual for Nate to wake up between 11:30 am and noon.

How many hours of sleep should a 17-year old get? The Fix

I had a number of suggestions for Nate.

For the average sleepy teenager, there are factors that cannot be changed, and a few that can. The start time for school should be later, but for now, 8:30 am remains too early for the average teen.

How many hours of sleep should a 17-year old get 3
How many hours of sleep should a 17-year old get? Girlfriend time is tough to negotiate

Sports are important to Nate, and I certainly would not recommend that he cut out track from his life. I have clients who play sports and participate in other after school activities as well. In these cases I recommend cutting out some activities. I call this “simplifying” the life of the teenager. Simplification is sometimes easier said than done.

Do homework during school hours

I asked Nate if he had a free block, formerly known as “study hall”. When I was in high school, very little studying got done in study hall. These days, over-scheduled students are taking advantage of study hall to get their homework done. It’s not possible for Nate to do all 3.5 hours of his homework during the 50 minute block, but it’s better than nothing. Nate admitted that it would be painful, but he could do the writing-intensive part of his homework during free block.

Bedrooms are for beds, not for phones

I also suggested that Nate’s family make a rule about technology in bedrooms. No intervention like this will work unless everyone else in the home is on board as well. There were no televisions in the bedrooms. This alone was a terrific start. The next step was to get everyone to agree to leave their devices in the kitchen, plugged in.

I left it to Nate and his mother to negotiate the time for plugging in the phone. I was a high school boy once. I know what this is like. I didn’t speak to my girlfriend nearly as often as kids these days do (I had to share the one land line we had with three sisters and my parents). But I probably would be texting her if I had a smart phone back then.

Get Back to Basics

It never hurts to make sure that you are eating well and getting plenty of exercise. By eating well, I mean something fairly specific:How many hours of sleep should a 17-year old get 5

  • Meat and vegetables
  • Nuts and seeds
  • Some fruit
  • Starches rarely
  • Sugar NEVER

Easier said than done, right? A growing body of evidence is supporting these basic guidelines.

Nate has already gotten the vigorous exercise part covered. If your child is not doing any exercise, I recommend they get out and move. It doesn’t really matter what they do as long as they do something regularly.

Now that you know how many hours of sleep should a 17-year old get, the last piece is convincing the school system. Later start times have been shown to show benefits and few down sides. If an effort to start school later is not underway in your district, I recommend getting one started!

And if you need a sleep coach, I can help!

Infant Wearables: Good or Bad Idea?

In the age of the Fitbit, it is only a matter of time before devices designed for babies appear on the market. There are a whole bunch available now. There is a pacifier that doubles as a thermometer. You can buy a device to prevent heat stroke in your baby. There is even a GPS tracking devices for babies. The particular segment of the infant wearables market that concerns us here are the devices that measure infant blood oxygen levels. The unstated reason for buying such devices is the prevention of death by SIDS, or other sleep-related infant deaths.

Infant Wearables in the Age of Back-to-Sleep

These devices are based on a well-tested technology from the world of medicine called pulse oximetry. The “pulse ox” works by shining a red light onto the skin and simultaneously measuring the wave-length of the light that bounces back. The device then calculates the amount of oxygen in the bloodstream. Such devices have been used in even tiny babies for many years. Now, several companies are marketing these devices for parents worried about SIDS.

Do they work? Do infant wearables really prevent SIDS?

These are obviously two separate questions. We’ll tackle them one at a time.

To address the question of whether home pulse oximeters work, a few studies have been published. The study that best answers the question was published the the UK in 1991.

The British investigators focused on a group of babies that recently had been discharged from hospitals with apparent life-threatening events. Translated into English, the babies had turned blue at home, either because of choking or lung disease related to prematurity. This was a good population to study. The chance that these babies would actually need the alarm was greater than the general population of babies. Most of these babies had some kind of medical problem that made them more vulnerable to dropping their oxygen levels. This means the investigators were not measuring rare events and it would be unlikely that the number of events measured would be too small to give meaningful results.

The investigators also gave monitors to parents who had already lost a baby to SIDS.

The study looked at the number of events that the wearable devices picked up. Importantly, they also looked at false alarms, and measured side-effects of the devices, such as blisters and other skin burns.

The Results

A total of 201 babies were monitored for 30 months. Only 19 families withdrew from the study before it ended.

The pulse oximeters recorded 81 events, of which 52 were true episodes of blueness. No episodes were missed. In other words, the sensitivity of the device was 100%. Any time a test shows a 100% sensitivity (no true positives missed), there is going to be a substantial false positive rate. For these parents, that means an alarm going off for no reason. Sometimes the sensor would move out of position or fall off, activating the alarm. Sometimes it was a true false alarm. The device would go off when nothing was wrong.  In the UK study, false alarms happened about once every 4 days.infant wearables 2

Very few of the babies got skin redness from the red light source and none were burned.

Four babies actually died during the study. One sibling of a SIDS victim died while the infant wearables were in calibration mode. That is to say they were not turned on correctly. The cause of death was ruled SIDS as well. The other three babies died of the severe congenital heart and lung problems that got them included in the study.

There are two important take-aways from this study. Pulse oximeters work well. They will catch every dip in a baby’s blood oxygen level. But the devices cannot prevent death in severely ill babies. As was demonstrated catastrophically in this study, the devices won’t work if they are not turned on.

Infant Wearables and SIDS

The second question we asked was whether these devices can prevent your baby from dying of SIDS. The honest answer is “nobody knows”. In the UK study, the only baby to die of SIDS was not wearing an alarm. One other sibling of a SIDS victim in the study had a substantial dip in her oxygen and was later found to have meningitis. The answer remains open. We simply do not know if infant wearables prevent SIDS.infant wearables 3

But wait! Didn’t this study show that the alarm always goes off when the baby’s oxygen dips too low? If so, won’t any baby in danger of SIDS set off the alarm?

It’s a reasonable question. The answer is “yes, you are probably right”. And yet, we simply do not know because the studies have not proven the point to a degree of scientific certainty.

The Question You Didn’t Ask

It’s clear that pulse oximeters for use at home are very sensitive. They catch every event. This also means they “catch” events that are not events. Imagine how unbelievably frightening it must be to be awakened in the middle of the night by such an alarm. You cannot be sure if you are answering a false alarm or if you will be dialing 911. The question we didn’t ask at the outset was “do you think infant wearables make you more relaxed, or more anxious?”

The American Academy of Pediatrics has not taken a position on these devices for healthy infants. The organization’s silence probably reflects the absence of scientific evidence on SIDS prevention. Pediatricians disagree as to whether or not it’s a good idea for parents to buy such a device. My recommendation would be to discuss it with your pediatrician before buying.

And if you have any issues or (non-medical) concerns about your baby’s sleep, I’m a sleep consultant.

 

Teen Car Accidents: School Start Time Matters

The two age groups most at risk for getting into car accidents are teenagers and the elderly. The reasons for the high accident rate in each group are obviously different. Elderly people’s faculties tend not to be as sharp as they once were. Reaction time slows. Eyesight and hearing decline. The causes of teen car accidents are completely different. Besides lack of experience, there is risk-taking behavior and poor judgment. But one factor in the high rate of teen car accidents is getting more attention in recent years: sleepiness. It is well known that early high school start times make for sleepier teenagers. Now there is a growing body of scientific literature that is suggesting a link between school start time and car accidents.

What Does School Start Time Have to Do With Teen Car Accidents?

In 1998, University of Kentucky researchers Fred Danner and Barbara Phillips got word that a single county in their state planned to increase high school start time. In 1998, schools in the county started at 7:30 am. In 1999 start time was moved to 8:30 am. The remainder of the state kept the same start time. Danner and Phillips seized on this opportunity to test whether the change in start time would have any effect effect on the rate of teen car accidents.

Danner and Phillips found that high schoolers in all four years got substantially more sleep in 1999 than in 1998. The number of students getting the recommended amount of sleep, 9+ hours, increased from 6.3% to 10.8%. The number of students getting at least 8 hours increased from about one-third to over 50%.

But the most interesting finding was the drop in the rate in teen car accidents.

Despite rapid population growth, with many more cars on the road, the rate of crashes in the study county dropped after the change in school start time. The average crash rates in the 2 years after the change in school start times dropped 16.5% in the study county.  At the same time, the car accident rate increased 7.8% in the rest of the state.

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Danner and Phillips were careful not to conclude that the school start time directly caused fewer accidents. The study hampered by the unforeseen circumstance that the student ID numbering system changed between 1998 and 1999. As a result, the investigators could not go back and find out if particular teens involved in accidents were sleeping more or less.

The Virginia High School Start Time Study

One study alone cannot answer a question. This is especially so when the study only shows a correlation (as opposed to a causal relationship) between teen sleep and car accidents. Any scientific question is best answered by several studies looking at the same problem. In 2011, a group of researchers at Eastern Virginia Medical School published a study similar to the 2008 Danner and Phillips study.teen car accidents 2

The Virginia investigators compared teen driver accident rates in two neighboring counties with different high school start times. The Virginia Beach district started high school 75-80 minutes earlier than the neighboring Chesapeake district. The investigators guessed that the rate of teen car accidents would be higher in  Virginia Beach than in Chesapeake.

This is indeed what they found.

For Virginia Beach and Chesapeake, teen drivers’ crash rates in 2008 were 65.8/1000 and 46.6/1000, respectively. In 2007 were 71.2/1000 and 55.6/1000. Teen drivers accident peaks in the morning occurred one hour earlier in Virginia Beach than in Chesapeake, consistent with school commute time. Congestion data for the two towns did not explain the different accident rates.

The Australian Teen Car Accidents Study

This study, published in 2013, was the first study of teen car accidents that was prospective as opposed to retrospective. That is, a large group of young people (over 19,000!) was signed up to participate. They were then followed over a number of years, while carefully documenting hours of sleep and other important contributing factors.

Here’s what they found: On average, teens who reported sleeping 6 or fewer hours per night had an increased risk for accidents compared with those who slept more than 6 hours. If the teen slept less on weekends, they were more likely to be involved in “run-off-road” accidents. Peak hours for these accidents occurred between 8 pm and 6 am. teen car accidents 3

Whereas the study did not address school start times as such, it offers some very strong data to the body of literature. First, it was a very large study. It also controlled for various factors that could skew the results of a smaller studies. As the evidence grows stronger that sleepiness leads to car crashes, the case for later school start times becomes stronger as well.

Back to Virginia

Finally we look at a second study published in 2014 by the Eastern Virginia Medical School group. This time, the investigators compared data for teen car accidents in two neighboring counties in central Virginia. Henrico County schools began at 8:45 am and Chesterfield County schools began at 7:20 am.  This time, investigators not only compared the rate of teen car accidents in each county, they also compared the rates of adult accidents as a comparison group.

For 2009-2010, Chesterfield teens had a higher accident rate than the later starting Henrico teens. There was no such difference in adult crash rates for either year in Henrico County and Chesterfield County, making it less likely that a systemic (not teen-specific) difference between the two counties was to blame for the difference.

Investigators also found two peak hours for teen car accidents, one in the morning when teens drive to school, and another in the afternoon when sleep deprivation begins to kick in.

Putting It All Together

One study never answers an important scientific question. The more studies that look at a question, the more likely we are to come up with an answer that approaches the truth. As the body of evidence grows, we are beginning to see a picture emerging that describes the dangers of early school start time for high schoolers. It seems that teens who must get up earlier than they should are more dangerous on the road.

There is an easy fix for this one. Start school later. There are a number of objections to this concept that deserve attention. Indeed attention has been paid to these objections. We will address them in future posts.

Extinction: Why Cry It Out is Extinct

I have argued before that no modern sleep expert recommends pure “cry-it-out” (CIO) sleep training. Here I want to explain in more depth where CIO stands currently. In order to simplify the discussion, I’ll call it by its more technical name, extinction. Some versions of this method are widely recommended today. One kind, unmodified extinction, has all but disappeared, or become extinct. That’s a shame, because it is highly effective, as I’ll explain below.

When it comes to any kind of human or animal behavior, “extinction” refers to the disappearance of a behavior in the presence of a stimulus. Pavlov famously could make his dogs salivate when he rang a bell (the stimulus). The dogs had learned that the bell meant Dr. Pavlov was about to feed them. That was only the first part of the experiment. In the second part, the dogs stopped salivating after a while. In other words, the salivating behavior “extinguished” with time.

Extinction in Sleep Training

When it comes to sleep training, the behavior we are trying to extinguish is crying. In sleep training, there are now three versions: Extinction with parental presence, graduated extinction, and unmodified extinction.

Extinction with parental presence is a version of CIO where the parent stays in the baby’s room, but does not respond to cries. With time, the caregiver moves farther away from the crib. Finally, the baby sleeps alone. This method has been championed by Kim West. She renamed the method “The Sleep Lady Shuffle”.  The terms get even more confusing because West’s followers refer to her method as “bedtime fading”. This is very different from true fading techniques.

The graduated variety is today better known as “Ferberization“. The method involves answering the baby’s cries, but doing so at longer intervals every night until the baby goes to sleep on her own.

Finally, we come to the true dinosaur, the unmodified CIO technique, sometimes called “cold turkey”. The villain of the CIO story is a late-19th century pediatrician named Luther Emmett Holt. The first time we see the words “cry it out”, they appear in Holt’s 1894 catechism “The Care and Feeding of Children.”

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Holt’s book is not a “sleep book”. In fact, there is no section on bedtime routines such as the kind we’ve grown used to. There is, however, a section on the types of infant cries and what to do about them. The section that follows is really about “problem crying”.

What should be done if a baby cries at night?

One should get up and see that the child is comfortable—the clothing smooth under the body, the hands and feet warm, and the napkin [diaper] not wet or soiled. If all these matters are properly adjusted and the child simply crying to be taken up, it should not be further interfered with. If the night cry is habitual some other cause should be sought.

How is an infant to be managed that cries from temper, habit, or to be indulged?

It should simply be allowed to “cry it out.” This often requires an hour, and in extreme cases, two or three hours. A second struggle will seldom last more than ten or fifteen minutes, and a third will rarely be necessary. Such discipline is not to be carried out unless one is sure as to the cause of the habitual crying.

Holt is describing a particular kind of crying here. This is crying born of habit. These are babies who have learned that crying can draw her parents’ attention. I suspect he is referring to babies who’ve acquired “object permanence“. That is, the baby knows that mom or dad is still there when they leave the room, and she can induce them to come back.

Dr. Holt is not describing a way to get a baby to fall asleep. He is describing a solution to a problem. That sleep problem is “bad sleep associations“. For example, the baby won’t sleep unless she has physical contact with a parent, or if she has a binky in her mouth. Likewise, sleep books that discuss “cold turkey” or any other CIO technique are aimed at families that already have developed bad sleep associations and want to reverse them.extinction 3

The Moa is Extinct. So is the Cold Turkey

Of the three types of extinction methods, only unmodified extinction, or cold turkey, has disappeared. It has ceased to be (see video below). And yet, cold turkey has been tested experimentally and found to be extremely effective. Several arguments agains cold turkey have been raised, not least that the method stresses the baby and caregivers. These objections have also been tested and so far have proven to be false. Even the most-cited article arguing for the negative effects of CIO  failed to show that the stress hormone cortisol goes up in crying babies!

The main reason cold turkey has gone extinct is that it is really difficult to listen to a child cry. Most parents can’t handle it. I know I couldn’t (the boys’ mother was the stronger partner). Listening to crying becomes even more difficult because of a thing called the “extinction burst”. This is an increase in crying as the sleep training process proceeds. Sometimes the burst happens after it appears that you’ve succeeded and the baby is sleeping through the night. In either case, the stress for parents becomes too much.

A second reason, perhaps more important, is that many parents believe cold turkey CIO will psychologically damage the baby. There is absolutely no evidence for this. To the contrary, the evidence suggests that babies sleep trained with unmodified extinction get good quality sleep. Parents report better sleep for themselves and their children. Overall there are only positive results for the family.

extinction 2
The reasons for the disappearance of a perfectly good sleep training method appear to be cultural, rather than scientific.

One more cultural factor deserves mention: consistency. Probably the number one reason why any of the extinction methods fails is that parents cannot or will not stick to the plan consistently. Consistency is the number one most important feature of any sleep training method, whether you are doing scheduled awakenings, bedtime fading, or the “Sleep Lady Shuffle” (which is, to repeat, extinction with parental presence).

To Extinguish This Line of Argument

  • The bottom line is that extinction methods are effective.
  • Extinction methods do not harm your baby or your bonding with her
  • Consistency, consistency, consistency. This is the essential piece of solving any sleep problem

Finally, let us explore the true meaning of life extinction with the help of our panel of experts, John Cleese and Michael Palin.

Scheduled Awakenings: The Original No-Cry Method

Long before there was a “no-cry” solution to baby sleep training, there was a thing called “Scheduled Awakenings”.

What? You’ve never heard of scheduled awakenings? There’s a reason for that. It’s really really hard to do. Too bad, though: it appears to work.

Scheduled Awakenings: The Original No-Cry Method

In 1980, Rita J. McGarr was completing her Bachelor of Science in Nursing degree at Stanford. For her thesis, project, she performed a case study of a 3-month infant with frequent night awakenings. The objective of Ms. McGarr’s study was to test whether a mother could shape her baby’s waking pattern. Just prior to the time the baby would wake up naturally, the mom would wake the baby up at intervals using a music box. Then she would gradually move “music box time” later in the evening. The baby went from sleeping 5 hours straight to sleeping 7 hours sleep. Not great, but enough to get published. And a new sleep training method was born.

The method Rita McGarr tested came from Behavioral Learning Theory. Briefly, the theory says that all behavior can be learned. What’s going on inside the learner’s head is not as important. The idea that any behavior, including sleep, can be taught leads eventually to parent-led sleep training methods.

Other investigators would later test the method. The best of these compared scheduled awakenings to other methods such as “graduated extinction“. It turns out to work very well.

Here’s How it Works

First, you have to keep a log. Keeping records became a lot easier in the 21st century with the advent of smart phones. There was no more taking notes in crayon on toilet paper!

First, you put the baby down the same time every night. This is an important first step in any baby sleep method. You write down the hour the baby wakes up. When she wakes up, you do what you usually do to get her to go back to sleep: rock her, feed her, etc. You should do this every night for as many nights as it takes to see a pattern emerge. Obviously, one night is too few. A week may be to many. I usually settle on three days.

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Once you have a schedule of the baby’s wake-up schedule, you set your alarm clock. Again, the smart phone comes in handy. You want to set the clock for 15 minutes prior to the time you’ve noted that the baby usually wakes up.

The waking up process should be as gentle as possible. I like Rita McGarr’s music box idea. When the baby is awake, you nurse or feed her as you usually do, and put her back down to sleep.

After about a week of this, you gradually increase the times you go in to wake the baby up. A good starting point is 15 minute increments. For example, if you had been waking her up at 1:00 AM, start waking her up at 1:15, etc. Do this three nights in a row.

scheduled awakenings

Then start dropping the awakenings. If the baby had been waking up only once, great, drop the scheduled awakening and you are done. If she’s doing it more than once, start dropping them in order: Drop the first awakening first, then the second, etc.

Et Voilà!

Now you have a sleeping baby! You did an awful lot of work to get here. There is a good chance that you would have about the same success with scheduled awakenings as you would have had with one of the extinction techniques, only without the crying.

Problems with the Technique

Schedule awakening training is difficult. I mean, it’s really difficult. Of all the sleep training techniques, it is clearly the most labor-intensive. It asks of parents that they wake themselves up, rather than being awakened by the baby. It also requires more time than other techniques. Even if there are no set-backs along the way, the entire process will require a minimum of two weeks. This is something to consider in light of the following facts: all the extinction techniques, including old-school Holtian cry-it-out, require 3-5 days; Extinction is at worst equally effective as scheduled awakenings; Finally, there is no evidence that extinction techniques have any negative effects on babies or bonding with caregivers.

Scheduled awakenings remains a viable option, especially parents who absolutely cannot stand hearing a baby cry. I know how to train a baby this way, and I can help you do it. How many parents do I know who have tried it? I have that number memorized: it’s zero. For most parents, especially sleep-deprived, stressed out parents, the scheduled wake-ups are more stressful, not less.scheduled awakenings 3

Nevertheless, if you’ve “tried everything” to get the baby to sleep, and you haven’t tried scheduled awakenings, you have not in fact tried everything! Behavioral learning works. It requires strength and patience. You got this.

 

How to Do Bedtime Fading: Best Sleep Training Method?

The so-called “cry it out” techniques for sleep training are getting a lot of attention. Meanwhile, there is another method that gets very little press, but which is highly effective. It’s called “bedtime fading”.

What is Bedtime Fading?

Bedtime fading is a method for teaching a child to fall asleep that is based on a simple principle: a child who is not tired will not go to sleep!

Babies and children are famous for “fighting” bedtime. Parents tell me that their child “fights” sleep. Or they tell me the child fights the parents at bedtime. The truth is that the child is fighting neither sleep nor the parents. She is fighting the time. She isn’t ready to sleep yet. Forcing the baby to bed earlier than she wants to is a recipe for conflict. Worse, the baby may develop negative associations surrounding sleep. This is never a good thing.

The Three Key Features of Bedtime Fading

One key feature of bedtime fading is finding the child’s “natural” time of sleep. This is presumably later than the perplexed parents want, but it’s what the baby wants. There are a couple of ways of finding out what the natural time of sleep is. See “The Bedtime Fading Technique” below.

Another key feature is “sleep onset latency“. This is nothing more than the amount of time it takes a person to fall asleep after getting into bed (or the crib in this case). Sleep experts agree that it’s never a good idea to have a long sleep onset latency, with a limit at about 20 minutes. Anything longer than that suggests the individual will not or cannot sleep. Ideally, you want the child to be falling asleep within 10 minutes. Less than 5 minutes, though ok, suggests that the child has a “severe sleep debt”. This is another way of saying “she’s totally exhausted”.

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The third feature are good sleep associations. We want the child to associate going to sleep with calm and quiet. We want her to feel comfortable and safe. This step is essential to teaching the child to self-soothe, and to wind herself down to sleep on her own, without assistance from caregivers.

How to Do Bedtime Fading

Step One

The first step is to determine the baby’s natural sleep time. There are at least two ways to figure this out. The first is to keep a sleep diary. Parents or caregivers write down the times the child falls asleep every day. They should do this for every nap as well. Doing so provides useful information for them and for the sleep coach. The last time she falls asleep is probably the time she is “set” to fall asleep.Print

A second method for determining baby’s sleep time is called the “response cost” method.

[A Digression: The official name of this method is called “bedtime fading with response cost”. I never liked this expression. It’s high-tech expression for a truly low-tech idea.]

It works like this: you put the baby to bed at the time you want (the desired bedtime). If the child doesn’t fall asleep within 15 minutes, you remove the child from the crib or bed and allow her to play (quietly) and otherwise stay awake for 30-60 minutes. This is the “response cost” to the child. Then you try again. If the child still won’t fall asleep within 15 minutes, you repeat the procedure. You do this until the child falls asleep rapidly. Now you’ve found the child’s natural bed time.

Step Two

For at least two days, you treat this later bedtime like the normal bedtime. This means establishing a steady, consistent bedtime ritual.  You want to aim for any activity that promotes calm and quiet.  I recommend starting the routine at dinner time, no matter how late. From then on the routine is completely predictable. It’s usually a mix of these activities: a warm bath, brushing teeth (if she has teeth), book reading, lullabies, prayer, etc.

Step Three

From here, you gradually fade bedtime earlier to your desired bedtime (hence “bedtime fading”). Experts differ as to the number of minutes to fade and the number of days to stay at each bedtime. Some recommend fading 30 minutes earlier every night until hitting the target. Others recommend moving in 15 minute increments. This is my preference. Half an hour is too big a jump for some children. I also recommend two days for each bedtime. This means the entire bedtime fading technique may require two weeks or more to complete. It is well worth the effort.bedtime fading 3

Setbacks can happen. Sometimes the child will revert to her previous “natural bedtime”. If so, I recommend repeating the fading technique, but this time taking it more slowly. Perhaps spend three days at each time point.

Other children might fall asleep well as a result of a successful bedtime fading campaign but will continue to wake up frequently at night. In this case, many experts recommend using an extinction method (since we don’t want to call it by its more infamous name. Okay, okay: cry it out.)

This is Great! How Come I’ve Never Heard of It?

bedtime fading 4
This lucky man got to hit in front of Bonds

Good question. Here’s a baseball analogy: Say your team has a power hitter batting in the clean-up spot (fourth in the order). He’s having a monster year. By the end of April he already has 12 home runs. People are already starting to compare him to Barry Bonds or even Babe Ruth. Camera crews follow him to every ballpark. He’s all they talk about during the sports segment on the evening news. Meanwhile, the guy hitting in front of him (the number three hitter) is quietly having a career year. He’s in the top 5 in just about every offensive statistical category. Why? Because pitchers don’t want to face the monster following him. So they throw strikes to the number three hitter, trying to get him out. And instead of getting him out, he’s getting hits. But no one pays attention because the monster sucks up all the headlines.

That’s kind of like what’s happened to bedtime fading. Extinction methods are like the home run hitter hitting clean-up. Bedtime fading is like the number three guy racking up all the amazing numbers that no one notices. Bedtime fading is an amazingly successful technique that is based on all the principles we know are essential for good sleep: a tired child, consistency, routine, and good sleep associations.

So keep this method in mind. If you need any help figuring out how to do it, that’s why I’m here.

 

Cry It Out is OK, Say Researchers

So it turns out that Cry It Out is ok, after all!

I believe that no major sleep expert actually recommends “cry-it-out”. Nevertheless, the term has become attached to a method formally called “graduated extinction“. The method is made most famous by Dr. Richard Ferber in his 1986 classic “Solve Your Child’s Sleep Problems”.

Graduated extinction was criticized by proponents of “Attachment Parenting” styles of sleep training, particularly William Sears. In “The Baby Sleep Book”, Sears makes frequent reference to the relationship between baby crying and elevated levels of the stress hormone cortisol. Lots of crying leads to cortisol going up.  Sears says this leads to all kinds of negative outcomes for baby. For example:

“Science (sic) tells us that when babies cry alone and unattended, they experience panic and anxiety. Their bodies and brains are flooded with adrenaline and cortisol stress hormones. Science has also found that when developing brain tissue is exposed to these hormones for prolonged periods, these nerves won’t form connections to other nerves and will degenerate. Is it therefore possible that infants who endure many nights or weeks of crying it out alone are actually suffering harmful neurological effects that may have permanent implications on the development of sections of their brain?”

It was a rhetorical question. Sears goes on to say that cortisol damages babies brains in all kinds of ways. In extreme cases, I will grant that chronic stress is bad for babies. But the “research” Sears cites has nothing to do with crying at bedtime. No one had ever measured levels of stress hormones at bedtime. Furthermore, no one had tested whether different sleep methods stressed out babies more than other sleep methods. No one had asked whether a particular sleep method damaged (or helped) develop a bond between baby and mother.

Until now.

New Research Says Cry It Out is OK

Investigators in Australia asked mothers in pediatric clinics if their babies had a sleep problem. The doctors recruited 43 babies between 6-16 months of age. They divided the babies randomly into three groups. One was assigned to try “graduated extinction” (AKA “cry-it-out”).  Another group would try “bedtime fading“. This is a technique in which you move bedtime later in the evening to match the child’s “internal” bedtime clock, then gradually move bedtime back to your desired time. For example, if you want your baby to go to bed at 8:30, but she usually does not fall asleep until 10:30, choose 10:30 as his temporary bedtime. Then move bedtime gradually earlier.

A third group in the Australia study was handed a list of sleep instructions. This was the “control group” for comparison to the graduated extinction and the bedtime fading group.

Need a SLEEP COACH?

During the study, investigators had the parents swipe a cotton swab on the inside of their babies’ mouths to measure the hormone cortisol. Motion sensors were given to parents in the study to measure baby’s wakefulness (actigraphy). The parents also filled out questionnaires to measure their own stress and anxiety. Finally, the mothers and babies took a standardized behavior test to measure their level of attachment.

Cry It Out is OK with Respect to Sleep
cry it out is ok

Compared with the control group, babies taught with graduated extinction and bedtime fading took less time to fall asleep (sleep latency, panel A). They also woke up at night less often (panels C). If these babies did wake up, they stayed awake fewer minutes than the control group (panel B).

You can see that the control group showed some improvements across the board. This suggests that sleep education helps. It also could mean simply that babies sleep better as they mature. This is why it is so important to include a control group. To study an intervention like a sleep method, you need to know what the “background” improvement is. Otherwise you’ll never really know if your intervention works.

Babies in the graduated extinction group got more hours of sleep in the early stages of the study. However, these gains appeared to disappear by the end (panel D).

Cry It Out is Ok? What About Stress?

cry it out is ok 6
The central issue in the Australian study was stress. Does graduated extinction really raise cortisol? Does the method damage the relationship between mother and baby? The answer was ‘no’.

Other researchers have shown that minor stressors can elevate cortisol levels in newborns; But this goes effect goes away at about 4 months of age. The Australian study only looked at babies older than 6 months. So you might think that this study misses an important point that Dr. Sears and others were trying to make.

However, the investigators did something clever to get around this limitation. Sears and others insinuate that cry-it-out sleep methods cause chronic increases in cortisol. These investigators measured cortisol twice, once in the morning and once in the afternoon. They saw no difference among groups. This suggests that cry it out is ok from the standpoint of stress as well.

So Cry It Out is OK for Baby: What About for Mom?

Mothers in both intervention groups reported less stress than mothers in the control group. You see this in panels C and D in the second figure I show here. The researchers also looked at mother-baby bonding one year after the study was over. They found no differences in the ability of moms and babies to bond with one another. The levels of attachment between the two appeared to be identical in all groups. Finally, the babies in the cry-it-out groups had no more emotional or behavior problems than the control babies.cry it out is ok 7

This last finding was similar to a much larger study published in 2012. That study, also done in Australia, involved 326 children. These investigators found that sleep method had no effect on attachment, bonding, and behavior. This study was five years after the intervention, suggesting that there was nothing was messed up permanently by allowing your baby to cry at bedtime.

Limitations: Maybe Cry It Out is OK for Some, But Not for All?

The investigators acknowledge that their study has some problems. For one thing, it was relatively small. There were only 43 babies involved. With small studies like this, there’s a chance that you cannot generalize the results to all babies. This includes your own baby! That is why the investigators were careful to compare their results to other similar studies. We can believe in your conclusion more strongly if you do your study in a slightly different way, but come up with the same answers.

They also noted that they didn’t measure cortisol continuously, or even at night when the crying was happening. It’s possible that cortisol does indeed go up in a crying baby. It would be surprising if it didn’t! But the study was looking at chronic elevations. That is, cortisol stays up over time. This, after all, is the accusation that Sears and others hurl at the Ferber method. Here, the investigators have a point: sleep method does not change cortisol long-term.

Implications

The investigators conclude from these data that sleep education alone may not be enough to get your baby to sleep. You may need an intervention if your baby has a sleep problem beyond 6 months of age. They propose an interesting combination of methods: Their results suggest that bedtime fading could be done first. Then graduated extinction could be used to reduce nighttime wakings.cry it out is ok 8

Conclusions

  • Graduated extinction (cry it out) and bedtime fading are both effective.
  • Extinction-based methods do not stress out a baby chronically
  • These methods do no have long-term effects on a baby’s emotional life or her attachment to her mother.

My suggestion: find a sleep method that works for you and don’t worry about it. Show your baby a lot of love and attention and you don’t need to worry about bedtime. Above all, stay consistent: find a routine that works for you and stick with it!

If you need help doing that, go ahead and contact me. I can help.

School Start Time: City Boys Matter!

Is a later school start time better for teenagers?

“Yes, of course”, you say! But how do you know that?

What if I told you that the correct answer is  “It depends”?

Does School Start Time Matter?

To answer this question, investigators at the National Institutes of Mental Health (NIMH) sent surveys to high school students, aged 13-17, all over the US. Almost 10,000 kids participated.

NIMH investigators asked questions about bedtimes, amount of sleep, and various other questions to tease out important demographic information. Weeknight bedtime was assessed with the question “What time do you usually go to bed on weeknights?” Sleep duration was assessed with the question “How many hours of sleep do you usually get on week (weekend) nights?” They asked this question to indicate whether the teenagers slept at least 8.5 hours of sleep. This number was chosen, instead of 9.5 hours, as is currently recommended, because at the time of the study, the National Sleep Foundation (NSF) recommended only 8.5 hours for teens.

Any high school kid will tell you that it’s much more complicated to understand the truth about their sleep. For this reason, the NIMH investigators asked about family characteristics, after-school jobs and extracurriculars. They also asked about school type (public vs. private, etc) and grade level.

Here’s What They Found

The NIMH school start time study is a good example of why it’s never a good idea to assume you know the answer to a question. Always investigate.

Need a SLEEP COACH?

The results were surprising. Investigators found some results they expected, but many others they did not expect.school start time 2

Teenagers Don’t Sleep Enough

The average number of weeknight sleep hours was 7.71 hours (7.60 for girls and 7.81 for boys). Not only was this result almost an hour less than the recommended NSF nightly allowance, it was almost two hours less than current recommendations!

But as this number was an average, it is obvious that some teenagers slept less than 7.71 hours, and some slept more. Extra sleep was associated with some surprising findings, which we’ll get to soon.

When school started later, students went to bed later. This was one of the expected findings.  And here is where it gets interesting.

School Start Time Matters… Until 8 AM

The investigators looked at school start times and then asked how many students got adequate sleep at each starting hour (e.g., 6:30 AM, 7:00 AM, etc.) When school started later, students got more sleep and more got the recommended amount of sleep (8.5 hours), but the effect went away for start times after 8:00 AM. In other words, if school started at 8:30 AM, or 9:00 AM, the students on average did not get more sleep! There appeared to be “diminishing returns”. In other words, later school start times was good for high schooler’s sleep… up to a point, namely 8:00 AM.

It Gets More Complicated…

It turns out that the benefits of later school start times may fall to boys only. When investigators looked at boys and girls separately, they found some unexpected results. School start time was not associated with hours of sleep for girls, regardless of start time. Similarly, later start times did not correlate with girls getting their 8.5 hours of sleep. School start time just didn’t seem to have anything to do at all with girl’s sleep. school start time 3

What about the boys? Since girls’ sleep didn’t seem to be affected by school start time, you would think that when you removed girls from the analysis that the effect would be even bigger for boys.

And it was… up to a point.

When school started later, boys got more sleep, and more boys got “adequate sleep” but the effect went away after 8AM.

City Boys vs. Country Boys

It turns out that location of the school mattered quite a bit. Investigators divided the kids into three groups: major metropolitan county (census-defined metropolitan counties with ≥ 1 million residents), other urbanized county (metropolitan counties with < 1 million residents), and non-urban county (non-metropolitan counties).

For boys living in major metropolitan areas, later start time was associated with adequate sleep, but only until 8 AM. For boys living in “other urbanized counties” and non-urban counties, start time had no effect on adequate sleep. Put another way, for boys going to big-city schools, later start times were associated with better sleep (up until 8 AM, of course…) For boys in smaller cities or suburbs, start time appeared to have no effect on quality sleep.school start time 4

Once again, girls sleep was unaffected by location. City girls got just as much sleep as country girls.

Make-up Sleep

In an earlier post, we showed that teenagers tend to sleep differently on weekends. These are the days we expect teenagers to “make-up” on sleep.

It is reasonable to guess that the teens who go to high schools with later start times might not need to make up for lost sleep on weekends. Indeed this is what the NIMH investigators found at first… until they “adjusted” the results. “Adjustment” means eliminating or reducing the confounding effects of extraneous confounding factors like sex, age, etc. The NIMH investigators adjusted data for all their results in this study, but when they used adjustment to look at make-up sleep, they got an unexpected result:

There seemed to be a correlation between later start times and less make-up sleep, but the effect would go away after normalizing for age, sex, school level, and school location (city vs. country, etc). In other words, overall later school start time did not give teenagers the opportunity to make up for lost sleep.

Strengths of the Study

Large studies are always better than small studies. The statistics always get better for one thing. Put another way, you can resolve small differences, and bring out subtleties better if your study has more subjects. We believe something closer to the truth is found when you look at very large populations. Almost 10,000 high school kids is a large enough sample size to give results we can believe. And indeed this study found some interesting differences: between boys and girls, and between city boys and country boys.school start time 5

The large sample size also allowed the NIMH investigators to uncover the compelling finding about the hour of 8:00 AM: Later start times did indeed matter, but the effect would disappear after 8.

Limitations of the Study

Survey results are never the best way to arrive at the truth. Think of those times in American history when opinion polls grossly mis-calculate the outcomes of elections! The NIMH school start time study was limited by use of a cross-sectional survey as the research tool. As a result, all the investigators could tell us is that there were associations between things like school start times and hours of sleep. They were unable to tell us if any two things were causally related to each other.

Furthermore, it’s far more accurate to measure hours of sleep than it is to ask a teenager how long she slept! In a study this large, actual measurement was not possible. They also did not ask the kids about confounders like cell phone use, which may vary from group to group.

Finally, there is the question of generalizability. It is important, when reading about studies like this on the internet, to ask an important question: “Does this study apply to me?”  If this same study were performed on teenagers living in isolated villages deep in the Amazon River basin, you might justifiably say “I’m not sure this study tells me anything about my teenager’s sleep”. But you can still ask the question about studies done on American teenagers. Look carefully at the study and ask yourself how easily your child could have been one of the kids who turned in a survey.

Summary: The NIMH School Start Time Study Suggests…

  • That teenagers don’t get enough sleep
  • That later start times matter, but
    • only if you’re a boy, and
    • only if you live in a big city
    • only until 8 AM

What they’re saying about Sleep, Baby!

[testimonials]

Why Does My Teen Sleep So Much?

Why does Jackie sleep so much?

As Jackie’s mother was asking the question, I was already suspecting that Jackie actually didn’t sleep enough!

They Sleep So Much, and Yet So Little!

Jackie (not her real name) is a pretty typical high-school sophomore. She’s a good student. She plays three sports. When I met her she was running track in the fall. The problem, Jackie told me, was that she needed to do homework, but she couldn’t keep her eyes open during dinner. She was afraid that her grades were going to suffer if she couldn’t complete her school work.

She would wake up at 6:30 in the morning. Or rather, Jackie’s mother would wake her up at 7. There’s no way Jackie would wake up on her own. On Saturdays and Sundays, the girl would wake up at 10.

The school day would go fine. Jackie didn’t report any sleeping or even drowsiness during the day. Immediately after school she’d go to track practice, four days per week. She’d compete once per week. After track, Jackie would come home, eat dinner and do homework. Most nights Jackie wouldn’t get to bed until after 11 PM.

Lately the fatigue was catching up to Jackie. By dinner time she was wiped out. That’s when they sought my advice.

The Story

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Do I sleep so much?

I took a complete history from Jackie and her mother. She was healthy (no snoring, no asthma), had no emotional or drug problems (that she would admit to). There was no television in her room. The rule in house was that no cell phones or tablets were allowed in the bedroom. Jackie’s parents kept to this rule as well. She had been a good sleeper up to this point. There was no family history of parasomnia.

The answers to these and other questions led me to believe that the reason for Jackie’s sleepiness after school was not a result of any health or emotional problem. Jackie would sleep so much after school because she wasn’t sleeping enough at night.

Teens Don’t Sleep So Much

Teenagers are supposed to get 9 1/2 hours of sleep every night. But on average, teens get 7- 7 1/2 hours. In addition, the teen sleep cycle is delayed compared to their younger peers. The teenage sleep cycle is such that they will tend to want to fall asleep at 11 PM, but they’ll need to wake up at 8:30 AM in order to get their 9 1/2 hours. Jackie was already in school when her brain wanted her to be waking up!

As a result, Jackie was genuinely exhausted by the time track practice was over. Her mother had wondered if Jackie needed to quit track so that she could get her homework done earlier.

Sports are Good for Kids

I explained that the issue was not track, it was the early wake-up time required by Jackie’s school. Jackie was glad to hear this. She really enjoyed track. She enjoyed the competition, and several of her good friends were on the team.

Need a SLEEP COACH?

In fact, vigorous exercise is good for teens (as it is for all of us!) I suspect that if Jackie wasn’t running track she probably would not be doing as well as she was. Teens who participate in sports tend to be more organized than their non-athletic peers, not least because sports schedules force the young person to be more efficient with study and homework.

The Fix for Jackie

sleep so much 3
If I’m going to sleep so much, I’m going to do it by the lake

Jackie’s situation is far from unique. High school administrators are well aware of sleep issues among the student body. With so many students involved in after-school activities, the sleep-deprivation problem is made worse. To respond to the problem, many schools have devised an ingenious solution: the study hall.

Study hall of course is an old concept. But these days schools are permitting extra study hall periods dedicated to homework.

There are several advantages to the student who is permitted to get homework done during school hours. Not least, student-athletes like Jackie can return from practice, shower, eat dinner, and go to sleep!

The solution is not ideal, however. The best solution would be to start school later for high schoolers. Such solutions in fact have been tried in several school districts, with positive results.

Jackie’s guidance counselor was enormously helpful. With her help, Jackie was able to schedule two extra study hall periods per week, which were enough to allow Jackie to finish all her homework before track practices and meets.

The take-home lesson for parents is that your teen isn’t sleeping as much as you think. In fact, they probably aren’t sleeping enough. I recommend trying to figure out how much sleep your teen is getting at night. Chances are very good that she is not getting 9 1/2 hours. If daytime sleepiness is becoming a problem, then some kind of intervention would help you.

That’s where I come in. I help parents solve their teenagers’ sleep problems. If you are dealing with a sleepy teenager, who nods out during school, or upon returning home, I can help.

Teens Don’t Sleep Enough. It’s YOUR FAULT

We all know that teens don’t sleep enough. Why don’t they?

Parents, you aren’t going to like the reason: it’s your fault.

 

Why Teens Don’t Sleep Enough

 

The National Sleep Foundation (NSF) performs an annual poll to learn more about the way Americans sleep. In 2014, the poll focused on parental attitudes toward their children’s sleep. In particular NSF asked parents how much they valued sleep and how much sleep they believe their children actually got.

Then NSF asked a series of questions about household rules regarding sleep, including questions about limits setting on caffeine and use of technology in the bedroom.

Parents were asked to fill out a survey on the internet. Questions were asked about demographics (age, socioeconomic status, etc), followed by questions about sleep.

The Results

Most parents (>90%) reported that sleep was either “very important” or “extremely important” for good mood, health, and performance in both themselves and their children.

teens don't sleep enough
Teens don’t sleep enough and neither do their younger sibs

However, almost 90% children did not in fact sleep the recommended number of hours, whether they were younger children or adolescents. The children in the study reportedly sleep fewer hours than children in other comparable developed countries.

Children 6-11 years of age ideally should get about 10 hours sleep. Teenagers should get 9 1/2 hours. In the NSF study, both groups got about one full hour less sleep than recommended.

Adolescents (12-17 years old) slept fewer hours than their younger siblings during the week. However, on weekends, both groups slept the same number of hours.

The survey was concerned not only with quantity of sleep, but also with quality. Slightly less than half of parents thought the quality of their children’s sleep was “excellent” or “good”.

Limits Setting and Enforcement

The survey was particularly interested in rules setting and enforcement, and the effect of rules on sleep. The results were significant.

Long hours of sleep were significantly associated with parents being married, always enforcing rules about how late the child can consume caffeine, and never leaving any technology on in the bedroom. Excellent sleep quality was significantly associated with always enforcing a bedtime for the child and with never leaving any technology on in the bedroom.

Not surprisingly, if parents slept with electronic devices, so did their children. Many parents admitted on the survey that they would read and respond to text messages after they had planned to go to sleep!

“Technology” was defined as virtually any electronic device with a screen, including television. In the age of the cell phone, the television continues to be the biggest contributor to loss of sleep.

TV is a Bad Actor

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Teens don’t sleep enough if they watch the big flat screen before bed

The study did try to explain why television appears to be worse than cell phones for inhibiting sleep. We can make some guesses, however.

It is well known that the blue light emitted from screens is bad for sleep. Exposure to this light tends to delay the sleep cycle and to increase the amount of time it takes to fall asleep (“sleep latency”). Television screens are larger than cell phones or tablets. In fact, on average television screens are larger than they have ever been! It’s possible that the larger the screen, the larger the amount of blue light. As a result, sleep is even more inhibited.

Conclusions

Like it or not, parents are role models for their children. It’s not reasonable to hold your kids to a standard that you yourself cannot keep up. If you have a television in your bedroom, how can you deny one to your child? If you sleep with your cell phone or tablet on your end table, your child is going to find out.

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Teens don’t sleep enough after an espresso

The parents who sleep the best, and who have children who sleep the best, make rules about technology use, enforce those rules, and observe the rules themselves!

 

Removing technology from the bedroom is easy, or should be. More difficult is modeling behavior for your children around healthy bed times. The NSF study showed that parents who get enough sleep quantity and quality have children who also sleep long and well.

Caffeine use is an important contributor to sleep hygiene, but it’s not often discussed. This study does us a favor by raising the issue of caffeine consumption in both parents and children.

As an admitted caffeine addict, I appreciate that the issue is being raised and I’m grateful to the NSF for bringing it up. I’m also grateful that my children have not inherited my addiction. But perhaps we’re not merely lucky. We make a conscious effort to model healthy eating and drinking behavior for our children. The same goes for exercise.

My own parents were heroic coffee drinkers and neither lifted a finger of exercise. How my sisters and I ever became health nuts will remain a mystery. Perhaps our parents modeled better behavior than I give them credit for.

Most children today are not so lucky. Parental modeling of behavior matters.

When I counsel a family about a sleep problem, I’m really counseling the entire family. To me the expression “sleep hygiene” refers to the sleep habits of the entire family, not just a child’s.

The truth is, fixing a child’s sleep problem often means fixing the entire family’s sleep problem. If you want to find out more, feel free to contact me. I can help.