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Jane* is a 3 year old girl who attends the sleep wellness clinic for sleeping late. Her parents try to put her to bed at 10pm but she refuses, often throwing a tantrum and insisting on watching TV and playing with her toys. She ends up sleeping as late as 3am after much coaxing from her parents. She still requires one milk feed in the middle of the night. She then has difficulty waking up for pre-school, and parents also feel exhausted.

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In Singapore, bedtime resistance occurs in about 25-50%  of toddlers and may co-exist with negative sleep associations (see article on “night-wakings”). This may manifest in many ways – the child stalling for time before bedtime (“just some more play time”, “one more video”); taking a long time to fall asleep; outright tantrums and refusal to go to bed; refusal to sleep in his/her own bed or bedroom; or coming to the parents’ bed or bedroom in the middle of the night (curtain calls). Bedtime resistance usually reflects a lack of boundaries or rules surrounding bedtime.

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What can we expect at a consultation to manage bedtime resistance?

• Because of the detailed nature a typical first consultation would take at least 1 hour.

• The specialist will take a detailed history of how, when and where the child sleeps.

• A diagnosis of the sleep problem will be made.

• The family’s needs and expectations will be evaluated.

• A core skill in developing positive sleep associations in the child will be taught to parents. This is based on a combination of planned ignoring and intermittent comforting by parents, called graduated extinction in medical terms.

• Realistic targets should be set,

  • e.g. one family may wish to see improvement in a week;

  • another family may desire a stepwise approach, e.g. camping out with the child in the same room before the parents move out of the room.

• An individualised sleep management plan will be proposed.

• Techniques to gradually shift the child’s body clock (circadian rhythm) earlier are often used.

• In older children, more creative means like reward charts, surprise gifts and even games related to sleep are usually employed in the sleep management plan.

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References

*not her real name

1. Aishworiya R, Chan P, Kiing J, Chong SC, Laino AG, Tay SKh. Sleep behaviour in a sample of preschool children in Singapore. Ann Acad Med Singapore. 2012 Mar;41(3):99-104.

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