Chapter 1: At the End of Your Rope The most frequent calls I receive at the Center for Pediatric Sleep Disorders at Children's Hospital Boston are from parents whose children are sleeping poorly. When the parent on the phone begins by saying "I am at the end of my rope" or "We are at our wits' end," I can almost always predict what will be said next. Typically, the couple or single parent has a young child (often their first) who is between five months and four years old. The child does not fall asleep readily at night or wakes repeatedly during the night, or both. The parents are tired, frustrated, and often angry. Their own relationship has become tense, and they are wondering whether there is something inherently wrong with their child and whether they are unfit parents. In most cases the parents have had lots of advice from friends, relatives, and even their pediatrician on how to handle the situation. "Let him cry; you're just spoiling him," they are told, or "That's just a phase; wait until she outgrows it.

" They don't want to wait, but they are beginning to wonder if they will have to, since despite all their efforts and strategies the sleep problem persists. Often, the more the parents do to try and solve the problem, the worse it gets. Sooner or later they ask themselves, "How long do I let my child cry --all night?" And if the child gets up four, five, or six times a night, "Will this phase pass before we collapse from exhaustion?" Everything seems pretty hopeless at first. If your child isn't sleeping well or has other problems that worry and frustrate you -- such as sleep terrors, bedwetting, nightmares, or loud snoring -- it won't take long for you to feel as if you're at the end of your rope, too. Let me assure you that there is hope. With almost all of these children, we are able at least to reduce the sleep disturbance significantly, and usually we can eliminate the problem entirely. The information in this book will help you identify the type and cause of your child's particular disturbance, and it will give you a variety of practical ways of solving the problem. When a family visits the Sleep Center, I meet with the parents and child together and learn all I can about the child's problem.

How often does it arise, and how long has it lasted? What are the episodes like? How do the parents handle the child at bedtime and during the nighttime wakings? Is there a family history of sleep problems, and are there social factors that might be contributing to the problem? Given this detailed history, a physical examination, and, in certain cases, laboratory study, it is usually possible to identify the disorder and its causes. At that point I can begin to work with the family to help them solve their child's sleep problem. At the Sleep Center, our methods of treatment for the "sleepless child" rarely include medication. Instead, I work with the family to set up new schedules, routines, and ways of handling their child. Often the child's biological rhythms may need normalizing, or at least his sleep-wake schedule may need to be changed. He may have to learn to associate new conditions with falling asleep or get used to fewer and smaller nighttime feedings. The family may have to learn how to set appropriate limits on the child's behavior, and the child may need an incentive to cooperate. And any anxiety in the child (or parent) must be taken into account.

I always negotiate the specifics of the plan with the family. It is important that they agree with the approach and feel confident that they will be able to follow through consistently. As much as possible, I offer choices. Thebestsolution frequently differs considerably from family to family, and from one culture or social group to another. If the child is old enough, we include him in the negotiations. Thus we use a consistent and firm but fair technique tailored to the.