CHILD BEHAVIOR
This article summarizes
current understanding and insight concerning sleep requirements, patterns and problems of young
children which may be helpful to the practitioner caring for children. Fundamental principles regarding children’s sleep are individually presented, followed by a brief discussion of each principle.
The
Sleep
General
Patterns of Preschool Children
Principles and Current Knowledge
ALFRED HEALY, M.D.*
&dquo;There never was a child so lovely but his
mother was glad to get him aslee~.&dquo;-Emerson
Parents Should Not Rigidly
Child’s Required Amount of
The apparent overestimation of
RrOR
sleep requirements during
JLRIOR
to
ties&dquo;
based
14 hours.
The sleep differences among newborns
measured by Parmelee 8 et al. Seventyfive infants observed continuously during
their first three days of life averaged 16.6
hours of sleep during a 24-hour period, with
individual variation ranging from 10.5 hours
to 23 hours.
were
Assistant Professor,
of Iowa, Iowa
University
of
Iowa 52240.
Department
City,
Pediatrics,
sleep
re-
variability
in
sleep
needs of individual
children, would indicate that it is impossible
on
In a study of the sleeping practices of twoand-one-half-year-olds,? the duration of total
sleep per 24 hours averaged 12.9 hours, but
ranged from eight to 17 hours. The duration
of night sleep averaged 11.2 hours, ranging
from less than eight hours to more than
*
great
predict the appropriate amount of sleep
given child. Within the same family,
know
that one child will consistently
parents
more
or
less
than another.
sleep
be encouraged which
habits
should
Sleep
allow a child to remain healthy and alert,
while sleeping at socially desirable times. To
quote Illingworth: 9 &dquo;The best guide to the
adequacy of sleep is the absence of fatigue
in the daytime.&dquo;
to
1, derived
Large Individual Differences in Sleep
Requirements .Are to Be Expected
the
quirements by authorities, together with the
the mid-192~’s
all estimates of
mid-1920’s,all
the preschool years
prescriptions of &dquo;authorifrom personal impressions.
Subsequent to the mid-1920’s, more objective
studies, based on observations of large groups
of children 3-6 consistently reported that one
to two hours less sleep occurs than the &dquo;authc~riti~~&dquo; had prescribed. The individual differences in sleep requirements are too diverse,
however, to be accommodated by attempts to
prescribe &dquo;normal&dquo; amounts of sleep required
by a child of a particular age.
were
Specify
Sleep
for any
’
The Total Daily Sleep Requirement
Decreases as a Child Progresses from
Infancy to School Age
Sleep, rather than wakefulness, is the predominant state during infancy. During the
first year of life a pattern gradually evolves
characterized by a morning nap, an afternoon nap and night sleep. During the second
year the morning nap is gradually relinquished while the afternoon nap is retained.lo
After two years of age, the total daily sleep
decreases, due primarily to the shortening of
the nap period,5 as illustrated by the data of
Foster, Goodenough and Anderson (Fig. 1).’11
Total night sleep remains relatively constant
from two through five years of age, averaging
11 hours per night.
174
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016
The Afternoon Nap Is a Valuable Component
of a Young Child’s Sleep Pattern. Typically,
the Afternoon Nap Is Slowly Discarded between the Ages of Two and Five. Cessation
of the Afternoon Nap Is Not Accompanied
by a Lengthening of Night Sleep
As the average afternoon nap time diminishes from one-and-one-half hours for oneyear-olds to one-half hour for four-year-olds,
each particular claild will take an afternoon
nap totally or not at all .12 The length of the
afternoon nap for children taking a nap averaged slightly over one hour for two-, threeand four-) ear-olds.13 Thus, if an older child
doss sleep, he sleeps almost as long as a
younger child.
It is quite common for a two- or three-yearold to occasionally refuse an afternoon nap.’
At five years of age the child typically gives
this up. Dales 13 in an observational study in
a nursery situation found that four per cent
of the two-year-olds, ten per cent of the threeyear-olds and 30 per cent of the four-year-olds
did not take afternoon naps.
An interaction appears to exist between
age of the child and the effect of an afternoon nap upon night sleep.6 A child over
three years of age who takes a long afternoon
nap frequently has difficulty falling to sleep
and may sleep less at night. At younger ages
this appears not to be true. There is some
evidence that a long afternoon nap taken by
a young child will be associated with a shorter
presleep period at night. The child under
three years of age should be permitted to
sleep as long as he wishes during nap and
Day Variations in Total Sleep Occur
Ages, but a Child Will &dquo;Make Up&dquo; for
Lost Sleep Quite Consistently, Requiring Two
to Four Nights to Do So
to
at All
A child’s total
of nap and
daily sleep, being the sum
night sleep, varies greatly from
day
but the total
of sleep,
day,
when measured over periods of several weeks
each, will be quite constant. Children &dquo;make
up&dquo; lost sleep, but usually require several
days to do so.6 No observational studies have
supported theories of consistent daily rhythms
of sleep and wakefulness.
to
and Anderson 11 of the Institute
Child Welfare, University of Minnesota.
Goodenough
of
Average Child, Regardless of Age, Usually
Requires a Presleep Period of Approximately
20 Minutes before His Afternoon Nap. A
Longer Presleep Period Is Required for Night
Sleep
The
associated with afterof all ages is about
for
children
naps
20 minutes in duration.6 For children between two and five years of age, as much as
one hour may be required before falling
The
presleep period
noon
asleep at night. Over-fatigue may result, paradoxically, in a longer presleep period and a
shorter duration of night sleep.9
Significant Differences in
Patterns between Boys
Requirements
and Girls Sleep
There Are No
or
night sleep.
Day
FIr;. 1. ;B comparison of mean total slee~, night
sleep, and day sleep obtained by 1,186 children over
a seven-day period in their homes. This chart is constructed from questionnaire data presented by Foster,
amount
A consistent finding in all observational
studies has been the absence of significant sex
differences in total amount of daily sleep,
length of presleep period, length of naps and
length of night sleep.5
Any Discussion Which Relates
Intelligence and Sleep
Avoid
Older studies report that the more intelligent child sleeps less than the less intelligent
child.14 However, in view of great individual
variation in sleep requirements, the predictive
value of this relationship is questionable.
5
Faegre, Anderson, and Harris reported a
175
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016
tendency for children of mothers with a high
level of educational achievement to go to
bed earlier and to take a greater amount of
total sleep than children whose mothers are
less educated. They found that better educated mothers provide their children with
better sleeping conditions and put them to
bed earlier than do mothers with less education.
in the Same Room with Other
Children Does Not Shorten the
Sleeping Period
Sleeping
Observational studies conducted in nursery
settings have found that the presleep period
and the length of the afternoon nap are comparable for children sleeping alone and for
those in a room with other children.,’ Interestingly, children who slept in rooms with other
children took more naps than children who
slept in individual rooms.
Mean total sleep is greatest when young
children sleep in a room with other children,
less when sleeping in a room by themselves,
and least when sleeping in a room with
adults.15
A Consistent Time for
Retiring, Along
Familiar Bedtime Routine, Appear
Reasonable Goals
to
with
Be
a
Sleep habits are so much a part of the life
style of the individual family that generalities concerning them are difficult. However,
it appears reasonable for a child to be put to
bed at a time which allows the fulfillment of
his total daily sleep requirement, considering
the time the child will usually be awakened
by household activity in the morning. A consistent bedtime determined by the clock is advisable, due to its impersonal nature. A child
will usually accept a fixed bedtime with little
dispute, if such a habit is initiated at an
early age and consistently enforced.
Nlost young children have definite routines
associated with bedtime.7 Two-thirds of the
routines are simple, and one-third are ritualistic. An elaborate bedtime routine should
be eliminated, particularly if a child is expanding it.
Data from observational studies strongly
suggest that children who go to bed late require a longer presleep period at night and
do
not
make up the
sleep
deficit
by sleeping
proportionately later in the morning.5 Such
findings imply that an early bedtime is important.
enforcement of a sleep schedule by
parents may lead to sleep refusal. It is important to warn the child when the hour for
sleep is approaching, and to set the amount
of time needed to complete a current activity.
He should be encouraged to participate in
the bedtime routine, for example, by putting
away toys and selecting a bedtime story. After
the child’s needs are met, he should be affectionately but firmly put to bed.
Rigid
Factors
Sleeping
Influencing Childhood
Patterns
No individual child will fit into a routinely
prescribed sleep pattern. If the spectrum of
individual variation in sleep requirements is
explained to the mother when she first raises
questions, anxiety and time consuming sessions with the physician may be obviated.
There are other factors influencing the
sleeping patterns of children which have not
been fully investigated. What effect does physical activity prior to bedtime have on length
of the presleep period and on total night
sleep? How closely can the termination of
the afternoon nap precede night sleep and
not interfere with night sleep? What has been
the influence of television upon sleeping practices ? What are the optimal conditions for a
child’s sleep?
Traditional answers to these questions are
available, though
documented.
avoid boisterous
physical activity immediately preceding bedtime, yet one observational study showed no
relationship between the activity of children and the duration of their afternoon
naps.16 A long afternoon sleep tends to be
associated with a long presleep period at
night and a short night sleep.11- Children deprived of a nap go to sleep more quickly at
night than those who have had a nap.
Television influences the sleeping habits of
many children. Young children who are allowed to view programs past the normal bedtime tend to be sleepy during the daytime
Parents should closely monitor their children’s sleep habits, particularly when nursery
or school activities require
an alert and
healthy child.
It
would
seem
not
necessarily
best
176
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016
to
When preparing a child for sleep, the goal
should be to reduce the number of intruding
stimuli as much as possible. Thus the room
should be darkened and well ventilated. Accustom the child to sleeping with the bedroom door closed in order that ordinary
household routines may proceed as usual.
Parents should not have to creep about the
house after the child’s bedtime. It is highly
advisable that a child sleep in his own bed
regardless of age, and have a bedroom apart
from that of the parents’. There is evidence
that sleeping in the parents’ bedroom is
associated with sleep disturbance,17
Strained parent-child relations often lie behind sleep disturbances.18 The young child
may be trying to communicate his anxiety
and apprehension to his parents; the basis
for this anxiety must be learned. Parents who
are unsure of their own feelings toward their
child may not establish consistent boundaries
to guide the child’s behavior. Such inconsistency and lack of clarity contribute to a
child’s anxiety.
Sleep disturbances .may also be related to
maternal overpermissiveness. Such mothers,
overly absorbed in their maternal roles, may
encourage crying and other sleep disturbances
at bedtime, because they emphasize the child’s
dependence upon his mother.19
Other questions should be asked when anxiety seems to be the basis for a child’s sleep
disturbances. Do both parents, when possible,
participate in the child’s bedtime routine?
Are the parents present in the morning when
the child awakens or does he find a &dquo;sitter&dquo;
present? Are there or have there been occasions when the child on awakening has been
unable to locate his parents? Is the child
sometimes sent to bed as punishment for misbehavior, thereby associating his bed with
unpleasant experiences? Is his pattern of daily
activity so pleasurable that he can look forward to a repetition on the next day? Do
older siblings who stay up later make the
younger child feel he is missing ongoing activities ? Questions of this sort will usually
disclose reasons why a child employs delay
tactics in order to prolong his presleep period. Such tactics are rarely employed by the
child who is secure in his relationships with
his parents and whose parents understand the
principles surrounding sleep
patterns.
of the traditional concepts concernmechanisms of sleep may have to
be revised as current electroencephalographic
and neurophysiologic investigations 2° provide
new understanding of sleep patterns, requirements and problems. The principles developed in this review and that of Battle 21 reflect current clinical thinking.
Many
ing the
References
1. Hess,
J.
H.:
Principles
and Practice of Infant
Feeding, 2nd ed. Philadelphia, Davis, 1919.
2. Brown, A.:
Feeding.
The Normal Child: Its Care and
McClelland and Steward,
Toronto,
1926.
3. Chant, N. and Blatz, W. E.: A study of sleeping
habits of children. Genet. Psychol. Monog. 4:
13, 1928.
4. Reynolds, M. M. and Mallay, H.: The sleep of
young children. J. Genet. Psychol. 43: 322, 1933.
5. Faegre, M. L., Anderson, J. E. and Harris, D. B.:
Child Care and Training. Minneapolis, University of Minnesota Press, 1958.
6. Despert, J. L.: Sleep in pre-school children: a preliminary study. Nerv. Child 8: 8, 1949-50.
7. Roberts, K. E. and Schoellkopf, J. A.: Eating,
sleeping, and elimination practices of a group
of
two-and-one-half-year-old children. III.
Sleeping practices. Amer. J. Dis. Child. 82: 132,
1951.
8. Parmelee, A. H., Jr., Schulz, H. R. and Disbrow,
M. A.: Sleep patterns of the newborn. J. Pediat.
58: 241, 1961.
9. Illingworth, R. S.: The Normal Child; Some Problems of the First Five Years and Their Treatment, 3rd ed. London, J. and A. Churchill,
1964.
10. Murray, E. J.: Sleep, Dreams and Arousal. New
York, Appleton-Century-Crofts, 1965.
11. Foster, J. C., Goodenough, F. L. and Anderson, J.
E.: The sleep of young children. J. Genet.
Psychol. 35: 201, 1928.
12. Kleitman, N.: Sleep and Wakefulness, 2nd ed.
Chicago, University of Chicago Press, 1963.
13. Dales, R. Y.: Afternoon sleep in a group of
nursery school children. J. Genet. Psychol. 53:
161, 1941.
14. Wagner, M.: Day and night sleep in a group of
young orphanage children. Ibid. 42: 442, 1933.
15. Erwin, D.: An analytical study of children’s sleep.
Ibid. 45: 199, 1934.
16. Sherman, M.: The afternoon sleep of young children : some influencing factors. Ibid. 38: 114,
1930.
17. Anthony, J.: An experimental approach to the
psychopathology of childhood: sleep disturbances. Br. J. Med. Psychol. 32: 19, 1959.
18. Hirschberg, J. D.: Parental anxieties accompanying sleep disturbance in young children. Bull.
Menninger Clin. 21: 129, 1957.
19. Klatskin, E. H., Jackson, E. B. and Wilkin, L. C.:
The influence of degree of flexibility in maternal child care practices on early child behavior. Amer. J. Orthopsychiat. 26: 79, 1956.
20. Hartman, E., Ed.: Sleep and Dreaming. Boston,
Little, Brown and Company, 1970.
21. Battle, C. U.: Sleep and sleep disturbances in
young children. Clin. Pediat. 9: 675, 1970.
177
Downloaded from cpj.sagepub.com at PENNSYLVANIA STATE UNIV on May 11, 2016