Frustrated, helpless—and utterly exhausted. That’s how my husband and I felt last August when we arrived at the offices of a Yale Medicine pediatric sleep specialist with our nearly 4-year-old son, Zachary, in tow.
Like most parents, we understood that uninterrupted sleep was something we might not enjoy until our kids went to college—if ever. But our situation with Zach had become untenable. He woke up multiple times each night and wouldn’t go back to sleep unless we lay beside him.
When he was a baby, the situation was even worse. The only way I could get him to sleep was to lie next to him on our bed at 7 p.m., with my nose practically touching his.
But now that he was older, more mobile and able to express his fears, standard baby sleep-training methods were no help. Desperate for a solution, I read scores of books, beseeched our pediatrician for suggestions and talked to other parents. None of the advice worked.
Since I had just started working at Yale School of Medicine, I knew there were resources at the ready. We made an appointment with Yale Medicine’s Craig A. Canapari, MD, director of the pediatric Sleep Medicine Program. The program treats a variety of respiratory and nonrespiratory sleep disorders from insomnia and restless legs syndrome to obstructive sleep apnea and complications from neuromuscular diseases.
We tailor our approach both to the child and the needs of the parents. Craig Canapari, MD
Our first appointment was at Yale New Haven Health's Pediatric Specialty Clinic in New Haven. I was nervous that Zach would get antsy and make it difficult for my husband, Hugh, and I to speak to the doctor about these problems, which were making everyone in the house irritable, to say the least. Luckily, Dr. Canapari has a cheerfully silly bedside manner that immediately put Zach, our normally tough customer, at ease. He obediently sat through the physical exam. Dr. Canapari, who has two young sons of his own, was sympathetic about what our family was going through, took copious notes and asked pointed questions.
To rule out any medical issues, Dr. Canapari, who is board-certified in pediatric pulmonology and pediatric sleep medicine, told us we would need an overnight sleep study. He didn’t think Zach had a condition like obstructive sleep apnea (when airways become blocked during sleep), but he needed to be sure. Likely, the problem was behavioral, he told us. He offered strategies to get Zach in his own bed again. At this point, Zach was sleeping on the floor in his older brother’s room—and we had to stay with him until he dozed off.
I was daunted by the idea of a sleep study. How were they going to place sensors all over Zach’s face and body and expect him to sleep in a hospital bed when he barely slept at home? Dr. Canapari and his staff assured me that they did these studies all the time, often with kids who are autistic or have other special needs.
Hugh volunteered to accompany Zach on the overnight study at the end of September. This made sense since he can sleep anywhere, and because he had assumed most of the middle-of-the-night duties.
We told Zach he was having a fun sleepover and he was game for an adventure. Zach and Hugh “checked in” to the Sleep Center at Yale New Haven Children’s Hospital at 7 p.m. on a Sunday. Zach brought his jammies, toothbrush, a book and a stuffed Dalmatian puppy. The sleep lab has three rooms where the patients spend the night. Outside the rooms, technicians sit at computers to monitor patients and collect data.
The room had brightly painted walls with alphabet letters and planet decals. It felt almost like a bedroom in somebody's home, save the few pieces of medical equipment that weren't stashed in cabinets. One other child was having a study the same night.
Once Zach got settled and started watching “Thomas the Tank Engine,” two sleep technicians placed sensors on his face, arms, legs and tummy. At first, he objected, but by the time they finished—it took about an hour—he was so tired that he was snoozing within minutes.
My husband, also tired from the usual sleepless nights in our home, promptly passed out on the bed next to Zach’s. Later, Zach did his usual awakenings and the technicians got the data they needed. At one point, he tugged the oxygen sensor out of his nose, but a technician popped it back in. Come morning, he chose a nice set of wooden castle blocks as a prize and happily went home, bragging to his big brother about his sleepover.
A week later, Dr. Canapari called to tell me that the results didn’t show any problems, respiratory or otherwise. Though I was relieved, the truth is that I had also hoped we’d find some kind of explanation for Zach’s sleeping difficulties.
Separation anxiety and fears
After another week or two, we visited Dr. Canapari at Yale New Haven Health’s Park Avenue Medical Center in Trumbull. Now that we were sure Zach’s issues were behavioral—perhaps a mixture of separation anxiety and fears—we discussed other strategies we could tackle. Some were variations of things I had read in parenting books and on websites. But others we hadn’t heard of before. Best of all, they worked—at least for a while, as is the way with Zach.
In general, Dr. Canapari said his patient mix is split evenly between respiratory and nonrespiratory cases. “With rare exceptions, the nonrespiratory issues are more complex to address as it takes longer to get a good history and counsel families about the appropriate way to proceed,” he told me. “We tailor our approach both to the child and the needs of the parents.”
Since Zach doesn’t exhibit symptoms of anxiety during his waking hours, Dr. Canapari didn’t think he needed psychological support, but he did say we could talk to our pediatrician about a play therapist if we thought that might help address his night-time fears.
Usually, behavioral sleep problems in early childhood and issues like nightmares and night terrors improve as children get older. We think Zach has bad dreams, but Dr. Canapari didn't believe Zach was having night terrors, which are more extreme. Sometimes problems change with time, he added. “For example, many teens I see in clinic have a history of sleep problems in early childhood,” he said, quickly adding that I shouldn’t worry: “I think Zach is going to do fine!”
Tips from the sleep doctor
Here are a few methods Dr. Canapari suggested:
Problem: Zach was not sleeping in his own room.
Solution: We put Zach back in his own bed, but moved in (in parenting sleep circles, this is often called “camping out”). My husband set up an air mattress beside Zach’s bed and slept there all night. Each night, we gradually moved the air mattress closer to the door.
When the air mattress reached the doorway, we deflated it. Then my husband started sitting outside the bedroom until Zach fell asleep each night.
Problem: Zach was now back in his room, but he wouldn’t fall asleep unless my husband or I sat outside his room.
Solution: We introduced the “check” method. We would tuck him in, sit by the door for a minute and then announce that we had to let the dog out or do some other task. We’d come back in 20 seconds and praise him for staying in his bed like a big boy. Then we’d wait a few minutes and do the same thing again. The next night, we would lengthen the time we were away with each check. Our goal, Dr. Canapari advised us, was to get him to fall asleep without us there.
In the beginning, Zach would scream out as soon as we left, so we would literally “check” for 2 seconds, then praise. We were taking baby steps, for sure, but, after a few weeks, we were able to put Zach in his bed, say goodnight and leave.
Problem: He still woke up in the middle of the night screaming “Bad guys!” or calling our names.
Solution: Was he having nightmares? Did he have a true fear or was this a way to get us in his room? We didn’t know, but we had to go in or he would not stop screaming and yelling. So we’d reassure him and do the “check” or sitting-by-the-door method until he fell back asleep. At the beginning, this might happen five times in one night and it hasn’t stopped completely yet. During rough patches, the air mattress returns and my husband will just stay with Zach instead of going back in over and over again. This is all normal Dr. Canapari has reassured us on subsequent follow-up visits.
Lately, what happens most often is that Zach wakes up one to two times in the middle of the night. My husband goes into his room and tells him to go back to sleep, and usually he does.
Problem: Zach was afraid of his room, and wouldn’t enter it unless we came with him.
Solution: We got him a night light that didn’t cast what he called “scary” shadows. You want it to be bright enough that a child isn’t scared, but not so bright that you could read a book by the light, as that could disturb circadian rhythms, Dr. Canapari advised. We also made an effort to play in his room every day in the hope he’d begin to see it as a happy place.
We tried other techniques, too. We started a reward chart for meeting sleep goals, like going to bed without making a fuss and not crying out at night. I don’t think the chart made a difference, but a game called “flashlight scavenger hunt” did. We’d hide a few toys so Zach and his brother could race to find them in dark rooms—including his own—with flashlights. All of this was meant to normalize the dark and his room. It helped, and eventually, Zach started going in his room again on his own.
Our story doesn’t have a perfect ending. Since our sleep study, we still have episodes where Zach wakes up five times in one night and my husband ends up trudging across the hall and sleeping on the floor again. Occasionally, he sleeps through the entire night. Usually, there is at least one wake-up.
I liken it to dog training, which we have had mixed results with, too. We know that good behavior from our strong-willed hound Zelda is dependent on us, the “parents,” enforcing boundaries and rewarding positive behavior. But sometimes we get lax and don’t bother chasing Zelda off the couch. Likewise, when Zach is going through a stretch of difficult nights, we find ourselves giving up on the “checks.” We’ll sit with him until he finally dozes off. Not surprisingly, we now have a dog that refuses to get off the darn couch and a son who doesn’t always fall asleep on his own.
The difference, however, is that we know what it takes to lead them back to where they should be. We just need a little more sleep to actually accomplish it.