Annoyed by the lack of new and innovative ways for keeping children in bed, parents of young children have started to explore techniques for getting little ones to sleep by themselves. "All of these researchers are trying to help us, we know. But we had enough,” said one frustrated parent of a four year-old sleepless child. "These kids have a sixth sense about them – they know when I am deep in REM sleep and come and wake me up.” Parents across America are losing sleep and have attempted to keep their children in bed. One father shared his failed attempts to keep his child in his room, "I have tried Avengers-themed bed straps and padlocks, and ice cream laced Benadryl. Nothing works. He finds his way to my room like a candy bar finds its way into my mouth. It just knows the way.”
Despite these struggles, one researcher has found a solution. Connie Schnoes, a mother of six and director of National Behavioral Health Dissemination at the Boys Town Center for Behavioral Health in Boys Town, Nebraska, created the "Bedtime Pass.” The National Public Radio (NPR) article which highlighted this research describes how it works: Every night, parents give their child a five-by-seven card that is the bedtime pass. They explain to their child that the pass is good for one excused departure from the bedroom per night, whether that's to use the bathroom, get one more hug, report a scary dream, whatever. After the pass is used, the child may not leave the bedroom again, and the parents are not to answer if they call out. (NPR, 2015). Schnoes’ study was published in October 1999 in the Archives of Pediatrics and Adolescent Medicine.
My (JM) initial reaction to the bedtime pass was "it can't be that easy” because like most things, if it were an easy fix we wouldn't be having this discussion. Behavioral insomnia is not an uncommon phenomenon and occurs in 10-30% of children. As noted by the American Academy of Family Physicians (AAFP), this condition is typically the result of a child refusing to sleep without certain conditions or limit-setting types. Instead of relying on the "Band-Aid” that is the bedtime pass, we should embrace that the best treatment is prevention. As noted in the 2014 AAFP journal (Carter, Hathaway, & Lettieri, 2014), physicians should encourage good sleep hygiene including setting boundaries and consistent sleep times. Previous studies (Anders & Keener, 1985; Goodlin-Jones et al., 2001) show that infants who are placed in the crib awake versus asleep are more likely to become self-soothers. By setting a routine we create expectations and a reliable foundation, which I believe is better than a temporary fix.
We, as family medicine physicians, forget that giving advice is hard and getting a parent to consider advice from a physician without children is sometimes harder. I (JM) think we also forget that not only are these sleep issues affecting the children, but advice we give the parents affects their sleep as well. We may recommend that parents keep to a sleep schedule and facilitate optimal sleep hygiene. Advice or recommendations sound great, but execution is tough. For example, I (JM) met a single parent who works third shift while her oldest daughter, in college, helps with the kids at home. It is one thing to give advice to the parent, who implements changes at home. In this case, one may seem almost guilty to pass along the advice knowing that more burden is placed on the eldest child, who is already dealing with college responsibilities and now has another added task. Patient in context is important.
Similar to JM, "It can't be that easy," was my (ES) initial reaction to this allegedly revolutionary "Bedtime Pass." I have visions of walls reverberating with screams and the magical pass reaching its untimely demise in shreds scattered over the ground. However, my pessimistic stance stems from perceived and not personal frustration with this problem, as I listen sympathetically to the parents of my young patients as they describe the bedtime woes, offer some vague supportive advice, and leave the room with a good-luck pat on the shoulder as I head home for a quiet evening in a kid-less house. As a family medicine physician, I advise sleep deprived parents of young children to ignore the unwanted behavior and reward the desired behavior with positive attention.
Research suggests that a contributing factor to children’s behavioral problems is negative (i.e., harsh discipline) parenting behavior (McKee et al., 2007). The "Bedtime Pass” may work for parents and children because of the respect for children’s agency, creates a balance between limits and latitude, and allows children to regulate their emotions to a certain degree. For example, the child who is given a "Bedtime Pass” may choose when and where to use it, without a negative consequence for their actions. A child’s freedom to make choices and mistakes within limits is a main tenant of parenting techniques such as Love and Logic (Fay, Cline, & Fay, 2015). Considering the difficulty of tackling the philosophy of parental discipline in a quick clinic visit, the "Bedtime Pass" is quite attractive given the simplicity of the idea and a concrete plan that is easy to prescribe for at least a trial run.
I want to first disclose that I (LS) am not a parent. And what I say to those parents who are patients in my practice is, "I know that you probably hear more parenting advice from those who do not have children. So, bear with me.” I hope you, the reader, bear with me as well. Before sending this to our CFHA blog editor, Dr. Matt Martin, I thought the article was cold blooded! It reminded me of the Ferber Method… let the child cry it out. I think the "Bedtime Pass” has some credibility but I would be hesitant to direct my sleep deprived parents of young children to use this method. Instead, I would want to ask a few questions to figure out which method may fit to solve their child’s sleep issues. You know, because we are patient-centered. I would first want to understand the parent-child relationship and how the parent interacts with the child. For example, how does the parent respond to the child if the child becomes upset? Teaching a child how to self-soothe is important as it leads to positive outcomes for building resilience (Buckner, Mezzacappa, & Bearslee, 2003), good interpersonal relationships (Rubin, Coplan, Fox, & Calkins, 1995) and reduced risk for developing depression and anxiety (Alvord & Grados, 2004). If the parent is anxious or misreads the child's cues, then I (LS) would focus on the parent first and coach them in session. Or if a child is anxious, I use breathing techniques to help them self-regulate. I think the "Bedtime Pass,” as my colleagues have mentioned, may not be addressing the core issue – the problem could be a behavioral issue which can be a result of an emotional regulation or attachment issue. This is, of course, in my (non parent) clinical opinion.
When it comes to getting more sleep, our position is that people will try anything and everything. We would do anything it takes to get more sleep if it were us in the position of having young children who didn’t stay in their room. Our recommendation, however, is to remember the patient in context and be patient-centered in your approach to help sleep-deprived parents get more sleep.
Alvord, M. K., & Grados, J. J. (2005) Enhancing resilience in children: A proactive approach. Professional Psychology: Research and Practice, 36, 238-245. doi: 0.1037/0735-7028.36.3.238
Anders, T. F., & Keener, M. (1985). Developmental course of nighttime sleep-wake patterns in full-term and premature infants during the first year of life. Sleep, 8, 173-192.
Buckner, J. C., Mezzacappa, E., & Beardslee, W. R. (2003). Characteristics of resilient youths living in poverty: The role of self-regulatory process. Development and Psychopathology, 15, 139–162. doi: 10.1017.S0954579403000087
Carter, K. A., Hathaway, N. E., & Lettieri, C. F. (2014). Common sleep disorders in children. American Academy of Family Physicians, 89, 368-377.
Fay, J., Cline, F. W., & Fay, C. (2015). https://www.loveandlogic.com/about/bios. Accessed January 6th, 2016.
Goodlin-Jones, B. L., Burnham, M. M., Gaylor, E. E., & Anders, T. F. (2001). Night walking, sleep-wake organization, and self-soothing in the first year of life. Journal of Developmental & Behavioral Pediatrics, 22, 226-233.
McKee, L., Roland, E., Coffelt, N., Olson, A. L., & Forehand, R. (2007). Harsh discipline and child problem behaviors: The roles of positive parenting and gender. Journal of Family Violence, 22, 187-196. doi: 10.1007/s10896-007-9070-6
Rubin, K. H., Coplan, R. J., Fox, N. A., & Calkins, S. D. (1995). Emotionality, emotional regulation, and preschoolers' social adaptation. Development and Psychopathology, 7, 49–62. doi: 10.1017/S0954579400006337
Wendy Mitman Clarke (September 18, 2015). The bedtime pass helps parents and kids skip the sleep struggles. http://www.npr.org/sections/health-shots/2015/09/18/441492810/the-bedtime-pass-helps-parents-and-kids-skip-the-sleep-struggles. Accessed September 18th, 2015.
|Dr. Jennifer Miller is a third year Family Medicine Resident at Wake Forest. She graduated from Florida State University College of Medicine with an interest in sports medicine. Moving forward she hopes to practice in an integrated care model with a focus on community awareness of preventative health measures.|
|Dr. Elizabeth Skidmore is a second year Family Medicine Resident at Wake Forest Family Medicine. She looks forward to being a general practitioner after completion of residency, and enjoys opportunities to combine an interest in writing with her interest in medicine.|
|Laura Sudano is an Assistant Professor and the Director of Behavioral Science at Wake Forest Family Medicine Residency. Her interest is in the application of integrated care in different medical settings, residency training, and interprofessional education/training. She enjoys collaborating with different departments in the institution to provide comprehensive, integrated care services to patients in the Wake Health system.|