Unsurprisingly, anxiety and sleep problems often go hand-in-hand. Whether it is anxiety driving the sleep challenges or the lack of sleep worsening the anxiety, an anxious brain is not very good at switching off and being relaxed enough to sleep. When it takes a long time to fall asleep (more than 20 minutes or so), it typically creates faults in what sleep professionals refer to as “sleep hygiene” – which has nothing to do with how clean your bedding is and everything to do with the habits and practices that are necessary to take good-quality night-time sleep. Unsurprisingly, the ideal is to spend the time we are in our bed asleep, rather than lying there awake (or worse still, worrying).
Falling asleep isn’t the only challenge. Anxiety has been shown to affect the architecture of sleep as it causes us to spend a greater proportion of our night in REM sleep, at the cost of reduced NREM/slow-wave sleep which is the deeper and more restorative form of slumber. This “wrong type” of sleep causes us to wake still feeling tired, despite the full night of shut-eye.
In children, sleep problems are sometimes the most obvious manifestation of anxiety – typically appearing in the form of bedtime resistance, frequent night-waking, requests for extended parental presence, fear of the dark or nightmares. A word of caution here however – many of these things can also stem from poor boundaries and parental inconsistency!
Therefore, if a parent reports seeing no signs of anxiety in their child at other times, save for very normal and temporary periods of separation anxiety, I would generally look initially at how the family applies boundaries. Bedtime does not exist in a vacuum – children ordinarily expect the same from their parents round the clock and so a child who sees in the daytime that he can hold out long and hard enough for a boundary to move, is unlikely to accept that night-time boundaries are any less flexible.
But what of a situation where a family does have gentle and clear boundaries which are consistently enforced and/or a child shows genuine signs of anxiety? Whilst almost all children feel anxious from time-to-time, we know that a troubling presentation of anxiety is more prevalent in children who: were born to mothers who were stressed, anxious or depressed (pre and/or postnatally); have a disorganised or insecure attachment to their primary caregiver; lack or have lacked support for emotional regulation; have been exposed to traumatic events (even indirectly); have been bullied; are behaviourally-inhibited/extremely shy; and those with ASD, Asperger’s, sensory processing disorders and/or an unusually high IQ
Children with notable anxiety need support beyond my remit as a sleep specialist. A family that has recognised their child’s anxiety and sought professional guidance may be utilising techniques such as promoting self-confidence through giving their child opportunities to succeed, big-body play (where sensory-processing abilities will allow), role-modelling and supporting emotional regulation and emotion coaching. These, and other techniques, can be successfully applied to sleep.
The most general piece of advice with a child exhibiting anxiety around their sleep may seem obvious but is still worth noting: I would never suggest that a parent uses an out-of-the-room strategy with an anxious child. Children need parental help and support to recognise and manage anxiety and to develop their ability to regulate their emotions. Taking smaller steps successfully, even if this means a parent camping out in their child’s room initially, will lead to a less stressful, more positive process and ultimately to long-lasting sleep success.
Here is my step-by-step guide to helping an anxious child to sleep well.
A child’s perception of their ability affects their motivation, learning potential and also how well they are likely to cope in a situation they find challenging – such as bedtime. Parents can use “growth mindset” language to build their child’s belief in their potential to grow and adapt. To be effective the mindset needs to become part of the family culture and not exclusive to sleep – so “you can’t quite do that yet but with a little more practice you’ll ace it”, is just as important as the sleep-specific, “I know you find bedtime hard right now but we’re going to try something new tonight”.
Parents should be mindful of their own mindset and language too. We are often our worst critics but little ears can hear that a minor mistake such as forgetting our keys renders us “stupid” or “useless”. Similarly, asking our child in a moment of exasperation why they can’t do something as simple as go to bed or them overhearing our comment that we’re “never going to get her into bed without a battle”, will all serve to establish a fixed mindset where a child feels unable to build their way out of the current bedtime challenge.
The night-time boundaries we draw for our children must be reasonable, age-appropriate and consistent. Boundaries which are loose, flexible or confusing lead children to become anxious because they are required to make numerous decisions which they often lack the life experience to make confidently and soundly. Keeping the steps in a plan to help a child sleep better small and manageable is infinitely better than trying to take bigger steps then backtracking. So for a child who wants a parent to lie in bed with them whilst they fall asleep, it would typically be more successful to have a first step of sitting on the bed holding the child’s hand than the parent trying to get out of the bed and onto a chair halfway across the room all in one go. It’s better to consistently take small steps forward rather than unsuccessfully attempt a big stride.
This is a short sentence covering a genuinely huge aspect of managing anxiety around sleep! All emotions are normal and require an appropriate response. Fears, worries and negative thoughts are real and should not be dismissed. In many ways, overtly challenging conduct around sleep is easier to manage than a situation where a child has previously received a negative response to perceived difficult behaviour as the latter is more likely to hide or internalise their emotions. Normalising, labelling and, crucially, supporting a child to develop techniques to manage negative feelings will enable him to learn to deal with bedtime anxiety. For younger children, a “worry eater” may provide a useful aid to overcoming anxiety.
There is a delicate balance to be struck between supporting our child to recognise and manage their emotions and “rescuing” them from the negative experience. Where the line falls will vary between families but is also likely to move over time – offering a child lots of support and celebrating the progress (no matter how small) in the early days of a plan to improve sleep, will lay the foundations to take bigger strides later on. Allowing a child to experience stress in a supported way provides an opportunity to connect and back them to a positive outcome, building their resilience to challenge.
Sometimes the bedroom is either over-stimulating or contains items that cast unsettling shadows. Checking out the room from the child’s perspective (even if that means crawling around the floor!) and/or asking a child whether there is anything in the room that they would like removing are good starting points but be careful not to plant the idea that there is anything scary that ought to be removed! Younger children may be afraid of “monsters” lurking and a common parental response is to check and reassure that there aren’t any. Unfortunately, this often reinforces to a child that the risk of monsters is real so a more honest explanation that monsters only exist in stories, founded in logic, can be more effective. For children who are anxious about the dark, a dim nightlight can help – it is worth knowing that a red bulb will cause the least interference with sleep.
For younger children, taking responsibility for a teddy or doll at bedtime can help them to manage their own anxiety about the process – or to at least verbalise what they are feeling. A little one may tell you that teddy is worried about something which is often a way of making their own fear tangible and provides an opportunity to help them understand and manage the feeling via the avenue of reassuring teddy. For some children this is less intimidating than discussing their own anxiety about the process.
Similarly, social stories and a bespoke bedtime book can be effective tools. For a child who has anxiety around the bedtime process, the phrase “it’s bedtime” may be simultaneously vague and terrifying. It can really help to break down the instruction into its component parts such as: “in five minutes, you need to stop your game”; “in one minute you need to stop your game”; “it’s time to stop your game now”; “you need to go upstairs now”; “it’s time to get into the bath”; “in five minutes, you need to get out of the bath”, and so on. You can back up each instruction with a picture (Pinterest and parenting websites are a goldmine!). Far from being patronising, many children struggle to hold one instruction in mind whilst preparing for the next one which can aggravate feelings of anxiety. Breaking bedtime down into each step not only simplifies the process but often enables a parent to see where the anxiety triggers are.
A bespoke bedtime book, where a parent takes a photo of their child at each distinct stage of the process and puts it all together as a story, can again help a child to understand what will happen, in what order and for the parent to understand any anxiety triggers in the process.
Whilst anxiety will typically adversely affect sleep, helping your child to achieve restful nights will pay dividends in terms of his ability to positively manage his emotions and “big” feelings during the day, helping to gently break the cycle. Guiding a child through sleep-related anxiety can be a challenge so never be apprehensive about seeking help with this tricky issue.