Sleep: we all know we need it, we all know it’s vitally important to our health and well-being; but for some adults and children sleep can be so elusive. From difficulty falling asleep, to problems staying asleep, sleep issues can leave you feeling frustrated and exhausted. By the time most people contact me in search of sleep help, they are feeling hopeless. Many sleep-deprived adults and parents of children with sleep problems struggle to get to the bottom of what’s actually causing sleep problems, and often (incorrectly) assume that sleep problems are medical or biological in nature. Luckily, most sleep problems are actually behavioral in nature, and believe it or not, there tends to be only four main underlying issues that cause just about every sleep problem I see in my practice. My goal in this week’s blog post is to help you understand the four main causes of sleep problems so you can identify where your (or your child’s) sleep might be getting off track.
Types of sleep problems (and why it doesn’t always matter what the problem looks like)
Sleep challenges can present in many forms, including difficulty falling asleep, middle-of-the-night awakenings, early wakings, insomnia, night terrors, nightmares, restless sleep, bedtime anxiety, insistence on co-sleeping, and difficulty settling, among others. In behavior analysis, we refer to this as the “topography” of the behavior- or what the problem looks like. Many people (adults and children alike) suffer from more than one type of sleep problem. For example, you may have difficulty falling asleep and difficulty staying asleep. While it’s important for me to understand what your sleep problem looks like, it might surprise you to learn that the topography of the sleep problem has little to do with how we treat it. Regardless of what the specific problems look like, it’s actually more important for us to assess what is causing poor sleep. Once we can nail down the causes, we can work to change your sleep environment to help you learn healthy sleep habits. Typically, adults and children who are struggling with sleep are struggling with more than one (and sometimes all) of these four common causes.
#1: Not Being Tired at Bedtime
One common cause of sleep problems is that the person is just not tired at bedtime. They might get into bed and toss and turn, or might avoid going to bed altogether and stay awake until the wee hours of the morning. Often, the biggest reason a person isn’t tired at bedtime is a disruption of the circadian rhythm (the internal clock that regulates our sleep-wake cycle), usually caused by an inconsistent sleep schedule. If you don’t stick to the same bedtime and same wake-up time every day, you cause your circadian rhythm major confusion. Your body’s internal clock likes to keep a regular 24-hour schedule (although, oddly enough research has shown that the human body clock is actually about 24.2 hours when light cues are taken away), and when you stick to a regular sleep schedule your body knows exactly when it needs to be alert and when it needs to get sleepy and fall asleep. A regular sleep schedule helps your brain regulate important hormones like melatonin, which makes you sleepy and helps you to fall asleep faster. If you don’t keep a regular schedule though, your brain will struggle with knowing when it should be alert and when it can rest, and you’ll feel sleepy at the wrong times and may struggle to fall asleep at night.
This issue can also arise when bedtime is either too early or too late, if you spend too much time in bed, or if you sleep in too late in the morning. Even just sleeping in an hour or two on the weekends can have a huge effect on your sleep. Think of it this way- if your body is used to a regular schedule Monday-Friday where you go to bed at 10 and wake up at 6, it will learn to start sending sleep signals to the brain to make you sleepy just before 10, or about 16 hours after you wake up in the morning. But if you sleep in until 8 on the weekend, now your brain is still going to wait 16 hours to send those signals, meaning now you won’t get sleepy until around midnight, which is probably going to be a problem on Sunday night if you’ve got to wake up early for work Monday.
#2: Chaos and Unpredictability Before Bedtime
Another major factor that contributes to many sleep problems is the absence of a regular calming bedtime routine. Without a consistent routine, your body and brain struggle to transition from wakefulness to sleep. By establishing a calming and predictable routine before bed, you can signal to your body and brain that it is time to unwind and prepare for restful sleep. This helps jumpstart the process of falling asleep by releasing important hormones like melatonin, which makes us sleepy at bedtime. Without a predictable routine and chaos before bedtime, your body has a hard time knowing when sleep is going to happen and keeps you primed to stay awake to continue your day.
In addition to a regular routine, consistent expectations about bedtime and sleep are important, especially for children. Without consistency in bedtime expectations, we leave children to wonder (and test) what the boundaries are at night. While it might seem like a good idea to give your child (or teen) some freedom and independence, inconsistency and unpredictability can actually be very anxiety-inducing. It puts the responsibility on your child to figure out what they should do and forces them to test boundaries to see what works/doesn’t work every night. For example, if the expectations are unclear about what is a must-do in the bedtime routine (e.g., bath, brush teeth, change clothes) you might find your child pushing back and protesting the bedtime routine every night to test what the boundaries are. Similarly, if there are no consistent rules (and consequences) for getting out of bed most children will repeatedly test the waters to see what happens when they do. If I get out of bed and bug my parents enough, will they eventually snuggle with me…will they let me watch more TV….will they let me get into bed with them? This can set the stage for chaos during the bedtime routine and at night, bedtime anxiety, and power struggles for parents and children, all of which result in more arousal and alertness, and more difficulty winding down and getting a good night’s sleep. Setting and enforcing consistent bedtime rules and boundaries can help everyone rest easier.
#3: Unhealthy Sleep Dependencies
Sleep dependencies are anything that a person needs in order to be able to fall (and stay) asleep. It could be a stuffed animal, a special pillow, a full belly, a parent, a spouse, a pet, a radio, etc. Sleep dependences can be classified as healthy or unhealthy. Healthy sleep dependencies are anything that is available consistently throughout the night, remains unchanged from the time you fall asleep until the time you wake up, and is consistently available every night (ideally even if you are sleeping somewhere else). Some examples of healthy sleep dependencies might be a teddy bear, a white noise machine, a special pillow, or darkness.
Unhealthy sleep dependencies- those that do not meet these criteria- are very common in both adults and children and can lead to difficulty falling asleep and frequent awakenings. Examples of unhealthy sleep dependencies include electronics in the bedroom (e.g. falling asleep watching a video that shuts off after 30 minutes), the presence of a parent or pet, or having a glass of wine before bed. In order to fall asleep quickly and stay asleep all night, we want to ensure our environment (and our body state) remains unchanged all night.
The reason it’s so important to keep things consistent all night long is that our brain has what I like to think of as a built-in “fail safe” called micro-arousals or micro-awakenings that occur throughout the night. Even healthy sleepers have these multiple times per night where the brain briefly wakes and resets during sleep cycles. With a consistent environment, a healthy sleeper won’t even remember these micro-awakenings because they will be so brief. Since your environment remains the same, your brain has no reason to be worried and to fully wake you. But for those with unhealthy sleep dependencies, a change in the environment between the initial onset of sleep and a micro-awakening can lead to a full-blown awakening and difficulty re-initiating sleep. The brain sounds the alarm bells that something has changed and you need to wake up and fix it. This is why many children who fall asleep with a parent in the room (only to have the parent sneak out once they are asleep) will almost certainly wake a few hours later and come searching for their parent so they can fall back to sleep. Making sure to identify unhealthy sleep dependencies and keep your sleep environment the same all night can significantly improve sleep quality.
#4: Competing Activities at Bedtime
Let’s face it: sleep isn’t that fun, especially not for kids. Most kids can probably think of a million things they’d rather do than lay in a boring bed, alone, in the dark for hours on end. And while adults may find more enjoyment in sleep, we often have many other pressing responsibilities to attend to that cut down on the amount of time we can devote to a restful night of shut-eye. For both children and adults, the presence of stimulating and engaging activities at bedtime can really hinder the transition to sleep. Kids may be tempted by electronics, seeking attention from parents, or playing with toys, while adults may find themselves burdened with end-of-the-day responsibilities or caught up in racing thoughts. By reducing or eliminating these competing activities at bedtime, we can help ensure an easier transition into sleep. For children, it’s important to have consistent rules and boundaries about when activities and fun end for the night, and even more important to keep tempting items like phones and other electronic devices out of the bedroom at night. For adults, it’s equally important to set rules and boundaries for yourself about when work, household chores, Netflix, and social media need to end for the night. If you can’t trust yourself to enforce the rules, enlist the help of phone timers and apps that can lock you out of tempting content at night. Be sure to schedule some non-electronic, relaxing “buffer time” into your bedtime routine no matter what your age and stick to your schedule!
So, how do we fix these causes of sleep problems?
Sleep problems can take on various forms, but they often share common underlying causes. Understanding these causes is the first step toward fixing sleep issues. The four main causes of sleep problems: not being tired at bedtime, chaos and unpredictability before bedtime, unhealthy sleep dependencies, and competing activities at bedtime – all have fairly simple and straightforward behavioral solutions. Over the next few weeks of the blog we will break each of these causes down a bit more and look at some solutions. You can also check out this video where I talk about common problems and solutions if you want a sneak peek! But if you don’t want to wait or you need some help, contact me! By working with a sleep coach and implementing behavioral sleep treatment, you can take back the night!