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The symptoms of sleep deprivation mimic those of depression - irritability, feeling low and tearful, a lack of patience and poor concentration. Little wonder then that parents whose baby, toddler or even school-aged child keeps them up at night find it hard to cope.

Little wonder too that children who don't get enough sleep are prone to tantrums and find it hard to learn. Claire Halsey, a consultant clinical psychologist who works in five Sure Start programmes in the Stoke on Trent area, says it is a myth that children always get the sleep they need. "Children don't necessarily go to sleep when they need to for all sorts of reasons, including poor sleeping habits or the feeling that they might be missing out on family activities. When children have inadequate sleep they tend to be more irritable and their eating and behaviour is poorer."

Although Sure Start works predominantly with families in disadvantaged neighbourhoods, Halsey sees people in a variety of circumstances who are struggling to deal with their child's sleep problems. She says: "Sleep problems compound other problems, like worries about benefits, or having a roof over your head. Pressures are incremental. If you have to spend your time queuing in benefit offices you've got less time and energy for focusing on your child." And because problem-solving skills are affected by lack of sleep parents find it harder to sort out their difficulties.

Terry Jones, a social work team leader at a Barnardo's family centre in Fulford, Bristol, finds that sleep problems in children that go on for a long time can have a profound affect on family relationships. She says: "Parents are likely to have a tense relationship with the child whom they see as the cause of the difficulties. The child then picks up on the tension and anxiety and is less likely to be able to sleep." She also finds that sleep problems can cause conflict between parents, particularly if it is always the mother who gets up while the partner stays in bed, or if parents disagree on how to tackle the problem.

Jones believes that offering consistent support to help parents find their own solution to the problem can be critical. She says: "People are more likely to cope if they have someone to support them. It's especially difficult for single parents if they're living in a flat or have older children. It's hard to follow advice to leave a child to cry if you're worried about disturbing the neighbours or older children."

Sleep problems in children are the most common behaviour difficulty reported to health visitors. Often they arise because the child lacks a consistent bedtime routine or because the parent may have unwittingly taught the child to fall asleep in their arms or on the sofa. In most cases they respond well to simple behavioural techniques applied consistently by parents.

Ann Buchanan, reader in social work at the Department of Social Studies at Oxford University, agrees that sleep problems are at the root of a wide range of difficulties experienced by families. Buchanan worked in child guidance clinics during the 1980s and 1990s and found behavioural programmes very effective in tackling sleep problems. She says: "People have to be pretty desperate to get family therapy. A lot of the psychiatrists would do family therapy first and look for underlying problems.I found that once the family got the child to bed a lot of other problems disappeared. "

A simple behavioural approach advocated by Buchanan and widely used by health visitors works well with children aged three or four who only sleep for short periods but who are motivated by the idea of getting stickers for co-operating (see below).

Giving parents the opportunity to swap experiences with other parents can also be helpful. Jones says: "Most families have experienced sleep problems at some time or another. So one of the things that happens in groups is that the problem is normalised - there's always someone else in a similar position. It can also help people to recognise the huge diversity in children's behaviour, including in their sleep needs."

On the other hand, there's also a danger of people making negative comparisons between their child and other people's, which is where a professional facilitator can be helpful. "Drawing comparisons," says Jones, "is something that can make people feel particularly vulnerable. Part of our role is enabling people to manage the particular child they've got."

Professionals are divided on the kinds of sleep programmes which are most appropriate to use with babies. Research published in the British Medical Journal in May found the "controlled crying" technique effective in reducing sleep problems in babies and in reducing depression in mothers.¹ The method involves visiting a child who is crying and then leaving them in their cot to cry for increasing intervals.


The study looked at 156 babies with problems judged as "severe" by their mothers including waking frequently at night and needing their mothers with them to get to sleep. Nearly 90 per cent of the problems were solved within two months.

However, Halsey regards controlled crying as a last resort for children under 18 months. She says: "It's distressing for the child and there are attachment issues. The only proviso would be if parents are fearful that they would harm the child. When children cry excessively it can be a trigger for abuse." Instead, she advocates methods such as the "disappearing chair" where the parent starts off sitting near the child and gradually moves it further away over a period of time.

The Child Psychotherapy Trust encourages parents to take a more accepting approach to babies waking in the night.² The trust points out that a baby who finds it hard to relax and let go at night might have had a busy and stressful day, with insufficient peaceful time with their parents. Or it might be that the family is going through a worrying or unhappy time which is unsettling the baby.

In older children too, sleep problems like persistent nightmares and night terrors can sometimes be indicative of deep-rooted problems, such as abuse or abandonment, where more therapeutic approaches are needed. Or sleep problems may reflect tensions which a child is experiencing because of changes in their routine or care-setting or difficulties in the family. Jones believes it is important to give parents the opportunity to look at what else might be happening and to see the sleep difficulties as a symptom. She says, "We wouldn't assume that there was a deeper problem, but where an older child is up and down a lot it could be a reflection of deep-seated anxieties. We would want to look at it in a more psychodynamic way."

On the other hand, as Buchanan points out, if you start digging around in people's psyche you will always come up with something. She says: "I would always try sleep programmes first. In about three out of four cases it works and everything else falls into place."

Carrot and sticker

The worker draws a picture contract for the child that reflects the bedtime routine. The reward is a smiley face - a sticker with a face drawn on it. The child asks for it in the morning and the parent sticks it on. If the child gets out of bed the parents are encouraged to act "boring" and allow the child to sit with them with minimal attention until the child can gently be put back to bed. After a few days - the child may need to be encouraged with half a smiley face for nearly succeeding - most children manage to remain in their beds as long as the family routine remains constant. After about a month the child's biological clock ticks in and the programme gets forgotten and is only re-introduced if the waking behaviour returns.
Source: A Buchanan, What Works For Children With Emotional and Behavioural Problems, Barnardo's, 1999   

¹ H Hiscock H, M Wake, "Randomised controlled trial of infant behavioural infant sleep intervention to improve infant sleep and maternal mood," British Medical Journal, 4 May 2002

² J Shuttleworth, Understanding Childhood, Crying and Sleeping in the First Months of Life, leaflet from the Child Psychotherapy Trust, www.childpsychotherapytrust.org.uk