For almost ten years now I’ve suggested using a simple, easy “Get Out of Bed Free Card” for those who want to help preschool and school-age children learn to happily stay in their own rooms at night. I’ve heard from thousands of parentsaround the world who have been thrilled with the results.

Now, in the April 2007 Journal of Pediatric Psychology the author of the original study on the technique, and colleagues, report a randomized controlled trial in 19 children whose sleeping habits were carefully monitored and measured. All of the children in the study were bedtime resistant at the start; they regularly cried, called out, and/or left their rooms after bedtime. Half received bedtime passes, which I’ll describe in a moment. The children who received passes quickly began to call and cry out significantly less frequently. The time to quiet dropped significantly. And trips out of the bedroom dropped to near zero. When the children were monitored again 3 months later, the families were still enjoying these benefits, even though none of them were still using the passes. The children who had never received sleep passes, though, were still crying and calling out, taking longer to quiet at bedtime and still leaving their rooms afterwards. The parents who tried the bedtime passes were very satisfied – 92 percent reported that it was easy and stress-free for them and 100 percent believed that their children experienced no discomfort. This is so important. Not responding to a crying child can be very stressful for both parents and children, and cut against our primal instincts.

So how do you use bedtime passes? Simple.

1. Give your child a special card good for one free trip out of their room each night or one visit from a parent – for a brief, acceptable purpose such as a drink and a hug. Many families decorate the cards, often with the child.
2. Require the child to get in bed at bedtime, but be sure the free pass is close at hand.
3. When the child uses the pass, the card is surrendered for the rest of the night.
4. If children leave the room again that night, they are walked back without a word and without eye contact.

This method can work like magic for children age 3 to 10, if your goal is for them to sleep in their own rooms. I’ve also seen it work wonders in some younger and older children. The first couple of nights most children try the pass to be sure it works. They will often try an extra visit or two to be sure you are serious about no attention later in the night. Then, the magic happens: most kids start holding onto their cards throughout the night, in case they might need it later, and fall asleep on their own, remaining in their own rooms all night. If you leave the pass on the nightstand, you might find it in your sleeping child’s hands in the morning. Aren’t they beautiful when they sleep?

What’s your experience with sleep?

Today’s generation of children is growing up unlike any previous generation in history. In the last 10 years there has been an explosion of digital and electronic media available to and even targeted at children – even our very youngest children. Lots of DVDs are aimed at kids 0 to 18 months old. Television networks for toddlers, handheld video games for preschoolers, and computer games for children as young as 9 months. And of course, there is the Internet… What’s the impact of all this media on the young? Is it decreasing their time spent reading or playing outdoors? A preliminary study published in the May 2007 Pediatrics at least catalogued what is going on in today’s kids aged to 6 months to 6 years. Children in the study were reported (by parents) to watch an average of 1 hour 19 minutes on a typical day (more if there was a TV in the child’s bedroom, or in single parent families). In addition, children averaged 1 hour 18 minutes of DVDs. According to the parents, most kids do not play any form of video games on a typical day (only 16 percent of 5-6 year oldsdo), but those who do spend about an hour a day playing. By contrast, the kids were much more likely to spend time at the keyboard, either playing computer games or other computer activities – taking about another hour. This is starting to add up!

And the kids are quickly becoming comfortable using these media by themselves. More than half of the 6 month to 2 year olds were already turning on the TV themselves. Many were already inserting and watching DVDs on their own. By age five, more than 70 percent were comfortable navigating a computer with a mouse. They are off to a different start than we were.

We live in a digital world, and I am glad that kids are getting an early exposure to this ‘language’ of our new century – as long as it does not crowd out other important ‘languages’ to learn to understand and love at an early age: outdoor play, reading, and spontaneous and imaginative creation.

This study measured reading time and outdoor play time. Not surprisingly, some kids got plenty, others not enough. What was surprising, though, was that there was no difference in these items overall between those who spent many hours with digital media and those who did not. Media did not seem to be a culprit here! My take home: be sure kids are enjoying the important parts of childhood that we and our parents before us grew up with. Modern marvels can enhance their lives without crowding these out.

What’s your take? Many parents in the study were fans of bedroom TVs to help their kids sleep. Ironically, it seems that the televisions often worsen sleep in the short-run and lead to sleep problems down the road. They just keep our overtired children quieter.

Vanderwater, E.A., Rideout, V.J., Wartella, E.A., Huang, X., Lee, J.H., and Shim, M. “Digital Childhood: Electronic Media and Technology Use Among Infants, Toddlers, and Preschoolers.” Pediatrics. May 2007, 119, pp. e1006-e1015.

Sleep problems in babies, toddlers, and preschool kids are common. So are mental health problems, such as depression, in parents. Postpartum depression in mothers gets the most attention, but when a mother is depressed, up to 50 percent of fathers will be as well. And depression is not restricted to the postpartum period. It’s also common among preschool parents. What is the link between kids’ sleep and parents’ health?

We know that sleep problems in children can lead to depression in mothers, which can improve as the child’s sleep improves. A study of about 10,000 Australian infants and preschool children and their families was published in the May 2007 Pediatrics. The results showed a clear connection between poor sleep in the children and general health issues in both mothers and fathers (as well as specific mental health issues in mothers), even after taking into account other risk factors for these health problems.

The authors conclude that solving children’s sleep problems can help improve mothers. mental health and the general health of both parents.

This makes sense to me, and is worth making a priority. It also makes sense to me that parents. addressing their own physical health issues may help their children to sleep better. The study shows a link, but does not show which causes which. I suspect that they both affect each other, in what can be an upward or downward spiral. Each step forward could have rippling positive effects.

What’s your experience? What would you recommend to other parents?

Martin, J., Hiscock H., Hardy, P., Davey, B., and Wake, M. “Adverse Associations of Infant and Child Sleep Problems and Parent Health: An Australian Population Study.” Pediatrics. May 2007, 119, pp. 947-955.

Would you rather your kindergarten-age child had blood lead levels 3 times the safe limit (like children living next to a lead smelters – double the level of most kids with lead toxicity), or would your rather your child snored? The impact on the brain is about the same, according to a provocative study in the October 2004 Journal of Pediatrics.

Sleep-disordered breathing (SDB) is the name given to a spectrum of sleep breathing patterns ranging from mild snoring to obstructive sleep apnea. In this study of more than 200 children, those with SDB scored significantly worse on tests of behavior, memory, intelligence, and ADHD than did their peers – even if they only had snoring without sleep apnea.

Given the poor scores on wide variety of tests, it’s not surprising that their school performance also suffered. Thankfully, treating snoring at this age seems to improve performance. The authors suggest that 3 to 6 years old is the peak period where snoring is harmful to development, and also the peak age at which treating snoring can make a big difference in behavior and learning. Overall, about 1 in 10 children this age snore.

At around age three, most children enter into a magical time where make-believe is the order of the day. Imagination and creativity spring to life. Playtime becomes a setting where wonderful dreams and desires are acted out as kids learn how to pretend. A few props can turn an ordinary rainy afternoon into a trip to a magic castle or the Old West. But this rich imaginary world is peopled with both heroes and villains, with both marvels and monsters. New fears are a necessary part of entering the world of possibilities.

As the imagination blossoms, kids who never before had problems with the dark are now terrified. The neighbor’s friendly dog is seen as a menacing danger. An ant on the sidewalk might as well be a powerful alien. Monsters!

Acknowledge the fear, while remaining calm yourself. Assure her of your protection and support. When children see that you take their concerns seriously, they feel closer to you and are more ready to work through the fears.

Dr. Greene’s Answer:

How exhausting! Missed sleep is tough for all of us, but yours has been long and consistent and without a failsafe solution if you just get too tired. Most young kids will return to sleep well if rocked, or cuddled, or fallen asleep with (of course, whether or not you want to do this is another issue).

Sometimes adjustments in bedtime or napping can make a difference. In some children, periods of waking can occur when a child is toilet training. In these children, taking them to the bathroom in the middle of the night can solve the problem. If a child wakes up in need of comfort, a special blanket or stuffed animal may help.

But when kids don’t sleep well in the most conducive setting, I like to have them seen at a sleep center. Thankfully, sleep is beginning to get the attention it deserves, and sleep centers are springing up in many places.

Occasionally, sleep specialists recommend medicines after other options have been explored. I am in favor of this (although I am not a fan of the Benadryl class, at least as either a medium- or long-term solution). I prefer medicines in the hypnotic class that are eliminated from the body relatively quickly. Sleep is so valuable for health (his and yours) that, in some situations, the benefits clearly outweigh the costs. Your doctor can refer him to a sleep center if necessary.

The October 1999 issue of the Archives of Pediatrics and Adolescent Medicine reports success with giving preschool and school-age children a free pass to get out of bed once each night. Originator, clinical psychologist Dr. Patrick C. Friman, gave children 5×7 cards embossed with their names. Each night they could turn in the card for one brief visit out of their room. The visits were to be for a specific purpose — a drink of water, a hug, or a bathroom visit. If children cried or left the room after they had already used their pass, the parents ignored the crying and returned the children to their room without eye contact and without a word. Many children saved the pass for later and then fell asleep — secure, knowing they had the pass. Also, knowing that leaving the bedroom was no longer forbidden removed some of its allure. However it works, though, parents and children both love it!

Dr. Greene’s Answer:

Many families throughout history have chosen a “family bed.” In fact, in most cultures around the world today, a “family bed” is the norm. If that is a family’s choice, it can work very well. It is clear, however, that a “family bed” is not your choice. It also works well to teach children to sleep in their own bed. It does not work well, however, to tell children to sleep in their bed and then relent when they act up. This only teaches them that their persistence will be rewarded with a trip to your bed.

The most common ways of dealing with this situation include threats, punishment, bribes, speeches (“big boys and girls sleep in their own bed…”), etc. Usually these approaches don’t work. The best approach is to discover the underlying cause or causes for your daughter’s behavior. At some level your daughter herself knows why she doesn’t want to sleep in her own bed, even if she isn’t able to articulate what she is feeling. If you ask her out right what she is feeling, though, you might not get any valuable information.

A great way of discovering what your child is feeling is to play with her using dolls or action figures to represent members of a family. Have the characters act out several typical family situations: meal time, going to the park, driving in the car, etc. Enact several of these non-threatening situations, and let your child put words into the figures’ mouths. When you get to bed time, if your daughter is hesitant to talk, you can try speaking for the characters. If your daughter has gotten into the play, she will correct you if you give the characters motivations that are inaccurate from her perspective. Another approach is to encourage her to color or paint while she tells you about what she is creating. Be sure to allow her lots of time to open up and don’t react negatively if she says something you don’t want to hear.

The things you are most likely to find are: your daughter has night time fears, i.e. she is afraid of the dark, being alone, closet monsters, etc.; she is jealous of one parent or a sibling; she is afraid of losing your affection if she “grows up”; or some variation of one or more of these. All of these are very real and important in the life of a four year old.

If she is suffering from night time fears, give her tools that empower her to overcome her fears. Here are a few ideas: give her a flashlight to play with (especially during the day in a darkened room) to help overcome fear of the dark; give her a spray bottle filled with “monster spray” so she can shoot the monsters if they come out; record a tape of her favorite stories and songs that she can turn on whenever she is feeling alone or afraid (it is best if the recording is of your voice); give her a stuffed animal as big as she is to sleep with; or best of all, ask her for suggestions (perhaps to help the doll in her scenario). If the primary reason she wants to sleep with you is night time fears, you should be able to switch her into her own bed as soon as she has the tools to cope with her fears.

If you discover that she is jealous of one parent or a sibling, evaluate the situation and determine if she has reason to be jealous. If she has a younger sibling who is getting most of your attention during the day, she may feel the only time she “gets you” is at night. The best way you can help overcome her jealously is to pay special attention to her when she is not asking for it. If she reveals that she is afraid that she will lose your affection when she grows up, take stock of what you are communicating to her regarding growing up. You may inadvertently be sending her the message that you want her to stay a baby. If this is the case, consider how you can change her feelings by the way you communicate with her. In both of these situations, you will need to take some time for her feelings to change before you can move her into her own bed. When you do, you may need to make the change in several stages. The first few nights, she might sleep on the floor beside your bed. The next move might be right outside your door, then into her own bed. The large stuffed animal or the tape recording of your voice may help ease the transition.

With awareness and understanding of what your child is feeling, you can turn this difficult situation into something that will help your daughter feel much better about herself and much closer to you. It will be well worth the time and effort. Take heart, there is light at the end of the tunnel!