Drugging Children to Sleep

A recent study published in the journal Sleep Medicine revealed that most child psychiatrists prescribe medication for sleep at least once a month, despite the fact that no sleep medications are approved for use in children. The study was funded by Sanofi-Aventis, makers of Ambien.

Managing sleep is one of the greatest challenges of being a parent. It represents the first major separation and can be fraught with complex ambivalent feelings. As children get older, battles for control often play out around sleep. Most significant behavior problems are associated with major emotional dysregulation. Calming down sufficiently to fall asleep may be very difficult. Sleep deprivation, in turn, exacerbates emotional dysregulation. Children learn to regulate emotions in relationships with the people who care for them. Efforts to help children regulate emotions must focus on supporting these relationships.

The trend towards medicating away these complex sleep problems, rather than getting at the root cause, is, in my opinion, quite disturbing.

Consider the following story. I first saw Charles when he was three. His mother, Anne, described terribly disrupted sleep (details, as always, have been changed to protect privacy.) He would wake multiple times at night and scream for his mother who was, in fact sleeping right next to him. Even as she held him he would continue to thrash and cry out. His behavior was so wild and out of control that his parents feared he was having a seizure. To reassure both them and myself, I sent him to a neurologist, who after an exam and EEG, declared that there was "nothing wrong." He prescribed a tricyclic anti-depressant.

His mother threw the pamphlet about the drug in the garbage and arrived at my office horrified, yet ready to do the difficult work addressing this problem in a meaningful way entailed.

Charles had been a dysregulated baby since birth. In addition, as we came to understand in or time together, Anne had been abandoned by her own mother, who had severe mental illness. Not only had she been left alone in her crib as an infant, but as she grew up, her mother had not been emotionally available to her, though she had provided physical care. Anne recognized that in order to be emotionally available to Charles in the way he needed, she would have to address her own trauma.

With time and lots of hard work, Anne came to understand that Charles' neediness at bedtime was so disturbing to her that in a sense she was not there emotionally, though physically she was present. Once she felt supported and understood, she was able to be emotionally present with Charles at bedtime as well as other times that were difficult for him. Gradually the sleep disruption subsided. By the time Charles was in Kindergarten he was sleeping well and thriving in school.

There may well be a role for short term use of sleep medication for children in situations where families are spiralling dangerously out of control. But routine use, without careful thought, as was the case when the neurologist prescribed a tricyclic for Charles, represents a risky oversimplification of often very complex problems.

Toddlerhood, Teenagers and Winnicott's Wisdom

Psychoanalyst Peter Blos describes the "second individuation process of adolescence," referring to the way in which adolescence shares many qualities with toddlerhood in terms of developmental tasks. Sometimes when I listen to parents describe their struggles with their teenage children, I have an image of trying to contain a person, often bigger than themselves, with advanced thinking skills. The tantrums of adolescence involve not thrashing arms and legs, but rather words, often cruel and vicious words.

Once again D. W.Winnicott, pediatrician turned psychoanalyst, comes through with some words of wisdom that I believe can serve well to guide a parent through this challenging and often tumultuous period. He writes, in his book Playing and Reality

If you do all you can to promote personal growth in your offspring, you will need to be able to deal with startling results. If your children find themselves at all they will not be contented to find anything but the whole of themselves, and that will include the aggression and destructive elements in themselves as well as the elements that can be labeled loving. There will be this long tussle which you will need to survive.

This idea resonated with Pam, mother of 16 year old Eva, who had come to see me for a consultation. She described the following scene. Pam and Eva had planned to have a nice lunch together. Eva was busy at school and had developed an increasingly serious relationship with her boyfriend, Chris. Eva and Pam had always been close and both eagerly anticipated this opportunity to spend a bit of time together. Things started off well enough. Eva excitedly told her mother about the latest social happenings at school and about a paper she was working on.

But then over some little thing, Pam couldn’t even remember what it was when she told me the story in my office, Eva had exploded with a burst of venomous rage. “You never think about my feelings,” she’d started with, calmly enough. But when Pam tried to get her to explain what she meant, Eva’s anger only increased. Vicious insults started flying at her. Caught off guard, Pam found herself becoming defensive.

Their discussion escalated into a shouting match as they quickly paid their bill and left the restaurant. Pam, in an effort to get home without being in an accident, stopped talking to Eva, who, she felt, was becoming increasingly irrational in her verbal assault on her mother. Pam’s silence only further enraged Eva and she screamed at her mother, who held tight to the wheel, hands shaking.

They made it home and immediately went their separate ways. Pam called her husband. As he was not the recipient of the full intensity of Eva’s distress he was able to support his wife and help her to calm down. Eva closed the door to her room and called her boyfriend. Several hours later Eva emerged from her room. “I’m sorry, Mom, she said. I’ve been feeling so much stress trying to balance work and friends and Chris.” “I understand that this is a very difficult time for you,” Pam had replied. “But," she went on to say, "it is not acceptable for you to speak to me the way you did.”

Pam was feeling beaten down by these repeated interactions with her daughter. She had experienced what she described as a highly traumatic transition to adolescence. When she was 16, her parents divorced. She recalled seeking comfort from her mother, who was so bereft about her own circumstances that she was totally unavailable for any meaningful emotional support. Pam had descended into a serious depression and only many years of therapy had gotten her to a place where she could have her own family.

While she had been able to negotiate the prior stages of development with Eva, the intensity of feelings directed at her from her teenage daughter sometimes was too much to bear. I told Pam that she was doing just what she needed to do, namely withstand the full intensity of her daughters feelings , both the negative and positive ones, yet set limits on her behavior. Pam needed to show Eva that she loved and supported her daughter, but would not allow her destroy her mother.

Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle”of adolescence. He writes, also in Playing and Reality

Your rewards come in the richness that may gradually appear in the personal potential of this or that boy or girl. And if you succeed you must be prepared to be jealous of your children who are getting better opportunities for personal development than you had yourselves. You will feel rewarded if one day your daughter asks you to do some baby-sitting for her, indicating thereby that she thinks you may be able to do this satisfactorily; or if your son wants to be like you in some way, or falls in love with a girl you would have liked yourself, if you had been younger. Rewards come indirectly. And of course you know you will not be thanked.

Thoughts on a Toddler's Declaration of "Mine"

As a child makes moves to assert his independence, he begins to test the limits of what he can and cannot do. Limit setting is not only about controlling your child’s behavior. It is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. Setting limits helps children learn to manage healthy aggression.

“Mine” is favorite word of most toddlers. This word represents not greed, but rather joy in a newly emerging sense of self. Toddlers delight in their expanding language and motor skills and the power these skills give them in the world. Recently I was visiting a friend whose 20 month old son described everything he touched as "mine." Then he proclaimed happily, "Run!" as he toddled back and forth across the kitchen floor.

But imagine that your toddler sets his sight on your glasses and declares proudly, “mine.” In an appropriate way, you might calmly say, “No, those are Mommy’s. I need them to see.” Suddenly he is confronted with the fact of his relative smallness and powerlessness. If your child happens to be in a particularly vulnerable state, such as before lunch or naptime, he might become enraged that you, his beloved mother, have burst the bubble of his omnipotence. Unable to contain his intense feelings, he might lash out and hit you.

Feeling angry at such an assault is a natural reaction. Yet it is important to contain your own response and to recognize the two year old meaning of his behavior. What he needs from you at that moment is the assurance that you accept his feelings but that you will help him to contain and manage his rage. This might be in the form of a firm statement of “no hitting” or even a brief time out.

A toddler on a Youtube video who declares to his mother, “I love you but I don’t like you,” offers an example of the fact that intense but opposite feelings are a healthy part of any passionate relationship. John Bowlby has written extensively on this subject. His ideas are well summarized by Miriam Steele when she writes: ‘What distinguishes healthy individuals from unhealthy individuals is the extent to which the inevitable conflict between feelings of love and hate, often directed towards the same person, are controlled, regulated and so resolved. For children, Bowlby tells us this will develop naturally if young children have the loving company of their parents who put up with outbursts of hostility by showing that they are not afraid of hatred and conveying a belief that it can be contained and controlled.”