WANT OF SLEEP
So far, almost all that has been written--and there has been a great
deal of unavoidable repetition--has been devoted to an attempt to
determine the causes which lead the child to refuse food and the
methods which we adopt to prevent or overcome the difficulty. Other
neuroses may be studied in less detail, because they depend for their
existence upon the same causes. For example, the habit of refusing
sleep, which is as common and almost as distressing as the habit of
refusing food, depends both upon a perversion of suggestion and upon
the phenomenon that we have called negativism.
If struggling and crying has occurred upon a series of nights, the
child comes to associate his bed not with sleep but with tears. If a
mother values her peace of mind, if she would spare herself the
discomfort of hearing her child sob himself nightly into uneasy sleep,
she must be wary how this all-important event of going to bed is
approached. With a nervous and restless child the preliminaries of
preparing for bed must be managed carefully and tactfully. The hour
before bedtime is almost universally the most interesting of the
whole day for the child. Then the baby, with his best frock on, and
books and toys, is the centre of interest in the drawing-room, till
the clock strikes and the nurse appears at the door. Suddenly it is
all over, and inexorable routine sends him off to bed. The good nurse
will give the child a little time to recover from the shock of her
arrival, and will not hurry him. She knows that his little mind is
slow to act, and that he must be led gradually to face a new prospect.
If she hurries him, catching him up in her arms from the midst of his
unfinished pursuits, resistance and tears are almost sure to follow,
and the difficult task of the day--the putting to bed--has made the
worst possible start. When this has happened on one or two successive
evenings, the habit of resistance to going to bed becomes fixed, and,
like all bad habits, is difficult to break. A nurse who has a way with
children will arouse his interest in a new pursuit, in which he can
play the chief part, the putting away of his picture books and toys.
If he is too small to carry his own chair or table to its allotted
place in the room, at least he can show his learning by pointing out
the spot. In the waving of good-byes he is expert and takes a
legitimate pride, and upstairs he has learnt that there are new
delights. He himself can turn on the taps in the bathroom, and he can
set every article in the proper place ready for use. All children love
their bath, and if interest and good temper has been so far preserved,
without a break, it will be ill-fortune if even the drying process is
not carried off without a hitch. Afterwards, for a little, nervous
babies, whose brains still teem with all the excitements of the day,
are best left to sit for a few moments by the nursery fire, while the
nurse puts all the garments one by one to bed. Each as it goes to rest
will be greeted by him with cheerful farewells; and so does the force
of suggestion act, till the central figure himself plays his part in
the scene, of which he feels himself the controller and director, and
climbs to bed. But if there has been a hitch anywhere, if the bugbear
of negativism has appeared, if he has been scolded or coaxed or
repressed too much and there have been tears and struggles, then going
to bed is a poor preparation for instant and quiet sleep.
With excitable, highly-strung children, the best laid plans and the
most tactful nurse will not always succeed, and to place him in his
cot is to provoke a storm of angry refusal and resistance. There are
mothers who believe that the best way is then to turn out the light
and leave the child to cry himself to sleep. This is a point on which
no one can lay down rules which are applicable for all children. It
may sometimes succeed, and the child may reason correctly and in the
way we wish him to reason, deciding that the game is not worth the
candle and so give it up. But with nervous, highly-strung children I
doubt if this Spartan conduct is commonly successful. Often if the
attempt is made, the troubled mother, listening to all these
heart-breaking sobs, can bear it no longer, and goes back to the side
of the cot to soothe and persuade him. Then certainly the longer she
has restrained her natural inclination, the longer the child has
sobbed himself into a pitiful little ball of perspiration and tears,
the more difficult will be her task in quieting him, the stronger will
be the impression formed on the child's mind, and the greater will be
the suggestion which will act under the same circumstances to-morrow.
Children who fall a prey to this uncontrolled crying, cry on because
they cannot stop when they have begun. They do not then cry purposely
or with a fixed intention, desiring to attain some object. They cry
because their minds are not at rest, but are irritated and overwrought
by the happenings of the day. We decided that it was useless to
attempt by exhortations at meal-times to induce a nervous child to eat
who habitually refuses food, and that we can only cure the condition
by eliminating from his daily life the elements of repression and
opposition which provoke the counter-opposition. And we must seek the
same solution in this other difficulty of the refusal of sleep. It is
useless to attempt to treat the symptom of refusal of sleep and to
leave the cause of that symptom still constantly in action.
If, in spite of our care to avoid unrest and irritation of the child's
brain, sleep is refused, as may often happen, it is, as a rule, wise
to cut short the crying if we can, before a vicious circle has been
formed and the unrest has been intensified by the emotional storm. It
is useless with little children to urge them to go to sleep or to
coax. It is not usually wise to leave the child for a little and then
to return. Each time the child is left, each time the mother or nurse
returns, the crying bursts forth again with renewed force and vigour.
It is at least one good plan with a little child to turn the light
out, and, treating the whole incident in the most matter-of-fact way
possible, lightly to stroke his head or pat his back rhythmically
without speaking. With older children, if the crying is more
purposeful and less emotional, the mother may busy herself for a
little with some task in the room, ostentatiously neglecting the storm
and making no reference to it. If she speaks to the child at all she
should do so in a matter-of-fact way, referring lightly to other
matters. If only she can convince him that his conduct is a matter of
indifference to her, the victory is won. It is because the child knows
so well that his mother does care that he so often has the upper hand.
It is not difficult to distinguish between a true emotional storm and
the tyrannous cry of a wilful child who demands his own way.
Light and broken sleep is a common accompaniment of a too excitable
and overstimulated brain. The placid child, who eats well, plays
quietly, and does not cry more than is usual, as a rule sleeps so
soundly that no ordinary sounds, such as conversation carried on in
quiet tones in his neighbourhood, have the power to waken him. When he
wakes, he does so gradually, perhaps yawning and stretching himself.
The nervous child may move at the slightest sound, or with a sudden
start or cry is wide awake at once. A hard mattress should be chosen
without a bolster, and with only a low pillow. Flannel pyjamas, which
cannot be thrown off in the restless movements of the child, should be
worn. The temperature of the room should be cool, and the air from the
open window should circulate freely, while draughts may be kept from
striking on the child by a screen. All the sensations of the nervous
child are abnormally acute. Thus, for example, an itching eruption, or
tight clothing, will produce an altogether disproportionate reaction,
and may result in a frenzy of opposition. Especially such a child is
sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool
rooms and warm but light and porous clothing are essential. An
electric torch, which can be flashed on the child for an instant, will
assist the mother or nurse to make sure that the child has not thrown
off all the bedclothing.
Sometimes want of sleep is accounted for by a real want of physical
exercise. Town children especially are apt to suffer from their
limited opportunities of running freely in the open. It is often
considered enough that the child seated in his perambulator should
take the air for three or four hours daily, while much of his time
indoors as well is devoted to sitting. It is necessary for his proper
development that he should have opportunities of daily exercise in the
open. If for any reason this is not always practicable, a large room,
as free as possible from furniture, should be chosen, with windows
thrown wide open, in which the child may romp until he is tired.
It is rare for children of two or of three years of age, whose case
we are now considering, to be troubled by bad dreams, nightmares, or
night-terrors. If these should occur, obstructed breathing due to
adenoid vegetations is sometimes at work as a contributory cause.
Finally, we should always remember that refusal of sleep is, for the
most part, caused and kept up by harmful suggestions derived from
mother and nurse, who allow the child to perceive their distress and
agitation, who speak before the child of his habitual wakefulness, who
unwittingly focus his attention on the difficulty. It is cured in the
moment that the suggestion in the child's mind is reversed, in the
moment when he comes to regard it as characteristic of himself not to
make a fuss about going to bed, but to sleep with extraordinary
readiness and soundness. Let every one join together to produce this
effect. Let the suggestion act strongly on his mind that all these
troubles of sleeplessness are diminishing, that night after night sees
an improvement, and soon his reputation as a good sleeper will be
established, and, as always with children, it will be rigidly adhered
to.
In assisting to break the habit of sleeplessness, and in the process
of altering the character of the suggestions which act on the child's
mind, we can be of the greatest assistance to the mother by
prescribing a suitable hypnotic. As to whether it is right in insomnia
in childhood to prescribe depressant drugs is a question on which very
various opinions are held. That it is wrong and probably ineffective
to trust entirely to the drugs is certainly true, but as a temporary
measure, to break the faulty suggestion and the bad habit, their use
is both legitimate and successful. The dose required in children
relatively to the adult is much smaller. In grown people, some
specific distress of mind, whether real or imaginary, may suffice to
resist very large doses of hypnotic. In children it is rare to find
the same resistance, and comparatively small doses have a very
constant effect. With deeper and more refreshing sleep, the conduct of
the child during the day almost always changes for the better. A sound
sleep, for a few nights in succession, will produce apparently quite a
remarkable change in the whole disposition of the child. When good
temper and interest take the place of fretfulness and restlessness, we
may confidently expect that the symptom of sleeplessness will begin to
abate. Sleeplessness by night and fretfulness by day form a vicious
circle, and attempts must be made to break it at all points.
Chloral occupies the first place as a hypnotic for young children. In
combination with bromide its effects are wonderfully constant and
certain. Two grains of chloral hydrate and two grains of potassium
bromide with ten minims of syrup of orange, given just before bedtime,
will bring sound sleep to a child of a year old. At three years the
dose may be twice as great, and three times at six years. It is seldom
that other means are required. Aspirin for children seems relatively
without effect. For children who are both sleepless and feverish, a
grain of Dover's powder, and a grain of antipyrin, for each year of
the child's age up to three, is very helpful. Lastly, if chloral and
bromide cannot break the insomnia, and the condition of the child is
becoming distressing, we can almost always succeed if we combine the
prescription with an ordinary hot pack for twenty minutes.