Sleep
and Bedtime
Behavior
in
Preschool-Aged
Children
Antonio U. Beltramini, MD, and Margaret E. Hertzig, MD
From the Department of Psychiatry, Cornell University Medical College, New York
ABSTRACT. Age stage-specific changes in patterns of
sleep and bedtime behavior were examined in 109
nor-mally developing preschool-aged children who were the
subjects of the New York Longitudinal Study of
Temper-ament and Development. The data were derived from
information abstracted from interviews conducted with
parents about the behavior of their children in daily life
situations at 1, 2, 3, 4, and 5 years of age. The following
age trends were found: older children were significantly
more likely to exhibit a prolongation of bedtime routine,
insist on sleeping with the light on, take a treasured object to bed, request parental attention after being told
good night, and experience delays in falling asleep than
were younger children. The frequency of occurrence of
night awakening was not different at the different age
levels examined, although older children were signif-icantly more likely to experience nightmares. The fathers
of older children were significantly more likely to
partic-ipate in bedtime routines, and older children were also
significantly more likely to share a bedroom with a sibling.
No sex differences were found. Pediatrics
1983;71:153.-158; sleep, bedtime, development, preschool.
The present report is concerned with the
exami-nation of age stage-specific changes in patterns of sleep and bedtime behavior in normally developing
preschool-aged children who were the subjects of
the New York Longitudinal Study of Temperament
and Development.”2 Interest in this question
de-rives from the fact that the establishment and
main-tenance of stable patterns of nighttime sleep is of
major importance to both the developing child and
his or her caretakers. For the child, adequate sleep
at night is an essential precondition for maximal
daytime alertness and responsivity to social
inter-actions and other environmental stimuli and events.
In addition, prolonged delays in falling asleep and/ or frequent night awakening may be poorly toler-ated by many parents and disruptive to their func-tioning both within and outside the family setting. Moreover, pediatricians and family practitioners are frequently consulted when a child’s behavior at bedtime or during the night is defined as a problem
by the rest of the family.
Gesell3 has contrasted the ease with which the 1-year-old child is put to bed with the difficulties experienced by the parents of many older children. The “typical” preschooler is described as likely to
insist upon a specific bedtime routine, request a
particular toy to take to sleep, call out to his or her
parents after being put to bed, and to awaken frequently during the night with reports of dreams or nightmares. Although numerous clinicians48 have confirmed and amplified Gesell’s observations, no clear answer is as yet available to the question, how many children are “typical”? Quantitative studies are rare, and, for the most part, have been confined to a consideration of a single age level within the first 2 years of lifeY’6
The data base of the New York Longitudinal
Study provided a unique opportunity to fill this
gap. The records maintained in the course of that anterospective investigation contain detailed
de-scriptions of the nature and duration of each child’s
bedtime routine and behavior during the night. Not
only has it proved possible to subject this
informa-tion to quantitative analysis, but the fact that the same children have been studied over time permits the examination of age trends without concern about sample comparability.
SUBJECTS
Received for publication Feb 12, 1982; accepted April 23, 1982. Reprint requests to (M.E.H.) New York Hospital-Cornell
Uni-versity Medical Center, 525 E 68th St, New York, NY 10021.
PEDIATRICS (ISSN 0031 4005). Copyright © 1983 by the
American Academy of Pediatrics.
Enrollment of subjects in the New York
Longi-tudinal Study began in 1956 and continued over a
6-year period. The sample included 133 children
parents were born in the United States; 87% of the
fathers and 89% of the mothers had some college
education, with 64% of the fathers and 36% of the
mothers having acquired postgraduate degrees; 75%
of the fathers were professionals or business
exec-utives, 20% were small businessmen, and 5% were
highly skilled artisans. By the time the children had
reached their fifth birthday, one third of the
moth-ers had returned to either full-time or part-time
work, and of these 80% were engaged in professional
occupations.”2
Expressed parental attitudes emphasized the
im-portance of identifying and satisfying the needs of
infants and young children. Permissiveness in
rela-tion to feeding and toileting was viewed as
partic-ularly desirable. However, as a group, these parents
were much concerned with the age at which their
children could assume responsibility for and exhibit
skifi in carrying out activities of daily living and
self-care. They often expressed the opinion that the earlier a child was able to sleep through the night,
feed himself, dress himself, tie his shoes, and so
forth, the better. Precocity in task mastery had high
prestige and status value for these families.’7
Spock’s manual, Baby and Child Care,’8 was
uniformly utilized as a source of child rearing
ad-vice, although a number of mothers felt free to
diverge from its specific recommendations on
oc-casion. Most of the families actively consulted their
pediatricians for guidance in the routine care of
their infants and young children. The parent group,
as a whole, was oriented toward the desirability of
obtaining psychiatric advice and, if necessary,
treat-ment for a child with deviant behavioral
function-ing.’9
The present report is based upon information
abstracted from the interviews conducted at 1, 2, 3,
4, and 5 years of age on 109 (82%) of the 133 New
York Longitudinal Study subjects. Six children
were eliminated because a review of records
mdi-cated that interviews had not been conducted for
two of the indicated ages, and the other 18 children
were eliminated because a single record was missing
from their folders. There is no evidence to suggest
that the children for whom available information
was incomplete were in any other way atypical.
METHODS
The methods of the New York Longitudinal
Study have been described elsewhere,”2 and will
therefore be only briefly summarized here. Parents
were the primary source of information concerning
their child’s behavior. Initial interviews were
con-ducted when the child was 3 months of age, at
3-month intervals until age 18 months, and at
6-month intervals until age 5 years. Parents were told
that the project studied the individual behavior of
normal children in normal homes. The interview
was designed to elicit detailed descriptions of be-havior in everyday life situations. The format of the
interview was semistructured in that the
inter-viewer was required to obtain answers to specific
questions, but the order ofpresentation was flexible.
Responses were recorded in narrative form. The
following aspects of sleep and bedtime behavior
were routinely explored. Parents were asked to
indicate the time and regularity of bedtime and
naptime behavior and to describe the bedtime rou-tine. They were also asked how long it took for the
child to fall asleep after being put to bed and to
recount his/her behavior during this interval.
Ad-ditional questions focused on whether or not the
child slept through the night. If the child awakened,
note was made of the frequency, behavior on
awak-ening, and what was required to get him/her back
to sleep. The time of and behavior on morning
awakening was also described.
For the purposes of the present examination of
sleep and bedtime behavior, each record was
ab-stracted to a protocol that permitted the recording
of the following information: (1) who usually put
the child to bed, (2) where the child slept, (3) the duration of the bedtime routine, (4) whether the child regularly took a specific blanket or toy to bed,
(5) whether the light was left on, (6) the length of
time required to fall asleep, (7) the frequency of
night awakening, and (8) the occurrence of night-mares and night terrors.
RESULTS
The analysis of the data addressed the following
aspects of sleep and bedtime behaviors: (1) sleeping
arrangements and adult supervision at bedtime, (2)
bedtime activities, and (3) interruptions of sleep. In
each instance, attention is directed toward the
de-termination of overall frequency of occurrence of
the specified behavior as well as the examination of possible sex differences and age trends.
Sleeping Arrangements and Adult Supervision at Bedtime
Sleeping Arrangements. All of the children slept
in their own crib or bed at each of the age levels
examined. Seventy-two percent of the children
shared a room at some time during the first 5 years
of life (Table 1). The sleeping arrangements of boys
and girls did not differ significantly
(f
= 0.237, df= 1). However, the proportion of children sharing
a room was significantly different at different ages.
As the data of Table 1 indicate 29% of the children did so at 1 year of age as compared with 39% at age
2, 49% at age 3, 54% at age 4, and 49% at age 5 years
TABLE 1. Sleeping Arrangements and Adult Supervision at Bedtime Year 1 N (%) Year 2 N (%) Year 3 N (%) Year 4 N (%) Year 5 N (%) Ever N (%) Coch-ran Q dl P
Shares bedroom 32 (29) 43 (39) 53 (49) 59 (54) 56 (49) 78 (72) 33.97 4 <.001
Father regularly partici- 7 (6) 13 (12) 21 (19) 16 (15) 18 (17) 35 (32) 19.01 4 <.001
pates in bedtime routine
the most common roommates at all ages, but one
child at 1, 4, and 5 years of age regularly slept in
the parental bedroom. Other children regularly shared a room with a grandmother or housekeeper.
The arrangement was reported for one child at age
1, four children at age 2, five children at age 3, and
one child at age 4.
Adult Supervision at Bedtime. Maternal
super-vision of bedtime activities was the predominant
pattern during the preschool period. Nevertheless,
paternal participation at bedtime was reported for
32% of the children at some point during the first 5
years of life (Table 1). Fathers were equally likely
to become involved in the bedtime routines of girls
as of boys
(x2
= 2.2559, df = 1). However, as thedata of Table 1 indicate, significantly more fathers
participated in bedtime routines as the children
grew older. When children were 1 year of age, seven
fathers (6%) were involved in bedtime activities on
a regular basis as compared with 18 (17%) when
children were age 5 years (Cochran
Q
= 19.01, df= 4, P < .001). Less than 5% of the children were
regularly put to bed by their grandmothers or housekeepers, but this arrangement was not de-scribed after 3 years of age.
Bedtime Activities
Duration ofBedtime Routine. A regular bedtime
routine, usually involving some combination of
dia-per change or toileting, drink from a bottle or glass,
song and/or story, followed by good night kisses,
was followed by all children of all ages. Sixty-six
percent of the children required more than 30
mm-utes for the execution of this routine on a regular
basis at at least one age level during the preschool
period. The number ofboys and girls whose bedtime
routines were prolonged did not differ significantly
(x2
= 0.0734, df= 1). However, as the data of Table2 indicate, it took more than 30 minutes to put only
6% of the children to bed at 1 year of age as
compared with 12% at 2 years, 24% at 3 years, 49%
at 4 years, and 33% at 5 years. These differences
are significant at the 0.001 level of confidence
(Cochran
Q
= 73.02, df= 4). Moreover, two childrenat 1 year of age, three children at age 2, and two
children at age 3 years were never actually put to
bed but were permitted to fall asleep elsewhere and
then carried into their own room.
Falling Asleep with Light On. Forty-seven
per-cent of the children regularly insisted on sleeping with the light on at at least one age level during the
first 5 years of life (Table 2). This. behavior was
exhibited with equal frequency by both boys and
girls ( = 0.2257, dl = 1). As the data of Table 2
indicate, increasing numbers of children, up to age
4 years, demanded that a light be left on. The
proportion of children sleeping in an ifiuminated
room was 7% at 1 year, 13% at 2 years, 22% at 3
years, 30% at 4 years, and 25% at 5 years of age.
These differences are significant at the 0.001 level
of confidence (Cochran
Q
= 24.54, df = 4).Treasured Objects. Slightly more than three
fourths of the children regularly took a particular
toy or blanket to bed at at least one age level during
the preschool period (Table 2). The number of boys
as contrasted with girls who exhibited this behavior
pattern was not significantly different ( = 0.1567).
However, the frequency with which children made
such a demand was significantly different at differ-ent ages. As the data of Table 2 indicate, more than
40% did so at 2, 3, and 4 years of age as compared
with 20% at 1 and 5 years of age (Cochran
Q
=154.48, df= 4, P < .001).
“Curtain Call” Behaviors. Seventy-five percent of the children regularly recalled their parents at least once every night after being put to bed at some point during the preschool period (Table 2).
These curtain-calls, which included requests for a
service such as a drink of water or another good
night kiss, occurred with equal frequency among boys and girls
(x2
= 0.3730, df = 1). However, asindicated in Table 2, significantly greater numbers
of older children engaged in this behavior as
con-trasted with younger children. Fourteen percent of 1-year-old children displayed this pattern as
com-pared with 26% of 2-year-old, 42% of 3-year-old, 49%
of4-year-old, and 50% of 5-year-old children
(Coch-ran
Q
= 75.46, df = 4, P < .001).Length of Time Required to Fall Asleep. Nearly
90% of the children frequently (three or more times
per week) required more than 30 minutes to fall
asleep at at least one age level during the preschool
period (Table 2). Boys and girls were equally likely
to experience delays in faffing asleep ( = 0.1094,
df = 1). The proportion of children in whom the
onset of sleep was frequently prolonged increased significantly with increasing age. As the data of
Table 2 indicate, 26% of the children exhibited this
TABLE 2. Selected Bedtime Activities in Preschool-Aged Children
Year 1 N (%)
Year 2 N (%)
Year 3 N (%)
Year 4 N (%)
Year 5 N (%)
Ever N (%)
Cochran Q
df P
Bedtime routine >30 mm 7 (6) 13 (12) 26 (24) 53 (49) 36 (33) 72 (66) 73.02 4 <.001
Falls asleep with light on 8 (7) 14 (13) 22 (20) 33 (30) 25 (23) 52 (47) 24.54 4 <.001
Requests treasured object 20 (18) 50 (46) 54 (50) 46 (42) 22 (20) 83 (76) 154.48 4 <.001
1 or more “curtain calls”! 15 (14) 28 (26) 46 (42) 53 (49) 55 (50) 82 (75) 75.46 4 <.001
night
Requires >30 mis to fail 28 (26) 47 (43) (17 (61) 75 (69) 72 (66) 96 (88) 70.52 4 <.001
asleep
age 5 years (Cochran
Q
= 73.02, df = 4, P < .001).The behavior of the children during this period of
wakefulness also differed as the children grew older.
Until 2 years of age the majority of wakeful children
tended to talk or play quietly by themselves or with
a sibling. After age 3 years, children who
experi-enced a delay in falling asleep were far more likely
to call for their parents.
Interruptions of Ongoing Sleep
Nighttime Awakening. Ninety-five percent of the
children were described by their parents as
regu-larly crying or calling during the night as frequently
as once a week at at least one age level during the
first 5 years of life (Table 3). No sex differences
with respect to this pattern were observed
(x2
=0.2393, df = 1). Moreover, similar numbers of
chil-dren exhibited this behavior at different ages. As
may be seen in Table 3, 57% awoke once a week at
ages 1 and 2 years, 66% at age 3 years, 65% at age 4
years, and 61% at age 5 years (Cochran
Q
= 4.29, df= 4, P = not significant). Although the proportion
of children who regularly awoke one or more times
every night was smaller, 70% of the children were
noted to do so at some point during the preschool
period (Table 3). Again, with respect to the sex of
children exhibiting this behavior no significant
dif-ferences were found
(x2
= 0.9590, df = 1). Thefrequency of occurrence of this pattern did not
differ significantly at different ages. Even at 5 years
of age nearly 20% of the children cried or called to
their parents at least once every night (Table 3).
Nightmares and Night Terror. Sixty-two percent
of the children were reported to have regularly
experienced nightmares as often as once every 2
weeks at some point during the preschool period
(Table 3). Nightmares occurred with equal
fre-quency in boys and girls
(x2
= 0.1541, df = 1). Asindicated in Table 3, nightmares were significantly
more likely in older children. This behavior was
described in 5% of 1-year-old children as compared
with 38% of 5 year olds (Cochran
Q
= 67.71, df = 4,P < .001). Night terrors, characterized as episodes
of intense crying accompanied by difficulty in
arousal, were reported by the parents of a total of
seven children (6%) during the preschool period.
Two children exhibited night terrors at age 1 year,
none at age 2 years, two at age 3 years, and three at
4 and 5 years of age.
DISCUSSION
This report has utilized information from the
New York Longitudinal Study of Temperament and
Development to determine the age-specific
fre-quency of occurrence of selected aspects of sleep
and bedtime behavior in normally developing
chil-dren between the ages of 1 and 5 years. The
follow-ing age trends have been described: Older children
are significantly more likely than younger children
to exhibit a prolongation of bedtime routine, insist
on sleeping with the light on, take a treasured object
to bed, request parental attention after being told
good night, and experience delays in falling asleep.
However, the frequency of occurrence of night
awakening was not different at the different age
levels examined, although older children were
sig-nificantly more likely to report nightmares. Thus, the behavioral patterns displayed by these children
born and raised in New York City during the 1950s
are very similar to those described by Gesell3 as
occurring in preschool children living in New Haven
more than 30 years previously.
Our findings also closely resemble those of other
studies in which aspects of sleep and bedtime
be-havior have been examined from a quantitative
perspective. For example, Bernal’#{176} observed that
31% of the 77 predominately middle-class
12-month-old infants born in Oxford in the early 1970s
awakened at least once every night, as compared
with 29% of the children in the New York
Longi-tudinal Study. In the study of Ragins and Schacter’4
the proportions of 44 middle-class and lower
mid-dle-class 2-year-old children born in Pittsburgh
dur-ing the late 1960s who recalled a parent after being
put to bed, required more than 30 minutes to fall
asleep, regularly insisted on sleeping with a
partic-ular blanket or toy, or who awakened during the
night, are also closely similar to those found in the
present study. Although the results of an
investi-gation of 783 2#{189}-year-old children who attended
well baby clinics in Rochester in the 1940s’6 are not
TABLE 3. Interruptions of Sleep in Preschool-Aged Children Year 1 N (%) Year 2 N (%) Year 3 N (%) Year 4 N (%) Year 5 N (%) Ever N (%) Cochran Q dl P
Night awakening at least 62 (57) 62 (57) 72 (66) 71 (65) 66 (61) 104 (95) 4.29 4 NS once/wk
Awakens 1 or more times 32 (29) 30 (28) 36 (33) 32 (29) 21 (19) 76 (70) 3.57 4 NS every night
Nightmares at least once 5 (5) 10 (9) 31 (28) 42 (39) 41 (38) 68 (62) 67.71 4 <.001 every 2 wk
ages at which the children were examined, the
findings that 90% had a definite bedtime routine
and 44% regularly awakened during the night are in
general accord with those of the present study.
Furthermore, the proportion of children in this
sample who insisted on sleeping with a treasured
object during the first 2 years of life is no different
from that retrospectively reported by the parents
of school-aged children of similar social class born
in New York City some 15 years later.2#{176}
The similarity between the findings of studies of
children living at different times and in widely
disparate geographic areas and social circumstances
is striking, and raises the possibility that
age-spe-cific patterns of sleep and bedtime behaviors may
have a neurophysiolgoic base that undergoes
mat-urational change during the preschool period.
Re-cent reports have described shifts in the length of
the rapid eye movement (REM)-nonREM cycle
during the first 5 years of life.2’ Such
electrophys-iologic changes may well be expressed behaviorally
in the increased frequency of occurrence of reports
of nightmares among older children.
Analytic contributions to the understanding of
the sleep and bedtime behaviors of young children
have stressed the role of the growing complexity of
the mental apparatus in interfering with the
phys-iologic process of sleep.7 The development of
bed-time rituals and other delaying tactics, as well as
the emergence of nightmares, are believed by many
to reflect the child’s efforts at resolution of the
conflicts of the separation-individuation and
phal-lic-oedipal phases of development.22 In addition, as
Anna Freud is reported to have suggested, such
behaviors may represent a common range of
adap-tive behavior on the part of the human infant and
young child to the “unnatural” conditions in which
he is required to sleep (alone and between cold
sheets).7
The data of the present report lend support for
these views. The majority of children studied
en-gaged regularly in a prolonged and elaborate
bed-time routine, experienced delays in falling asleep,
and awoke frequently during the night at some
point during the preschool period. Such behavioral
patterns are frequently of concern to parents, either
because the behaviors themselves are inconvenient
or annoying or because they may be considered
symptomatic of more serious emotional
disturb-ance. Advice and guidance is most effectively
for-mulated and received within the context of a clear
understanding of the developmental course of sleep
and bedtime behavior during the first 5 years of life.
If a child is functioning well in other areas of life,
parents can be assured that age-stage typical
be-haviors are not of serious import, and they should
be encouraged to set limits appropriate to the needs
of both the developing child and his family.
ACKNOWLEDGMENTS
We thank Alexander Thomas, MD, and Stella Chess,
MD, for making the data of the New York Longitudinal
Study available to us.
REFERENCES
1. Thomas A, Chess 5, Birch HG, et al: Behavioral Individu-ality in Early Childhood. New York, New York University
Press,1963
2. Thomas A, Chess S: Temperament and Development. New
York, Brunner/Mazel, 1977
3. GeseIl A: The First Five Years of Life. New York, Harper and Brothers, 1940
4. Despert JL: Sleep in pre-school children: A preliminary
survey. Nervous Child 1949;8:8
5. Fraiberg S: On the sleep disturbances of early childhood. Psychoanal Study Child 1950;5:285
6. Healy A: The sleep patterns of pre-school children: General principles and current knowledge. Clin Pediatr 1972;11:174
7. Nagera H: Sleep and its disturbances approached
develop-mentally. Psychoanal Study Child 1966;21:393
8. Sperling M: Neurotic sleep disturbances in children. Nervous Child 1949;8:28
9. Anders TF: Night-waking in infants during the first year of life. Pediatrics 1979;63:860
10. Bernal JF: Night waking in children during the first 14
months. Dev Med Child Neurol 1973;15:760
11. Blurton-Jones N, Rossetti Ferreira MC, Farquar Brown M, et al: Association between perinatal factors and later night awakening. Dev Med Child Neurol 1978;20:427
12. Carey W: Night awakening and temperament in infancy. J Pediatr 1970;84:756
13. Moore T, Ucko LE: Night awakening in early infancy. Arch Dis Child 1957;32:333
14. Ragins N, Schacter J: A study of sleep behavior in two year old children. JAm Acad Child Psychiatry 1971;10:464 15. Richman N: A community survey of characteristics of
one-to-two year olds with sleep disruptions. J Am Acad Child Psychiatry 1981;20:281
Am JDiS Child 1951;82:127
17. Hertzig ME, Birch HG, Thomas A, et al: Class and ethnic
differences in the responsiveness of pre-school children to
cognitive demands. Monogr Soc Res Child Dev (series No. 117) 1968;33:1
18. Spock B: The Pocket Book of Baby and Child Care. New
York, Pocket Books, 1946
19. Thomas A, Chess 5, Birch HG: Temperament and Behavior
Disorders. New York, New York University Press, 1968 20. Sherman M, Hertzig ME, Austrian R, et al: Treasured
ob-jects in school-aged children. Pediatrics 1981;68:379
21. Kahn E, Fischer C: 24-Hour sleep patterns. Arch Gen
Psy-chiatry 1973;29:380
22. American Psychiatric Association: Syllabus: Psychiatric Knowledge and Skills Self-Assessment Program IV.
Wash-ington, DC, American Psychiatric Association, 1979
PIERRE BROUZET ON JEALOUSY AS A CAUSE OF FAILURE TO THRIVE
IN INFANCY (1754)
Pierre Brouzet (c. 1714-1772), the author of a two volume work on diseases of
children, first published in Paris in 1754,’ included jealousy as one of the causes
of poor nutrition in infancy.
He wrote:
When it is suspected that this leanness is owing to the infant’s pining we should
endeavour to discover what it is that makes him pine and we shall generally perceive
that greater fondness is shewn [sic] to some other infant in the house than to him, and
that on this account he is filled with jealousy. We cannot conceive the sensibility of an
infant in this respect: he conceals his uneasiness within his own heart and keeps it an
impenetrable secret; we must guess at his pain. The only means of discovering it is to
shew less fondness to his brother or sister to whom there has before been shewn a great
deal.
We should then carefully observe his eyes and we shall soon know if his disorder
proceeds from jealousy: for if it does, he will no sooner perceive this change than his
looks will become more serene and he will appear less melancholy and thoughtful than
usual. As soon as the mystery is discovered, all about him should in his presence avoid
all the caresses they were used to bestow on others and as much as possible bestow them
on him, but in such a manner that he does not perceive the plot . . . . That infants are
capable of jealousy is a point that cannot be doubted, they are so even while at the
breast.
REFERENCE
Noted by T.E.C., Jr, MD