Is it bedtime yet

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Is it bedtime yet?

• A Review of Behavior and Sleep Management
• October 7, 2008
• Christopher Giuliano, MD
• Pediatrician, Pediatric Specialists of Foxboro
  and Wrentham
• School Physician, Plainville Public Schools

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Test subjects
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Why manage behavior?

• To keep our children safe
• To teach respect for others
• To teach socially accepted and appropriate
  behavior
• Because children need order and consistency both
  for security and to thrive

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Obstacles

• Guilt and frustration
• Lack of cooperation among parenting team
• Inconsistency of approach
• Lack of support from other family members
• Challenging children
• Busy schedules

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Guilt and frustration

• Parents feel they are saying no all the time
• Discipline is not a lack of love
• Frustration is a normal reaction managing this
  increases success

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United we stand

• Parents at odds with eachother create confusion
  and inconsistency
• Children learn quickly to play both sides
• Disagreement in front of a child displays
  weaknesses he or she may exploit
• Behavior improves when there is no easy way out

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Inconsistencies

• Change takes time. Be patient.
• A behavioral approach requires that children
  learn that actions, whether good or bad, have
  consequences. This must be learned.
• Be persistent with your approach.

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Be the parent

• Everyone has advice, some good, some less good
• Assert yourself
• Set expectations for others to follow

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Challenging Kids

• Each child poses different challenges at
  different ages
• Expectations can be the same
• Results or time to success may vary

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Finding the time

• Parents are pulled in many directions
• Discipline is often inconvenient
• Easier may be quicker, but rarely better

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3-Tiered Approach to Behavior Management

• Provide structure and routine to limit incidents
  of misbehaving
• Deal with negative behaviors quickly and
  consistently
• Reward and reinforce good behavior in a manner
  that creates lasting change

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Structure and Routine

• Children have varying understanding of time
• They are very concrete and live in the here and
  now
• Provide a consistent framework of expectations
  and a reliable schedule of daily events

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Daily Routine

• Children thrive on routine
• There is security in knowing what comes next
• An opportunity to set the agenda
• Part schedule/Part process

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Daily routinemeals

• Hungry children are irritable!
• Schedule meals together
• Avoid grazing
• Assign tasks
• Allow self-regulation

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Daily routinebedtime

• Schedule some activity that expends energy during
  the day
• The right time is the same time
• Have a wind-down period

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Daily routinebedtime

• Limit anxiety
• Stick to the routine
• Give choices when equally acceptable
• Security devices
• A promise to return and a thought for tomorrow

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Daily routineother tips

• Consider consequences of changes in the routine
• Stimulate and enrich
• Limit screen time!!!
• Take a moment to remind yourself of the wonder
  and joy of raising a child

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Expectations

• Rules are rules. They dont change with our
  moods.
• By being consistent, we show that we follow
  rules, too.
• Be clear, not wordy.
• Affection and love should be a part of every day.
  This is unconditional and does not change with
  fatigue or stress.

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Time-outs
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Effective Time-outs

• Make them portable
• Long enough to matter
• Short enough that they remember why

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Effective Time-outs

• Make them portable
• Long enough to matter
• Short enough that they remember why
• Be impersonal during
• Be affectionate after

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Time-outs (cont.)

• Use them frequently
• Be consistent
• Avoid repeated warnings one or two is enough
• A childs room/crib/bed should be his or her safe
  haven

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Incentive System

• Children may not understand why we want them to
  behave
• Children do understand rewards and secondary gain
• Positive system where good behavior is rewarded
  instead of just punishing bad behavior

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Implementing an Incentive Plan

• Decide on a behavior to work on
• Choose a reward
• Set the terms and how to measure
• Get started

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The behavior

• Significant
• Measurable
• Individual
• Understood by child

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The reward

• Decided in advance
• Chosen by child
• Inexpensive

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The process/measurement

• Keep track visually
• Involve child in placing stickers/stars
• How to earn?
• How frequently?
• How many to get reward?

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Pitfalls

• Too much too soon
• Taking away stickers earned
• Forgetting once things go well
• Not making good

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Success

• Once behavior has improved, reinforce
• Work to create a sense of pride in the child for
  what has been accomplished
• Start again new behavior, new reward

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Common Questions

• What if my child wont sit in time out? He keeps
  getting up.

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Common Questions

• A gentle hand on the leg, a calm and firm voice
  are most effective to achieve success
• Keep the child nearby, within sight. This should
  limit destructive behavior that may occur if
  gated within a room.

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Common Questions

• We just completed a time-out and the child
  immediately returned to the behavior which led to
  the time-out. What do we do next?

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Common Questions

• Repeat the time-out.
• Children learn through repetition. It is also
  important to make them understand that you can
  remain calm and that, in the end, they will not
  win this battle.

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Common Questions

• What if he or she has a tantrum when placed in
  time-out?

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Common Questions

• Make sure he or she is in a safe place to have
  the tantrum and not get hurt
• The tantrum is a sign that the child has some
  understanding of the situation
• Do not end time-out until the tantrum comes to an
  end

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Common Questions

• My child caused a scene while shopping. Do I
  bring her home and give her a time-out?

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Common Questions

• Remember that time-out is a portable technique
  and can be used anywhere.
• The most effective time-outs are immediate so
  that the child associates them with the behavior.

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Common Questions

• How do you discipline when I child hits a parents
  or another child?

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Common Questions

• First, stay calm. Try to avoid meeting this with
  an equal level of emotion.
• Time-out should be away from any possible
  attention, secondary gain
• Discuss managing frustration at calmer times
• Consider using incentive system for dealing with
  frustration in a more constructive way

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Managing Your Childs Sleep
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How much?

• No magical number of hours
• Average for a school-age is 9-11 hours per day,
  preschool 10-12
• Use your childs energy level and sense of
  well-restedness as a guide

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Bedtime

• Establish a routine

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Bedtime

• Establish a routine
• Start early in winding down

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Bedtime

• Establish a routine
• Start early in winding down
• Brush, toilet, etc

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Bedtime

• Establish a routine
• Start early in winding down
• Brush, toilet, etc
• Read

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Bedtime

• Establish a routine
• Start early in winding down
• Brush, toilet, etc
• Read
• Sing

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Bedtime

• Establish a routine
• Start early in winding down
• Brush, toilet, etc
• Read
• Sing
• Say goodnight

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Sleep Aids

• Security device
• Night light
• Music
• A promise to check on him or her

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Problem Spots

• Child refusal build in choices where able if
  you need to make concessions, gradually rescind
  them
• Night terrors frightening, but child will have
  no memory of them
• Nightmares reassurance
• Sleep apnea watch for pauses in breathing

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Problem Spots (cont)

• Frequent wakenings, calls back to his or her
  room consider using a token system to limit
  call-backs

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Token system

• Use to create a limited number of calls back to
  room
• Provides security because tokens can be used
• Number of tokens is limiting in childs mind

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Token system (cont)

• Tokens not used can be banked for future reward
• Dont save tokens for use on a later night!

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Summary

• Be consistent, calm, and firm
• Show your love and affection every day
• Different caregivers, same expectations
• Be positive when you can. Self-esteem is
  important.
• If you are saying no and setting limits, youre
  probably doing things right.

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Resources

• Pediatrician bring your list of questions and
  make the most of your visits
• Family members ask for advice, not criticism
• Books libraries, bookstores
• Solve Your Childs Sleep Problems, by Richard
  Ferber, MD.
• Kidshealth.org/parent/general/sleep
• The Childrens Hospital Guide to Your Childs
  Health and Development
• The Everything Parents Guide to Tantrums, by
  Joni Levine, M. Ed.
• Raising Your Spirited Child, by Mary Sheedy
  Kurcinka

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