Ask the Doctor - Answers to your Parenting Questions

I can see why you're concerned.  Your wonderful son (and he does sound wonderful to  me) has been such an easy sleeper, and now has developed some anxiety that is keeping him from settling without your presence, both as he first falls asleep and then when he awakens during the normal sleep cycles during the night.  You want to support him, but don't want him to develop habits that will then prove hard to break. 

Of course, the reasons for his anxiety are numerous.  Most importantly, your being away at hospital for a week would naturally suggest to him the terrible possibility that your presence could, at some point, end. Even toddlers understand this, because it is a life or death matter to them.  So your absence for a week would be expected to trigger some deep fear, even if his father and grandparents were with him. This would be worsened by the fact that your surgery was unplanned, so naturally you and his father had some feelings that the whole thing was "an emergency" which your little one certainly would have picked up on.

And this is not a one-time event, the ongoing reminder is that you are not able to interact with him the way you previously did and his father has taken over as his primary caregiver.  This is a huge adjustment for a toddler.  Then there is the lead-up to Christmas, the scare of Santa, the vacation from creche, and the presence of the grandparents, which is a change, even if overall a positive one.

And then he has been sick. It is possible that his chest infection is related to his emotions, since children, especially, feel everything in their bodies, and he has had such a lot to cope with. 

What happens to children when they have a major separation from the primary caretaker is that they have big feelings of panic they can't handle because their primary caretaker is gone.  So they push those feelings away. 

As you probably know, when humans are willing to let their feelings sweep through them, those feelings then evaporate.  But when we push them away, they are stored in the body, making us tense and tightly wound.  These "repressed" feelings press to come out and up, and can cause behavior problems, clinginess and sleep issues.

This would be likely for a child who has felt the terror of his beloved mother vanishing for a week.  Once the parent returns, hopefully the child will feel safe enough to let those feelings surface, which means to feel and express them.  I think that is why even though your hospitalization was seven weeks ago, your son has only begun this new bedtime anxiety in the past two weeks.  It has taken him this long to be reassured that you are really home to stay, so that he feels safe letting his fear come up.

So we can assume that your son is feeling some big feelings, especially fear.  He has told you this, although he was focusing this fear on Santa.  How could he tell you that he is worried you will vanish and never return?  He probably cannot even admit this to himself, but any child his age who has endured a week's separation would be feeling this.

His reaction to this fear is that he is no longer comfortable snuggling down into his cot to fall asleep.  Instead, he wants you in the room with him. Then, when he awakens slightly during the normal light phases of the sleep cycle, he checks to be sure you are there and when you aren't, he calls for you.  This is completely normal, of course -- since he is worried that you will again disappear for a week, or forever.  But because he is not so exhausted, since he has just slept for a number of hours, he does not fall back to sleep so easily.  It is wearing for you, of course, to have to sit up with him in the wee hours until he falls back to sleep.

So what can you do?

First, I would strongly advise you NOT to leave him to cry, because it will make his fear worse.  Even if he "learns" to sleep he will actually be learning that you do not come when he calls, and his fear will get bigger and come out in other ways, during the day, in difficult behavior. 

I would also advise you to wait to transition him to the toddler bed.  It is a big change for children, and tends to make them insecure and nervous. Many children begin getting out of bed in the night once they are in the toddler bed, and you can be sure he would be one of them.  I think this would be a fairly certain path to him ending up in your bed or your needing to lie with him all night to keep him asleep--exactly the "habits" you don't want to create.

I think you have two choices.  You can continue what you are doing now, and hope that as your health improves, and the hospital separation recedes into the past, and your little guy gains maturity, he will begin soothing himself back to sleep.  I am positive this will happen.  However, it could take a long time, I would bet a year.  That's because the habit of needing you to fall asleep will get more firmly established the longer it goes on.  His increased maturity and re-solidified sense of safety will eventually outweigh that habit, but will take some time to do so.

Your other choice is to help your son to feel and express to you all those fears that are keeping him from relaxing into sleep without your presence. I advise this course, because I think it is what your son really needs.  How can you do this? 

1. Play.  Surprisingly, this can help your son begin to access the upsetting fear and express it.  Since giggling releases the same anxieties that crying does, play games with him that get him giggling.  NOT tickling, since that actually seems to increase fear and build up stress hormones.  Go for any kind of play other than tickling that gets him giggling, with as much eye contact and warmth as possible.

Have his dad play bucking bronco with him on his back, giggling as Dad scrabbles around the room on all fours, trying to toss him off.  Have his dad toss him in the air, or play airplane and zoom him wildly around the house.

Separation games are also important, especially for you to play with him.  One game is "Please Don't Leave Me."  When you have been reading to him and he starts to get off your lap, pull him back to you and tell him how much you love holding him, and please don't go away from you ever and you want to hold him always. Keep your voice light and playful rather than needy so he feels free to pull away, and keep scooping him back to you and begging him to stay.  The point of this is to heal those feelings inside him of how much he needed and wanted you when you left him, so he now gets to play the "leaver."  Again, go for giggles.

Another game is a simple version of Hide and Seek that triggers just a little separation anxiety, just enough to get him giggling.  Say "I'm going to play bye-bye.  If you want me, yell Peanut Butter" (or whatever he would think is funny.)  Then hide behind the couch, or the door, for just a moment before YOU yell "Peanut Butter" and run out, and hug him.  Say "I missed you!  Ok, let me try that again."  and go hide again.  Again, come back out before he yells for you, which should get him giggling, especially if you play act being silly and excessively worried.  Keep playing this, letting him yell or you yell, as long as he is giggling, to surface his anxieties about being separated from you.

I am sure you and your son's dad can come up with more rough-housing games that get your son giggling.  Sometimes when children have a knot of fear, they can get very serious and find it harder to giggle, so don't give up.  Notice what makes him laugh and do more of it, no matter how silly it is. The more giggling the better to help him let up all that fear. This strategy alone (play) will almost certainly help him sleep better.  It is also essential to begin with play, because even if he still needs to cry to express his fear (which is likely), the play will bring the fear closer to the surface so it can easily come up and out.


2. Connect.  I am sure from your description that your son feels very connected to you. However, when kids close off their feelings, they lose some connection to themselves, and therefore to us.  So even though you have a strong bond, your son needs some strengthening of your connection.  That will help him feel safe enough to let that terror inside him out.  Make sure you have half an hour every day to simply focus completely on your son and pour your love into him.  Do whatever he wants during that time, to build connection and trust.  If he is playing, just sit with him and watch him play.  You can make comments occasionally "Now the red truck is racing the blue truck" or whatever.  Mostly just adore him.


3. Help him cry.

After a week of strong connecting and lots of giggling play, your son may be able to settle without you in the room.  However, if that is not the case, it means he has more panic inside him that needs to come out, and he needs your help to surface it.

To do this, he will need to cry in your arms, or his father's arms, or if not in arms, then at least with one or both of you in close proximity.  It is essential that one of you (and ideally you, since you seem to be at the core of this anxiety) is present with him, helping him to feel safe enough to feel those upsetting fears.  I want to be sure I am being clear that I am not suggesting leaving him alone to cry, but giving him the safety of your presence so he can finally "show" you the terror locked inside him, and let it go.

We know your son will cry if you leave the room, but that doesn't help him here, because he will not feel safe in your absence.  Instead, we need to help him cry in your presence.  Children have an instinct for healing themselves, and it may be that your son will create an opportunity to cry.  Little ones do this by having a meltdown about something that seems inconsequential to us.  So if at some point your son begins to sob or reacts angrily to something that disappoints him, remind yourself that he is seizing this opportunity to "vent" some big feelings.  Welcome those emotions. 

He might simply cry.  But often when children express fear that has been locked up inside them, it looks like they are fighting for their lives.  He might struggle against you, sweat, get red-faced, yell.  Of course, protect yourself, but stay as close to him as possible.  If he tries to hit you, hold him as gently as possible so that he can't hurt you.  Breathe deeply, remind yourself that he is doing exactly what he needs to do, and stay calm (which I know takes a lot of deep breathing and talking yourself through it).  Tell your son "You are safe...I am right here...I am not going anywhere...I am so sorry I was gone in the hospital, Sweetie....I know you were scared...but you are safe...I am here, and your dad is here."

Because you have back issues, your son's dad will probably have to be very involved in this process, so he will need to understand what you are trying to do together.  But because the necessary healing revolves around your previous absence (and to some degree, your current removal from his care), it seems essential to to me that you be present as well and as involved as possible.   

What if your son does not find a way to get upset about something during daily life? Well, we know that his fears surface at bedtime, so that is when you will have to help him cry.  (In other words, this crying doesn't have to take place at bedtime, but it can.)  Don't do this until you have at least a week of daily connection time and concentrated play with him, so that you build up a strong bond of trust and loosen up his fear so it can pour out. 

Then, before bedtime, take his stuffed animals and have a mom and dad stuffed animal tuck the baby into bed and kiss him goodnight and leave the room.  Have the baby protest and the parents reassure him.  Act out the whole bedtime routine as you used to successfully do it, and have the baby snuggle down and go to sleep easily when the parents leave.  THis shows your son what will happen and helps him see how positively things can go.

Then tell him that tonight you will be doing what the animal family did, and what you used to do.  Here's the thing to remember:  You aren't actually going to do this.  You are helping your son face his fear by having him imagine the thing he is so frightened of -- being left alone.  You won't actually leave him alone because that would reawaken the trauma without your being there to help him heal it.  But you do need to reawaken the trauma in order to help him, by staying with him so he can cry.  Think of this as cleaning a wound that has been festering.  It will help, but it will then allow him to heal.   And you will be with him the whole time.

When you explain what is going to happen, your son may begin to cry and protest.  That's a good thing.  Welcome those emotions, just as described above.  If he doesn't, then he is either not understanding or hoping that you won't follow through.  Just keep gently reminding him throughout the bedtime routine that tonight you and his dad will leave the room and he will sleep by himself.  Tell him that he is completely safe, and you are right there in your own room near him.  Sooner or later his upset will surface.

IF it doesn't, and he remains calm, then continue with the bedtime routine as you used to, and head for the door.  Presumably, he will cry then.  Stop right where you are, and reassure him that he is safe.  If you can, go back to him and touch and hold him, but if that stops him from crying, then you will need to stay by the door.  In other words, your goal is to help him cry in your presence.  Think of yourself as the witness to his traumatic experience, which he is now telling you about.  Stay 100% focused on him and pour your love out to him even if you can't touch him.  He will sense it.  Stay as close as you can to reassure him, but not so close that his upset vanishes.  Again, welcome his upset, keep reassuring him that he is safe and you are there and will always be there for him.  If he stops crying, remind him that you will be leaving, and presumably he will begin crying again.

If at any point you are uncomfortable with how upset he is, move closer so he calms a bit.  If he will cry with you holding him, that's terrific.  If he wants you to pick him up, that's fine, but if he stops crying, you will need to tell him that you will be putting him down again, so that he can continue crying.  If when you pick him up, he struggles against you, that is his fear being released, so that is great.  Just keep breathing and reminding yourself that he is letting up old fear created by your hospitalization.

Once he finishes crying, he will probably simply fall asleep.  If not, he will simply be peaceful and yawning.  At that point, hold him and tell him how much you love him and that he did good, hard work.  When he's ready, put him in bed.  He will almost certainly snuggle down and sleep. 

If he doesn't, and you are up for more hard work, you can repeat the whole process.  If you don't have the internal resources left inside you to stay calm--at any point--you can simply sit in his room while he falls asleep.  Just tell him that you will stay tonight but tomorrow you will leave the room. Then repeat the entire thing the next night.

During the night, if he wakes up, you will probably be too tired to be fully present with his crying.  That full presence matters because it is what helps him feel safe.  He will sense your love pouring into him, even from across the room.  So given that, I don't really recommend doing this in the middle of the night unless you think you can really stay present.  Just do what you have been doing, where you stay in his room.  He will probably fall asleep fairly easily given that he has already released a lot of fear.

It may take only one session of crying.  In fact, you may not even need the bedtime session I've described here, if the play and connection alone help him settle, or if he cries about some pretext during the day.  Or, you may need to do a bedtime session every day for a week to help him dissolve and release his panic.  But over the course of a week or so, you will see him become much more relaxed (at all times) and able, finally, to return to his previous relaxed trust in his cot.

What I am describing is very hard work because it requires you to stay calm, but to really see your son's terror.  You can't just leave the room and leave him to cry, or he won't actually process the emotions and they will come out in some other way.  That's why this is so different from sleep training approaches.  But you ARE helping him to cry so that he can release  the emotions that are getting in his way.

If this seems like too much to you, there is no harm in waiting and continuing what you are doing, for as long as you want to.  It may be that you want to wait to get stronger physically before you do this hard work.  But it is my opinion that your son does need a chance at some point to surface these fears and release them, or they will continue to try to find their way out.

I hope this is helpful.  I wish you healing, both physical and emotional.  I hear your love for your son and your commitment to give him what he needs.  He's a lucky boy.  Good luck and please let me know what happens!

warmly,
Dr. Laura