Children with sensory integrative dysfunction related to hypersensitivities to touch and sound might experience sleep problems because they are easily hyperaroused and find it difficult to get comfortable and settle for sleep. A child with this problem may become agitated with the bed sheets laying on their body or fuss with the way their pajamas feel. Sometimes the tactually defensive child falls asleep more easily if they have the body contact of a parent lying next to them, which in turn reinforces the child needing a parent to lie next to them to fall asleep. A 4-year-old boy named Sam had this problem. Ever since he was an infant, he insisted that his parents go through a series of bedtime rituals. First, his mother would give him a 15-minute massage and get him dressed, but only after Sam changed his night clothes several times before finding just the right one. This was followed by three bedtime stories with Dad. Mr. N. would then lay down next to Sam and sing several songs while Sam would shine his flashlight at the glow-in-the-dark stars on his ceiling. Mrs. N. would return to the bedroom and lay down next to Sam. He would fall asleep while twirling his mother’s hair in tight knots for almost 30 minutes. This routine took about 2 hours each night. Sam often reawakened in the night and wanted parts of the routine to settle him back to sleep. His parents eventually gave up and began taking turns sleeping in Sam’s room, but they remained exhausted by their child’s obsessive needs for settling that centered around his sensory and emotional needs.

Another type of sensory integration problem that may affect sleep is the child who craves vestibular stimulation, but becomes hyperaroused by the movement. Young infants with this problem love to be bounced vigorously, wish to be held and carried constantly, like to ride in the infant swing, and may fall asleep only if they ride in the car for long periods of time. Some young babies with this need for movement also like vibration. For example, one 9-month old would only fall asleep if he was placed in a laundry basket on the clothes dryer (with the heat turned off, of course). Many parents report how their child is gleeful when father comes home from work and can rough house or wrestle with them on the floor after dinner. Although the child needs vestibular stimulation, they become overstimulated by the movement and find the task of settling for sleep very difficult. Many times children who crave movement stimulation also like heavy proprioceptive input (e.g., climbing, pushing heavy objects, wrestling with a sibling). At 7 years, Joshua was a hyperactive boy who constantly moved and sought movement activities. If he wasn’t directed to do focused movement activities, such as riding his bicycle to get milk from the grocery store after school or playing soccer with his friends, he would become aimless, running up and down the stairs and whirling around the house, crashing into furniture and people. At nighttime, he was at his worst. After the bedtime routine, his parents would put him into bed, then after a few minutes, he would escape from the bedroom, run up and down the hallway, jump on his parent’s bed, and laugh loudly. Limit setting at bedtime was unsuccessful until it was coupled with a program of helping Joshua to get enough vestibular stimulation in the afternoon with slow movement and deep pressure activities after dinner.

Some children struggle with falling and staying asleep because of problems related to attachment. Problems separating from family members can occur for several reasons. The child with an insecure or disorganized attachment will become anxious whenever they are alone and have to separate from people important to them during the day or night. The origins of the insecure or disorganized attachment need to be explored in order to properly address its impact on sleep. Oftentimes, the parent experiences conflicts around leaving their child, projecting fears related to their past. For example, one couple had tried to use the Ferber method (Ferber, 1985) (e.g., involves putting the child in bed drowsy, going into their bedroom after increments of crying to soothe them, then leaving the bedroom) with their baby but could not stand the crying and felt compelled to rush in immediately to console their baby. They found the crying so intolerable, that soon the child was sleeping in their bed, which lasted for the next 4 years. When I explored this with them, they revealed that each felt that they were abandoning their child, but for different reasons. When the mother was 8 years old, she had a sister who died from leukemia. The ghost of the sister seemed to loom over her parenting, affecting how she parented Danielle and her ability to allow her daughter space to leave her side and explore the world. She constantly hovered over Danielle, creating the feeling that there were constant dangers in the world around her. For example, she would not allow her to play at other children’s houses or go to birthday parties without her being present and within sight. The father was anxious about being left alone and needed to be surrounded by people and activity all day long. He was less open to exploring what it was about being alone that troubled him. By the time Danielle was 4 years old, she appeared to be a highly anxious, hyperactive child who needed to be occupied by her parents all of the time, unable to organize even a single play activity by herself. It wasn’t until Danielle was 5 years old and had been in psychotherapy for about 6 months that her parents were finally able to allow her to sleep in her own bedroom. At first her parents needed to constantly check on her to be sure that, she was safe in her bedroom. Mr. P. took to sleeping in a sleeping bag in the hallway for a while until he felt assured that Danielle was secure. Despite their anxieties about leaving her alone, they did not know how to play with Danielle and needed help in developing a healthy attachment to Danielle. It was difficult for Mr. and Mrs. P. not to constantly teach her or provide structured activities all day long. Emphasis in the treatment was placed on helping Mr. and Mrs. P. to understand the developmental task of feeling secure to sleep alone, the importance of gaining a sense of self and separateness from others for themselves and their child, and in learning how to negotiate normal boundaries of intimacy with each other. Addressing the parents’ difficulties in engaging with Danielle around developmentally appropriate and pleasurable interactive activities while helping Mr. and Mrs. P. develop their own security and separateness remained a major focus of treatment.

As sleep is a separation issue, playing separation games during the daytime help both parents and child to become comfortable with the process. Later are listed some activities which can be modified depending upon the age of the child.

In this next section, three cases are presented that demonstrate different types of sleep problems and how they were treated using different approaches.

Ms. T. was a 36 year old single woman who had wanted a child desperately and chose to become pregnant through artificial insemination. She first came to see me when her baby was 18 months old. Madison was a very competent toddler who experienced difficulties in self-soothing and separating from her mother. Although Madison improved temporarily in her sleep problems using approaches described in this chapter, it seemed that Ms. T. had difficulty following through on the treatment program. The Ferber method was one of the things that had been recommended, but Ms. T. found Madison’s screaming intolerable. According to Ms. T., nothing seemed to work but when I asked how long she tried any one technique, it seemed that consistency was a problem. Over the intervening 3 years, Ms. T. tried numerous different approaches to address Madison’s sleep problems. Ms. T. called me when Madison was 4 years old. She was desperate, feeling that she needed to solve Madison’s sleep problems because she was exhausted and unable to function in her job as a school teacher.

When I met Madison, I was struck by her waif like appearance. She appeared anxious about seeing me, but with urging, she was able to pick something that she liked to play with. She began playing in the doll-house, remaining silent except for occasional whispers in her mother’s ear. She wanted her mother to watch her solitary play. A scene was set up as if in slow motion. The dolls were eating at the table, but the same scene kept repeating itself. The table was set over and over again with cups and utensils, but food was never served to the doll family. The play was silent. Madison did not talk nor did her mother talk. After the foodless meal, she put the dolls to sleep. Soon every room in the house was filled with dolls piled high, one sleeping on top of another.

In our first parent guidance session, Ms. T. and I talked about how Madison’s sleep and bottle drinking problems were linked and how Madison was controlling her mother with her oral dependency and separation needs. Ms. T. appeared eager to embark on a therapy plan. I prepared her for the treatment by suggesting that Madison needed to develop other ways to self-soothe than to rely on oral gratification. She also needed appropriate ways to express control, emphasizing mastery of things that she could learn and do.

Rachel was referred at 26 months because of difficulties that she was having with sleep, social difficulties, and tactile hypersensitivities. Rachel was very creative and imaginative, but extremely challenging to parent, seeming to demand constant attention. When Rachel was born, she was wide-eyed and very alert. Due to her intensity, her parents felt that they were suffering from “parent burn-out” and had a hard time getting through the day. Rachel seemed to have a great need to control her mother, wanting her attention constantly. As a result, mother was finding that she had no free time and ended up devoting every minute to caring for Rachel. She also had a difficult time making transitions from one activity to the next and needed preliminary warning before an activity was going to change or if something new would happen in their routine. For example, they had to give Rachel 2 weeks’ notice before taking her to a birthday party at someone’s house. When the day arrived, Rachel did well until a clown appeared at the party, then she screamed so long and hard that they had to leave.

When I tested Rachel, I found her to be a very competent little girl. She could put together long sentences with as many as 17 words. She could memorize stories, count to 20, and had a remarkable memory. She loved fantasy play, liked friendly people, and was very definite about her likes and dislikes. All of her developmental milestones were progressing normally. She had an excellent attention span and her cognitive and language skills were at least at the 30-month level. By observing her play and taking a thorough history, I found that Rachel had a number of sensory hypersensitivities. Tactile problems were shown by the distance she kept from other people, including her mother. She was never cuddly and disliked having her hair brushed. She would become very upset if her hands became the least bit dirty. Although she avoided close contact with persons in everyday activities and play, she seemed to need physical contact from her parents to help her sleep. Her aversion to being touched or fear of being touched when approached by others affected her ability to play with other children. Rachel often became hyperexcited if she went to noisy or busy settings, such as a shopping mall. After being in a stimulating environment, Rachel would often come home and retreat, going behind the sofa or crawling under a table. She was hypersensitive to sounds, noticing the slightest sound, particularly when she was trying to fall asleep. Rachel was also hypersensitive to movement, hating to ride on swings.

The treatment focused on Rachel’s sleep problems, her tactile and auditory hypersensitivities, and how to tolerate transitions in activities. To help her sleep problem, we focused on helping Rachel to find ways to self-soothe, to reduce her high state of arousal at night, to separate from her parents especially her mother during the day time, and to help her make transitions from one activity to another without falling apart or needing extensive help from her parents. The treatment also focused on diminishing Rachel’s tactile and auditory hypersensitivities through play and everyday activities.

Although our sessions together ended, Mr. and Mrs. D. continued to come in periodically to discuss Rachel’s progress and their concerns, as she grew older. Her sensory hypersensitivities remained a problem over the next few years to the point that it interfered with her ability to cope with school. She would often come home from school and wish to retreat to a corner by herself. Mrs. D. was very creative and suggested that they spend quiet time together doing craft projects which seemed to help settle Rachel. At 4 years of age, Rachel received occupational therapy using a sensory integration approach to help her with these needs.

When Rachel reached 13 years of age, she returned to individual therapy with me because of anxiety, social difficulties, and sleep problems. She was a very talented young lady, gifted in acting and violin. She reported that anytime she participated in a group experience, she felt totally overwhelmed and then needed to isolate herself in her bedroom, reading or playing the violin. Taking hot baths with scented lit candles also helped to relax her. Rachel often felt easily irritated when people got near her, very similar to her need for space as a young child. She was easily bothered by noises, such as her younger brother burping, her dad clearing his throat, or people talking or eating. If she was on a family outing, she always walked behind them. Rachel felt that she was often in a steady state of quiet anger and overwhelm.

Emma was a 16-year old teenager who had a long-standing sleep disorder since she was a young child. She was living at home with her parents and her mother was her alarm clock in the morning. Emma had been to six different therapists, all for three sessions apiece. I was Therapist Number Seven. When I asked Emma to describe her problem, she launched into what felt like a recorded announcement. “My mind races constantly. I am anxious all the time. I have panic attacks, but it’s no big deal. I manage them with medication. The problem is that I can’t fall asleep. Nothing works. The other six therapists said to have a routine and to notch back my bedtime. I lay down at 10:00 and don’t fall asleep until midnight. Then I wake up and can’t fall asleep until 5 or 6 in the morning. I hear everything in the house—the floor creaking, the wind outside, the tree branches rubbing on the windowpane, my dad’s snoring. When I fall asleep, I sleep until 2 or 3 in the afternoon. That’s on sleep medications. The reason that I’m here is that I’ve missed so many classes at school that I’m going to fail a few courses. That’s never happened to me before. Besides that, I’m worried that I’m not doing well on tests.”