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.