Case Study: Supporting Regulation and Sleep in a 3-Year-Old

Presenting Concerns: Bedtime Struggles, Meltdowns, and Low Distress Tolerance

L. had just turned 3 and the family was struggling with controlling bedtime behaviors and large 45–60 minute meltdowns. She had significant controlling issue around bed time routines and sleeping, not getting to sleep until 9:30–10:00 at night, waking during the night several times and ending up in the parents bed. She had very little distress tolerance and would cling to parents when she became upset, and then begin hitting and kicking when her distress was not immediately resolved. Mother described her as always on the go. All of these issues were impacting her relationships with her older siblings as they resented all the time parents were spending attending to L.’s needs.

Evaluation Findings: Reflex Integration and Sensory Seeking

Evaluation showed that many of her reflexes weren’t integrated, some having motor responses that were expected from other reflex patterns, and she was vestibular and proprioceptive seeking. Additionally, she was having difficulty with bilateral activities such as running with control, going up and down stairs with alternating feet, and riding a bike.

Treatment Focus: Regulation Through Sensory Input and Parent Coaching

Treatment began with helping her parents provide more vestibular and proprioceptive input in appropriate ways as well as providing deep tactile input through bonding activities. She did not tolerate being still for Masgutova Reflex Integration activities very well, or more in-depth tactile work. Archetype movement activities were presented in playful ways, along with attempts to engage in less controlled, more generalized reflex activities.

Listening Programs and Bedtime Routine Support

She began and finished both the Rest and Restore as well as the Safe and Sound Listening Protocols. Parents were coached in how to slowly swap out with each other during the night time routine, how to form more structure and boundaries, and eventually how to leave her by herself for short periods as she went to sleep listening either to music or a sleep story on the Calm App. They also were coached on how to allow her to sleep in their room on a chair or a sleeping bag on the floor instead of their bed after first attempting to have her return to her room.

Progress Over Time: Improved Sleep and Communication During Meltdowns

Over the course of 3 ½ months L. began sleeping in her own bed all night, allowed either parent to put her to bed, and was falling asleep by herself without a parent in the room. Her meltdowns had greatly decreased in quantity as well as how long they lasted. When she did meltdown she was now verbalizing during them what she wanted/needed instead of just crying.

New Challenges During Seasonal Transition

Not all success stories are perfect however, and as the family transitioned into summer with different schedules and evenings that were much busier with activities for the older siblings, she began to have more meltdowns and the intensity of them returned with new behaviors such as biting and pulling hair.

Adjusting Support and Expanding the Care Team

At this point Misti taught the parents what to do when she bites and pulls hair so she will release her mouth or hand with minimal damage. It was also becoming apparent that these behaviors only happened when she was in activities with her immediate family, never at school or in larger family/group activities. Although she was making really nice progress with her bilateral skills and was allowing more in-depth work on reflexes for her feet and whole body, the family really needed more support in dealing with the behaviors.

Collaborative Care for Ongoing Family Support

Misti helped them find a child psychologist that used the Parent Child Interaction Therapy modality and the family shifted to put their energy and resources into this modality with Misti consulting on sensory needs in the home so Lilly could be more regulated in the home.