Clinical Management of Behavioral Insomnia of Childhood: Treatment of Bedtime Problems and Night Wakings in Young Children

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1 Behavioral Sleep Medicine ISSN: (Print) (Online) Journal homepage: Clinical Management of Behavioral Insomnia of Childhood: Treatment of Bedtime Problems and Night Wakings in Young Children Lisa J. Meltzer To cite this article: Lisa J. Meltzer (2010) Clinical Management of Behavioral Insomnia of Childhood: Treatment of Bedtime Problems and Night Wakings in Young Children, Behavioral Sleep Medicine, 8:3, , DOI: / To link to this article: Published online: 24 Jun Submit your article to this journal Article views: 3434 View related articles Citing articles: 27 View citing articles Full Terms & Conditions of access and use can be found at Download by: [ ] Date: 11 January 2018, At: 10:52

2 Behavioral Sleep Medicine, 8: , 2010 Copyright Taylor & Francis Group, LLC ISSN: print/ online DOI: / Clinical Management of Behavioral Insomnia of Childhood: Treatment of Bedtime Problems and Night Wakings in Young Children Lisa J. Meltzer Department of Pediatrics and Division of Pulmonary Medicine The Children s Hospital of Philadelphia and University of Pennsylvania Behavioral insomnia of childhood (BIC; more commonly known as bedtime problems and night wakings) commonly occurs in young children (5 years). If left untreated, bedtime problems and night wakings can result in impairments in behavior, emotion regulation, and academic performance. Yet, treatments for bedtime problems and night wakings have been found to be efficacious and durable. This article begins with a review of the diagnostic criteria and clinical presentation of BIC. This is followed by a brief review of how operant theory is applied to behavioral interventions for BIC and a detailed discussion of how to apply these treatments for bedtime problems and night wakings in young children. Bedtime problems and night wakings are common in young children, affecting up to 30% of infants, toddlers, and preschoolers (Goodlin-Jones, Burnham, Gaylor, & Anders, 2001; Lozoff, Wolf, & Davis, 1985; Mindell, Kuhn, Lewin, Meltzer, Sadeh, & Owens, 2006), as well as 15% to 27% of school-aged children (Archbold, Pituch, Panahi, & Chervin, 2002; Blader, Koplewicz, Abikoff, & Foley, 1997; Owens, Spirito, McGuinn, & Nobile, 2000). Further, studies have suggested that when left untreated, bedtime problems and night wakings in young children do not spontaneously resolve (Jenni, Fuhrer, Iglowstein, Molinari, & Largo, 2005; Kataria, Swanson, & Trevathan, 1987; Lam, Hiscock, & Wake, 2003; Zuckerman, Stevenson, & Bailey, 1987). The diagnosis of behavioral insomnia of childhood (BIC) was introduced in 2005 in the International Classification of Sleep Disorders Second Edition (ICSD 2; American Academy of Sleep Medicine, 2005; see Table 1). The hallmark feature of BIC is difficulty falling asleep or staying asleep, similar to adult insomnia. However, the etiology and treatment of BIC differs from adult insomnia in several ways. For young children (5 years), difficulty falling Correspondence should be addressed to Lisa J. Meltzer, Department of Pediatrics, National Jewish Health, 1400 Jackson Street, Denver, CO meltzerl@njhealth.org 172

3 BEHAVIORAL INSOMNIA OF CHILDHOOD 173 TABLE 1 Diagnostic Criteria of Behavioral Insomnia of Childhood A. A child s symptoms meet the criteria for insomnia based upon reports of parents or other adult caregivers. B. The child shows a pattern consistent with either the sleep onset association type or limit-setting type of insomnia described below: i. Sleep onset association type includes each of the following: 1. Falling asleep is an extended process that requires special conditions. 2. Sleep onset associations are highly problematic or demanding. 3. In the absence of the associated conditions, sleep onset is significantly delayed or sleep is otherwise disrupted. 4. Nighttime awakenings require caregiver intervention for the child to return to sleep. ii. Limit-setting type includes each of the following: 1. The individual has difficulty initiating or maintaining sleep. 2. The individual stalls or refuses to go to bed at an appropriate time or refuses to return to bed following a nighttime awakening. 3. The caregiver demonstrates insufficient or inappropriate limit-setting to establish appropriate sleeping behavior in the child. C. The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, or medication use. Note. Source: American Academy of Sleep Medicine (2005). asleep ( bedtime problems ) is generally associated with either a parent who provides poor or inconsistent limits at bedtime, or a child who requires a parent to help him or her fall asleep. Difficulties maintaining sleep ( night wakings ) is most often a result of a negative sleep onset association (SOA) that is required to help a child return to sleep following normal nighttime arousals. The diagnosis of BIC relies on the report of parents or caregivers (referred to as parents for simplicity) as opposed to the self-reported complaint in adult insomnia. Finally, rather than standard sleep restriction and stimulus control utilized with adults (for a review, see Morin et al., 2006), treatment for BIC involves teaching parents about behavior management (e.g., limit-setting and extinction). This article reviews the typical clinical presentation of BIC, the application of behavior theory to treatment for BIC, and practical clinical procedures for the treatment of BIC. SOA Type CLINICAL PRESENTATION OF BEHAVIORAL BIC Frequent or prolonged night wakings are the typical presentation for the BIC SOA type. An SOA is a condition required for children to fall asleep at bedtime and return to sleep during the night following normal arousals. Positive SOAs occur when children are able to provide the required condition to fall asleep (e.g., thumb-sucking or stuffed animal). Negative SOAs, on the other hand, require parental assistance (e.g., nursing), an external source of stimulation (e.g., vacuum cleaner), or a setting other than the child s crib or bed (e.g., being driven in the car). Because arousals are developmentally normal, occurring two to six times per night (Goodlin-Jones et al., 2001), negative SOAs that are present at bedtime will also likely be

4 174 MELTZER required during the night. In other words, whatever children need to fall asleep at bedtime, they will also likely need during the night to return to sleep. The ability to self-soothe helps a child learn to fall asleep and remain asleep through the night. Although this is a developmental skill that occurs between 3 and 6 months in typically developing, healthy infants (Goodlin-Jones et al., 2001; Sadeh, Mindell, Luedtke, & Wiegand, 2009), children who do not acquire the ability to self-soothe will likely have more difficulties with sleep. In addition, because the ability to sleep through the night develops between 3 and 6 months, a diagnosis of BIC SOA is not appropriate before 6 months of age. It is important to note that some negative SOAs begin through developmental need (e.g., nursing during the night) or necessity (e.g., lying with the child to facilitate sleep because a parent has to wake early for work). Although some negative SOAs will decrease naturally with development (e.g., discontinuation of nursing; Mindell & Owens, 2009), others will become problematic when the parent no longer wants or needs to provide assistance (Lam et al., 2003). Limit-Setting Type When parents complain of bedtime problems, they are most often referring to either bedtime refusal or bedtime stalling (Moore, Meltzer, & Mindell, 2007). Bedtime refusal is when a child refuses to get ready for bed, go to bed, or stay in bed. Bedtime stalling is an attempt to delay bedtime, most often with multiple requests for attention (e.g., drink of water or an extra kiss) or additional activities at bedtime (e.g., one more story). Although sleep onset may be delayed, resulting in shorter total sleep time, once children with a BIC limit-setting type fall asleep, they generally have normal sleep quality with few arousals (American Academy of Sleep Medicine, 2005). Although more common in younger children, bedtime problems are also seen in school-aged children (Liu, Liu, Owens, & Kaplan, 2005; Mindell & Owens, 2009; Owens et al., 2000). The American Academy of Pediatrics suggests that consistency is important both in providing a daily routine, as well as when responding to children s behavior (Committee on Psychosocial Aspects, 1998). Consistent parenting includes providing stable, reliable, and dependable responses to children s behavior, as well as providing a relatively stable and predictable daily routine that enables a child to successfully navigate through their day. Yet, providing limits and being consistent are skills many parents struggle with, particularly at bedtime. Some parents may set few, if any, limits at bedtime (e.g., allowing children to set their own bedtime or fall asleep in front of the television). Other parents may set unpredictable or inconsistent limits, which can be confusing to children. For example, one night a parent may refuse to lie with a child until she is asleep, but the next night the parent gives in when the child throws a tantrum. A parent s failure to provide both clear and consistent limits can result in prolonged sleep onset for children, and a parental complaint of bedtime problems (Owens-Stively et al., 1997). Combined Type Because children may experience both an SOA type and limit-setting type together, the ICSD 2 includes a third diagnostic category of BIC: combined type (American Academy of Sleep

5 BEHAVIORAL INSOMNIA OF CHILDHOOD 175 Medicine, 2005). An example of combined type would be a child who delays sleep onset by stalling and refusing to go to bed (limit-setting type); but, after a prolonged tantrum, a parent will lie with the child until he is asleep (SOA type). When the child then wakes during the night, he will require parental presence to return to sleep. Combined type often presents clinically as a child with bedtime refusal, who then migrates to the parents bed during the night. CONSEQUENCES OF UNTREATED BIC If left untreated, BIC can negatively impact the daytime functioning and behavior of the child, as well as the functioning of the entire family (Fallone, Owens, & Deane, 2002). Bedtime problems or night wakings can shorten total sleep time, resulting in increased irritability, temper tantrums, and behavior problems in young children (Bates, Viken, Alexander, Beyers, & Stockton, 2002; Lam et al., 2003). Unlike adults who become lethargic when sleepy, young children are more likely to become hyperactive when sleepy (Mindell & Owens, 2009). At night, parents may misinterpret this energy as a sign that their child is not ready to sleep, further prolonging bedtime. In school-aged children, shortened sleep has been associated not only with behavior problems, but also with impairments in academic, neurobehavioral, and emotional functioning (Fallone et al., 2002; Johnson, Chilcoat, & Breslau, 2000; Sadeh, Gruber, & Raviv, 2002). Early sleep problems are associated with later daytime behavior problems (Kataria et al., 1987; Lam et al., 2003; Thunstrom, 2002), suggesting the importance of treating BIC in young children. The sleep and daytime functioning of parents is also disturbed when a child has BIC. Most children who wake during the night will then wake their parents. This can decrease parent total sleep time by almost 1 hr and contribute to increased daytime sleepiness, decreased concentration at work, drowsy driving, and negative mood in parents (Boergers, Hart, Owens, Streisand, & Spirito, 2007; Meltzer & Mindell, 2007; National Sleep Foundation, 2004). Further, when parents do not agree on how to manage a child s sleep problems, this can result in further inconsistencies in terms of parental responses to a child s behavior (Lam et al., 2003). Finally, because bedtime is so stressful for some families, many parents will delay bedtime or prolong the bedtime routine in order to avoid the negative behaviors that arise at bedtime. However, this often results in delaying the child s sleep onset time, shortening the total sleep time, and further perpetuating the negative cycle. BEHAVIOR THEORY APPLIED TO PARENT TRAINING The successful treatment of BIC is based on operant conditioning theory, which posits that a behavior that is reinforced will increase in frequency, whereas a behavior that is ignored will decrease in frequency (Ferster & Skinner, 1957). There are two primary types of reinforcement schedules that shape behavior. A continuous reinforcement schedule is one that is consistent and happens in a predictable way. For example, going to work every day (a consistent behavior) results in getting paid (a consistent reinforcement), resulting in regular

6 176 MELTZER attendance. If paychecks stop coming (ignoring the behavior of working), people will stop going to work. With an intermittent reinforcement schedule, behavior is reinforced in an unpredictable way and, thus, is more difficult to extinguish. For example, when playing a slots machine, a person may get rewarded after 4 plays or 25 plays, encouraging the continuation of the behavior (in this case, playing slots) until the desired outcome is reached (winning money). Since a player is unsure if he will be rewarded after the next pull, he will continue playing. Parents who set inconsistent limits are utilizing an intermittent reinforcement schedule. Children will make requests for attention at bedtime if they believe that eventually a parent will give in and respond to the request. If a parent consistently ignores these requests every single time and every single night, eventually the requests will stop. But if after 10 requests the parent decides it is simply easier to respond to a child than continue to ignore her, the child simply learns that attention may come after 10 requests. The next night, if the parent waits longer, responding after 25 requests, the child learns that as long as she continues to make requests, eventually, she will get the desired attention from her parent. This negative attention can be paradoxically rewarding since yelling at a child (although negative) is still attention from the parent. When applying operant conditioning principles to parent training, it is essential to inform parents about how the child will respond. When switching from an intermittent reinforcement schedule to a continuous reinforcement schedule, an unwanted behavior is consistently ignored. This results in a sharp increase in the unwanted behavior prior to a decrease in this behavior (i.e., the behavior gets worse before it gets better). In addition, several days to several weeks after treatment is completed (and the unwanted behavior is no longer reinforced), an extinction burst may occur. This return of the original unwanted behavior, if again consistently ignored, will general cease in only a few days. Parents should expect an increase in protests at bedtime or during the night while treating BIC (e.g., child may cry 30 min the first night of treatment, but 60 min the second night of treatment). Again, the child s goal is parental attention, so a child s negative behaviors will increase in an attempt to gain the attention of a parent. If parents are not prepared for this increase in negative behaviors, they may inappropriately respond to the child after 45 min. This inconsistent response makes the extinguishing of behaviors even more difficult, and can result in treatment failure. The following procedural section provides details about how to apply these behavior concepts to bedtime problems and night wakings. Most of these interventions have been recommended as efficacious in reducing bedtime problems and night wakings by the Standards of Practice Committee of the American Academy of Sleep Medicine (Morgenthaler et al., 2006). The goal of treatment is a shorter sleep onset latency and decreased night wakings. CLINICAL PROCEDURES The treatment for BIC generally includes three primary areas: (a) setting a consistent sleep schedule with an age-appropriate bedtime and napping, (b) implementing a consistent bedtime routine, and (c) teaching the child to fall asleep independently (see Table 2). The following describes each aspect of treatment.

7 BEHAVIORAL INSOMNIA OF CHILDHOOD 177 TABLE 2 Key Procedural Elements for the Treatment of Behavioral Insomnia of Childhood 1. Consistent sleep schedule with age-appropriate bedtime Set consistent bedtime between 7:00 and 8:30 p.m. Maintain bedtime 7 nights per week Use bedtime fading to advance bedtime if needed 2. Consistent bedtime routine Provide verbal cues or warnings prior to transition to bedtime routine Implement standardized routine, min in duration, with 2 3 activities Move routine toward the child s sleeping environment Use bedtime chart used to maintain standardization 3. Teach child to fall asleep independently Select approach based on child s temperament and parent s tolerance (standard extinction, graduated extinction, or fading of parental presence) Consistent Sleep Schedule With Age-Appropriate Bedtime and Napping The first part of any treatment for bedtime problems is an early, consistent, and age-appropriate bedtime. Although commonly part of treatment packages, no studies have independently examined the benefits of a consistent bedtime (Mindell et al., 2006). However, a national survey found that toddlers with a bedtime after 9 p.m. slept 1.3 hr less than toddlers with a bedtime before 9 p.m. Similarly, preschoolers with a late bedtime slept 48 min less than preschoolers with an early bedtime (Mindell, Meltzer, Carskadon, & Chervin, 2009). For most young children, the recommended bedtime is between 7:00 p.m. and 8:30 p.m. (Mindell et al., 2009; Mindell & Owens, 2009). If bedtimes are later, children may become overtired, interfering with their ability to fall asleep and increasing the likelihood for disruptive bedtime behaviors. Bedtime schedules for young children should be consistent every night, with minimal variation between weekdays and weekends. Further, parents should not determine a child s bedtime based on when the child appears sleepy. It is believed that children are often likely to become more energetic as they get tired, so delaying bedtime only serves to increase the likelihood of bedtime behavior problems (Mindell, Meltzer, et al., 2009). Having a consistent naptime every day is also important, as many children who are deprived of their nap may become overtired at bedtime. However, naps should end early (by 3 or 4 p.m.) in order for children to be ready to sleep again at bedtime. Most children are still napping at age 3, with naps decreasing with age (Acebo et al., 2005; Ward, Gay, Anders, Alkon, & Lee, 2008). However, one national survey found that 26% of children continue to nap until the age of 5 years (Mindell, Meltzer, et al., 2009). Although napping may improve sleep in toddlers (Mindell, Meltzer, et al., 2009), naps in preschoolers may result in shorter nocturnal sleep times (Acebo et al., 2005; Mindell, Meltzer, et al., 2009). This highlights the importance of evaluating an individual child s sleep need. Further, racial differences have been reported in terms of napping, with African American children ages 2 to 8 years napping more days per week, as well as giving up their nap at a later age, than other children (Crosby, LeBourgeois, & Harsh, 2005).

8 178 MELTZER Faded Bedtime With Response Cost When a child presents with a late sleep onset time, bedtime fading can be used to change the child s sleep schedule. The first step for this treatment is to set a consistent bedtime that is close to when the child is actually falling asleep, with a consistent wake time in the morning. Once the child is quickly falling asleep at bedtime, this bedtime can be moved earlier by 15 min every 2 to 3 nights. For children who have an early bedtime but a late sleep onset time, this approach can help prevent many of the bedtime problems families experience. Response cost involves removing a child from bed for a prescribed period of time if she does not fall asleep, and setting a scheduled wake time. Naps should only occur if age appropriate. A small number of studies have examined bedtime fading in combination with response cost in children with developmental disorders, with faded bedtime with response cost reported to be more effective than bedtime scheduling alone (consistent bedtime and wake time; Piazza, Fisher, & Moser, 1991; Piazza, Fisher, & Sherer, 1997). More research is needed in populations of typically developing children, but faded bedtime with response cost may also be successful in schoolaged children with anxiety. As with the treatment for insomnia in adults (Morin et al., 2006), this variation of stimulus control and sleep restriction may remove some of the anxiety and stress associated with not being able to fall asleep quickly. Although faded bedtimes may be useful for children with developmental disorders or younger children who appear to have a significant phase delay, response cost may not be a good option for typically developing young children. Removing a typically developing young child from her bed or crib may serve to reinforce the child s desire to escape going to bed. However, more research is needed in this area. Standardized Bedtime Routine A number of studies have included a standardized bedtime routine as part of a treatment package, such that it has become a common sense treatment recommendation (Mindell et al., 2006). Yet, only recently did a study focus solely on a standardized bedtime routine without any other behavioral treatment, demonstrating that a bedtime routine alone is sufficient to improve bedtime problems and night wakings in young children (Mindell, Telofski, Wiegand, & Kurtz, 2009). Routines are an essential part of daily life for young children, who use this structure and predictability to explore their environment (Bornstein & Lamb, 1999; Fiese et al., 2002). When children know what to expect, they are able to transition between activities more easily and successfully. Although no studies have examined the individual components of a bedtime routine, most clinicians recommend that the bedtime routines should be short (approximately 30 min) and consist of 2 to 3 relaxing and enjoyable activities (e.g., bath, 2 stories, and songs or prayers), with the routine always moving toward and ending in the child s bedroom (Mindell & Owens, 2009). To help prepare children for the transition to bedtime, parents should provide verbal cues (e.g., 5 min until bedtime or 1 min until bedtime), giving children the message that the parent is in charge and sets the bedtime rules. The use of a bedtime chart may help parents provide consistency in the bedtime routine. This chart can include pictures of each step of the bedtime routine (e.g., snack, bath, two books, and bed). When each activity is completed, the child or parent puts a check, star, or sticker

9 BEHAVIORAL INSOMNIA OF CHILDHOOD 179 next to the picture. The use of this structure prevents children from making extra requests (e.g., one more book) and prevents parents from giving in to extra requests (which is easy to do when tired). No studies have examined the use of a bedtime chart in the treatment of BIC. Another empirically validated treatment approach for bedtime problems is positive routines (Adams & Rickert, 1989; Galbraith & Hewitt, 1993). The goal of positive routines is to decrease the stress at bedtime by implementing a bedtime routine that is positive and enjoyable for both the parent and child. This should include one or two of the child s favorite activities. If the child protests or throws a tantrum, the enjoyable routine ends immediately and he is put to bed without delay. Parents should consistently provide praise and positive verbal reinforcement when the child participates with the routine. If the child misbehaves, there must be an immediate consequence of the child going to bed with no further discussion, bargaining, or possibility of continuing the positive routine. Positive routines have been well tolerated by parents, reducing the child s crying and bedtime struggles as well as decreasing parental anxiety (Adams & Rickert, 1989; Galbraith & Hewitt, 1993). Falling Asleep Independently To teach a child to fall asleep independently at bedtime, the negative SOA (e.g., rocking or lying with a child) needs to be eliminated. This can be done using a global approach of simultaneously treating negative SOAs at both bedtime and following night wakings, or by using a targeted approach focusing only on bedtime, maintaining a consistent response to night wakings. With the latter approach, within 2 to 3 weeks after a child learns to fall asleep independently at bedtime, this skill often will generalize to nighttime arousals, decreasing the frequency of night wakings. Although no studies have examined factors that contribute to treatment success, clinically it has been suggested that the decision about whether to use a global or targeted approach should be based on the parents tolerance for the child crying or protesting and the child s temperament (Mindell & Owens, 2009). Parental readiness for change should be considered, as some families are ready to address all sleep problems immediately, whereas others may only want to change one behavior at a time. The most straightforward approach for teaching children to fall asleep independently is standard or unmodified extinction (France & Hudson, 1990; Hiscock & Wake, 2002; Reid, Walter, & O Leary, 1999; Rickert & Johnson, 1988). Standard extinction has been shown to be an effective treatment, with durable and lasting treatment changes (Mindell et al., 2006). More commonly known as cry it out, this treatment is straightforward operant conditioning, with parents simply ignoring any and all bedtime problems every night until the problems cease to exist. Although the approach is most commonly associated with the sleep training of infants, it can also be used for young children who are unable to fall asleep without parental assistance. For extinction, children should be placed in the crib or bed awake, and then parents should ignore cries or protests until the child falls asleep. When parents consistently do not respond to the child (with the exception of safety issues), within about 1 week most children will begin to fall asleep independently at bedtime (France & Hudson, 1990; Mindell & Owens, 2009). Parents must be reminded that the child s protests will likely increase on the second or even third night, but then progressively decrease over the next few nights. Although effective, extinction is not well-tolerated by most families, resulting in poor adherence to treatment recommendations (Hiscock & Wake, 2002; Reid et al., 1999; Rickert &

10 180 MELTZER Johnson, 1988). Most parents who seek assistance for sleep problems cannot tolerate prolonged crying in their children. To prevent inconsistent responses by parents, practitioners should provide the following information to help parents successfully implement this treatment. First, as previously mentioned, a child s crying or protesting will increase before it improves. Second, parents should be prepared for a worst-case scenario for example, that the child may vomit if she becomes upset. Problem solving with parents around these worst-case scenarios is important. Therefore, in the case of vomiting, one solution may be placing a second set of sheets on the crib or bed. If the child does vomit, the parent can respond quickly by removing the sheets, changing the child s pajamas, giving a second kiss goodnight, and leaving the room after returning the child to bed. Third, and most important, parents must be informed that there should be no long-term psychological harm caused by the use of an extinction approach. Instead, it should be explained to parents that by learning to fall asleep independently, children will obtain more sleep at night, in turn allowing for improved growth, development, and daytime functioning. Further, parents should understand that children are not crying because of anger or feelings of abandonment, but simply because they are tired and frustrated that they are unable to fall asleep. A variation of extinction that is more acceptable to families, known as graduated extinction, has also been found to be an effective treatment approach for teaching children to fall asleep independently (Adams & Rickert, 1989; Hiscock & Wake, 2002; Lawton, France, & Blampied, 1991; Mindell et al., 2006; Pritchard & Appleton, 1988; Reid et al., 1999). This treatment also begins with putting children in the crib or bed awake and then leaving the room. However, rather than ignoring the child s cries or protests until morning, a parent should wait to check on the child for progressively longer periods of time each night (e.g., 1 min, 3 min, 5 min, etc.) or over several nights (e.g., 3 min the first night and 5 min the second night). In both situations, the parent s responses should be consistently brief and boring, providing minimal interaction with the child (e.g., Time for sleep. I love you. ). The goal of this approach is for the child to fall asleep while the parent is not in the room. Because parents can check on their crying child at regular intervals, families better tolerate graduated extinction, although it may take longer than unmodified extinction. Parents should continue to be advised about the extinction burst and other obstacles faced with any type of behavior modification. For a child who is accustomed to one parent falling asleep next to him, fading of parental presence is another graduated extinction approach to help a child fall asleep independently (Hiscock & Wake, 2002; Minde, Faucon, & Falkner, 1994). Parents should gradually move a little further from the child every 3 to 7 nights. This progression may include (a) the parent sitting on the bed next to the child, (b) the parent sitting on the floor next to the child s bed, (c) the parent sitting half the distance between the child s bed and the door, (d) the parent sitting in the child s doorway, and (e) the parent sitting outside the child s room where the child cannot see the parent. Alternatively, a parent may lay with the child at bedtime, take a short break (e.g., 3 min), and return to lying with the child until she is asleep. With each night, the break becomes longer (e.g., 5 min, then 10 min), increasing the likelihood that the child will fall asleep independently. Clinicians need to carefully determine which treatment approach is best for the family by considering the child s temperament and parent s tolerance. For children with easy temperaments and parents who can tolerate long periods of crying, unmodified extinction will result in the fastest treatment success. However, by the time families reach health care providers, they are

11 BEHAVIORAL INSOMNIA OF CHILDHOOD 181 likely unable to tolerate such prolonged periods of crying. In addition, children with difficult temperaments may potentially cry even longer than other children. A graduated extinction (including fading of parental presence) should be used for these families. The decision about how frequent the breaks or checks should be is also determined by child temperament. Some children are quickly comforted by the parent checks, so the time between checks may be short. Other children will get more upset each time a parent comes into the room, so less frequent checks should be performed. Treatments should allow the family to be successful at each step. In other words, clinicians need to meet the parents where they are by designing a treatment the family can tolerate and follow through with. If the first step is too difficult (e.g., place the child in the crib and ignore for 10 mins), the parents will likely not be consistent, resulting in treatment failure. Thus a more acceptable first step should be chosen (e.g., rocking the child to sleep every night for 5 nights). There are times when children stop crying for a short period of time, only to resume crying a few minutes later. Parents should be advised that the child must be fully asleep before considering these renewed cries a night waking. For all treatment approaches, the use of a video monitor may empower parents to have less frequent checks, as they can monitor the child s health and safety without entering the room. Night Wakings There are two approaches to handling night wakings. The first is to apply the selected treatment at bedtime and for every night waking. This approach is best for parents with high tolerance for child crying (and parent sleep loss) and children with easy temperaments. The second approach is simply wait and see if the night wakings spontaneously resolve. Once children are falling asleep independently at bedtime, this skill is likely to generalize to night wakings within about 2 weeks (Mindell & Owens, 2009). Parents who prefer the wait and see approach should be advised that during bedtime sleep training, they should respond immediately and consistently to night wakings. This will allow the parent and child to obtain as much sleep as possible. For example, if a child is typically brought into her parents bed after the third or fourth night waking, instead she should be brought in after the first waking. Similarly, if after 1 hr of crying in the middle of the night a mother finally nurses the child to sleep, instead the mother should immediately nurse the child after he wakes up. Early Morning Wakings For some children, it can be difficult to determine if an early morning waking (approximately 4 6 a.m.) is sleep termination or a final night awakening. No studies have examined specific interventions for early morning sleep termination. Yet, a careful query of what happens after the child wakes can determine the best way to apply the techniques already described. Clinical questions should include whether the child gets nursed or brought into the parents bed in the morning, whether the child is likely to fall asleep if she receives parental attention, and whether the child is ready for a nap shortly after waking. This information can be used to determine if the child has a morning circadian preference (i.e., morning lark) or if this waking is due to BIC.

12 182 MELTZER For example, some parents may have a predetermined time when it is acceptable for the child to come to the parents bed (e.g., 5 a.m.). However, this time is usually arbitrarily selected and is not aligned with the child s actual sleep rhythm or sleep need. This may perpetuate night wakings, with the child unsure which of the night wakings will get the desired goal of moving to the parents bed. If a child quickly returns to sleep with parental assistance or presence, this should be treated as a night waking. Similarly, if a child is ready for a nap within 1 to 2 hr, he has not obtained sufficient sleep, and this early waking should also be treated as a night waking. In both of these cases, treatment approaches for BIC can be applied to these night wakings. In addition to using these techniques, in our clinic we have found the good morning light to be useful for teaching young children the difference between night and day. This light is simply a nightlight or small table lamp attached to a clock timer, and provides a visual cue that it is okay for the child to get up. The timer should initially be set for the child s current wake time to build an association with the light going on and the child being allowed to get out of the bed or crib. During this initial training, if a child wakes during the night, she should be told that it is still night since the light is off, and to return to sleep. Once the child understands the association between the light and getting up in the morning, the timer can be adjusted by 10 to 15 min every week or so, until an age-appropriate wake time is reached, allowing the child a sufficient sleep opportunity. For a child who is a morning lark, a good morning light can also be used to teach a child that he is not allowed out of his bedroom until the light goes on, and that he should self-entertain until the rest of the household rises for the day. As with any new specific behavior change (e.g., stay in bed until the light goes on), a rewards system may be paired with the good morning light to increase treatment success. PRACTICAL SUGGESTIONS FOR SUCCESSFUL LIMIT-SETTING As part of normal development, children test the limits, pushing the boundaries of appropriate behavior. This helps children learn about their environment, how to behave, and what they can and cannot control. It is a parent s job to set appropriate limits and enforce rules for appropriate behavior (Barkley, 1998; Kazdin, 2008). Although children may protest when limits are set, they desire these limits, as they provide a sense of safety and security. For many parents, the goal at bedtime is simply for the child to fall asleep. By giving in to the child s protests, many parents believe the child will fall asleep faster. Although this accomplishes the parent s goal of the child falling asleep, the protests will continue the following night. In addition, at bedtime, both the child and the parent are tired, increasing negative behaviors on the child s part, and making consistency even more difficult for parents. The following are guidelines for limit-setting, not only at bedtime, but also during the day. Educating families about how to set appropriate limits and manage unwanted behaviors, both at night and during the day, will contribute to treatment success. Positive Reinforcement Children are constantly seeking parental attention and reinforcement for behavior; this includes both positive and negative behaviors. Thus, it is important at bedtime for parents to selectively

13 BEHAVIORAL INSOMNIA OF CHILDHOOD 183 attend to positive behaviors (e.g., I like the way you tucked yourself in ), rather than negative behaviors (e.g., get back in bed ; Kazdin, 2008). In particular, positive reinforcement should be used for desired targeted behaviors (e.g., If you stay in bed, I ll come back in a few minutes for another goodnight kiss ). Positive reinforcement should be rewarding and immediate. Thus, the use of a small token reward system may be warranted (Kazdin, 2008). Tokens can include things like stickers, decorated index cards, or pennies that are given as a reward for the targeted behavior. The child can exchange the tokens for activities (e.g., going on a bike ride with dad or watching an extra TV show the next day) or small gifts. Initially, children should be able to exchange two or three tokens for a reward, with the required number of tokens increased over time. Further, parents may have to change the rewards to keep a child motivated. For older children, a grab bag of small gifts may be more appropriate. There are several ways to apply reward systems to BIC. First, a sticker chart allows children to earn a sticker for targeted bedtime behaviors, such as brushing teeth or putting on their pajamas. This will not only reduce some of the bedtime tantrums and stalling exhibited by children, but will make the evening routine more enjoyable for the child and the parents. Second, after the child falls asleep, they can be visited by the sleep fairy, who leaves a small token under the child s pillow (e.g., a sticker or penny). Initially, the sleep fairy comes every night, but after a few weeks, the sleep fairy comes on a more variable schedule, reinforcing the behavior of having the child stay in bed (Burke, Kuhn, & Peterson, 2004). Third, a bedtime pass can be used to prevent multiple requests or parental visits after bedtime (Freeman, 2006; Moore et al., 2007). The child can initially be given two to three passes, which have to be exchanged for each request made (e.g., drink of water, trip to the potty, or hug). Once the passes have been used, the parents should then ignore all additional requests. If the child does not use the passes, he can exchange them for small rewards in the morning. Over time, the number of passes given to the child can be decreased. As with any behavioral intervention, each of these reinforcement systems requires 100% consistency from parents, who are required to provide positive and immediate feedback to the child. Ignoring Negative and Unwanted Behaviors Along with consistently providing positive reinforcement for desired behaviors, parents must also consistently ignore negative or unwanted behaviors (Kazdin, 2008). As previously mentioned, a child s desire for parental attention can result in multiple requests at bedtime, temper tantrums, or power struggles. Providing positive reinforcement as previously described will reduce some of these negative behaviors, but parents must also ignore negative behaviors, including complaints, protests, and other inappropriate behaviors. When parents respond to unwanted behaviors, children get attention, prolonging the bedtime routine and delaying bedtime. Choices and Commands During early childhood, children are learning to be independent and want to be in control of their environment (Bornstein & Lamb, 1999). Therefore, when working toward a targeted goal, such as bedtime, children should have as much control over the situation as possible. Forced choices, which are limited in number (no more than two) and possibility, can provide this sense

14 184 MELTZER of control (Barkley, 1998). For example, a child can be given the option between two sets of pajamas or two bedtime stories. In addition, parents should not ask questions ( Do you want to brush your teeth? ) when they want to give a command ( Time to brush your teeth ) and, if appropriate, provide the child with a choice (e.g., red toothbrush or green toothbrush). Again, these skills should be implemented not only at night, but can be applied throughout the day. TREATMENT OUTCOME MEASURES There is no standard outcome measure utilized for the treatment of BIC in young children. Primary outcomes include duration of child s sleep, sleep onset latency, and the frequency and duration of both problematic bedtime behaviors (e.g., crying or tantrums or leaving the bedroom) and night wakings (Burke et al., 2004; Durand & Mindell, 1990; Minde et al., 1994; Mindell & Durand, 1993; St. James-Roberts, Sleep, Morris, Owen, & Gillham, 2001). The majority of studies have relied on parent-completed sleep diaries for outcome data. Clinically, the use of sleep diaries is likely the best option. Diaries are cost-efficient, both in terms of production and clinician interpretation time. They can also be tailored to collect data on the desired outcome (e.g., sleep routine, sleep schedule, etc.). Diaries are relatively easy for families to complete, without requiring a significant amount of time. Further, data can be collected over prolonged periods of time, with changes noted during treatment. The main limitation with sleep diaries are reporter bias and incomplete data. Polysomnography is an overnight sleep study done in a sleep lab, but is not indicated as a measurement of treatment outcome for BIC due to cost, a single night of data collection, and the lack of behavioral information. Actigraphy, an ambulatory wristwatch device that estimates sleep-wake patterns for a 1- to 2-week period in the child s natural sleep environment, may provide more objective data than diaries (Sadeh, 1994). However, the devices are expensive (i.e., watches cost approximately $1, each, plus the cost of software and computer interface). In addition, actigraphic studies are currently not reimbursed by insurance. DISCUSSION BIC is a common sleep disorder experienced by young children, resulting in shortened total sleep time for the child and increased stress for parents. Although there is no single treatment for these sleep problems, a combination of treatments based on behavioral principles is an effective way to reduce bedtime problems and night wakings (Mindell et al., 2006). The key features across treatment components are the child s ability to fall asleep independently and the parent s ability to set consistent and appropriate limits. Strengths and Limitations of Treatments There are a number of strengths to the treatment components described in this article. First and most notably, when applied with consistency, treatment is effective and behavior change enduring (Mindell et al., 2006). Second, initial treatment benefits can be seen in as few as 3 to 4 days for some families. Third, because each treatment component has different options, a

15 BEHAVIORAL INSOMNIA OF CHILDHOOD 185 treatment approach can be created that fits best with the child s temperament, as well as the parent s tolerance and parenting style, ensuring treatment success. Along with being clinically feasible, a combination of treatments (e.g., bedtime routine and graduated extinction) have been shown to be highly effective (Eckerberg, 2002; St. James-Roberts et al., 2001; Wolfson, Lacks, & Futterman, 1992). Finally, the principles of limit-setting that are recommended for bedtime can also be used to address daytime behavior concerns. These interventions are not without weaknesses. Many parents find it stressful to ignore their child s cries at bedtime, resulting in poor adherence (Reid et al., 1999). The use of graduated extinction is more tolerable, yet can still result in treatment failure if parents are unable to follow through for more than 1 or 2 nights. Initial treatment requires multiple days and even weeks of consistently implementing rules, utilizing rewards and consequences, and creating overall behavior change in the child. Some parents may find even the initial limit-setting to be too challenging, whereas other parents who are successful in the short term may regress to more permissive behaviors over time. Fortunately, behavior change is still possible, even for a family who has previously failed treatment, as long as parents are committed to being consistent. Common Obstacles The clinician should assess what obstacles may prevent parents from setting limits, with these issues addressed prior to initiating treatment. Common obstacles encountered during the treatment of BIC, and ways to address these issues, are found in Table 3. Along with inconsistent limit-setting, parenting style may differ between two parents, resulting in conflict TABLE 3 Common Obstacles in the Treatment of Behavioral Insomnia of Childhood 1. Inconsistent parental limit-setting Give positive reinforcement for targeted behavior Ignore unwanted and negative behaviors Give child control over situation through forced choices Use commands instead of questions 2. Parental disagreement about how to handle bedtime problems Include both parents in design of treatment plan to ensure buy-in and success Encourage parents to support one another 3. Other children in the home Put a fan, humidifier, or white noise machine in bedrooms of the patient and siblings Use reward system for all children in the home, targeting sleep or other specific daytime behaviors If the child shares a room with a sibling, consider moving the sibling to another room for the duration of treatment 4. Child does not stay in crib or bed Use crib tent to keep child safely in cribs until the age of 3 years when possible Place baby gate in bedroom doorway for toddlers to keep them in their room 5. Treatment difficult due to time and energy required Education about how the long-term benefits outweigh the short-term time and energy commitment Regular phone support with trained professionals may increase adherence by providing minor modifications to treatment plan

16 186 MELTZER over how to handle the child s sleep problems. Although one parent may be ready to ignore a child s protests, the other parent may believe this is harmful to the child, and respond to the child s cries. This can derail treatment efforts, making a behavior more difficult to extinguish due to the variable response. When two parents are involved, there must be support from both parents, as well as a clear agreement on how to respond to the child. In addition, as sleep training is stressful under the best circumstances, parents must be ready to support and encourage each other. Another common obstacle faced by families is what to do with other children in the home. If treatment will increase crying in an infant or protests in a young child, parents should be encouraged to place a fan, humidifier, or white noise machine in both the patient s and sibling s room to reduce noise. Further, for a child receiving rewards for targeted sleep behaviors, siblings should also receive rewards for similar sleep behaviors, or for other targeted daytime behaviors (e.g., making the bed). Finally, many parents may feel as if they are too tired or do not have the time to be consistent with treatment recommendations, including limit-setting. It is important to remind parents that the short-term cost of being consistent is outweighed by the long-term benefits of improving the child s (and the parents ) sleep. When possible, weekly phone contact with a trained specialist can bolster parents commitment and result in improved adherence to treatment (St. James- Roberts et al., 2001). Special Populations BIC is seen not only in typically developing children, but also children with developmental delays, autism, attention deficit hyperactivity disorder (ADHD), and other comorbid psychiatric or medical disorders (Ivanenko, Crabtree, & Gozal, 2004; Meltzer & Mindell, 2006). Although the treatment approaches described can be applied to all children, some special considerations may need to be given to special populations of children. For example, treatment of bedtime problems in a child with ADHD may need to be done in conjunction with treatment of daytime behavior problems, tying together reinforcement charts and other interventions (e.g., having child repeat instructions back to parent to ensure understanding; Barkley, 1998). Setting limits or using extinction with children who have severe anxiety or obsessivecompulsive disorder needs to be done carefully to avoid worsening of the child s anxiety. In these cases, it may be better to first address the child s global daytime anxiety issues, as some sleep problems may resolve when the anxiety improves. Other behavioral treatments for bedtime problems and night wakings should be introduced gradually and modified on a slower schedule than for typically developing children, so as not to worsen the child s anxieties at bedtime. For children with autism, bedtime problems may be a result of a circadian phase delay; thus, clinicians may want to consider a trial of melatonin in combination with behavioral approaches, including faded bedtime (Andersen, Kaczmarska, McGrew, & Malow, 2008; Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006). When a child has a chronic or serious illness (e.g., cystic fibrosis or cancer), parents may be less likely to enforce limits due to guilt or concerns about the child s health. However, providing a normal and consistent routine provides children with a sense of security, and will contribute to improved sleep continuity.