Sleep Strategies: A Cry in the Dark: The Best Therapy for Childhood Insomnia?



No area of pediatric sleep medicine stirs more controversy in the mainstream media than the treatment of behavioral insomnia of childhood (BIC), defined in the International Classification of Sleep Disorders (American Academy of Sleep Medicine [AASM], 2005) as difficulty falling and/or staying asleep that is behavioral in etiology and not explained by a medical or psychiatric cause.

The diagnosis, which is usually made via a caretaker report, is divided into three subtypes: limit-setting type (ie, bedtime problems), sleep-onset association type (night-wakers), and a combined type. Including all three subtypes, disease prevalence is estimated at 20% to 30% in infants, toddlers, and preschoolers (Morganthaler et al. Sleep. 2006;29[10]:1277). Though the disease has been associated with diurnal behavioral problems, it also has significant adverse effects on the parents, including sleep deprivation, maternal depression, and increased parental stress (Wake et al. Pediatrics. 2006;117[3]:836). Unfortunately, an astounding 84% of children with sleep disturbances continue to have them at 3-year follow-up, with persistent sleep fragmentation noted in as many as 18% of school-age children (Kataria et al. J Pediatr. 1987;110[4]:642; Sadeh et al. Dev Psychol. 2000;36[3]:291).

Treatment options

One likely contributor to the endurance of BIC into later childhood is the uncertainty about the optimal method of treatment. According to the AASM’s behavioral practice parameters for bedtime problems and night-waking in infants and children, the standard of care is to use the behavioral strategy of unmodified extinction, more commonly known as the "cry-it-out" method. This technique involves putting the child to bed at a designated time and not responding to the child’s protests/cries until it is time to wake up in the morning, unless there are significant safety or illness concerns.

Another practice standard is to use unmodified extinction, allowing a parent to remain in the room without reacting to the child ("extinction with parental presence"); a gentler method called "graduated extinction" or "modified extinction" allows the parent to briefly check on the child at predetermined times but with progressively longer intervals until sleep is achieved. The idea behind each of these methods is to allow the child to develop self-soothing skills so that he or she is able to fall asleep independent of parental intervention. By not providing the positive reinforcement of parental attention, the undesired behavior (crying or screaming) is extinguished.

Although a number of studies support the efficacy of these behavioral interventions in significantly reducing bedtime resistance and night-wakings (Mindel et al. Sleep. 2006;29[10]:1263), controversy understandably exists about the morality of allowing a child to cry for extended periods of time without consolation. Proponents of attachment parenting dub unmodified extinction as cruel and unusual punishment. The debate lies in whether withholding a parent’s response to a child’s cries at night results in long-term damage to the child or the parent-child relationship.

A well-written theoretical review of this practice has questioned the use of extinction techniques to help infants sleep independently (Blunden et al. Sleep Med Rev. 2011;15[5]:327), arguing that nocturnal crying has culturally been deemed undesirable, even pathological. The authors make arguments for the social and biological utility of infant crying and cite studies proposing that prolonged crying could result in increased cortisol, stress, withdrawal behaviors, attachment disorders, and potential neuronal changes. Because extinction methods are likely to involve prolonged periods of crying and thereby increase biological stress, they postulate that these methods are not completely benign, though the referenced studies of adverse outcomes of prolonged crying were not specifically related to the use of extinction therapy for BIC.

Until recently, no long-term studies had addressed the longitudinal effects of "crying-it-out," though short-term studies had shown no adverse effects. A recent publication evaluated the effects of an infant behavioral sleep program at 5-year follow-up on the child, the parent-child relationship, and maternal outcomes (Price et al. Pediatrics. 2012;130[4]:643). This study was an extension of the previously published Infant Sleep Study, a randomized controlled trial evaluating the shorter-term effects of a behavioral sleep intervention on infants who were identified by mothers as having sleep problems at 8 months of age (Hiscock et al. Arch Dis Child. 2007;92[11]:952).

Two techniques were used in this study: "controlled comforting" (graduated extinction) and "camping out." This latter technique, also known as adult fading, is similar to "extinction with parental presence," with the parent gradually distancing himself or herself from the child. Price and colleagues followed up on those children at 6 years of age, analyzing differences in intervention vs. control groups based upon parental reports and standardized questionnaires of emotional and behavioral problems, perception of sleep as a problem, clinical sleep problems, psychosocial health-related quality of life, and stress, as measured by morning cortisol levels. Additionally, researchers assessed the child-parent relationship; parenting styles; and evaluated maternal depression, anxiety, and stress. Results showed no statistically significant difference between the intervention and control groups in any of the measured outcomes, supporting the theory that behavioral sleep interventions have no long-term adverse effects on children.

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