Evidence-Based Reviews

When a child can’t sleep, start by treating the parents

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Behavioral insomnia of childhood may manifest as sleep-onset association and limit-setting types.9 The two often coexist, and many children present with both bedtime delays and nighttime arousals.

Sleep-onset association type. The presenting problem is usually prolonged nighttime arousals resulting in insufficient sleep. The child has learned to fall asleep only with sleep associations, such as being soothed by a parent, that usually are available at bedtime.

During the night, when the child experiences the type of brief arousal that normally occurs at the end of each sleep cycle (every 60 to 90 minutes) or awakens for other reasons, he is unable to get back to sleep (“self-soothe”) unless those same conditions are available to him. The child then “signals” the caregiver by crying (or coming into the parents’ bedroom) until the necessary associations are provided.

Limit-setting type is characterized by active resistance, verbal protests, and repeated demands at bedtime (“curtain calls”) rather than nighttime arousals. If sufficiently prolonged, the sleep-onset delay may result in inadequate sleep duration.

Sometimes bedtime resistance is related to:

  • an underlying problem (a medical condition such as asthma or medication use, a sleep disorder such as restless legs, or anxiety)
  • a mismatch between the child’s intrinsic circadian preferences (“night owl”) and parental expectations.
Usually, however, this disorder—most common in preschool and older children—develops from a caregiver’s inability or unwillingness to set consistent bedtime rules and enforce a regular bedtime. The child’s oppositional behavior worsens the problem.

Behavioral therapy can alleviate bedtime resistance and nighttime arousals in young children.10 Controlled group studies strongly support three techniques: unmodified extinction, graduated extinction, and preventive parental education (Table 3).

To use graduated extinction, tell parents to ignore bedtime crying and tantrums for specified periods before checking. Tailor the duration or interval between check-ins to the child’s age and temperament; the limiting factor is how much crying the parents can tolerate, as checking is often more to reassure them than the child.

For younger children, parents might check every 2 minutes initially, then gradually lengthen to 5-, 10-, and 15-minute intervals. A common scenario is to double the time between each successive check-in (2 minutes, 4 minutes, 8 minutes, etc.). For older children, checking could start at 5- or 10-minute intervals.

During check-ins, the parents briefly comfort the child (usually 15 seconds to 1 minute). Advise parents to minimize interactions that may reinforce the child’s attention-seeking behavior.

To treat limit-setting sleep problems, recommend a combination of:

  • decreased parental attention to bedtime-delaying behavior
  • establishing a consistent bedtime routine that does not include stimulating activities such as television viewing
  • bedtime “fading” (temporarily setting bedtime to the current sleep-onset time and then gradually advancing bedtime)
  • positive reinforcement (sticker charts) for appropriate behavior at bedtime.
Self-relaxation techniques and cognitive-behavioral strategies may help older children.

Behavioral treatment strategies require parental consistency to avoid inadvertently reinforcing nighttime arousals. Warn parents that children’s protests frequently escalate temporarily as treatment begins (“postextinction burst”).

How parents define a sleep “problem” and how well they accept your treatment recommendations can depend on their cultural values and beliefs about sleep’s meaning, importance, and role in daily life. Family attitudes vary about solitary sleep versus co-sleeping and about offering children transitional objects such as a blanket or toy to help them sleep.

Parents who repeatedly fail to start or enforce behavioral management may have other issues to address, such as depression or marital conflict.

Table 3

3 treatments for behavioral insomnia of childhood

ExtinctionWithdrawing parental assistance at sleep onset and during the night (‘systematic ignoring’)
Graduated extinctionGradual rather than abrupt extinction treatment
For toddlers, parents check child briefly at successively longer intervals during wake-sleep transition
For older children, parents introduce transitional sleep association objects (a blanket or toy) and use positive reinforcement (stickers for remaining in bed)
Preventive parental educationParents must consistently use behavioral treatment strategies to avoid reinforcing the child’s nighttime arousals

Psychophysiologic Insomnia

Psychophysiologic insomnia (sleep onset and/or maintenance) occurs primarily in older children and adolescents and results from:

  • predisposing factors (genetic vulnerability, underlying medical or psychiatric conditions)
  • precipitating factors (acute stress)
  • perpetuating factors (poor sleep habits, caffeine use, maladaptive thoughts about sleep).
Conditioned anxiety about difficulty falling asleep or staying asleep heightens physiologic and emotional arousal, further compromising ability to sleep.11 Educate the patient about sleep hygiene, including:
  • using the bed only for sleep
  • getting out of bed if unable to fall asleep (stimulus control)
  • restricting time in bed to actual time asleep (sleep restriction)
  • learning relaxation techniques to reduce anxiety.
Delayed sleep phase syndrome. Some youths presenting with sleep-initiation insomnia—particularly adolescents—may have a circadian-based sleep disorder called delayed sleep phase syndrome (DSPS). DSPS is a significant, persistent phase shift in the sleep-wake schedule (later bedtime and wake time) that conflicts with the individual’s school, work, or lifestyle demands.

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