Bedtime problems, including difficulty falling asleep and problems staying asleep, are a common occurrence in childhood, affecting approximately 20-30% of young children (Goodlin-Jones et al, 2001). Problem behaviors surrounding sleep in children may include one or more of the following behaviors: bedtime refusals in the form of crying, stalling, refusal to go to bed, refusal to stay in bed, multiple requests for caregiver-mediated items (such as drink, food, stories, etc.), reliance on sleep-onset associations (such as parental rocking or singing), and frequent and/or prolonged night wakings.
A 2006 task force appointed by the American Academy of Sleep Medicine reviewed 52 treatment studies to develop parameters for behavioral treatment of children for bedtime problems and night wakings (Mindell et al, 2006). This research found that across all studies, over 80% of children who received one or a combination of various behavioral interventions displayed clinically significant improvement, which was maintained for 3-6 months following initial intervention.
Below are some pointers to address common bedtime issues. Remember, always consult your child’s pediatrician to rule out any potential medical issues that may interfere with sleep, especially if your child’s nighttime behaviors have changed suddenly.
Establish a consistent, relaxing bedtime routine. This may include a bath, a quiet story, and/or soft music. The bedtime routine should be predictable for the child and should signal a transition from active daytime to quiet nighttime.
Establish the bedroom and bed as a relaxing area designed for sleep. This means that no electronic devices such as ipads or televisions are on in the bedroom at bedtime, that the room is kept a comfortable temperature, and that the lights are very low or completely off. Devices that play only relaxing noise, such as calm instrumental music or white noise, may be acceptable as long as there are not stimulating visuals accompanying the sound.
Allow the child to learn to soothe him or herself to sleep. This is best completed by putting the child in bed following a bedtime routine and leaving the child in a quiet relaxed (but not yet sleeping) state. This process allows the child to develop independent sleep initiation skills, enabling him or her to return to sleep following normal nighttime arousals. If a child is able to soothe himself or herself to sleep, nighttime wakings may become less problematic because the child does not rely on the presence of a caregiver to fall back asleep.
Allow the child one or more comfort items that can substitute for more intrusive methods of helping to fall asleep. For example, a favorite stuffed toy or pillow are appropriate comfort items that can be used instead of the child being rocked or held to go to sleep.
Consider utilizing a bedtime pass program (Friman et al, 1999) for children of appropriate age/developmental level. This program is described by behavior analysts as DRA plus extinction, which means it allows the child to access a reinforcing consequence via the use of an alternate behavior (exchanging the pass rather that crying or repeatedly exiting the bed). Because this program involves an extinction procedure, it is highly recommended that parents work with a behavior analyst in the correct implementation of the procedure.
Approach extinction and graduated extinction procedures (ie, crying it out) with caution. It is strongly recommended that these procedures be undertaken only under the guidance of or consultation with a behavior analyst. The child’s age, cultural considerations, child’s developmental level and ability to communicate verbally, and parental fidelity to the procedure all are important considerations. Please consult a behavior analyst with experience in pediatric sleep disturbances as well as your child’s pediatrician before beginning an extinction or modified extinction procedure.
At Bloom, we provide consultation and ongoing treatment to address sleep disorders. Please contact us if you have questions or would like to consult a behavior analyst regarding your child’s sleep disturbances.
Friman, P.C., Hoff, K.E, Schnoes, C., Freeman, K.A., Woods D.W., & Blum, N. (1999). The bedtime pass: An approach to bedtime crying and leaving the room. Archives of Pediatric and Adolescent Medicine, 153, 1027-1029.
Goodlin-Jones, B.L., Burnham, M.M., Gaylor, E.E., & Anders, T.F. (2001). Night waking, sleep-wake organization, and self-soothing in the first year of life. Journal of Developmental and Behavioral Pediatrics, 22, 226-233.
Mindell, J.A., Kuhn, B., Lewin, D.S., Meltzer, L.J., & Sadeh, A. (2006). Behavioral treatment of bedtime problems and night wakings in infants and youg children. Sleep, 29 (10), 1263-1276