Children’s Sleep. Behavioral Insomnia of Childhood.
I would first like to note to families that this is a common issue. It can be disruptive to overall family sleep. Many parents feel they are doing something “wrong”, but no two kids are alike and individualized approaches are necessary.
Behavioral Insomnia of Childhood (BIC) commonly occurs in young children of less than 5 years of age. When left not addressed it may result in behavior problems and can affect academic performance.
Treatments for BIC have been shown to be effective. And in many circumstances the bedtime problems do not resolve when left untreated.
Concept: Kids aren’t little people!
Insomnia in childhood is different than adult insomnia in many ways. In young children (less than 5 years of age) difficulty getting to sleep is frequently referred to as “bedtime problems” and difficulties maintaining sleep is frequently referred to as “night wakings”.
Despite our best efforts as parents, sometimes out setting of limits may be inconsistent. Sometimes this may occur at bedtime as well. Also sometimes commonly a child may request a parent to help him or her fall asleep.
Night wakings commonly occur. Sometimes a child may request the parent to help them back to sleep. This may result in negative sleep onset association (SOA). Often the child may continue to return to the parent room or may cry out loud in there own room.
Diagnosis and Treatment Overview.
The diagnosis of BIC (Behavioral Insomnia of Childhood) relies on report of parent or caregiver, as opposed to the self-reported complaints in adult insomnia. Adult insomnia is generally treated with sleep restriction and stimulus control. And these concepts are important in children as well, however for treatment of BIC parental teaching about behavior management such as limit-setting, extinction, and operant theory is additionally needed.
I would again like to emphasize to parents is that this problem is common. How common? Well, it has a name in Behavioral Insomnia of Childhood. And it has been so commonly seen over the years that it has been frequently described and also given specific criteria.
More importantly what I would like to emphasize is that this is not a result of bad parenting. You are not a bad parent if your child has bedtime problems or frequent night wakings. Telling a parent that behavior needs to be modified doesn’t mean that you don’t know how to parent.
Breaking Down BIC.
BIC can be broken down into 2 main types. SOA (Sleep Onset Association) Type and Limit-Setting Type. However, it is very common to have overlapping features of both.
BIC Diagnostic Criteria.
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.
Source: American Academy of Sleep Medicine (2005)
I really feel compelled to break this down into English
A. The parent reports child has difficulty sleeping.
B. Symptoms of difficulty getting to sleep may include
– Child continues to get out of bed.
– Bedtime can be an extended process, where child continues to demand special conditions. Examples could be another glass of water, another hug, check for monsters, read another book, I have to tell you something (my personal favorite), etc…
– When the child awakens in the night, parent intervention is needed to get back to sleep.
– The sleep difficulty can be with getting to sleep, staying asleep, or both.
– The child stalls at sleep onset.
Examples may include deviation from night routine, wanting to brush teeth later, etc…
– The child may refuse to go back to bed, sneaks into parent bed (or even floor).
– Establishing limits is important (is it a rule that child is not allowed to get out of bed?).
– Enforcing the limits may be challenging (commonly eventually the parent lets the child sleep in the parent bed).
C. The insomnia is not due to other reason. Examples may include insomnia due to pain, Reflux or other GI problems, or frequent arousals from obstructive sleep apnea, or hyperactivity from ADHD, etc…
SOA (Sleep Onset Association) Type.
Frequent or prolonged night wakings are typically seen in BIC-SOA. An SOA is a condition that helps a child to fall asleep at bedtime and return to sleep after a normal night arousal. Positive SOA occur when the child is able to self provide this condition, examples can include thumb sucking or a stuffed animal. Negative SOA require parental intervention, examples including patting a baby to sleep, nursing, TV, etc… Whatever is required to get the child to get to sleep, is going to be needed to get the child back to sleep.
The ability to self soothe helps a child learn to fall asleep and remain asleep through the night. This generally occurs developmentally between 3-6 months of age. Coincidentally this is also the age range where sleep duration is more consolidated at night and an infant begins to develop the ability to sleep through night.
Limit-Setting Type.
When parents complain of bedtime problems they frequently are referring to child refusal or bedtime stalling. A child may refuse to get ready for bed, get in bed, or stay in bed. Most often it is an attempt to delay bedtime by asking for attention seeking tasks.
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. Yet, providing limits and being consistent are skills many parents struggle with at bedtime. Parents may allow 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.
Combined Type
Commonly a child has a combinations of symptoms. A child may delay 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. Typically the child initially has bedtime refusal, then migrates to the parents’ bed during the night.
Consequences of untreated BIC:
– Bedtime problems or night wakings can shorten total sleep time, resulting in increased irritability, temper tantrums, and behavior problems in young children.
– Unlike adults who become lethargic when sleepy, young children are more likely to become hyperactive when sleepy.
– Parents may misinterpret this energy as a sign that their child is not ready to sleep, further prolonging bedtime.
– Early sleep problems are associated with later daytime behavior problems.
– 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.
– 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.
– 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. But this worsens the problem.
Behavior Theory Applied to Parent Training.
In Operant Conditioning Theory a behavior that is reinforced will increase in frequency, whereas a behavior that is ignored will decrease in frequency.
A continuous reinforcement schedule is one that happens in a consistent and predictable way. An adult example is getting paid. If going to work everyday results in a paycheck, there is regular attendance. However if the paycheck stops coming, people stop going to work.
An intermittent reinforcement schedule is one that reinforcement is unpredictable. An example of this may be a slot machine, a player is unsure if with the next pull they will be winning money so they may keep playing – or they may walk away.
When a parent does not have consistent limits set, essentially they are utilizing an intermittent reinforcement schedule. A child may think that if the ask 25 times to avoid bed then eventually the slot machine will cash in. Alternatively they may ask because they know there is a good chance that this is not the time that the limit setting will actually be reinforced.
Things may get worse before they get better.
When applying operant conditioning principles to parent training, it is essential to understand the child may respond with initial worsening of the behavior. When switching from an intermittent reinforcement schedule (slot machine) to a continuous reinforcement schedule this may result in a sharp increase in the unwanted behavior before there is ever any decrease in the tantrum behavior.
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 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.
Treatment of BIC.
The treatment for BIC is as per Standards of Practice Committee of the American Academy of Sleep Medicine and generally includes three primary areas:
(a) setting a consistent sleep schedule with an age-appropriate bedtime and napping,
(b) implementing a consistent bedtime routine,
(c) teaching the child to fall asleep independently
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, 20–30 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 tolerance
(standard extinction, graduated extinction, or fading of parental presence)
Treatment of BIC.
The treatment for BIC is as per Standards of Practice Committee of the American Academy of Sleep Medicine and generally includes three primary areas:
(a) setting a consistent sleep schedule with an age-appropriate bedtime and napping,
(b) implementing a consistent bedtime routine,
(c) teaching the child to fall asleep independently
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, 20–30 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 tolerance
(standard extinction, graduated extinction, or fading of parental presence)
Keeping a consistent sleep schedule.
Consistent bedtime is important for the treatment of sleep avoiding behavior. Pediatric sleep experts advise a time between 7 pm to 8:30 pm. National data has found that toddlers whose bedtimes is after 9pm slept approximately and hour less per night on average than children whose bedtime was before 9pm.
Bedtime schedules should be consistent without variation between weekends and weekdays.
Very important, a parent should not base the bedtime on whether the child “looks sleepy”. Sometimes things are not common sense until they are explained. Many children actually get more energetic as they get tired. Think about it, when was the last time your toddler yawned and said they were sleepy? The opposite, a parent can hear a kids temperament and know the toddler is tired.
If you wait till your child “looks sleepy”, before that they will have their paradoxical hyperactivity period. This will lead to tantrum and further sleep avoiding behavior. Impulse control is clearly impaired when anybody is sleep deprived, and if the parent as well is sleep deprived because of a late time then this may lead to either giving in to the child, or to physical punishment if a parent loses their own self control.
Napping.
Most children are still napping at 3 years of age. Napping then decreases around school age. A child who is deprived of their nap may be overtired at bedtime, and frequently this is not noted by yawning but rather by temper tantrums.
And yet the flip side of the coin is extensive or late napping may reduce the sleep drive at bedtime. This is an area that varies greatly with every child and home circumstance, there is no magic number for the average nap of a 3 year old and 25% of children who still nap at 5 years of age. But what is advised is that nap time be as consistent as possible as well. And if for different reasons the nap is missed, an attempt be made to push the bedtime toward the earlier range.
Faded Bedtime.
If your child has been going to be at a later time than desired, How should one proceed in changing the bedtime earlier?
Faded bedtime is the process by which bedtime is incrementally changed to the desired time. Think about it from your own perspective. If generally you can’t get to sleep till lets say 11pm, will you suddenly fall asleep if you try to go to bed at 9pm? Probably not.
First I advise that you define the time that you have been putting your child to sleep, as well as define the desired bedtime. Then it is advised that you put the child to sleep 15 minutes earlier then you had been prior. Every 3 days you advance the bedtime by another 15 minutes until the desired bedtime is achieved.
Bedtime Routine.
Routines are not unique to sleep. Routines are an essential part of daily life in young children. This allows structure and predictability in a setting where they explore their environment and boundaries. And yes, children push daytime boundaries just as they push night boundaries. No different. However, when children know what to expect they are able to transition between activities successfully.
Pavlov’s dog applies again. I remember going to Music Together with Mrs Louanne. She would blow a certain note and would sing “The instruments are coming”. All the children would get wound up. Also, before each Music Together class as well as after using the instruments she would sing “Toys away, Toys away, Time to put the toys away….Away”, and actually she was never the one who said the last Away. She would say Aaa… and the children would finish saying Away. Likewise, prior to the nap song she would take out a magic wand, children would run to the light switch to see who gets to turn off the light once she counts to 3 and the lights turn off. Then she would play a light song as the children would lay down their sleepy little heads. — Interesting, Mrs Louanne pointed something out to me that to this day I still note. When the melody of a song slows down, it is associated with napping and wind down. Many children may tantrum at this time. I noticed this with Manuel when we are listening to music in the car and a slower song comes on. Manuel would rub his eyes and may say “I don’t wanaaaa”.
So now having this real life example of associations, we can understand that there should be 2 important things to a bedtime routine (1) One that it is consistent, and (2) Second that is something that is enjoyed by parents and children alike. Without the consistency the child will not learn the association. And if the child or parent do not enjoy the routine then it will be consistently avoided.
There really is no gold standard as to what the routine should entail or how long it should last. In regards to duration, most experts advise approximately 30 minutes. And this time is combined, so it is not a 30 minute story nor a 30 minute bath. Parts of a bedtime routine may include bath, story, prayer, or a lullaby. — Bath time and story is what I always used with Manuel. Funny, one night Manuel asked me for a lullaby (which was never part of our routine). I asked him what song, he said A-B-C-D. Initially I thought this was sleep avoiding behavior, However when I thought about it the same melody of Twinkle Twinkle Little Star is used in the ABCs.
Bedtime Chart?
Sometimes children can understand what they see better then concepts. A bedtime chart may be used to help with consistency in some families. Having pictures of each step with a spot for a check or a sticker can be helpful. Examples may include bath, brushing teeth, pajamas, book, and a bed. I would advise last picture be a bed or a child sleeping soundly.
Falling Asleep Independently.
Remember, If a child needs something to fall asleep, when they wake up they will need that to get back to sleep. First thing that needs to be eliminated is the parent association, such as rocking, patting, or lying with a child till they fall asleep.
The most straightforward manner is standard extinction. This is commonly misquoted as “cry it out”. Though this is most commonly used for the sleep training of infants, it can also be used for children who have difficulty with falling asleep without the parent. With this method the parent ignore any unwanted behavior or tantrums at sleep onset, and also any tantrum is ignored during the evening if the child awakens as well. It is very important to note that tantrums generally get worse before things get better. Partly this is because this has been tried before and after 2 or 3 nights the parent has given in, much like the slot machine approach. However, this does have very strong evidence that it is effective. Yet, it is not tolerated well by many families and frequently turns to an inconsistent approach.
One thing that should be noted is that there is no long-term psychological harm by the standard extinction approach. And though first 2-3 nights are particularly tougher, it may take 2-3 weeks for the child to adapt. Also it is very important to note that children are not crying because of anger but simply they are tired. Otherwise they wouldn’t keep trying to come back to you through the night or first then in the morning. Finally, the extra hour of sleep (or more) that the child receives per night is beneficial and crucial to further neurobehavioral development.
Gradual Extinction.
If standard extinction was so clear cut, then you probably would not be on this website. Many parents cannot tolerate prolonged crying from their children. Gradual extinction also begins with putting a child to sleep in the crib or toddler bed as the child is awake and then leaving the room. The difference is instead of ignoring the tantrum behavior, the parent returns to the child in gradually longer intervals. Most important is the continuation of consistency. The parent response should be brief and boring. A simple “good night, sleep tight” or whatever consistent phrase the parent wants to give should be provided. The intervals between the crying should get longer either each night. Whether its 1 minute the first night or 3 or 5 minutes the second night is not important to the overall process, the interval durations is actually more based on parental tolerance.
Overall.
It is essential to understand that children test limits. This is not done in blatant defiance. This is how children learn about environments and boundaries. — Think of yourself as learning to drive. You learn to stop at all stop signs. One day you slow down at a stop sign, don’t come to a complete stop, and may do a “rolling stop sign”. No harm no foul. But one day, hopefully by police intervention, you are ticketed and have a fine (a consequence). It is then reinforced that there are clear cues, rules, boundaries, that are to be followed.
Advice!
I strongly advise that the consultation of a behavioral therapist or a child psychologist is sought before implementing any of these approaches. Also, I advise that the child’s sleep problems are brought to the attention of the pediatrician to ensure that there is not a medical reason for the sleep problems.
Daytime discipline implementation is also advised. Whether your child has ADHD or not, I would advise:
