A pediatric sleep specialist explains the components of effective bedtime routines, as well as sleep training options. Parental adherence is crucial, as is screening for medical sleep disorders prior to implementing new behavioral routines and treatments.
Difficulty falling asleep and night awakenings are common sleep problems in young children. The American Academy of Sleep Medicine has published practice parameters for the behavioral treatment of bedtime problems and night wakings in infants and young children (available online at www.aasmnet.org/resources/practiceparameters/pp_nightwakingschildren.pdf).1 Additionally, investigators have continued to evaluate the efficacy of behavioral treatments for childhood sleep problems.2 This article describes common treatment recommendations for behavioral sleep problems, with a focus on practical tips on how to implement and increase parental adherence to sleep interventions for young children.
Most importantly, behavioral treatments may not be successful if medical sleep disorders are present. Therefore, prior to implementing new behavioral routines and treatments, screening for common sleep disorders is a must. Common sleep disorders include sleep apnea (snoring, pauses in breathing, gasping, or choking at night) and restless legs syndrome (RLS) (funny or uncomfortable sensations/pain or urge to move the legs, worse in the evening, better with movement/massage) that may be causing the child to have difficulty falling asleep or may awaken the child from sleep. Children with “growing pains’” may actually have RLS, a significant and easily treatable cause of insomnia.
For parents to successfully implement and adhere to behavioral treatments, it’s important to guide parents on what to expect in terms of time needed to establish a new routine, how to choose a treatment, and preparing them for possible responses from their child. Education of parents, either when pregnant or during the first few infant visits with the child’s clinician, improves infant and childhood sleep duration and patterns, according to multiple studies.1,2
Establishing a new routine can be difficult, and it may take up to 6 weeks (up to 42 evenings!) or longer of practicing for routines to become easy-to-remember, positive bedtime habits for the child. Deviation from the new routine or treatment for even one evening may confuse the child and bring back old habits, which can be frustrating for parents.
It is common for children to cry, protest, and have tantrums during the first 2 to 5 days of starting the new routine or treatment. This is a child’s way of showing he or she recognizes that the old, familiar routine is being changed. The protest may be the child’s way of expressing frustration with the change. Staying consistent with the new routine and therapy even through these difficult evenings is important. Parents can find it helpful to plan ahead and choose a 6-week period with the least amount of possible distractors (for example, no travel or grandparents watching kids overnight).
Several sleep-training resources are available online and in print, and they all may seem to recommend different behavioral sleep techniques. It can be difficult to determine which will work best for any given family. A child’s temperament and the parents’ ability to tolerate the child’s response (eg, crying for long periods) are important aspects to consider. It’s also important to recognize that what worked for one child (eg, an older sibling) may not work for another child.
Bedtime Routines for Children
Bedtime routines are commonly recommended by sleep clinicians. One of the largest randomized controlled studies in behavioral treatments for sleep problems examined the effects of having a bedtime routine on sleep onset and awakenings.3 It found that in 405 children aged 7 to 36 months, divided into two groups of “bedtime routine” or “usual habits” (no specified routine), children in the bedtime routine group fell asleep faster, stayed asleep longer, and had less nighttime awakenings, and maternal mood improved.3
To be effective, bedtime routines should be the exact same activities in the exact same order every evening. Bedtime routines help the brain unwind from a state of “go-go-go” to a more calm, relaxed state that makes the transition to sleep easier. Parents and children are more likely to be adherent if the child has some input to the activities of the bedtime routine and finds the routine to be pleasurable. Even on nights when there are late-night extracurricular activities, the bedtime routine should include the same activities in the same order, but completed faster. Additionally, if the bedtime routine is reasonably simple, it can be recreated easily even when traveling. Parents of children who fall asleep to night-lights or sound machines should be reminded to take these with them when sleeping away from home to recreate a similar sleep environment.
Extinction Techniques as Part of Sleep Training
The technique of unmodified extinction, or the “cry-it-out” method, is frequently described online/in print and prescribed by clinicians as an initial step of sleep training once a child is at least 6 months old. Parents place the child into the crib or bed after the bedtime routine, then ignore all crying, tantrums, and talking until the child falls asleep. Parents monitor for safety, but otherwise do not intervene. This allows a child to learn how to fall asleep on his/her own. It also helps the child learn to self-soothe, a necessary skill as children and adults of all ages have up to six or eight normal awakenings at night. Often these awakenings are so brief and uneventful (may look around, observe familiarity and safety of the environment, shift positions) that they are forgotten by morning.
Unmodified extinction can be difficult for parents who do not like to hear their child crying or screaming for long periods at a time; each parent has a different definition of “long period” that is tolerable. Ideally, there is less crying each successive night; sometimes this technique works within a week, and sometimes the treatment plan is wholly unsuccessful due to either child or parent intolerance. Some parents find it more acceptable to stand outside of the door where the child can hear the parent, but not see the parent. Then the parent calmly and softly talks the child through the process of settling down and falling asleep. For example, “It’s ok, mommy is right here. You need to lie down and go back to sleep. Lie down.…” Each evening, the parent is able to decrease how long and how much assistance is needed until the child is able to fall asleep on his/her own after being tucked in.
Extinction of undesired behavior with parental presence is a somewhat similar technique. The parent does not physically intervene; however, he or she is present in the room. A parent sits on a chair in the room with a child who is trying to fall asleep. On the first night, the parent sits next to the child’s bed. Each night, the parent moves the chair and sits one foot closer to the door. Usually within 10 to 14 days, the parent’s chair is outside of the room. This technique may not work if the child is mobile, climbs out of the crib/bed, and refuses to sleep, or other scenarios in which another technique may be more successful.
Graduated extinction may be more acceptable to parents and children than unmodified extinction. Parents should be counseled that while this technique is labor-intensive for the first 2 weeks, it is effective for children who stall at bedtime or have multiple requests after being tucked in. Parents decide ahead of time to use a check-in schedule of fixed intervals (eg, every 5 minutes) or progressively longer intervals (eg, 30 seconds, 1 minute, 2 minutes, 4 minutes, 4 minutes, 4 minutes, etc). During the second week, the intervals may be lengthened depending on the child’s improvements in sleep onset.
With graduated extinction, each night the child is tucked into bed after the bedtime routine. At the time of lights out, the parent indicates to the child that it is time to go to sleep, and that the parent will be checking in on the child. At each check-in, from the doorway, the parent will give the child a signal (eg, thumbs up), verbal encouragement (eg, “Great job trying to fall asleep!”), and let the child know when the parent will be returning (eg, “I’ll be back in 1 minute.”). The child will also give a signal (eg, thumbs up) in return without speaking. This modified extinction therapy is effective as the child stays in the bedroom, receives reassurance that the parent is still available, and any “runaway” thoughts can be redirected at the check-in.
Shalini Paruthi, MD
This technique can be further modified with the addition of a “bedtime pass.” At the time of lights out, a pass (index card or foam cutout) is given to the child. If the child needs to speak or get out of bed, the child must redeem the pass. If the child keeps the pass until morning, it is worth a reward that is provided immediately after the child awakens. Most young children have not yet developed a sense of delayed gratification (which may be a contributing factor to the failure of some techniques, such as sticker charts or rewards promised after several days). Rewards may include 5 minutes of extra screen time, stickers, or money depending on the child’s age, understanding, and motivation.
Delayed bedtime with removal from bed, ie, faded bedtime with positive response cost, is another technique that helps to couple a pleasurable bedtime routine with very little time awake in bed. Parents are instructed to temporarily place their child (3-years-old and older) in bed close to the time the child seems to actually fall asleep at night, thus minimizing the amount of time he or she is awake in bed. For example, the child who consistently takes an hour to fall asleep when put to bed at 7:30 pm, may benefit from being tucked in at 8:15 pm and falling asleep within 15 minutes. If the child cannot fall asleep within 15 to 20 minutes, the child should be removed from bed and guided to do a quiet calm activity in another room until the child appears sleepy.
Excessive time spent awake in bed creates a frustrating situation for the child and parent and may lead to more long-term insomnia. The goal is to help the child learn the association of the bed with falling asleep quickly. Additionally, parents must keep reasonable expectations for how long the child can sleep during one period. This varies by age, weight, and developmental stage. Many preschool children are unable to go without food and sleep for longer than 10 hours at a time.
Studies are lacking in terms of which technique works best or if techniques should be used in combination or alone. Selection of the best sleep training technique is an individual decision for each family, based on child temperament and the parents’ ability to implement and adhere to the new routines and treatments. Helping a child learn to fall asleep and stay asleep (ie, self-soothe with normal expected awakenings) is rewarding for the child and parents. Furthermore, improvement in sleep is associated with improvements in daytime functioning, attention, behavior, and quality of life.
Shalini Paruthi, MD, sees patients of all ages, with a special focus in pediatric sleep disorders. She is an adjunct associate professor in Pediatrics at Saint Louis University School of Medicine, co-director of the Sleep Medicine and Research Center at St. Luke’s Hospital in St Louis, and an editorial advisory board member at Sleep Review.
References
1. Morgenthaler TI, Owens J, Alessi C, et al. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006;29(10):1277-81.
2. Honaker SM, Meltzer LJ. Bedtime problems and night wakings in young children: an update of the evidence. Paediatr Respir Rev. 2014;15:333–9.
3. Mindell JA, Telofski LS, Wiegand B, Kurtz ES. A nightly bedtime routine: impact on sleep in young children and maternal mood. Sleep. 2009 May;32(5):599-606.
