Behavioral sleep problems in children
- Judith A Owens, MD, MPH
Judith A Owens, MD, MPH
- Director of Sleep Medicine
- Boston Children's Hospital
Behavioral sleep problems (behavioral insomnia) in children include bedtime refusal or resistance, delayed sleep onset, and prolonged night awakenings requiring parental intervention. All of these issues are common in the pediatric population, and often adversely affect the quality of life of both children and caregivers.
Medical issues, including medications, pain, and primary sleep disorders (eg, obstructive sleep apnea), may also cause sleep problems either directly or by creating conditions that contribute to unhealthy sleep practices (eg, irregular sleep-wake patterns) or negative sleep onset associations (eg, needing a parent present in order to fall asleep).
The causes and interventions appropriate to behavioral sleep problems, which are the most common sleep issues in children, will be reviewed here. The general clinical evaluation of sleep problems in children, including the steps needed to determine whether the problem is behavioral in origin, is discussed in detail elsewhere. (See "Assessment of sleep disorders in children".)
TYPES OF CHILDHOOD INSOMNIA
The 2014 revision of the International Classification of Sleep Disorders (ICSD-3) no longer separates insomnia disorders into discrete diagnostic categories . Rather, they are all included under the terms "chronic insomnia disorder," "short-term insomnia disorder," or "other insomnia disorder." However, for the purposes of evaluation and application of specific behavioral interventions in clinical practice, it is useful to consider the contributors to childhood insomnia in the following categories:
●Behavioral insomnia of childhood
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- TYPES OF CHILDHOOD INSOMNIA
- Behavioral insomnia of childhood
- - Insomnia related to sleep-onset associations
- - Insomnia related to inadequate parental limit-setting
- Psychophysiologic (conditioned) insomnia
- Transient sleep disturbances
- Intrinsic versus extrinsic factors
- YOUNG CHILDREN WITH BEHAVIORAL INSOMNIA
- General guidance to parents
- Specific techniques
- - Bedtime routines
- - Systematic ignoring
- - Bedtime fading
- - Strategic napping
- - Positive reinforcement
- OLDER CHILDREN AND ADOLESCENTS
- Psychophysiologic (conditioned) insomnia
- Delayed sleep-wake phase disorder
- PHARMACOLOGIC INTERVENTIONS
- SUMMARY AND RECOMMENDATIONS