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".)
The 2014 revision of the International Classification of Sleep Disorders (ICSD-3) no longer separates insomnia disorders into discrete diagnostic categories such as behavioral insomnia of childhood and primary or psychophysiologic insomnia . However, the conceptualization of the behaviorally-based childhood insomnias as primarily related to either maladaptive sleep onset associations or parental difficulties with limit setting (or both) remains a useful construct from the standpoint of evaluation and application of specific behavioral interventions in clinical practice.
Behaviorally-based insomnia in children — From a clinical perspective, insomnia in childhood presents as bedtime resistance, prolonged sleep onset, and/or night wakings. Although these issues are often discussed separately, they often coexist, and many children present with both bedtime delays and prolonged nighttime awakenings requiring parental intervention. The diagnostic criteria for a sleep disorder require that a specific constellation of symptoms meet a defined severity level, persist for a specified time, and result in significant impairment of functioning in the child, parent(s), or family. Behavioral insomnia is most common in young children aged zero to five years, but may persist into middle childhood and beyond.
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Burnham MM, Goodlin-Jones BL, Gaylor EE, Anders TF. Nighttime sleep-wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study. J Child Psychol Psychiatry 2002; 43:713.
- Kerr S, Jowett S. Sleep problems in pre-school children: a review of the literature. Child Care Health Dev 1994; 20:379.
- Owens JA, Spirito A, McGuinn M, Nobile C. Sleep habits and sleep disturbance in elementary school-aged children. J Dev Behav Pediatr 2000; 21:27.
- Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics 2006; 117:e247.
- Fisher A, van Jaarsveld CH, Llewellyn CH, Wardle J. Genetic and environmental influences on infant sleep. Pediatrics 2012; 129:1091.
- Touchette E, Dionne G, Forget-Dubois N, et al. Genetic and environmental influences on daytime and nighttime sleep duration in early childhood. Pediatrics 2013; 131:e1874.
- Sadeh, A, Lavie, P, Scher, A. Maternal perceptions of temperament of sleep-disturbed toddlers. Early Educ Dev 1994; 5:311.
- Mindell JA, Kuhn B, Lewin DS, et al. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006; 29:1263.
- 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; 29:1277.
- Wolfson A, Lacks P, Futterman A. Effects of parent training on infant sleeping patterns, parents' stress, and perceived parental competence. J Consult Clin Psychol 1992; 60:41.
- Gradisar M, Jackson K, Spurrier NJ, et al. Behavioral Interventions for Infant Sleep Problems: A Randomized Controlled Trial. Pediatrics 2016; 137.
- Price AM, Wake M, Ukoumunne OC, Hiscock H. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial. Pediatrics 2012; 130:643.
- Foley LS, Maddison R, Jiang Y, et al. Presleep activities and time of sleep onset in children. Pediatrics 2013; 131:276.
- Falbe J, Davison KK, Franckle RL, et al. Sleep duration, restfulness, and screens in the sleep environment. Pediatrics 2015; 135:e367.
- Hale L, Guan S. Screen time and sleep among school-aged children and adolescents: a systematic literature review. Sleep Med Rev 2015; 21:50.
- Scott G, Richards MP. Night waking in infants: effects of providing advice and support for parents. J Child Psychol Psychiatry 1990; 31:551.
- Owens JA, Babcock D, Blumer J, et al. The use of pharmacotherapy in the treatment of pediatric insomnia in primary care: rational approaches. A consensus meeting summary. J Clin Sleep Med 2005; 1:49.
- Owens JA. Pharmacotherapy of pediatric insomnia. J Am Acad Child Adolesc Psychiatry 2009; 48:99.
- Cortese S, Brown TE, Corkum P, et al. Assessment and management of sleep problems in youths with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2013; 52:784.
- Rossignol DA, Frye RE. Melatonin in autism spectrum disorders. Curr Clin Pharmacol 2014; 9:326.
- van der Heijden KB, Smits MG, van Someren EJ, Boudewijn Gunning W. Prediction of melatonin efficacy by pretreatment dim light melatonin onset in children with idiopathic chronic sleep onset insomnia. J Sleep Res 2005; 14:187.
- Behaviorally-based insomnia in children
- - Insomnia related to sleep onset associations
- - Insomnia related to inadequate parental limit-setting
- Other contributors to insomnia
- Medical history
- Developmental history
- Family history
- Behavioral assessment
- BEHAVIORAL INTERVENTIONS
- Bedtime routines
- Systematic ignoring
- - Counseling
- Bedtime fading
- Positive reinforcement
- Parent education
- OLDER CHILDREN AND ADOLESCENTS
- Delayed sleep-wake phase disorder
- PHARMACOLOGIC INTERVENTIONS
- SUMMARY AND RECOMMENDATIONS