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.
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- 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