Bedtime Problems and Night Wakings in Children

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Bedtime problems and night wakings in children are extremely common, and the treatment literature demonstrates strong empirical support for behavioral interventions. Empirically validated interventions for bedtime problems and night wakings include extinction, graduated extinction, positive routines, and parental education. Most children respond to behavioral interventions, resulting not only in better sleep for the child, but also better sleep and improved daytime functioning for the entire family. This article reviews the presentation of bedtime problems and night wakings, empirically validated interventions, and challenges to treatment in both typically developing and special populations of children.

Section snippets

Bedtime problems

Bedtime problems include both bedtime refusal (eg, refusing to participate in aspects of the bedtime routine, to get into bed, or to stay in bed) and bedtime stalling (eg, attempting to delay bedtime with repeated requests for hugs, food or drink, stories, and so forth) [7]. Bedtime problems typically begin with the developing independence of toddlers, but can continue or develop in preschoolers and school-aged children. Often children test the limits to determine boundaries and gain

Classification and prevalence

Most empiric research on behavioral sleep problems and interventions has not been conducted using strict diagnostic definitions. Rather, studies have used a multitude of definitions to designate bedtime problems and night wakings, from parental identification of their child experiencing a sleep problem to more empirically based definitions, such as a child waking three or more nights a week. No studies have classified children according to the designation of the recent International

Assessment

A comprehensive assessment of both sleep patterns and daytime functioning is needed to evaluate bedtime problems and night wakings [16]. One approach is to guide a family through a “typical” 24-hour period to assess factors that may impact both nighttime sleep and daytime sleepiness. This provides information about the child's sleep schedule (eg, bedtime and wake time on weekdays and weekends); bedtime routines (nighttime activities, bedtime stalling or refusal, sleep-onset latency); parental

Behavioral treatments for bedtime problems and night wakings

Behavioral interventions have been empirically validated for the treatment of bedtime problems and night wakings. A recent American Academy of Sleep Medicine review of 52 studies investigating behavioral interventions for bedtime problems and night wakings reported that 94% of studies demonstrated clinically significant effects [13]. Empirical evidence from controlled group studies using Sackett criteria for evidence-based treatment provided strong support for unmodified extinction and

Treatment challenges

Although behavioral treatments for bedtime problems and night wakings are effective, there are a number of barriers that may result in nonadherence to treatment recommendations. Behavioral treatments, such as extinction and graduated extinction, rely on behavioral principles, including schedules of reinforcement. Parent inconsistency results in an interval or unpredictable reinforcement schedule, which in turn maintains the unwanted behavior. When parents report that “they have tried

Developmental disorders

Children with developmental conditions, such as autism spectrum disorders (ASDs), may be at increased risk for bedtime problems and night wakings compared with typically developing children. In fact, 44% to 83% of children diagnosed with ASDs have a sleep problem as determined by actigraphy or parent report [49], [50], [51]. The most common problems reported are difficulty falling asleep, inability to sleep independently, frequent and lengthy night wakings, early morning wakings, and less total

Summary

Bedtime problems and night wakings in children are extremely common, and the treatment literature demonstrates strong empiric support for behavioral interventions. Empirically validated interventions for bedtime problems and night wakings include extinction, graduated extinction, positive routines, and parental education. Although parent report of bedtime problems and night wakings may be higher in children with ASDs and ADHD, behavioral interventions for sleep difficulties can be important

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    A version of this article originally appeared in Sleep Medicine Clinics, volume 2, issue 3.

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