Chapter 17: Treatment of Insomnia and

Nighttime Fears

Michelle ClementiJessica BalderasJennifer Cowie

Candice A. Alfano

Sleep Problems

Intermittent problems sleeping and nighttime fears are typical, and affect up to ¼ of all children (Meltzer & Mindell, 2006)

Sleep disorder if problem persists over time, is severe, and/or impairs daytime functioning

Children with insomnia may not complain of sleepiness or view sleep patterns as problematic

Parent understanding and awareness of sleep depends on: child’s age, family culture, SES, personal habits and experience (Owens, 2005)

ICSD-2 Behavioral Insomnia of Childhood

Two developmental subtypesSleep-onset association subtype: most common in infancy;

difficulty falling asleep in the absence of certain conditions (e.g., singing, rocking) both at bedtime and after nighttime wakings

Limit-setting subtype: common in preschool and school-age children; difficulty initiating sleep and resisting/refusing bed due to inadequate structure, limit setting, and/or behavior management by a caregiver

Nighttime fearsFear of the dark/shadows, separation from caregivers, bad

dreams/nightmares, strange noises, intruders/burglars

Evidence Based Approaches: Behavioral Insomnia of Childhood

Extinction-based procedures are most common components of treatments for BIC

Standard and graduated extinction: used with the goal of reducing inappropriate child behaviors during bedtime by altering parental responses

Standard extinction: completely ignoring all inappropriate behaviors (e.g., crying, tantrums) after bedtime once the child has been put to bed and until wake time

• Challenging to implement consistently, efficacy has been demonstrated

Graduated extinction: ignoring inappropriate behaviors and systematically increasing the amount of time before responding

• Easier to implement; well-established efficacy (Mindell et al., 2006)

Other Treatment Procedures: Insomnia

Bedtime fading: delaying bedtime until the child appears naturally sleepy, then systematically moving to an earlier bedtime based on mastery of sleep initiation

Positive routines: incorporating pleasant and structured presleep activities into the bedtime routine as environmental sleep cues

Response-cost: removing a child from bed if he or she is unable to initiate sleep within ~20 minutes

CBT Components: Insomnia

Stimulus control: strengthen the association between bed and sleep by encouraging the child to go to bed when feeling sleepy, removing clocks from the bedroom, and using the bed for sleep only

Cognitive techniques: target maladaptive beliefs or attitudes about sleep

Relaxation training: slow and deep breathing, progressive muscle relaxation(PMR), visualizing a peaceful scene

Progressive muscle relaxation: involves tensing (4–7 seconds) and then relaxing (30–40 seconds) different muscle groups

Treatment: Nighttime Fears

CBT techniques: self-control training, relaxation training, positive imagery, positive self-statements, differential reinforcement

Multiple techniques typically examined in most studies

Overall effectiveness of these interventions is high

Example: study of 33 school-aged children with severe nighttime fears (Graziano & Mooney, 1980)Used: self-control training, relaxation, positive imagery, and “brave”

self-statementsCompared to controls, children receiving CBT evidenced significant

reduction in frequency, intensity, and duration of nighttime fears

Parent Involvement in Treatment

Parent-child interaction is the primary context for behavior change in the treatment of BIC (Sadeh, 2005)

Difficulty setting firm nighttime limits is strongly associated with increased sleep disturbances in school-age children (Owens-Stively et al., 1997)

Parent-related factors that can interfere with implementation of treatment: Family discord/stress, parental psychopathology, single parent

status

Parental Involvement

Parent beliefs/attitudes can impact treatmentCan be an important target of CBT interventionsFaulty beliefs (e.g., “My child needs me in order to feel

safe and fall asleep”)Negative parental attitudes about treatment

If parents experience emotions such as fear, guilt, or shame when attempting to use extinction techniques interventions will most likely be used inappropriately

Correct and Consistent Treatment

To ensure techniques are implemented consistently and correctly, clinicians should prepare parents for potential increases in problem behaviors both during and after the course of treatment

Extinction bursts: temporary increases in a behavior following the removal of a reinforcer

Spontaneous recovery: reemergence of previously extinguished conditioned response after a delay

Adaptations and Modifications

Sleep patterns and practices are shaped by: Demographics: lower-SES children experience a greater

number of sleep-related problems and daytime sleepiness compared to peers

Race/ethnicity: minorities more likely to co-sleep, obtain less sleep at night, give up daytime naps at later ages

Culture

Developmental disorders: often experience frequent, severe, and chronic sleep problems (Wiggs, 2001)Learn bedtime routine, self-regulatory skillsDuration and pace of treatment may differ from typically

developing children

Modifications for Adolescents

Factors interfering with sleep (Carskadon et al., 1998): Early start times at schoolAfter-school sports, jobsHomeworkSocial activitiesIncreased use of electronic media

May need considerable support to make lasting changes in sleep due to these factors

Effective strategies often incorporate elements from both child and adult-based treatments

Gold Standard Measurement

Polysomnography

Actigraphy

Evaluation for children with behavioral insomnia does not necessarily require these measures

Overnight sleep study may be indicated depending on extent that other sleep disorders are suspected

Clinical Interviews

Structured interview with parents and children

Child’s current and historical sleep patterns/behaviors

Duration and chronicity of sleep problem

Description of the child’s sleep routine and environment

Parent responses: bedtime resistance, requests to co-sleep

Query presence of medical conditions (e.g., eczema, pain syndromes)

Assess for comorbid psychopathology (Alfano & Gamble, 2009)

Sleep Logs/Diaries

One-page, 24-hour gridRecord specific sleep-wake patterns and

behaviors on a prospective basis (usually 7 days)Daily bedtimes and wake timesTime required to fall asleep after getting into bedNumber and length of awakenings during the nightDaytime naps

Validated Sleep Questionnaires

Sleep Disturbance Scale for ChildrenFree; assesses a range of sleep disorders (e.g., initiating

and maintaining sleep, sleep-related breathing)Validated

Children’s Sleep Habits QuestionnaireWidely usedTotal sleep problems and eight subscalesChildren 4–10 years old

Clinical Case: Xavier

7-year-old Hispanic male

Symptoms: difficulty falling asleep, fear of the dark, defiant nighttime behaviors

Initial assessment: questionnaires for sleep and daytime behavior, sleep diary

Treatment plan: psychoeducation, sleep hygiene, positive bedtime routine, graduated extinction, sticker chart

Outcome assessment: sticker charts and weekly sleep diaries, indicated shorter sleep onset latency, sleeping in room by himself, increased average sleep time