II. Epidemiology

  1. Prevalence: 10-30% of children
  2. Gender predominance: None (boys and girls are affected equally)

III. Types

  1. Sleep Onset Association Type of Behavioral Insomnia
    1. Difficulty sleeping without specific conditions met (e.g. parent rocks an infant to sleep)
    2. Frequent night awakenings
    3. Bedtime process is arduous
  2. Limit-Setting Type of Behavioral Insomnia
    1. Bedtime refusal or stalling
    2. Child refuses to sleep after night awakenings
    3. Parents make concessions to the child to ease bedtime routine (e.g. allow Co-Sleeping)
    4. Consider other reasons for bedtime resistance
      1. Fear or anxiety (e.g. Nightmares, dark room, sleeping alone)

IV. Management: Initial Measures

  1. Maintain consistent consistent schedules
    1. Consistent bedtime routines
      1. Maintain same bedtime and awakening time daily
      2. Child should be drowsy, but awake when placed in bed
      3. Child should learn to fall asleep alone
    2. Consistent meal times
    3. Consistent nap times
  2. Sleep Hygiene
    1. See Sleep Hygiene
    2. Keep bedroom dark (nightlight if needed), quiet and at a comfortable Temperature
    3. Snack before bed may be given if child is hungry
    4. Avoid excessive fluid before bed
    5. Avoid caffeinated drinks or food (e.g. Chocolate) in the later part of the day
    6. Avoid vigorous activity before bed
  3. Maintain a positive bedtime
    1. Introduce calming activities prior to bed (e.g. reading bedtime story, bath time)
      1. Avoid television or electronic media immediately before bed
  4. Extinction Technique: Avoid reinforcing behavior
    1. See Trained Night Crier
    2. See Trained Night Feeder
    3. Child learns self-soothing techniques to return to sleep
    4. Child is checked on for serious cries of distress or checked on briefly (<1 minute) at regular intervals
    5. Frequent calls, tantrums, crying is otherwise ignored
    6. No rewards are given (no food, additional time, hugs, reading)

V. Management: Advanced techniques

  1. Faded Bedtime
    1. Goal: Decrease the time a child spends awake in bed
    2. Bedtime is delayed until the predicted time of sleep onset (with a consistent awakening time)
    3. Similar to Sleep Restriction Therapy
      1. Used for adults in Cognitive Behavioral Therapy for Insomnia
  2. Response Cost
    1. If sleep onset does not occur within a specific time period
      1. Remove child from bed for a pre-determined amount of time (e.g. 30 minutes)
    2. Similar to Sleep Stimulus Control
      1. Used for adults in Cognitive Behavioral Therapy for Insomnia
  3. Scheduled Awakenings
    1. Parents log the times of night awakenings
    2. Awaken the child prior to the expected time of night awakening
    3. Slowly decrease the number of scheduled awakenings over time

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