behavioral sleep disorders of childhood ... bedtime routine n bedtime routine alone shown to improve...

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  • + Sleepy, Dopey, & Grumpy:

    Behavioral Sleep

    Disorders of Childhood

    Courtney Du Mond, PhD, CBSM Clinical Psychologist & Behavioral Sleep Medicine Specialist

  • + Outline

    n Background & Conceptual Model

    n Sleep 101: Normal Sleep

    n Behavioral Sleep Disorders

    n Treatment & When to Refer

  • + Why Sleep?

    n  Sleep problems are common in early childhood

    n  When left untreated, sleep problems may persist and become chronic

    n  Poor sleep can have negative consequences across multiple domains of child, parent, and family functioning

  • + A Conceptual Model

    Excessive Daytime


    Insufficient Sleep (Sleep Deprivation)

    Fragmented Sleep (Sleep Disruption)

    Primary Disorders of


    Circadian Rhythm


  • Consequences

    School Performance Social/Family Functioning


    Cognitive Behavioral Mood

    Daytime Sleepiness/Insufficient Sleep

    A Conceptual Model

  • +Impact of sleep problems: Physical

    n Growth: disruption of normal growth hormone release during sleep

    n Immune function: sleep deprivation impairs host defenses; infection induces somnogenic cytokines

    n Endocrine system regulation: cortisol, prolactin thyroid

    n Metabolic regulation: obesity/metabolic syndrome linked to sleep deprivation

    n Injuries more common in sleepy children

  • + Sleep in the Modern Family

    2014 Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.

  • + Factors Affecting Sleep in Children

    Sleep Sociocultural

    (values, parenting practices)

    Sleep Practices (schedules,

    feeding, napping,


    Sleep Environment (temperature,

    light, sleep surface)

    Family/Parents (SES, family

    stress, parental competence) Health (illness,

    medications, reflux)

    Development (sleep, cognitive,

    separation anxiety)

    Social/Emotional (attachment,

    temperament, maternal mental


  • +

    What’s Normal?

  • From: Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics. 2003 Feb;111(2):302-7.

  • +What’s Normal

  • + Infants

    n 0-2 Months n 10-19 hours per 24 hours n Bottle-fed sleep longer periods than breastfed

    n  2-12 Months n 9-10 hours at night n 3-4 hours napping

  • + Toddlers

    n 12 months – 3 years n 9.5 to 10.5 hours sleep at night n 2-3 hours napping n Decreases with age

  • + Preschoolers

    n 3 to 5 years n 9 to 10 hours of sleep per night n Naps decrease from 1 to none

  • +School Age

    n 6 to 12 years n 9 to 10 hours per night


    n 12 to 18 years n Normal is not enough! n Sleep decreases with increasing age n Biologic and environmental shift to later sleep onset

    n Circadian rhythm disorders are very common and often present as EDS or insomnia complaints

    n Electronics, electronics, electronics!

  • + What parents think...

    2014 Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.

  • + What kids actually get...

    2014 Sleep in America Poll: Sleep in the Modern Family, National Sleep Foundation.

  • +

    Behavioral Sleep Problems in Early Childhood

  • + Common Sleep Complaints

    n  My child refuses to go to sleep

    n  “Curtain calls”

    n  He won’t sleep in his own room

    n  My child has ALWAYS been a terrible sleeper

    n  She wakes up 5 times every night

    n  We moved him to a bed and he won’t stay there at bedtime

    n  I have to lie down with her every night until she falls asleep

  • + Case Example

    n  3 ½ year-old with frequent night wakings

    n  Bedtime n  Routine: bath, snack, books, song, TV, lotion, prayers, more books, patted to

    sleep n  Negotiating n  Time-outs n  Typically falls asleep with mom in his bed

    n  Woke about every 60-90 minutes n  Getting out of bed about 35 times per night n  Running around n  Irritable, arguing with mom n  “I’m scared”

  • + Epidemiology

    n  Bedtime Stalling n  52% of preschoolers

    n  42% of school-aged children

    n  Bedtime Resistance n  10-30% of toddlers and preschoolers

    n  84% of children (15-48mo) continued to have sleep disturbance at 3-year follow up!

  • + Etiology & Risk Factors

    n Permissive parenting style

    n Conflicting parental discipline styles

    n Age

    n Temperament

    n Oppositional behavior

    n Environmental settings

    n Circadian timing

  • + Behavioral Insomnia of Childhood

    §  International Classification of Sleep Disorders – Second Ed. (ICSD-II) §  Sleep Onset Association Type

    §  Limit Setting Type

    §  Combined Type

  • +Sleep Onset Association Type

    n Complaint = nightwakings

    n Nighttime arousals are normal (for all of us)

    n What you need to fall asleep is what you need to return to sleep

  • + Sleep Onset Association Type (cont’d)

    n 6 months to 3 years

    n Involvement of sleep associations prevents returning to sleep independently

    n Problematic sleep associations interfere with learning to self-soothe

    n Requires parental intervention to sleep

  • +Limit Setting and Combined Type

    Limit Setting Type

    n  Bedtime struggles/bedtime refusal

    n  Prolonged sleep onset latency

    n  2-6 year olds

    Combined Type

    n  Bedtime struggle that ends with negative sleep association

  • + Key Features

    Sleep Onset Association Type

    S  Involvement of sleep associations prevents returning to sleep

    Limit Setting Type

    S  Bedtime struggles/bedtime refusal

    Combined Type

    S  Bedtime struggle that ends with negative sleep association

  • + Assessment of Behavioral Sleep Problems

  • + Screening for Sleep Problems: BEARS

    n  B = Bedtime problems

    n  E = Excessive daytime sleepiness

    n  A = Awakenings during the night

    n  R = Regularity and duration of sleep

    n  S = Snoring

  • + Sleep History – Sleep Habits

    § Sleep schedule/ patterns § Diaries

    § Weekday

    § Weekend

    § Naps

    § Consistency

    § Co-sleeping

  • + What’s wrong with this picture?

  • + Sleep History - Bedtime

    § Evening activities § Bedtime routine § Latency to sleep onset § What happens during that time § How do parents respond to stalling? § Sleep onset associations § Sleep location § Where child falls asleep & wakes § Who is present, where are they, what are they


  • + Sleep History – Nocturnal Behaviors

    n Night wakings

    n Night terrors/Sleepwalking

    n Sleep-disordered breathing

    n Leg movements

  • + Differential Diagnosis

    n  Delayed sleep phase

    n  Nighttime fears

    n  Transient insomnia

    n  Restless legs syndrome

    n  Obstructive Sleep Apnea

    n  Illness or other health issue

    n  Medication effects

  • + Empirically Supported Treatments

  • + Standards of Practice: American Academy of Sleep Medicine

    n Reviewed 52 treatment studies

    n “Behavioral therapies produce reliable and durable changes” n  80% of children treated demonstrated clinically significant

    improvement that was maintained for 3 to 6 months

    n 94% of behavioral interventions were efficacious

    Mindell et al. Review paper for AASM: Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006: 29: 1263-1276 Morgenthaler et al. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006: 29: 1277-1281

  • + Behavioral Treatments -- Basics

    n Working with caregivers to change their sleep-related interactions with their child

    n 2 main components n  Modifying parental/child cognitions

    n  Modifying parental behaviors and responses to the child

  • + Behavioral Treatment Cont’d

    n Common treatment components n Bedtime Routine

    n Extinction n Standard/Unmodified or graduated

    n Shaping

    n Reinforcement

  • + Bedtime Routine

    n Bedtime routine alone shown to improve problematic sleep behaviors in young chil

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