Bedtime Problems

Bedtime problems occur in about 10–30% of preschoolers and toddlers.⁹ Typical symptoms include avoidance of bedtime (such as refusal to get into bed, stay in bed, or participate in the bedtime routine) and frequent requests after lights out (such as for food, drinks, or stories). Bedtime problems often begin as part of the emerging independence of toddlers, but they can continue or develop in preschoolers and school-aged children as well. Often, children will test limits in order to determine boundaries and gain independence, both at night and during the day. In most cases these behaviors are developmentally appropriate; however, at bedtime these behaviors may be more difficult for parents to address, and they can result in inconsistent bedtime routines or parental limits that change with the child’s requests. When nighttime routines and appropriate rules are absent, inconsistent, or dependent upon the child’s requests, bedtime problems may emerge.

Night Wakings

Frequent night wakings of children are reported by 25–50% of parents10–12 and are found to be most problematic in infants and toddlers aged 6 months to 3 years. The conditions under which the child learns to fall asleep (i.e., sleep associations) may have a direct impact on the frequency of night wakings, as may other behavioral factors and circadian issues; however, medical causes, such as reflux and obstructive sleep apnea, should be considered. When sleep associations involve another person (typically a caregiver), it is more difficult for the child to return to sleep independently following normative night wakings. Parental presence (e.g., rocking, feeding, or lying down with the child) has been shown to be one of the most common predictors of frequent night waking.¹⁰ Although parents often perceive that their children with night wakings have more frequent arousals than do other children, in fact such wakings are a normal part of sleep architecture and are experienced equally by children with and without reported night waking.¹³ It is the child’s signaling at times of waking – by crying, calling, or getting out of bed (because of difficulty returning to sleep independently) – that makes the parents aware of, and thus report as frequent, the night wakings.

Children often have frequent night wakings and bedtime problems as coexisting symptoms. When bedtime problems lead to a long bedtime routine and increased time to sleep onset, caregivers may eventually do whatever it takes for everyone to get to sleep. Furthermore, inconsistent limit setting may facilitate the development of negative sleep associations. For example, a child may repeatedly prolong bedtime with demands (typically by calling out, crying, or having tantrums). If the caregiver eventually gives in to these demands, perhaps by lying down with the child or bringing him or her into the parental bed, these behaviors are reinforced. Thus, the sleep problem is related to both the negative sleep onset associations and to the lack of appropriate limit setting.

Sleep Hygiene

Sleep hygiene is typically a component of treatments for bedtime problems and frequent night wakings. Any intervention to address childhood sleep problems should begin with an assessment and, if necessary, recommendations for improving sleep hygiene. Positive sleep habits include having a consistent sleep schedule on weekdays and weekends (that provides the opportunity for adequate sleep duration), a regular bedtime routine, and conditions that are conducive to falling asleep. Several large-scale studies have found that absence of these sleep practices has a significant negative impact on bedtime and nighttime sleep behaviors.2,15

The evidence as to whether sleep hygiene itself directly results in improvements in sleep is mixed. For example, one study¹⁶ found that sleep hygiene alone significantly improved sleep in almost 20% of children with ADHD and insomnia. In contrast, another study found that although combined behavioral–educational intervention for new mothers resulted in significant improvement in maternal and infant sleep, just teaching maternal sleep hygiene and providing basic information about infant sleep did not.¹⁷ (Also see section on Education/Prevention below.)

Although inclusion of a bedtime routine is often recommended to caregivers as part of well child care or as a component of behavioral sleep interventions, the importance of the bedtime routine itself may be underappreciated. For example, a 2009 study found that, compared to controls, a bedtime routine alone resulted in improvements in sleep onset latency, number of night wakings, sleep continuity, problematic sleep behaviors, and maternal mood.¹⁸ Other important aspects of good sleep hygiene (besides having an appropriate bedtime routine) include avoiding letting the child fall asleep while feeding and moving the feeding to the beginning of the routine, eliminating caffeine, and avoiding use of electronics 30–60 minutes before bedtime.

Extinction

Standard extinction involves putting the child in the crib or bed at a consistent time and ignoring the child’s negative behaviors (such as crying, yelling, tantrums), while monitoring for safety, until a specified wake time. Extinction is one of the earliest behavioral interventions developed and tested for bedtime problems and frequent night wakings, and it has been well validated.¹ At least three randomized-controlled trials (RCTs)^19–21 provide empirical support for standard extinction. One RCT compared extinction to scheduled awakenings and to a control group. Based on parental reports it was found that the extinction group had fewer night wakings than controls, and that the improvements seen occurred more quickly than in the scheduled awakenings group.¹⁹ Extinction alone has also been compared with extinction combined with a medication (trimeprazine) or placebo.²¹ Extinction was effective in all three groups – with improvements maintained at both 6 and 30 months – but the fastest response was in the extinction plus medication group.

Consistency is the key to success with extinction, yet most caregivers find their child’s prolonged crying to be extremely stressful; thus the standard approach to extinction may be difficult for some parents. If parents respond to their child’s yelling and crying after a period of time, the child’s negative behavior is reinforced with attention and reward, increasing the likelihood of the behavior continuing. Parents should also be advised about the possibility of an initial or delayed extinction burst or brief worsening of negative behaviors. While this is a normative part of the extinction process, parents may perceive this as evidence that the intervention is not working.

Graduated Extinction

Graduated extinction, like standard extinction, involves ignoring negative behaviors, but only for a specified duration, before checking on the child and providing only brief reassurance and limited attention. These regular checks continue until the child falls asleep. The overall goal is to extinguish negative behaviors, thereby increasing the independence of the child (e.g., by moving them into their bed/crib/room and allowing them to develop their own soothing skills and positive sleep associations) and decreasing the child’s reliance on a caregiver to help fall asleep at bedtime and return to sleep following normative night wakings. This treatment can be implemented in a number of ways including gradually moving the parent out of the room (e.g., first sitting beside the bed, then in the doorway), checking at fixed intervals (e.g., 3 minutes between checks), or checking at increasing intervals (3 minutes, then 5 minutes, then 10 minutes). Studies have found all such approaches to be efficacious.1,22,23 In a clinical situation, the decision regarding the time between checks is usually based on parental comfort and acceptability, as well as on child temperament and the length of time the child will stay in bed (for toddlers).

A number of RCTs support the use of graduated extinction as an effective intervention for bedtime problems and frequent wakings. Hiscock et al.²⁴ compared graduated extinction, instituted at an 8-month well-child visit, to a control group. The intervention group demonstrated fewer sleep problems at 10 and 12 months. Adams and Rickert²⁵ compared graduated extinction (ignoring the child for a set amount of time determined by the child’s age and parent input) with positive bedtime routines. Both intervention groups were effective at reducing negative bedtime behaviors when compared with controls.

An RCT of 3–6-year-olds found the use of a bedtime pass to be an effective modification of graduated extinction. In this study, children were given a card (the bedtime pass), which could be traded in for a reasonable request (such as a visit from a caregiver or a drink of water).²⁶ After the bedtime pass was used, caregivers were instructed to ignore negative, attention-seeking behaviors from the child. Results demonstrated less frequent calling and crying out and shorter time to quieting in the intervention group compared to controls, and these improvements were maintained at 3 months. High parental satisfaction was noted.

Despite evidence that both graduated and standard extinction are effective, of the two approaches, graduated extinction is almost always the one recommended, as it is often perceived by parents and providers to be a ‘gentler’ approach. Overall, graduated extinction interventions are typically the most widely utilized behavioral treatment for bedtime problems and night wakings.

Positive Routines with Faded Bedtime

Positive routines with faded bedtime involves developing a short, enjoyable bedtime routine to be implemented at a later than desired bedtime (closer to the time the child is currently falling asleep). The goal is for the child to develop an association between the positive bedtime routine and falling asleep quickly. Once this association is established, the child’s bedtime is moved earlier in 15-minute increments. Unlike extinction, where the goal is to reduce negative behaviors, the goal of positive routines and faded bedtime is to reduce the physiological and emotional arousal that accompanies bedtime conflict and for the child to develop or increase appropriate bedtime behaviors.¹

At least three studies have found positive routines with faded bedtime to be effective in the treatment of bedtime problems and night waking.25,27,28 The only study of positive routines with faded bedtime to include a control group also had a group treated with graduated extinction. Prior to the later bedtime (in the positive routine group), the parent and child would complete 4–7 calm, pleasurable activities together; if the child began to tantrum, the parent was to end the activities and tell the child that it was time for bed; finally, the child’s bedtime was gradually moved earlier until the desired time was reached. In this study, the positive routines with faded bedtime and the graduated extinction treatments were both significantly more effective than was no treatment (the control group) but were not significantly different from each other.