The efficacy of various behavioral approaches and techniques for BIC has been established in controlled studies (Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006; Sadeh, 2005). Specific approaches/techniques are outlined in Table 17.2. Although prescriptive interventions corresponding with parental attitudes, abilities, and goals should be used, extinction-based procedures represent the cornerstone of most treatments for BIC. Both standard and graduated extinction interventions are used with the goal of reducing inappropriate child behaviors during bedtime by altering parental responses. Standard extinction involves completely ignoring all inappropriate behaviors (e.g., crying, yelling, tantrums, or unreasonable demands) after bedtime once the child has been put to bed and until wake time (except those posing a danger to the child). Several studies have demonstrated the efficacy of this approach in reducing bedtime resistance and sleep onset (Reid, Walter, & O’Leary, 1999; Rickert & Johnson, 1988; Seymour, Brock, During, & Poole, 1989). Although relatively straightforward, this approach may be particularly challenging for parents to implement consistently. Postextinction bursts, which include a sudden, temporary reemergence of the behavior, also are common (Owens, France, & Wiggs, 1999).

Graduated extinction consists of ignoring inappropriate behaviors and systematically increasing the amount of time before responding. Because the reward of parental attention is withdrawn gradually, graduated extinction often is easier than standard extinction for both parents and children. Using a graduated extinction approach, a parent might put a child to bed and then check on the child after progressively longer periods of time (e.g., 5, 7, 10 minutes) with the goals of having the child fall asleep independently. In between checks, the parent follows an extinction procedure and continues to ignore any inappropriate behaviors until the next check. Checks should include only brief periods of parental presence and praise; excessive dialogue, prolonged physical contact, or placating the child’s demands is avoided (Taylor & Roane, 2010). Theoretically, checks are aimed at modifying schedules of reinforcement so that the time interval rather than the child’s (inappropriate) behavior determines parental attention. Using this approach, checks may be faded out in one night or over successive nights, with the fading schedule determined by parental/child preference, the child’s age and temperament, and overall chronicity/intensity of the problem. The efficacy of graduated extinction in reducing noncompliant bedtime behavior is well established (see Mindell et al., 2006).

Extinction procedures also are frequently combined with other procedures to increase bedtime compliance and facilitate easier transitions to sleep (Kuhn & Elliot, 2003; Tikotzky & Sadeh, 2010). Bedtime fading involves delaying bedtime until the child appears naturally sleepy and then systematically moving to an earlier bedtime based on mastery of sleep initiation. This procedure reduces the amount of time spent in bed awake (i.e., stimulus control) while strengthening a child’s intrinsic sleep drive. Sadeh, Gruber, and Raviv (2003) have demonstrated that a delayed bedtime alone results in decreased sleep-onset latency in school-age children.

Positive routines incorporate pleasant and structured presleep activities into the bedtime routine as environmental sleep cues. For example, a school-age child might brush his or her teeth, put on pajamas and read a story independently, and then spend time reviewing the day with a parent leading up to bedtime. Throughout the routine, parents provide praise for compliant behaviors and avoid responding to negative behaviors. Based on review by Mindell and colleagues (2006), positive routines are at least equally as effective as extinction-based approaches and may provide a preferred alternative to extinction in reducing the likelihood of extinction bursts.

Response cost involves removing a child from bed if he or she is unable to initiate sleep within about 20 minutes. However, it is critical that children be allowed to engage only in calming, quiet activities during such periods in order to avoid increased levels of nighttime arousal. Bedtime may be delayed accordingly on subsequent nights based on the timing of successful sleep initiation on the previous night (Taylor & Roane, 2010). Research has shown that bedtime fading with and without response cost is an effective intervention in reducing bedtime resistance (Ashbaugh & Peck, 1998; Piazza & Fisher, 1991a, 1991b).

Although few controlled studies have focused on the treatment of insomnia in adolescents specifically, many of the cognitive behavioral treatment (CBT) components shown to be effective in adults (Taylor & Roane, 2010) can be used among teenagers. Stimulus control aims to strengthen the association between the bed and sleep by encouraging the individual to go to bed when feeling sleepy, removing clocks from the bedroom (e.g., since they can trigger frustration and arousal at night), and using the bed for sleep only. Cognitive techniques target maladaptive beliefs or attitudes about sleep (e.g., “I am a bad sleeper”; “I won’t be able to function tomorrow”), which may serve to fuel sleep problems, by directly challenging such thoughts (e.g., “Everyone experiences sleep problems sometimes”; “Poor sleep does not feel good but will not hurt you”). Cognitive techniques sometimes are used with relaxation training, which focuses on slow and deep breathing, progressive muscle relaxation, and/or visualizing a peaceful scene. Progressive muscle relaxation involves tensing (for 4–7 seconds) and then relaxing (for 30–40 seconds) different muscle groups throughout the body, including forehead, face, neck, shoulders, arms, wrists, hands, abdomen, buttocks, thighs, ankles, and feet. Preliminary research using such CBT techniques in substance-abusing adolescents is promising (Bootzin & Stevens, 2005).

Nighttime Fears

A variety of cognitive behavioral techniques have been examined in the treatment of children’s nighttime fears, including self-control training, relaxation training, positive imagery, positive self-statements, and differential reinforcement (Sadeh, 2005; Tikotzky & Sadeh, 2010). These approaches/techniques are outlined in Table 17.2. Because a combination of multiple techniques has been examined in most studies, the contribution of individual components is largely unclear at this time; however, the overall effectiveness of such interventions is high. For example, in a study of 33 school-age children with severe nighttime fears, self-control training, relaxation, positive imagery, and “brave” self-statements were used (Graziano & Mooney, 1980). During weekly group meetings, a trained therapist instructed the children to lie on the floor for 1 minute and practice maintaining a quiet and relaxed position while the therapist spoke in a soothing voice (relaxation training). Then the children imagined a pleasant scene (incorporated a comforting memory) that they described in detail to the therapist who recorded it in the child’s journal (positive imagery). Brave self-statements involved having children repeat positive statements, such as “I am brave” or “I can take care of myself in the dark” at the end of the exercise. Children were encouraged to practice these self-control skills for 5 minutes at night with the parents and alone when feeling afraid. As part of an additional contingency management component, parents gave tokens for “brave” behaviors (differential reinforcement were awarded for remaining in bed throughout the night and independently following the self-control training skills). In comparison to a wait-list control group, children receiving CBT evidenced significant reduction in frequency, intensity, and duration of nighttime fears as well as overall disruptive nighttime behavior, which was maintained at 1-year follow-up.

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