To determine the best way to deal with sleep problems, a task force appointed by the American Academy of Sleep Medicine reviewed 52 studies of behavioral interventions for treating bedtime struggles and night wakings in young children. Their findings indicate that behavioral therapies produce reliable and durable changes.“For parents and healthcare practitioners, this review and subsequent standards of practice provide guidelines on well-established treatments,” explains lead researcher Dr. Jodi Mindell, a pediatric sleep expert at the Children’s Hospital of Philadelphia.
Review of five types of behavioral interventions
Parents put the child to bed at a designated time and then ignore the child’s calls or cries, no matter how long they last, until a set time in the morning (unless they suspect illness or injury). Because this method can be stressful for some parents, some studies used extinction with parental presence, where the parents stay in the child’s room but ignore his/her behavior.
Graduated extinction (“sleep training”)
Parents ignore the crying but go into the room briefly at specific intervals. The duration of these intervals may be tailored to the child’s age and temperament, and the parents’ judgment of how long they can tolerate the child’s crying. They can follow a fixed schedule or wait for progressively longer intervals.
Positive Routines/Faded Bedtime with Response Cost
Parents develop a set bedtime routine characterized by quiet activities that the child enjoys. Faded bedtime with response cost involves taking the child out of bed for prescribed periods of time when the child does not fall asleep. Bedtime is also delayed to ensure rapid sleep initiation and that appropriate cues for sleep onset are paired with positive parent-child interactions. Once the behavioral chain is well established and the child is falling asleep quickly, bedtime is moved earlier by 15 to 30 minutes over successive nights until a pre-established bedtime goal is achieved.
The parents wake and console their child about 15 to 30 minutes before a typical spontaneous awakening. This is followed by the parents’ usual response to a spontaneous waking, such as rocking or nursing the child back to sleep. Scheduled awakenings are then faded out by slowly increasing the time between awakenings.
Strategies typically target bedtime routines, developing a consistent sleep schedule, parental handling during sleep initiation, and parental response to night wakings. Almost all programs recommended that babies be put to bed “drowsy but awake” to help them develop independent sleep initiation skills at bedtime, enabling them to sleep without intervention following naturally occurring night-time arousals.
After reviewing the 52 studies, which involved over 2,500 infants and toddlers, the researchers concluded that extinction (including extinction with parental presence) and parent education/prevention had the strongest empirical support, while graduated extinction, positive routines/faded bedtime, and scheduled awakenings were also effective interventions.
Dr. Shirley Blaichman, a community-based pediatrician who also works at the Montreal Children’s Hospital, sees parents of young children with sleep difficulties on a daily basis. She says it’s very helpful to know that the strategies she and other pediatricians have been recommending are backed by solid evidence. “When talking to parents, we can show them that this is not just what grandma or the neighbor says, but that it is truly evidence-based, it does work, and it has no adverse effects.”