While several sources have been used to compile this booklet, including Protocol #03 – Conquering Insomnia, This manual is particularly indebted to Vincent Mark Durand and his book Sleep Better! A Guide to Improving Sleep for Children With Special Needs, Paul Brookes Publishing Company, 1998.
Note: Error with Supplemental Document.
As was stated in Protocol #03 – Conquering Insomnia, between 20% and 25% of preschool and school age children have sleep problems. Perhaps more importantly, however, is the fact that sleep disorders have been found to link to behavior problems. Gordon Wrobel, health-care coordinator for the National Association of School Psychologists, links sleep problems with attention deficit hyperactive disorder [ADHD]. Wrobel goes on to say that students often have a combination of emotional disturbance [ED] and a sleep disorder since one feeds off the other, Ronald Chervin, director of the Michael S. Aldrich Sleep Disorders laboratory, states “…sleep problems in children could represent a major health issue. It is conceivable that by better identifying and treating children’s … nighttime … problems, we could help address some of the most common and challenging childhood behavioral issues”. And finally, Peg Dawson, states, “the sleep pattern is critical to look at for children with attention disorders as it may be part of the cause”.
V. Mark Durand suggests that children with disabilities are more likely to have more sleep difficulties than typical children. He uses the phrase ‘children with special needs’ to indicate a range of individuals with varying abilities but references most often children with such labels as autism, mental retardation, pervasive developmental disabilities and attention deficit hyperactive disorders. He also points out that other children who have not received official labels but have difficulty learning or may have experiences trauma [e.g., abuse, accidents] may manifest sleep difficulties as well.
Perhaps the definition could be expanded even further to include children who have been given such labels ad Conduct Disorder or Oppositional Defiant Disorder, i.e., kids whose behavior IS the problem. After all one major outcome of lack of sleep is irritability and crossness. It is possible that such children by manifesting an irritable nature instigate a negative feedback cycle in which they receive such negative responses that they help create a theory of meaning that incorporates beliefs about themselves as ‘bad’ and other people as not liking them. Such maladjusted thoughts are just waiting for a problem outcome. What we are suggesting is that sleep problems may lead to interpersonal difficulties in themselves. It is probably true that a child needs other negative aspects – such as negative role models – but this is relatively easy to obtain, particularly if one is looking for it and creating an environment in which it can occur.
If people are the ‘sum total of their thoughts’, getting a good night’s sleep and allowing those around you to get a good night’s sleep is probably a good foundation for an environment supportive of ‘good’ [balanced and rational] thoughts, while the contrary situation, with interpersonal relationships based on irritability and response, lesser functioning social an academic arenas and the interpretations available in that process, is very supportive of distressing thoughts about self, others and future prospects.
This booklet is not to replace Conquering Insomnia, but to extend it. It is an attempt to organize selected remedial techniques that can then be applied to two  patterns of sleep that may have up to one hundred causes or diagnoses.
We do not intend to address the nature of all the disorders completely and there are a variety of resources on the internet which can provide additional information to you as needed. However, some of these disorders require clinical involvement and there is a list of Certified Sleep Clinics for the Pennsylvania region listed in the Appendix. Some sleep disorder can be quite frightening, even thought they are not harmful in and of themselves. To help you understand some of these descriptions, you might first want to review the Sleep Stages Chart [see next page] and the nature of sleep.
During sleep, the brain processes information and makes it accessible to us later. Research has suggested that sleep also may be involved in the body’s ability to ward off illness. Helping to restore the immune system. Without sleep we die. With less sleep than necessary, we become irritable, our motivation declines and our ability to concentrate on everyday tasks is diminished. Such diminished capacity certainly does not support academic or social competence.
Sleep is not a time when the brain shuts down for a rest. IN REM [Rapid Eye Movement] sleep that occurs in the fifth or REM stage – we dream and with those dreams, we may have nightmares. Although the brain is very active during REM sleep, the body is almost paralyzed. This paralysis of the muscles keeps us from acting out our dreams – but as you will see, it also has other more negative effects.
Sleeptalking and sleepwalking [also called somnambulism], occurs during NREM (nonRapid Eye Movement) sleep and probably does not represent the acting out of a dream since they do not occur in the dreaming stage.
Sleep Stages Chart
|Bodily Activity||Depth of Sleep||Thought Process||Miscellaneous|
|Slows down, decreased muscle tension||Borderline wakefulness||Relaxation, mind wanders, awareness dulls||Heart rater, pulse, temperature and blood pressure slightly diminished|
|1||Eyes roll slowly on falling asleep, eyes motionless in later stage 1 periods, body movement slowed||Light sleep, easily awakened, might deny being asleep if awakened||Drifting thoughts and floating sensation||Temperature, heart rate, pulse decline further. Regular breathing. May have hypogenogic hallucinations on falling asleep.|
|2||Eyes quiet. Few body movements, snoring is common.||Light to moderate sleep. Relatively easy to awaken. Eyes will not see if open.||Some thought fragments, memory processes diminished, may describe vague dream if awakened.||Decreased heart rate, pulse, blood pressure, temperature and metabolic rate. Regular breathing with increased airway resistance.|
|3||Occasional movement, eyes still.||Deep sleep , takes louder sound to be awakened.||Rarely able to remember thoughts. A few vaguely formed dreams. Possible memory consolidation.||Metabolic rater, pulse, heart rate, blood pressure and temperature decrease further. Increased secretion of growth hormone.|
|4||Occasional movement, eyes quiet.||Deepest sleep, very difficult to awaken.||Virtually oblivious, very poor recall of thoughts if awakened – possible involved in memory consolidation||Continued decline in heart rate, temperature and metabolic rates. Increased secretion of growth hormone [possibly to restore body tissue].|
|REM||Large muscles paralyzed. Fingers, toes and facial muscles twitch. Erections, snoring uncommon.||Variable. If sound is incorporated into dream, then harder to awaken.||80% dreaming, good vivid dream recall, especially later in the evening. Probably involved in unconscious conflict resolution.||Heart rate 5% greater than above stages. Pulse, temperature and metabolic rates increase. Irregular breathing one-half extra breath per minute.|
Our biological clock has a lot to do with our sleep. A little bundle of cells – about the shape and size of this letter ‘v’ – that is called the superchiasmatic nuculeus [SCN] is our ‘biological clock’ – the part of the brain that keeps many body rhythms in sync. Researchers have discovered that most people have a sleep-wake cycle that leans toward twenty-five  rather than twenty-four  hours. The discovery has helped to answer several questions, such as why it is easier to stay awake an hour or so later at night than it is to fall asleep and hour earlier.
This twenty-five hour cycle is regulated for most people by the amount of light – ergo, we tend to get sleepy as the light disappears. Because people with blindness cannot receive light cues from the sun, their sleep-wake cycle sometimes runs through the full twenty-five hour cycle creating definite sleep problems. Other people also have unusual cycles of more than twenty-five hours that creates difficulties.
Delayed sleep phase syndrome and non-24 hour sleep-wake cycles are relatively rare problems; most people sleep at times that are less desirable because of other factors.
Our body temperature is at the lowest in the early hours of the morning [between about 4:00 a.m. and 6:00 a.m.] and begins to rise just before we awaken, This rise in temperature is involved in our alertness and also, signals the time to wake up in the morning.
Our high temperature occurs in the early evening [between 7:00 and 8:00 p.m.] and then begins to decline. This drop in temperature signals a time of decreased alertness and corresponds to when most people feel the need for sleep. This fact means that things that raise our internal body temperature, such as exercise, can diminish our sleep as well. In terms of helping our sleep, the best time to exercise is in the late afternoon. The rise in body temperature from exercise at this point of the day last for about six hours and then declines. This makes it optimal for falling asleep in the late evening.
For some children, bedtime difficulties stem from the inability or the unwillingness of parents to set limits on their children’s bedtime. It is therefore important that the sleep hygiene and bedtime routines be put in place.
TYPES AND PATTERNS OF SLEEP
Sleep professionals break insomnia into three different and distinct types:
- Difficulty falling asleep at night [difficulty initiating sleep]
- Waking frequently at night or too early [difficulty maintaining sleep]
- Not feeling rested after sleep [nonrestorative sleep]
In this booklet, however, we will organize the failure to sleep somewhat differently for the purpose of selecting techniques for use.
The two patterns that we will address are:
- Night waking and
- Sleeping at the wrong times
In either case, we can have a child who either manifests disruptive behavior or not. Obviously, if the child is having a tantrum every time s/he wakes up that is a different problem than if s/he wakes up but lies quietly in bed.
The model of this booklet therefore will look something like the diagram below.
|General Techniques||Sleep Patterns||Disruption||Specific Techniques|
|1. hygiene||a. waking in the middle of the night||yes||a. cognitive relaxation
b. bedtime fading
c. graduated extinction
d. paradoxical intention
e. progressive relaxation
f. scheduled awakening
g. sleep restriction
h. stimulus control
k. placebo ‘magic’
l. sleep extensions [night terrors only
|2. routine||a. waking in the middle of the night||no||a. cognitive relaxation
d. paradoxical intention
e. progressive relaxation
f. scheduled awakening
g. sleep restriction
h. stimulus control
j. bright light therapy
|3. thoughts||b. sleeping at the wrong times||6. Yes||a. cognitive relaxation
b. bedtime fading
c. graduated extinction
d. paradoxical intention
e. progressive relaxation
g. sleep restriction
h. stimulus control
j. bright light therapy
|b. sleeping at the wrong times||7. no||a. cognitive relaxation
d. paradoxical intention
e. progressive relaxation
g. sleep restriction
h. stimulus control
j. bright light therapy
The general techniques are potentially applicable to all situations, but also cover the category of difficulty initiating sleep. They also address the bedtime difficulties that stem from the inability or unwillingness of parents to set limits on their children’s bedtime.
We need to emphasize that giving medication to children to get them to sleep at night may quickly become a source of sleep problems. Pediatricians will often suggest sleep-inducing medication because it can help a child go to sleep quickly at bedtime and can prevent many bedtime disturbances. The problem with many of the medications is that when parents try to stop using them, it can actually make sleep worse than before. This phenomenon is called rebound insomnia and is sometimes the cause of nighttime disturbances in children. Medication for sleep, especially among children, is typically not recommended.
The general techniques are tied closely to the tools that will help you to determine exactly what is going on with the child’s sleep habits.
The Sleep Diary [CBT#44-001] shown in the Appendix provides space for the parents to collect and record data about when the child goes to bed, how long it takes to fall asleep, whether the child wakes up at night and how long it takes him/her to fall back to sleep, whether the child is disruptive when she wakes up at night and when s/he wakes up in the morning. Finally, it indicates whether the child takes any naps.
Normally, it takes anywhere from 15 to 30 minutes to fall asleep, although some people fall asleep right away. Taking longer than 30 minutes to fall asleep at night could indicate that the child is not tired at bedtime. There are many reasons why a child may not be tired or ready for bed, but sleep schedule problems would be suspected. The Sleep Diary would indicate if the child is sleeping too much during the day, or s/he might be manifesting a problem with his or her biological clock.
There is room on the Sleep Diary to indicate whether and how many times the child may have awakened during the night. If you record this happening, then you will want to describe the awakening. This information reveals how much the child’s sleep is disrupted and the kind of behavior problems that the parents face. If night awaking or bedtime is a significant behavior problem, then the parents also would complete a Behavior Log – also found in the Appendix as CBT-#44-002. Finally, information about the time when the child wakes up each morning and naps reveals the total amount of sleep time, any schedule problems [e.g., the child wakes up too early], and the way that sleep is or is not spread out during the day.
The Sleep Diary essentially provides information about the child’s sleep routine and/or sleep hygiene issues that need to be addressed.
For many children, just addressing these issues will be sufficient to improve their sleep. These implications can be further explored through the use of the Good Sleep Habits Checklist [CBT#44-003]
GOOD SLEEP HABITS CHECKLIST [CBT#44-003]
[ ] Establish a set bedtime routine: Usually 30 minutes of quieting down, washing and preparing to go to sleep.
[ ] Develop a regular bedtime and a regular time to awaken.
[ ] Increase the time between eating and bedtime – eating certain foods increases body temperature – warm body temperature signals ‘wake up’; cooler body temperature signals ‘go to sleep’.
[ ] Eliminate all foods and drinks that contain caffeine six  hours before bedtime.
[ ] Limit any use of alcohol or tobacco.
[ ] Try drinking milk before bedtime.
[ ] Do not exercise or participate in vigorous activity in the four hours before bedtime.
[ ] Restrict activities in bed to those that help induce sleep.
[ ] Reduce noise level in bedroom.
[ ] Reduce light in bedroom.
[ ] Avoid extreme temperature changes in bedroom.
NOTE: Sleep medications can often be a part of the sleep problem [rebound insomnia]. While medications may have some positive impact for short periods of time, they become more problematic with long use.
NOTE: Many sleep habits are learned in infancy – e.g., night waking includes food and cuddling – and requires specific techniques to overcome.
This good sleep habits check list will give you an indication of what specifically needs to be addressed in the area of sleep hygiene and routine.
Looking at the amount of sleep time across a 2-week period can give the parent an ‘average’ night. It is important that you estimate how much time the child actually sleeps as opposed to just the time spent in bed.
Adjusting either bedtime or awake time so that the child only sleeps for a new number of hours will provide for a better nights sleep. Sleep Restriction or Sleep Extension techniques provide methods of response.
One source of difficulty is bad associations between the bed or bedroom and sleep. The bed becomes a signal for play or worry. It is important that a child who is having sleep difficulties associate the bed only with sleep. This will require that s/he not read, watch TV or lie awake in bed for long periods of time.
Many people come to connect their bed or bedroom with activities that interfere with sleeping. Both positive and negative associations with the bed can cause a person to have trouble falling asleep.
Because it is difficult to determine whether these types of associations are the problems that are causing sleep difficulties, parents should restrict the child’s activities surrounding the only bed to only sleeping. This technique is called Stimulus Control, meaning that the bedroom or the bed can no longer trigger behavior that can help or hurt sleep. Previously learned associations are relearned to reflect new associations that are more beneficial to sleep.
There are certain daily living practices that influence your ability to fall asleep and stay asleep. While most people are aware of the effects of caffeine, many are not aware that caffeine stays in the system for up to six  hours. Nicotine is also a stimulant with long lasting effects. Not only is nicotine an addictive drug, but it is also one for which people need frequent ‘fixes’. Nicotine’s effects are relative short, only a few hours, which is why people will continue to smoke throughout the day. Waking in the middle of the night for some people is the result of withdrawal symptoms from nicotine. Getting up and smoking a cigarette temporarily satisfies the desire for nicotine and allows the person to fall back to sleep.
The medications Ritalyn and Cylert can interfere with sleep as well.
Exercising too close to bedtime, noise, too much light, or even an uncomfortable temperature can prevent a smooth bedtime. So we now have a general overview of the nature of sleep habits and the kinds of specific difficulties that can arise. Using the Sleep Interview that appears in the Appendix can collect further information. Armed with this basic information, we are now prepared to look at some of the techniques and procedures that can be used to help the child sleep better. These are structural responses that can enhance the sleep of the child.
- Sleep Hygiene: Some people’s daily habits can interfere with their nighttime sleeping. This approach involves instructing the sleeper about the negative effects of caffeine, nicotine, alcohol, exercise too close to bedtime, certain foods and medication, on their sleep.
- Bedtime Routines: Creating a consistent and unchanging routine lasting about thirty  minutes just prior to bedtime, including soothing activities (e.g., bath, reading a story), that always leads to bed. This can be useful for difficulties initiating sleep for children of all ages.
- Cognitive: This approach focuses on changing the sleeper’s unrealistic expectations and beliefs about sleep (“I must have eight hours of sleep each night, if I get less than eight hours of sleep it will make me ill”). The clinician helps to alter beliefs and attitudes about sleeping by providing information on topics such as normal amounts of sleep and a person’s ability to compensate for lost sleep. More appropriate for older children and adolescents.
a. Cognitive relaxation
Because some people become anxious when they have difficulty sleeping, this approach uses meditation or imagery to help with relaxation at bedtime or after waking up at night. This technique may be more appropriate for older children and adolescents. This technique is extensively reported in Protocol #03 Conquering Insomnia, so we will spend little time with it here except to say that helping a child think about [imagine] a place that s/he believes to be peaceful and pleasant helps to frame the process of relaxing for sleep. See also, CBT#04 – Relaxation.
b. Bedtime fading
For bedtime disturbances or sleep-wake schedule difficulties, using this intervention – the parent first establishes a time in which the child consistently falls asleep with little difficulty (e.g., 11:30 p.m.), then systematically makes bedtime fifteen  minutes earlier until the child is falling asleep at the desired time.
Some parents cannot tolerate the crying that occurs in graduated extinction. At other times children are so disruptive at bedtime that a parent cannot allow the child to continue the tantrum too long. Often this occurs as the child grows older and can inflict more damage on him or herself, on others or on property.
If bedtime is usually 9:00 p.m., but the child fights going to bed at this time, then temporarily make bedtime 11:30 p.m., a time when the child may be so tired that bedtime is no longer a battle. If this new bedtime is successful [i.e., the child falls asleep with little resistance], then you can begin to fade back bedtime in small increments until the bedtime at which you want the child to fall asleep is achieved.
The reason you want to avoid prolonged periods in bed without sleep is that you do not want the child to begin to associate the bed with not sleeping.
If the child is falling asleep within about fifteen  minutes at the new bedtime over two consecutive nights, then you can begin to move back the bedtime. For each two nights, move the bedtime back by fifteen  minutes.
- Select a bedtime when the child is likely to fall asleep with little difficulty and within about fifteen  minutes. To determine this bedtime, use the sleep diary to find a time when the child falls asleep when left alone [e.g., 1:00 a.m.] then add thirty  minutes to this time [new bedtime – 1:30 a.m.].
- If the child falls asleep within fifteen  minutes of being put to bed at this new bedtime and without resistance for two consecutive nights, then move the bedtime back fifteen  minutes [e.g., from 1:30 a.m. to 1:15 a.m.].
- Keep the child awake before the new bedtime even if s/he seems to want to fall asleep.
- If the child does not fall asleep within about fifteen  minutes after being put to bed, then have him or her leave the bedroom and extend the bedtime for one  more hour.
- Continue to move back the bedtime [e.g., from 1:15 a.m. to 1:00 a.m.] until the desired bedtime is reached.
c. Graduated Extinction
Used for children who have tantrums at bedtime or wake up crying at night, this intervention instruct the parents to check on the child after progressively longer periods of time, until the child falls asleep on his or her own.
Graduated extinction involves spending increasing longer amounts of time ignoring the cries and protestations of a child at bedtime. Ignoring the cries, but also periodically checking in case there really is something wrong.
Wait a full five minutes and then briefly go into the room – seeing that s/he is all right and tell him/her to go back to sleep. Importantly, do not pick the child up as is usually done at these times, do not feed the child, nor give something to drink, or play music. It is in and out in about fifteen  seconds.
Then the second night wait up to seven  minutes with everything else remaining the same. Next night extend the time to nine  minutes.
Graduated extinction seems to work by forcing the child to learn how to fall asleep on his or her own.
- Follow the procedure for establishing a bedtime routine
- Establish and be firm about bedtime
- Determine how long you are able to wait before checking on the child
- Pick the night to being the plan, assuming no one will have a good night’s sleep that evening – most people begin on a Friday night
- On the first night, put the child to bed, leave the room, then wait the agreed-on time [e.g., three (03) minutes]
- if after three  minutes the child is still crying, then go into the room [do not pick up the child, do not give him or her food or a drink, do not engage in extensive conversation, tell him or her to go back to sleep, then leave
- wait another three  minutes and go back into the room if the child is still crying
- continue the same pattern until the child is asleep
- On each subsequent night, extend the time between visits by two  or three  minutes. Continue the same procedure when entering the room.
d. Paradoxical intention
This technique involves instructing individuals in the opposite behavior from the desired outcome. Telling poor sleepers to lie in bed and to try to stay awake as long as they can is used to try to relieve the performance anxiety surrounding efforts to fall asleep. Virtually all paradoxical strategies are designed to counteract maladaptive responses by not actively contesting their existence. By doing so, by not feeding into the symptom through inadvertently setting up a power struggle, the technique subtly helps to redefine or ‘reframe’ the meaning of the symptom in a way that renders its alteration or removal as feasible. Regarded in this way, the use of paradoxical tactics suggests that all interventions strive to weaken or ‘undo’ problematic behavior by undermining its perceived meaning.
e. Progressive relaxation
This technique involves relaxing the muscles of the body in an effort to introduce drowsiness. The combination of having the skill to reduce tension and having the feeling of control has been helpful for many children.
- Have the child lie back on the bed – arms and legs should be limp as well as the head. For younger children, a simple instruction such as ‘act like a wet noodle’ may be enough to help them visualize what you want
- Now begin with the facial muscles, asking the child to slowly and carefully tense the muscles. The tension of the muscles should last for about five  seconds
- Following the tension of a set of muscles, have the child relax the muscles and give him or her ten [10/15] to fifteen seconds to experience the good feeling of relaxation.
- As you talk to the child, use a soothing and calming voice – take your time
- Move from the facial muscles to the jaw [clenching and relaxing], then to the neck and shoulders, to the arms and hands, chest, stomach, thighs, legs and feet
- Have the child tell you whether s/he is experiencing any pain or discomfort. You may need to instruct not to tense the muscles too tightly, or you may want to avoid certain muscle groups
- Have the child practice until s/he can run through it alone
- Have the child use the relaxation procedures any time s/he feels tense or anxious
For some children the relaxation exercises can be made a part of their bedtime routine – serving two important functions. First, it can help relieve some of the muscle tension that comes along with anxiety. Second, giving the child this task at night can help to keep his/her mind off the fearful thoughts.
Remind the child that this relaxation skill can be used at any time – in the middle of the night when s/he awakens and is fearful, even during the day if s/he is feeling tense. See CBT#04-Relaxation for complete details.
f. Scheduled awakening
Used for children who wake frequently during the night, this approach involves waking the child approximately sixty  minutes before s/he usually awakens at night. This helps teach the child to fall back to sleep on their own when they are aroused from a deeper stage of sleep.
This plan actually involves waking the child in the period before s/he usually awakens. You gently touch or shake the child to the point that s/he seems to awaken and then you led him/her fall back to sleep. This simple technique is often successful in completely eliminating night wakings – sometimes from the first night on.
How do you know whether you have picked the wrong time? One way to tell is to observe how the child reacts to being awakened. This type of plan seem to work best when the child does not full awaken but just opens his/her eyes briefly and then immediately goes back to sleep.
If the child awakens fully, then move back the scheduled time by fifteen  minutes for the next episode. ‘Play’ with the time in this way until you discover the right time to wake the child.
Scheduled awakening is an ‘errorless’ procedure because it can reduce or eliminate night waking without going through disturbing or dangerous tantrums.
- Use the sleep diary to determine the time or times when the child typically awakens during the night
- On the night that you are to begin the plan, awaken the child approximately thirty  minutes prior to the typical awakening time
- If the child seems to awaken easily, then move the time back fifteen  minutes the next and on all subsequent nights
- If there is a broad range in the times when the child awakens [e.g., from 12:00 a.m. to 1:30 a.m.] then awaken the child about thirty  minutes before the earliest time.
- Do not fully awaken the child. Gently touch or talk to the child until s/he opens his/her eyes, then let him/her fall back to sleep
- Repeat this plan each night until the child goes for a full seven  nights without waking. When the child has achieves this level of success, skip one night [i.e., no scheduled awakenings] per week. If the child has awakenings, then go back to every night. Slowly reduce the number of nights per week with scheduled awakenings until the child is no longer awakening during the night
g. Sleep restriction
This consists of limiting the child’s time in bed to the actual amount slept. This is done to help the sleeper associate time in bed only with sleeping and not with tossing and turning, trying to fall asleep.
Looking at the amount of sleep time across a two-week period can give the parent an ‘average’ night’s sleep. It is important to estimate how much time the child actually sleeps as opposed to just the time spent in bed.
Set up a schedule so that s/he will sleep somewhat less. Remember, the idea behind sleep restriction is to make the time in bed really count so that the child sleeps soundly through the night. Schedule about ninety [90%] percent of what the child is actually sleeping.
Adjust either bedtime or waking time so that the child only sleeps for the new number of hours. It is recommended that you adjust the schedule by waking the child earlier in the morning. Using the bedtime to adjust the schedule may work just as well, but once you try to move the bedtime to an earlier hour, you may run into some difficulty. Because of the way our biological clock works, it is always easier to stay up later than it is to fall asleep earlier. In this case, it is usually easier to let the child sleep later in the morning as you try to fade back to the previous schedule than it is to get the child to fall asleep earlier.
There may be times when the child is found lying in bed awake. If that ever happens and you believe that the child is wide awake, then have him/her leave the bed and do something quiet for 15-30 minutes. We do not want the child to associate the bed with anything other than sleep.
If the child goes for at least a week without waking in the middle of the night with this new schedule, then you can begin to slowly move forward to the previous sleep schedule by about fifteen  minutes each week.
- Use the sleep diary to estimate the number of hours that the child sleeps, on the average, each night. Exclude any time that the child is in bed but is awake.
- Multiply the average number of hours actually asleep each night by 0.9 to get 90% of the time, or the number of hours that the child should be sleeping on this new schedule. Do not allow fewer than four  hours when selecting a new sleep schedule.
- Adjust the child’s bedtime or the time when the child is awakened in the morning to approximate the new schedule
- If bedtime is a problem, then work on that sleep problem before you begin a sleep restriction plan
- If you find the child lying in bed wide awake, then have him/her leave the bed and engage in some soothing activity until s/he appears sleepy/ then return him/her to bed.
- If night waking is eliminated or significantly diminished for one  week, then you can readjust the bedtime or waking schedule by fifteen  minutes. This can be adjusted once per each successful week until the desired schedule has been reached.
|Graduated Extinction||Bedtime Fading||Scheduled Awakening|
|Can be used at the regular bedtime rather than having to wait until late at night||Requires listing to the child’s cries which can be difficult for many families||Often can be ‘effortless’, with no increase in behavior problems||Requires that someone remain up late at night||Often can be ‘effortless’ with no increase in behavior problems||Requires that someone remain up late at night|
|Can check on the child for reassurance||Can result in an increase in behavior problems||Often prevents long bouts of crying||Can take several weeks before the desired bedtime is reached||Results often can be observed in the first night||Requires regular and predictable waking|
|Usually works within the first week||Some behaviors such as injurious ones, cannot be ignored||Often prevents long bouts of crying||Can take several weeks before the desired bedtime is reached|
h. Stimulus Control
This approach includes instructions to go to bed only when sleepy, use the bedroom only for sleep (not reading, television watching or eating), get out of bed when unable to fall asleep, get out of bed in the morning at the same time each day regardless of the amount of time you slept.
This approach essentially involves keeping the child awake later and later on successive nights until s/he achieves the desired new sleep schedule.
- Use the Sleep Diary to identify the typical sleep-wake schedule of the child
- On the night when you are to begin the plan, keep the child awake approximately three  hours after his/her typical bedtime
- Do not allow the child to sleep at times other than the scheduled ones – no naps
- Each successive night, move the bedtime ahead another three hours
- Keep this schedule until the child’s new bedtime approximates the desired bedtime
Unfortunately, what this plan offers in terms of simplicity is usually offset by its lack of practicality. For most families, it would be extremely difficult, if not impossible to adhere to this type of sleep schedule. Implementing such a plan might have to wait until an unstructured time, such as a summer vacation, makes it possible.
j. Bright Light Therapy
Whereas chronotherapy takes advantage of our non-twenty-four hour biological clock, bright light therapy makes use of the brains reliance on light to trigger this biological clock. Remember that decreasing light in the early evening seems to be responsible for the release of the brain hormone melatonin. The increase in sunlight in turn signals the decrease in production, which corresponds to our increasing alertness.
Bright light therapy relies on banks of florescent light bulbs to provide a morning light boost, which, for some people, helps to reset their biological clock.
A typical plan involves having the child sit in front of a bank of lights for several hours after awakening. The lights must provide more light than is typical because they have to produce approximately the amount of light provided by the sun. ‘Light boxes’ are now commercially available and usually include about six fluorescent light tubes.
While this problem is relatively rare, the bad news is that it appears disproportionately affect people with special needs. People with severe visual impairments and people with autism appear to be at greater risk for experiencing this sleep problem.
k. Using ‘Magic’
A placebo is a non-active devise which is used to test medications and other interventions. In many cases the placebo works because the person believes that it is going to work. Many medications on the market – although designed with active ingredients – are mostly valuable for the placebo effect.
For some children, in some areas of the sleep problems, you will be able to use ‘magic’ as part of the placebo strategy. Durand describes a situation where the child was having nightmares about monsters. The parents purchased a ‘magic’ sword that was given to the child to drive away the monsters. The placebo effect of the sword was real enough for the child felt that the sword protected him – and it made him less anxious and perhaps feel more in command. This type of ‘magic’ can be very effective.
It is important to describe the technique to the child as a powerful one, because the child’s expectation for the technique can be just as important as the technique itself. Believing that something will work boosts the power of such efforts.
l. Sleep Extension
Our still limited understanding about the nature of sleep terrors [See Appendix B] suggests that having a child get more sleep may help to reduce these episodes.
Sleep terrors occur during the deepest stages of sleep. When we are sleep deprived, we tend to have more stage 3 and 4, or deeper sleep. This suggests that sleep terrors may be partly the result of a child’s not getting enough sleep. In contrast, sleeping more hours at night tends to decrease the amount of deep sleep. This obviously is not recommended for children who have other types of night waking problems.
m. Bedtime Pass
Recommended for ages three and up.
Give the child a special bedtime pass to be used only once per night. The pass can be used for a drink of water, one last hug or whatever the child is decides is worthy of using the pass.
One couple tried it the first night and it has worked wonders ever since. Their daughter was three and one-half when they instituted the bedtime pass. She was constantly coming out of her room after the whole bedtime routine – asking for water, telling her parents she wasn’t sleep, she was too hot, she wanted a hug – whatever she could come up with to put off the inevitable: falling asleep!
The parents gave her an old department store card to keep under her pillow and told her that if she needed something after she was in bed she could use her bedtime pass and come out just once. This has worked like a charm. She takes it very seriously.
The card can be something as simple as old store credit cards or you could make a fancy bedtime pass complete with sparkles and jewels – use you imagination.
OTHER INTERESTING OPTIONS
- Fill the bathtub ankle deep with cool water and have the child march around in it for a few minutes. It is a proven form of hydrotherapy for sleeplessness.
- Try one of the many herbal teas or capsules like Kava or St. John’s Wart; they could be a safe and effective alternative to traditional sleeping pills.
- Have the child start writing a journal about everything that is good that happened today – it is a way to re-focus negative thoughts. This can be the first part of the bedtime routine.
- Have the child wiggle his or her toes and keep wiggling until s/he falls asleep.
- Many stores sell tapes, records and CD’s with the sounds of nature like water flowing, rain falling and ocean waves rolling onto shore. It is a form of audio therapy and will tend to relax.
The bottom line is that a good nights sleep is very important for the physical and psychological health of both you and your child. Don’t accept that there must be a problem with sleep. There are ways to fix almost every difficulty and it is important to catch it early and organize sleep well.
It should be obvious that for children who sleep at the wrong time, there will be a judgement about whether to send the child immediately to the Sleep Clinic, or whether to implement some of the procedures in order to help you get a better handle on whether the problem is one of hygiene and habit or one of circadian rhythm problems [the biological closk being our of order]. It is not recommended that you talk to the child about the biological clock issues without being sure that this is the area of problems, because it becomes an easy excuse for not correcting problems that might be caused by hygiene and habit. A final determination of a circadian rhythm problem must take place in a sleep clinic.
On the other hand, there are other issues, such as sleep apnea or narcolepsy [described in CBP#03 – Conquering Insomnia] that can be dangerous and should have immediate clinical involvement.
SLEEP DIARY INSTRUCTIONS CBT#44-001
Parents or older child should take care to be as precise as possible about what is happening in terms of sleep. If child him/herself is keeping the Diary, s/he should NOT get up to fill it out when waking at night, which might only increase the awake state, and therefore diminish the sleep time. Both parents and child are likely to be ESTIMATING some of the time awake/asleep. For your own purposes, you may want to note this with an asterisk.
The purpose of the Sleep Diary is to get reliable information on the sleep-awake cycle of the child.
How long does it take the child to fall asleep. 15 – 30 minutes is the typical time. People who fall asleep quicker, even in the daytime, may have the problem of hypersomnia or narcolepsy. People who take longer to fall asleep may not be tired at bedtime and may need some sleep scheduling adjustments.
The information about night wakening contributes to the total sleep time, but also can give indication of other concerns.
For younger children, note whether the bedtime routine – being put to bed – and the night waking includes disruptive behavior. This is a different problem, which must be addressed with different techniques, even though the sleep schedule may contribute to it.
Keep the Diary for at least three  weeks before deriving conclusions.
Any person who appears to be getting a full night’s sleep but continues to have trouble staying awake during the day should be evaluated at a sleep center.
Pennsylvania Sleep Clinics
Lehigh Valley Hospital Sleep Disorders Center Lehigh Valley Hospital Cedar Crest and I-78, P.O.Box 689 Allentown, PA 18105-1556 610-402-8532 Phone 610-402-1692 Fax John P. Galgon, M.D.
Sleep Disorders Center Abington Memorial Hospital 1200 Old York Road Abington, PA 19001 215-576-2226 B. Franklin Diamond, M.D. Albert D. Wagman, M.D. Kevin R. Booth, M.D.
Sleep Disorders Center Lower Bucks Hospital 501 Bath Road Bristol, PA 19007 215-785-9752 Phone 215-785-9068 Fax Howard J. Lee, M.D.
Sleep Disorders Center * The Good Samaritan Medical Center 1020 Franklin Street Johnstown, PA 15905 814-533-1661 Eugene Friedman Brian Ahlstrom, M.D.
Sleep Disorders Center of Lancaster Lancaster General Hospital 555 North Duke Street Lancaster, PA 17604-3555 717-290-5910 Phone 717-290-4964 Fax Harshadkumar B. Patel, M.D. James M. O’Connor, RPSGT
Penn Center for Sleep Disorders University of Pennsylvania Medical Center 3400 Spruce Street, 11 Gates West Philadelphia, PA 19104 215-662-7772 Phone 215-349-8038 Fax Allan I. Pack, M.D., Ph.D. Richard J. Schwab, M.D. Louis F. Metzger
Department of Neurology – Sleep Disorders Center MCP – Hahnemann School of Medicine Allegheny University of the Health Sciences 3200 Henry Avenue Philadelphia, PA 19129 215-842-4250 Phone 215-848-3850 Fax June M. Fry, M.D., Ph.D.
Sleep Disorders Center Thomas Jefferson University 1025 Walnut Street, Suite 316 Philadelphia, PA 19107 215-955-6175 Phone 215-923-8219 Fax Karl Doghramji, M.D.
The Center for Sleep-Disordered Breathing * Passavant Hospital 9100 Babcock Blvd. Pittsburgh, PA 15237 Thomas Schauble, M.D.
Pulmonary Sleep Evaluation Center * University of Pittsburgh Medical Center Montefiore University Hospital 3459 Fifth Avenue, S639 Pittsburgh, PA 15213 412-692-2880 Phone 412-692-2888 Fax Nancy Kern, CRTT, RPSGT Mark H. Sanders, M.D. Patrick J. Strollo, M.D.
Sleep and Chronobiology Center Western Psychiatric Institute and Clinic 3811 O’Hara Street Pittsburgh, PA 15213-2593 412-624-2246 Phone 412-624-2841 Fax Charles F. Reynolds III, M.D.
Sleep Disorders Center Community Medical Center 1822 Mulberry Street Scranton, PA 18510 717-969-8931 S. Ramakrishna, M.D., F.C.C.P.
Sleep Disorders Center Crozer-Chester Medical Center One Medical Center Boulevard Upland, PA 19013-3975 610-447-2689 Phone 610-447-2918 Fax Calvin Stafford, M.D.
Sleep Disorders Center Mercy Hospital 25 Church Street Wilkes-Barre, PA 18765 717-826-3410 Phone 717-820-6658 Fax John Della Rosa, M.D.
Sleep Disorders Center The Lankenau Hospital 100 Lancaster Avenue Wynnewood, PA 19096 610-645-3400 Mark R. Pressman, Ph.D. Donald D. Peterson, M.D.
* Accredited as Specialty Laboratory for Sleep Related Breathing Disorders.
All other programs are accredited Full Service Sleep Disorders Centers
SELECTED SLEEP DISORDERS
Sleepwalking is a series of complex behaviors that are initiated during slow wave sleep and result in walking during sleep. Walking or moving about occurs during sleep. The onset typically occurs in pre-pubertal children.
Associated features include:
- Difficulty in arousing the person during an episode – although it is okay to awaken
- Amnesia following an episode
- Episodes typically occur in the first third of the sleep pattern
- The onset of episodes occur during stage 3 or 4 of sleep – see Chart above
- Other medical or psychological disorders may be present but do not account for the episodes
- The ambulation is not due to other sleep disorders such as REM sleep behavior disorders or sleep terrors
Medical reports show that 18% of the population is prone to sleepwalking. It is more common in children than in adolescents and adults. Boys are more likely to sleepwalk than girls. If a child begins to sleepwalk at the age of 9, it often last into adulthood.
In its most severe form, the episodes occur almost nightly and are often associated with physical injury. The sleepwalker may feel embarrassment, shame, guilt, anxiety and confusion when they are told about their sleepwalking behavior and these thoughts should be addressed through cognitive behavior management strategies.
There are some things you can do:
- Make sure the person gets plenty of rest; being overtired can trigger a sleepwalking episode
- Develop a calming bedtime ritual. Some people meditate or do relaxation exercises; stress can be another trigger for sleepwalking
- Remove anything from the bedroom that could be hazardous or harmful
- The sleepwalker’s bedroom should be on the ground floor of the house. The possibility of the person opening windows or doors should be eliminated
- An assessment of the sleepwalker should include a careful review of the current medications so that modifications can be made if necessary
- Hypnosis has been found to be helpful for both children and adults
- An accurate clinical evaluation could help to decide the need for clinical interventions
Nightmares and ‘Sleep Terrors’
We may spend one-third of our lives sleeping, but it is not always time well spent. Sometimes our imagination takes us to the wrong side of dreamland.
Nightmares are perhaps the most common form of sleep disturbance. Nightmares are distinctively frightening experiences that may be a reflection of significant psychological stress or may mean absolutely nothing. They tend to occur toward the end of sleep, usually an hour or two before awakening. If the dream is frightening enough, the child may wake up in a sweat, crying and often can remember much of what s/he has dreamed.
The beginning of sleep terror can resemble a nightmare. The child may begin screaming in a terrifying way in the middle of the night and the parent rushes to comfort, but it quickly becomes clear – this is different. Whereas you are able to comfort the child after a nightmare, now the child is inconsolable. Whereas, usually a nightmare ends suddenly with the person waking up, a child having a sleep terror remains asleep.
Nightmares are a near universal phenomenon. We all dream and most people occasionally have bad or frightening dreams. In fact, somewhere between 5% and 10% of adults have frequent nightmares and the proportion of children troubled by them is approximately 20%.
One group of individuals who seem to experience more nightmares are those individuals who have been through traumatic events, including automobile accidents and instances of abuse. It is important to recognize, however, that having nightmares does not necessarily mean that someone has been through some traumatic event.
Nightmares almost always occur during REM, or dream, sleep. In fact, knowing that nightmares occur during this stage of sleep helps to explain why many people report very similar experiences during these events. For example, having a nightmare in which you are trying to run toward or away from something but are having difficulty is common. The reason for these common nightmare experiences can be traced to the REM sleep stage. REM sleep is also a time when the major muscle groups in the body are virtually paralyzed. It is a good thing too, because if we could move our muscles when we dream, then there would be a lot of running around and screaming going on each night. The muscle paralysis keeps us secure in our beds.
Despite the fact that nightmares are so common, very little is known about why we have them and how to help those who are bothered by them.
The research points out that stressful events cause more nightmares, which may be what separates most of us from people who are bothered by them. What contributes to these nightmares may be stressful events but may also include a tendency to be more anxious in general, which in turn may cause nightmares to be experienced by different people.
Because of the connection between stress or anxiety and nightmares, efforts to help people who are bothered by excessive nightmare activity have focused on decreasing their anxious feelings using both relaxation [imagery, breathing and progressive muscle] and other cognitive behavior management techniques.
Sleep terrors probably have more discrepancy of information in the literature than almost any other problem in living. What is agreed upon is that such terrors are different from nightmares because technically they aren’t bad dreams; rather, they are ‘scary images’ that tend to occur a few hours after going to sleep. They can happen during and afternoon nap or at night, but always occur during the ‘slow wave’ NREM or non-dreaming portion of the sleep cycle. Nightmares, as we have stated, occur during the REM (rapid eye movement) dream sleep, later on in the sleep cycle.
Apparently night terrors can occur anytime in a person’s life span. The most common age is debatable, as some reports indicate the most frequent occurrences between the ages of three and five while others indicate five to eight. Recent studies have turned up showing that many adults as well as children as young as six months experience night terrors on a weekly basis – so apparently the facts are still to be uncovered.
Sleep terrors can be associated with stress, sleep deprivation, fever and some medications.
The child reacts with sheer terror and usually can’t remember what caused so much fear. “It’s even more frustrating the following morning, when the child may remember waking up scared but does not recall what scared him” says Dr. Zammit. A child might say “The bad man was going to get me,” but the description is vague.
Symptoms include persistent fear or terror that occur at night, screaming, sweating, confusion, unusually rapid heart rate, inability to explain what happened, usually no recall of ‘bad dreams’ or nightmares, may have a vague sense of frightening images. Apparently some people remember the night terror. Some don’t. there is no explanation to why most seem to have no recall of the events during a night terror. There seems, however, to be a common thread in how night terrors manifest themselves. Many people who remember the night terror have talked about seeing animals or people. Quite a few people see snakes and spiders. At first it seemed that people were seeing only things they are afraid of during working hours. More research shows that only a small percentage of people were afraid of what they see (in night terrors) during waking hours.
While both nightmares and sleep terrors may scare a parent as much as the child, they are a normal part of childhood. “As long as the nightmares or sleep terrors don’t interfere with you or your child’s daytime activities, you shouldn’t be too concerned”, says Peter Haure, Ph.D., co-director of the Mayo Clinic Sleep Disorders Center in Rochester, Minnesota. “mostly, the best thing you can do is endure it and be supportive of your child.
Sleep terrors can last anywhere from 30 seconds to forty minutes or longer, although again, the literature is discrepant. They typically occur in the first third of the night on nights when the child is over-tired, or when the sleep-wake schedule has been irregular for several days.
Arousal begins with the child moaning and moving about. It progresses quickly to the child crying out and thrashing wildly. The eyes may be open or closed, and perspiration is common. The child will look confused, upset, or even ‘possessed’ (a description volunteered by many parents). Even if the child does call out the parents’ names, s/he will not recognize them. Parental attempts to comfort the child by holding or cuddling are desperately fought and tend to prolong the situation.
Apparently, sleep terrors tend to appear on a regular schedule. “Most families tell me its like clockwork”, says Dr. Mark Splaingard, director of pediatric pulmonary medicine at Children’s Hospital of Wisconsin. “The children will sit up and start screaming at the top of their lungs about the same time each night, then collapse after a minute or two. During a sleep terror episode, they’re often impossible to wake up and they can’t be consoled.
These episodes tug at a parent’s heart. Just understanding what they are (normal childhood sleep phenomena that children outgrow – not a sign of maladjustment or the result of bad parenting) helps tremendously.
In summary, sleep terrors usually occur during the first third of the night during the deepest stage (Stage 4) of sleep. They normally last between one and ten minutes, but can leave a sleeper disoriented for much longer. Sleepers seldom recall details of the sleep terror. They are also usually unresponsive to efforts to comfort them.
In addition, sleepwalking and enuresis (bed wetting) are more common in people with sleep terrors than in the general population.
There are other physical characteristics of most sleep terror episodes. These include the following:
- Rapid breathing
- Dilation of pupils
- Increased muscle tone
- Tachycardia (abnormally fast heart rate – as much as four times the normal rate)
- Flushing of the skin
Sleep terrors are also called confusional arousal, night terrors, pavor nocturnes or incubus.
There is no known cause of sleep terror. It occurs equally in women and men. Incidents are not associated with any psychological problems in children, but are often thought to be linked to such issues in adults. These occurrences include posttraumatic stress disorder, borderline personality disorder and generalized anxiety disorder.
Several factors that can increase the risk of sleep terrors include:
- Family history
- Physical or emotional stress
- Sleep deprivation
- Disruption of routine sleeping schedule
Why sleep terrors happen is still a bit of a mystery. “But we know that about 90% of the kids who experience them have a parent who sleepwalks, talks in their sleep or has also suffered from sleep terrors.”
“emotional stressors, such as the beginning of a school year or the birth of a sibling can trigger sleep terrors”, says Splaingard. Sleep terrors, however, don’t seem to cause stress.
“Sleep terror suffers are almost always fine during the day, says Splaingard, “these are normal, usually wonderful, compliant kids. And usually around the age of eight, for no predictable reason, the sleep terrors will stop.”
Most sleep terror cases do not require treatment.
Most adult cases are first diagnosed between the ages of 20 and 30 and are more likely to require intervention.