Cognitive-Behavioral Strategies for Treating Child Sleep Problems�

Ariel A. Williamson, PhD, DBSM

August 13, 2024

​

Assistant Professor, The Ballmer Institute for Children’s Behavioral Health & Dept. of Psychology (Clinical)

University of Oregon

Common child sleep problems

Early childhood School-aged Adolescence

Sleep onset associations, frequent night wakings, and bedtime resistance (20-30%)

Trouble falling asleep and frequent night wakings (15-20%)

Trouble falling/staying asleep (15-20%)

Insufficient sleep (50+%)

Insomnia due to underlying mental, neurodevelopmental,

and physical health conditions (60-90%)

Calhoun et al., Sleep Med 2014; ICSD-3-TR, 2023

Nightmare disorder (3-6%, 9-12% for those with mental health concerns)

Adolescent sleep: A “Perfect Storm”

Carskadon et al., Pediatr Clin N Am 2011; Crowley et al., J Adolesc 2018

Recommended sleep duration by age (National Sleep Foundation)�

Ages 1-5: Insufficient sleep in ~30%

6-13: Insufficient sleep in ~50%

14-17: Insufficient sleep in ~60-70%

Buxton et al., Sleep Health 2015; Taveras et al., Acad Pediatr 2017; Wheaton et al., MMWR Morb Mortal Wkly Rep 2018; Williamson & Mindell, SLEEP 2020

Cognitive-behavioral strategies can effectively treat child sleep problems

Common treatment elements

Early childhood School-aged Adolescence

Sleep hygiene & education: Necessary, but usually not sufficient

Allen et al., Sleep Med Rev 2017; Harvey & Buysse, 2016; Meltzer & Crabtree, 2015; Mindell et al., 2006

Reducing sleep associations

Bedtime fading

Behavioral reinforcement

Cognitive strategies, relaxation, & coping

Sleep restriction & stimulus control

Behavioral activation & light therapy

Sleep hygiene & education: �Necessary, but usually not sufficient

Bedtime/wind down routine:

• 2-4 activities
• Family- and child-centered
• Dose-response link to sleep

Change the sleep schedule:

• Shorten or cut naps as appropriate
• Increase consistency on weekday and weekends
• Aim for recommended sleep duration by age

​

Allen et al., Sleep Med Rev 2016; Meltzer & Crabtree, 2015; Mindell, 2005; Mindell et al., Sleep 2015; Mindell & Williamson, Sleep Med Rev 2018

Sleep hygiene & education: �Necessary, but usually not sufficient

Cut caffeine:

• Many families unaware of caffeine in green or diet tea, sodas, etc.
• Assess in preschoolers, too

Limit electronics:

• Assess whether child needs electronics to fall asleep
• Harm reduction: Gradually reduce electronics at night
• Turn off notifications or remove device after lights out
• Family-based: Develop a plan for the whole family

Allen et al., Sleep Med Rev 2016; Meltzer & Crabtree, 2015; Mindell, 2005; Mindell et al., Sleep 2015; Mindell & Williamson, Sleep Med Rev 2018

Younger children: Reducing sleep associations

Meltzer & Crabtree, 2015; Mindell, 2005

“Whatever is needed to fall asleep is needed to get back to sleep after normal night wakings, which happen 2-6 times per night!”

Consider bedtime fading!

Add positive reinforcement!

Address fears!

Manage expectations!

Example:

• 8:45pm lights out
• 10:30pm fall asleep

Younger children: Bedtime fading

Meltzer & Crabtree, 2015; Mindell, 2005

• Temporarily moving the bedtime later to reduce time between lights out and fall asleep time

​

• Helpful to maintain when working on trouble falling asleep

​

• Continue with same wake time and nap time (or shorten nap if needed)

Move:

• Bedtime routine
• Lights out (9:45pm)

Address:

• Behaviors
• Family reaction

Younger children: Positive reinforcement

• Make bedtime special time (child-directed play activity)
• Labeled (specific) praise: “You’re doing a great job getting pjs on!”

• Develop a plan for “curtain calls” and tantrums
• Include caregiver coping strategies and self-talk
• Use the same boring redirection: “I love you, it’s bedtime, goodnight”
• Any attention is attention! Don’t complain, don’t explain.

​

Meltzer & Crabtree, 2015; Mindell, 2005

• Sleep fairy (or superhero) checks if child stays in bed at bedtime
• Child gets small prize or encouraging note in morning
• Eventually apply to night wakings

Younger children:

Manage bedtime fears and worries

• A flashlight treasure hunt can help with fears of the dark
• Gradual exposure to dark room with caregiver support
• Use brave talk: “I am strong, I can be brave!”

​

• Introduce a stuffed animal/superhero/Huggy Puppy
• Comfort object protects child OR child protects object
• Use brave talk

Kushner & Sadeh, Eur J Pediatr 2018; Meltzer & Crabtree, 2015

Older children and teens: Reduce time in bed

• Stimulus control: Break negative bed-brain association
• Only sleep in bed and only use bed for sleep
• Get rid of the clock or cover it
• Get out of bed and do something boring after 15-20 minutes
• Folding and unfolding socks X Laundry, chores, homework
• Reading a boring book X Reading something enjoyable
• Stretching, meditation X Exercise, electronics

​

• Sleep “restriction”: Temporarily later bedtime (like bedtime fading)
• No less than 6-7 hours in bed
• Avoid in context of bipolar disorder and in some cases suicidal ideation

Meltzer & Crabtree, 2015

Older children and teens:

Cognitive strategies, relaxation, and coping

• Challenge dysfunctional sleep beliefs: “I’ll fail if I can’t sleep tonight”

🡪 “Tell me about the last time you failed a test/couldn’t sleep…”

• Create cards/notes to cue challenging thoughts and reframing

Anbar & Slothower. BMC Pediatrics, 2006; Blake et al., J Child Psychol & Psychiatr, 2018; Meltzer & Crabtree, 2015; Nelson & Harvey, J Ab Psychol, 2002

• Implement relaxation strategies at bedtime with daytime practice
• Progressive muscle relaxation, mindfulness, visual imagery

• Consider a worry box that includes coping activities
• Integrate worry time to help limit worry and rumination

🡪 “I already thought about this during worry time, now it’s bedtime”

Addressing both insomnia and circadian issues:

Sleep scheduling, behavioral activation, & light

• Gradually shift sleep schedule
• Helpful to do on a summer break before school
• Schedule enjoyable morning activities
• Helps to limit morning time in bed, especially on weekend
• Encourage connections with friends and family members

• Increase exposure to morning light
• 10,000 lux light box or outside time/shades up
• Incorporate while gradually shifting bed and wake times
• Begin waking 30-60 minutes earlier every few days
• Move bedtime later once falling asleep more quickly

Harvey & Buysse, 2016

Adaptations will likely be needed

Williamson et al., J Pediatr Psychol 2020; Williamson et al., J Clin Sleep Med 2022

Electronics may be OK!

Graduated extinction may be very very (very) gradual

Sleep duration and/or later bedtime

might not change

Daytime naps might continue to happen

Now might not be the right time to make sleep changes

Bedtime/wind down activities may not be “quiet”

Goal setting and addressing family culture

American Psychiatric Association, DSM-5-TR, 2013; Chu & Leino, J Consult Clincal Psychol 2017; Williamson et al., J Pediatr Psychol 2020; Williamson et al., J Clin Sleep Med 2022

APA Cultural Formulation Interview Questions

​

“Families and clinicians often come from different backgrounds, such as race, ethnicity, culture, educational opportunities, and more. This is important because it means we may have different beliefs about healthy sleep and goals for sleep. I want to make sure we keep this in mind so that we can talk about what will work best for you and your family and meet your sleep goals. Have you experienced any differences with clinicians that were difficult to manage? How can I address that moving forward?”

Summary and Clinical Highlights

More research on behavioral sleep treatments across different populations and contexts is needed

Cognitive-behavioral approaches are the first-line treatment for behavioral sleep problems

Effective sleep treatment depends on family-centered care and shared decision-making

Selected books, websites, and apps

Doze App for teens (https://dozeapp.ca)

• https://www.startschoollater.net/
• https://www.geisinger.org/sleep-to-be-well/wake-up-and-learn

​

Contact: arielaw@uoregon.edu

THANK YOU!