Quality sleep is extremely important in the physiological, cognitive, and emotional development of children. At different stages of a child's development sleep needs change. In order to help children get as much quality sleep as possible, parents should have a strong understanding of the sleep requirements necessary for their children at various stages in their lives.
One study found that approximately 27% of children are sleeping less than is recommended for their age. Sleep debt in children can lead to an array of consequences including inattention, irritability, hyperactivity, impulse control problems, behavioral issues at home and school, learning troubles, and overall quality of life.
Poor sleep in children often leads to sleep troubles for the parents as well. When children frequently wake in the middle of the night unable to go back to sleep, most parents respond by waking up themselves and helping soothe them back to sleep. Over time both the parents and the children can become sleep deprived.
Of all the potential sleep disorders found in young children, Behavioral insomnia is the most frequently cited, surpassing other sleep disorders including breathing disorders like sleep apnea (1-3%), sleep related movement disorders such as restless leg syndrome (2-8%), and parasomnias such as night terrors (5-35%) [source].
What is Behavioral insomnia in Children (BIC)?
Behavioral insomnia is one of the most prevalent sleep disorders found in children. It is estimated that approximately 25% of children will experience it at some point in their childhood. Behavioral insomnia is characterized by children having difficulty falling asleep or maintaining sleep leading to poor sleep quality and duration.
BIC is very similar to poor sleep hygiene practices in adults, where the ability and opportunity to sleep are present, but poor practices lead to sleep loss.
There are two main types of behavioral insomnia: sleep-onset association and limit-setting.
Sleep-onset association is typically diagnosed in infants and toddlers. Sleep-onset association results from negative associations with sleep. These children usually need a parent, comfort item, or activity to initiate sleep. For younger children this can often be a need to be rocked, cuddled, or nursed to fall asleep by a parent. If the child awakes during the middle of the night they may not be able to go back to sleep without comfort from a parent.
Environmental factors may also play a role in the child's inability to initiate sleep. Lighting, temperature, and noises in the room may not be conducive to a sleep friendly atmosphere. Young children are especially sensitive to their environment. A poor sleep environment can make a child even more reliant on comfor from a parent to fall asleep.
For older children, sleep onset can also be associated with items in their room that prevent falling asleep such as having a phone, computer, tablet, or video gaming consoles that prevent them from going to sleep on time.
Portable devices help prevent sleep in two ways: (1) the content from these devices may be stimulating enough to keep their attention and thus keep them awake well past their intended bedtime; (2) light from the devices trick their circadian rhythm into associating it with daylight delaying the release of the sleep promoting hormone, melatonin.
Limit-setting type is often encountered when children challenge their parents during bedtime and refuse to go to sleep. This can often be seen in either defiant refusal to go to bed on time, or making many requests of a parent to delay bedtime such as asking for water, to go to the bathroom, or to read "one more story."
Children without set bedtimes, in which they go to bed varyingly throughout the week due to lack of parental enforcement, often challenge their parents during bedtime. Varying bedtimes can also disrupt a child's circadian rhythm.
Treatments for Behavioral Insomnia in Children
The first recommended treatment is parent education. Parents who understand the various stages of child sleep development will be more in-tune to the duration, timing, and frequency of their children's sleep requirements allowing them to prevent sleep issues from forming.
Parent education should start with teaching parents sleep hygiene practices of their own to follow. If parents are practicing good sleep hygiene themselves, they will more likely be able to help their children with their own sleep needs.
To treat BIC sleep-onset insomnia in children, parents should try and change the habits that are causing the sleep troubles. Replace the routine of nursing, rocking, or cuddling with other pre-bedtime relaxing activities. Vary these activities a little each night so they don't become overly attached to a specific activity.
For children that cannot sleep without the presence of their parent, three methods are recommended:
Extinction is the practice of teaching the child self-soothing skills by having the parent completely remove themselves while the child falls asleep. Parents are also discouraged from engaging with their child when they awake and seek out the external soothing techniques (nursing, cuddling, etc.) that they have grown accustomed to. Eventually the child will learn to self-sooth and fall asleep on his/her own. Graduated extinction involves parents ignoring the child's awakenings for a set period of time. If the child is still crying after a set time the parent then gets involved in helping put the child back to sleep. However, there should be very little interaction with the child during this time. Parents practicing graduated extinction should limit physical interaction, perhaps by being nearby in a separate bed pretending to sleep.
- For obvious reasons many parents may not be comfortable with extinction as they find it difficult to ignore their child while they are crying. This can lead to inconsistencies where the parent practices extinction some nights, but not on others, which can actually reinforce the child to continue crying until parental intervention is achieved, and can have adverse affects on the parent-child relationship.
Scheduled awakenings consist of waking the child 10-15 minutes earlier than they would during their normal nocturnal awakenings. During this time parents are encouraged to partake in the child's typical comforting routines such as feeding or rocking. As this treatment progresses the time in between scheduled awakenings increases until there are no more awakenings.
To treat BIC limit-setting insomnia parents will more than likely have to enforce strict bedtime routines and sleep hygiene practices.
These practices can include such things as:
Creating relaxing pre-bedtime activities leading up to bed such as a relaxing bath, putting on PJs, brushing teeth, and a good night kiss.
Creating a sleep friendly environment that is cool, dark, quiet, and free of clutter and distractions.
Turning off all electronic devices before bedtime.
Making sure children get plenty of exercise during the day so they don't have stored energy at night.
Avoiding meals and caffeine before bed. Caffeine should not be consumed after lunch.
- Choosing reading books over watching television before bedtime.
Not meeting unreasonable demands before bed. If a nighttime story is part of the routine, have an agreed upon time limit to when story time ends.
Keep children's sleep schedule the same every day including weekends.
- For older children, positive reinforcement techniques for following bedtimes may be appropriate.
Be consistent with routine.
Giving your child a consistent routine will help them understand appropriate expectations that you have of them, and that they can expect from you. Consistency is key in establishing bedtimes, and behavior will often fall in line in a short amount of time.
Children's sleep habits should always be discussed with their pediatrician. Typical discussions should include regularity of sleep and duration, bedtime resistance and sleep onset delay, night awakenings, symptoms of daytime sleepiness, and any potential sleep disorders such as snoring.
Parents concerned about their children's sleep habits should record their sleep activity in a sleep diary that includes intended bedtime, sleep-onset, duration of sleep, amount and duration of awakenings. To download a sleep diary, click on the link below.
If you've been having difficulty with helping your child get to sleep, stay asleep, or have suspicions they may have another underlying sleep disorder, contact the Alaska Sleep Clinic for a free 10-minute phone consultation with a sleep professional. Alaska Sleep Clinic owns 4 of the 5 clinics in Alaska that do pediatric sleep tests. Our Pediatric Medical Director is Dr. Harry Yuan.