Outlines the nature of behavioural aspects of children’s sleep and how these might be addressed by behaviour therapy. Clinical considerations concerned with the use of behavioural therapy are also highlighted.
Consider behavioural aspects (ie, learned behaviours) and their relevance for our understanding of children’s sleep patterns and management of their sleep disorders.
Increase awareness of how behavioural factors may play a role in the development and treatment of wide-ranging paediatric sleep disorders and to discuss clinical considerations relevant to management planning and decisions about whether to refer a child for specialist behavioural therapy.
International Classification of Sleep Disorders of ‘‘behavioural insomnia of childhood’’: (present with difficulty settling to sleep, nightwaking and/or early waking difficulties)
Overall prevalence rates of 30%
‘‘inappropriate sleep onset associations’’ (ie, where the child has not learnt to fall asleep without a set of problematic or demanding conditions such as parents’ being present), ‘
‘limit-setting sleep disorder’’ (ie where the care giver demonstrates insufficient or inappropriate limit-setting to establish appropriate sleep behaviour in the child)
‘‘combined’’subtype where these two problems co-exist.
25–50% of 6–12-month olds have difficulty settling to sleep or waking in the night
do not decrease with age: by age 3 years, 25–30% have sleeplessness problems
With similar percentages reported for the 3–5-year age group, 43% of 8–10-year olds
23% of 10– 17-year olds.
These problems are not transient; an epidemiological study of a cohort of 5-year olds suggested that sleeping problems at age 5 years were significantly associated with sleeping difficulties at age 6 months (or before) and that children with sleep problems at age 5 years were more likely to have sleeping problems at 10 years.
Over 80 sleep disorders listed in the International Classification of Sleep Disorders, which are divided into six main categories:
sleep-related breathing disorders,
hypersomnia of central origin,
circadian rhythm disorders (ex. Delayed sleep phase syndrome)
parasomnias (ex. Sleep terrors, nightmares) Helped by beh therapy.
sleep-related movement disorder (ex. nocturnal headbanging) (in preliminary reports)
Classical conditioning is a form of associative learning whereby a neutral stimulus is paired with a naturally occurring stimulus, which evokes the desired behavioural response until, after multiple pairings, the neutral stimulus alone is sufficient to elicit the desired behaviour; thus behaviours are conditioned to be elicited by antecedent conditions.
Operant conditioning involves the use of consequences to modify the occurrence and form of behaviour.
The particular intervention strategy used will vary depending on family and child factors and the nature of the sleep disturbance one hopes to address.
(The more consistently these principles are applied, the easier it will be for the child to learn)
Behaviour can be encouraged by linking it with an antecedent stimulus, which serves to trigger the desired behaviour.
Reinforcement- Behaviour is likely to recur if the consequences of the behaviour were reinforcing for the child. (Can be pos or neg)
Extinction, or removing reinforcement (eg, drinks, parental presence, attention) maintaining the undesired behaviour (eg, crying, refusal to settle to sleep without the above) can be achieved gradually or abruptly.
Shaping- A new behaviour can be encouraged by rewarding a series of responses that more and more closely resemble the desired behaviour.
Punishment- Behaviour is less likely to occur if followed by a punishing consequence. (Can be pos or neg)
On the basis of controlled empirical data, behavioural approaches are viewed as the first-line treatment of choice for this type of sleep disorder, because they have none of the potential associated negative side effects of sedative hypnotics,20 and a systematic review suggests that, long term, they are more effective.
The relative efficacy of specific behavioural strategies or components of behaviour therapy has been less well investigated so details of any behavioural plan should be explored in the context of collaborative therapy, considering the practical and emotional resources of individual families.
The developmental stage of the child is also an important consideration—for example, some strategies require the child to have verbal abilities of a particular level, and reinforcement programmes are likely to be particularly important for older children.
It should, of course, be noted that the effective use of behaviour therapy does not necessarily indicate that the sleep disturbance is behavioural in origin or being maintained by behavioural factors. Behaviour therapy may play a role in the management of disorders that are of definite organic origin.
(ex. behavioural therapy including planned naps, appropriate sleep routines and well-defined 24 h schedules may have a role in management of narcolepsy, a hypersomnia of central origin, or facilitate compliance with continuous positive airways pressure therapy for children who require this form of intervention for sleep-disordered breathing).
Behavioural therapy has been used successfully with a number of special populations who are at increased risk of severe and long-standing sleep disorders for a range of biological and psychological reasons. That this form of intervention does not rely on the use of verbal skills makes it especially appropriate for use with children with intellectual disabilities.
Delivering behavioural therapy in a brief, booklet form (with obvious economic implications) has been found to be as successful as behaviour therapy delivered face-to face in managing the sleeplessness problems of infants with intellectual disabilities.
There is a need for development of behavioural models specific to different types of sleep disturbance, and for children of various ages, to further understanding about the development and maintenance of sleep disturbance and to suggest therapeutic strategies for evaluation.
Consideration for clinicians is that multiple sleep disorders may coexist, and so behaviourally based sleep disorders may be present in children with other sleep disorders of more physiological origin or arise as a secondary problem. It may be necessary to use multiple forms of treatment to address individual sleep disorders.
It may also be appropriate to combine treatments in the management of one sleep disorder. (ex. Beh interventions & melatonin)
Although behaviour therapy delivered in conventional face to-face format may have apparent drawbacks in terms of the time and cost of implementing the interventions, the potential to prevent long-standing sleeping difficulties and their associated problems (which, as outlined above, may include adultmental health problems) is likely to far outweigh the limitations in both economic and social terms, at both the societal and personal level. Ensuring that families can access appropriate support and advice should be a service priority, and investigation of how to improve access (eg, with brief forms of treatment, low-cost delivery methods, identifying active therapeutic components and their efficacy for particular groups of children and different sleep disorders) should be key research targets for the future.