1. Chapter 17: Treatment of Insomnia and Nighttime Fears Michelle Clementi Jessica Balderas Jennifer Cowie Candice A. Alfano

2. Sleep Problems Intermittent problems sleeping and nighttime fears are typical, and affect up to ¼ of all children (Meltzer & Mindell, 2006) Sleep disorder if problem persists over time, is severe, and/or impairs daytime functioning Children with insomnia may not complain of sleepiness or view sleep patterns as problematic Parent understanding and awareness of sleep depends on: child’s age, family culture, SES, personal habits and experience (Owens, 2005)

3. ICSD-2 Behavioral Insomnia of Childhood Two developmental subtypes Sleep-onset association subtype: most common in infancy; difficulty falling asleep in the absence of certain conditions (e.g., singing, rocking) both at bedtime and after nighttime wakings Limit-setting subtype: common in preschool and school-age children; difficulty initiating sleep and resisting/refusing bed due to inadequate structure, limit setting, and/or behavior management by a caregiver Nighttime fears Fear of the dark/shadows, separation from caregivers, bad dreams/nightmares, strange noises, intruders/burglars

4. Evidence Based Approaches: Behavioral Insomnia of Childhood Extinction-based procedures are most common components of treatments for BIC Standard and graduated extinction: used with the goal of reducing inappropriate child behaviors during bedtime by altering parental responses Standard extinction: completely ignoring all inappropriate behaviors (e.g., crying, tantrums) after bedtime once the child has been put to bed and until wake time Challenging to implement consistently, efficacy has been demonstrated Graduated extinction: ignoring inappropriate behaviors and systematically increasing the amount of time before responding Easier to implement; well-established efficacy (Mindell et al., 2006)

5. Other Treatment Procedures: Insomnia Bedtime fading: delaying bedtime until the child appears naturally sleepy, then systematically moving to an earlier bedtime based on mastery of sleep initiation Positive routines: incorporating pleasant and structured presleep activities into the bedtime routine as environmental sleep cues Response-cost: removing a child from bed if he or she is unable to initiate sleep within ~20 minutes

6. CBT Components: Insomnia Stimulus control: strengthen the association between bed and sleep by encouraging the child to go to bed when feeling sleepy, removing clocks from the bedroom, and using the bed for sleep only Cognitive techniques: target maladaptive beliefs or attitudes about sleep Relaxation training: slow and deep breathing, progressive muscle relaxation(PMR), visualizing a peaceful scene Progressive muscle relaxation: involves tensing (4–7 seconds) and then relaxing (30–40 seconds) different muscle groups

7. Treatment: Nighttime Fears CBT techniques: self-control training, relaxation training, positive imagery, positive self-statements, differential reinforcement Multiple techniques typically examined in most studies Overall effectiveness of these interventions is high Example: study of 33 school-aged children with severe nighttime fears (Graziano & Mooney, 1980) Used: self-control training, relaxation, positive imagery, and “brave” self-statements Compared to controls, children receiving CBT evidenced significant reduction in frequency, intensity, and duration of nighttime fears

8. Parent Involvement in Treatment Parent-child interaction is the primary context for behavior change in the treatment of BIC (Sadeh, 2005) Difficulty setting firm nighttime limits is strongly associated with increased sleep disturbances in school-age children (Owens-Stively et al., 1997) Parent-related factors that can interfere with implementation of treatment: Family discord/stress, parental psychopathology, single parent status

9. Parental Involvement Parent beliefs/attitudes can impact treatment Can be an important target of CBT interventions Faulty beliefs (e.g., “My child needs me in order to feel safe and fall asleep”) Negative parental attitudes about treatment If parents experience emotions such as fear, guilt, or shame when attempting to use extinction techniques interventions will most likely be used inappropriately

10. Correct and Consistent Treatment To ensure techniques are implemented consistently and correctly, clinicians should prepare parents for potential increases in problem behaviors both during and after the course of treatment Extinction bursts: temporary increases in a behavior following the removal of a reinforcer Spontaneous recovery: reemergence of previously extinguished conditioned response after a delay

11. Adaptations and Modifications Sleep patterns and practices are shaped by: Demographics: lower-SES children experience a greater number of sleep-related problems and daytime sleepiness compared to peers Race/ethnicity: minorities more likely to co-sleep, obtain less sleep at night, give up daytime naps at later ages Culture Developmental disorders: often experience frequent, severe, and chronic sleep problems (Wiggs, 2001) Learn bedtime routine, self-regulatory skills Duration and pace of treatment may differ from typically developing children

12. Modifications for Adolescents Factors interfering with sleep (Carskadon et al., 1998): Early start times at school After-school sports, jobs Homework Social activities Increased use of electronic media May need considerable support to make lasting changes in sleep due to these factors Effective strategies often incorporate elements from both child and adult-based treatments

13. Gold Standard Measurement Polysomnography Actigraphy Evaluation for children with behavioral insomnia does not necessarily require these measures Overnight sleep study may be indicated depending on extent that other sleep disorders are suspected

14. Clinical Interviews Structured interview with parents and children Child’s current and historical sleep patterns/behaviors Duration and chronicity of sleep problem Description of the child’s sleep routine and environment Parent responses: bedtime resistance, requests to co-sleep Query presence of medical conditions (e.g., eczema, pain syndromes) Assess for comorbid psychopathology (Alfano & Gamble, 2009)

15. Sleep Logs/Diaries One-page, 24-hour grid Record specific sleep-wake patterns and behaviors on a prospective basis (usually 7 days) Daily bedtimes and wake times Time required to fall asleep after getting into bed Number and length of awakenings during the night Daytime naps

16. Validated Sleep Questionnaires Sleep Disturbance Scale for Children Free; assesses a range of sleep disorders (e.g., initiating and maintaining sleep, sleep-related breathing) Validated Children’s Sleep Habits Questionnaire Widely used Total sleep problems and eight subscales Children 4–10 years old

17. Clinical Case: Xavier 7-year-old Hispanic male Symptoms: difficulty falling asleep, fear of the dark, defiant nighttime behaviors Initial assessment: questionnaires for sleep and daytime behavior, sleep diary Treatment plan: psychoeducation, sleep hygiene, positive bedtime routine, graduated extinction, sticker chart Outcome assessment: sticker charts and weekly sleep diaries, indicated shorter sleep onset latency, sleeping in room by himself, increased average sleep time