Children & Adolescents with Behavioral Sleep Disorders

What is a Behavioral Sleep Disorder?

Behavioral sleep problems are described as sleep problems that do not have a physiological cause, but are the result of a behavioral or psychological component. Behavioral Insomnia of Childhood is the official name given by the American Academy of Sleep Medicine.¹ A sleep disorder can create a sleepy, cranky, and often poor-performing student at school, and an irritable, unhappy child or teenager at home.² Difficulty falling asleep, staying asleep, short sleep duration, or poor quality sleep all have a wide range of effects on mental and physical health, cognitive and social functioning, and development in children and teens.¹

All behavioral sleep disorders can occur at any time throughout childhood, some are more common during particular developmental stages. The following lists some common behavioral sleep disorders in children and adolescents.¹

1. Limit-Setting Sleep Disorder- Parents or caretakers have difficulty enforcing bedtime limits resulting in delayed bedtime and reduced sleep duration while the child stalls or refuses to go to bed at a healthy time. Reduced parental ownership of sleep practices during adolescence.
2. Sleep-Onset Association Disorder- Child is unable to “self-soothe” and cannot go to sleep without the presence of an object or caretaker or a specific location any time sleep is initiated, day or night. In school age children, difficulty falling asleep because of nighttime fears, or excessive worries. Can be caused by stressful events, trauma, or ruminating thoughts.
3. Inadequate Sleep Hygiene Syndrome- A child or teen does not perform normal activities that are consistent with maintaining good quality sleep and full daytime alertness.
4. Insufficient Sleep Syndrome- Child persistently fails to obtain sufficient nocturnal sleep required to support normal alert wakefulness.

What are symptoms of a Behavioral Sleep Disorder?

Behavioral sleep disorders usually present with at least one of the following:³

• Bedtime problems, including bedtime stalling or resistance
• Difficulties falling asleep
• Frequent or prolonged night wakings
• Early morning wakings
• Excessive daytime sleepiness

Behavioral sleep disorders are reported in 20-40% of children and adolescents.¹ Sleep disturbances can cause or exacerbate negative mood and psychiatric problems in children and teens.³ Children and adolescents with ADHD, autism, and mood-anxiety disorders commonly report sleep disturbances.⁴

What causes a Behavioral Sleep Disorder?

A child’s environment and caregiver can contribute to a behavioral sleep disorder. The temperament of your child may impact their likelihood to develop a sleep disorder, children who are more “needy” require more active parental participation.¹ Caregivers who set inappropriate or inconsistent sleep/nap schedules or remove napping inappropriately for their child can cause sleep disturbances.⁵ In school age children and teens, a demanding schedule of social activities, sports, part-time employment, and increased academic workloads can cause disruptions in sleep routines, delay sleep initiation, and decreases in total sleep time.¹

What can be done to treat a Behavioral Sleep Disorder?

Untreated behavioral sleep disorders can have a significant impact on the cognitive, social, and emotional functioning of children and adolescents. A complete assessment of sleep patterns, sleep disruptions, psychosocial factors, and psychiatric disorders is recommended in treatment.³ Behavioral Interventions help children and teens initiate and maintain sleep independently, increasing total sleep time and improving sleep quality.⁵ A child’s age and developmental stage will be taken into consideration when weighing different diagnosis and selecting an appropriate intervention.³

Interventions may include:^1,5,6

• Sleep hygiene education
• Relaxation techniques- Progressive muscle relaxation, deep-breathing exercises
• Stimulus control- Removal of media usage at bedtime, or in the bedroom
• Cognitive Behavioral Therapy- Thought stopping, journaling “worries” at bedtime, developing self esteem and confidence to sleep alone, and increasing positive thinking
• Imagery rehearsal-Rehearsing less fearful explanations and images of nightmares during the day to create positive dream imagery at night
• Parent education and limit-setting coaching- Emphasizing consistency, strict bedtimes, routines, reassurance, and positive reinforcement using rewards.
• Unmodified extinction, extinction with parental presence, preventative parent education, graduated extinction, bedtime fading, and scheduled awakenings.

Resources:
¹ Blunden, S. (2012). Behavioural Sleep Disorders across the Developmental Age Span: An Overview of Causes,  Consequences and Treatment Modalities. Psychology, 3, 249-256.
² National Association of School Psychologists
³ Sleep Medicine Clinics
⁴ American Academy of Child & Adolescent Psychiatry
⁵ Psychiatry (Edgmont)
⁶ American Academy of Sleep Medicine Report