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Behavioral Techniques to Improve Sleep

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Behavioral Techniques to Improve Sleep

Clinicians can help families wanting to improve their child’ s sleep habits by introducing behavioral techniques that help with sleep associations, limit setting, co-sleeping issues, and night awakenings. The following sleep methods can be used with typically developing children as well as children with special health care needs (CYSHCN).

Sleep Hygiene

Habits and practices that promote sleep are often referred to as good "sleep hygiene." The foundations of good sleep hygiene are establishing a set routine for getting ready for bed and a consistent time for going to sleep and, even more importantly, waking-up. In general, there should be no caffeinated drinks in the afternoons or evenings, electronics in the bedroom, or naps after 4 pm. Other practices that promote better sleep are exercising earlier in the day, reducing or eliminating unnecessary light (especially LEDs), and eliminating non-sleep activities in the bed.
Sleep Hygiene for Children (CHOC Children's) (PDF Document 32 KB) provides a printable, 2-page handout with 14 easy tips for good sleep hygiene in children ages 0-13.

Graduated Extinction

Graduated extinction can be used to help children fall asleep independently or to manage frequent night awakenings in which the parent has to intervene. In this method, a caregiver slowly decreases their support of bedtime soothing.
Variations include:
  • Parents can shift from sleeping with a child, to sitting in a chair, and then moving the chair further away from the bed until it is out of the child's visual field.
  • Parents can put the child to bed at a set time and then check-in on the child (without intervention) on a schedule with gradually increasing intervals until the child falls asleep on own.
Advantages include: [Honaker: 2018]
  • Can often be done in a week
  • Does not require the parent to stay up late
Disadvantages: [Honaker: 2018]
  • The child’s behavior often worsens before it improves.
  • The child is likely to cry heartily at the initiation of this process.

Bedtime Fading

Bedtime fading involves putting the child to bed at the time that the child is tending to fall asleep (which will likely be quite late initially). If the child does not fall asleep within 10-15 minutes, the child is taken back out of bed, and a parent stays up with the child for 1 full hour. Then, the child is put to bed again and gotten up if he/she does not fall asleep within 10-15 minutes for another full hour. This process is repeated until the child falls asleep during the 10-15 minutes in bed. Initially, this may be quite late into the night. Once the child is falling asleep consistently after 10-15 minutes, the family gradually moves the bedtime up to a more reasonable set bedtime.
Advantages include:
  • May avoid having to deal with extended bouts of crying
Disadvantages:
  • Parent may need to stay up late
  • May take weeks to complete the process.
Bedtime Fading: The “Secret Sauce” in Sleep Training (Dr. Craig Canapari) shows a 4-minute video that focuses on bedtime fading.

Visual Schedules

Some parents have had success using a visual schedule to help shuttle through the bedtime routine. Bedtime Routines Shown with Photos and Checklists (Autism Speaks) (PDF Document 2.1 MB) may be helpful for children with or without autism.

Bedtime Pass Sleep Tickets

This is a good system for children who keep getting out of bed before falling asleep or during the night. This system uses positive reinforcement by rewarding the child for staying in bed all night.
Variations include:
  • The child gets 1 “pass” (similar to a “hall pass” used at school) to use in the night, and if it is not used, the child can exchange it for a reward in the morning.
  • Alternatively, start with several tickets and gradually reduce the tickets over several days or weeks.
Bedtime Pass (OHSU) (PDF Document 101 KB) is a 1-page handout with helpful steps for using the bedtime pass system.

Scheduled Awakening

Scheduled awakenings can be used to manage night awakenings. In this option, the parent tracks the pattern of the awakenings for several nights. If the pattern is predictable, the parent gently rouses the child 30-45 minutes before they usually wake up. While counter-intuitive, this works because the parent is waking the child during deep sleep when the child will have an easier time going back to sleep. By rousing the child, the parent resets the sleep cycle avoiding the passage into light sleep and full awakening.
If the child has trouble going back to sleep after the parent rouses him/her, this means the child had already moved into light sleep and, on subsequent nights, the parents should wake the child earlier. Once the night awakenings have resolved, the family gradually weans the scheduled rousing (e.g., stops doing it 1-2 nights per week).

Restricted Sleeping Time

Restricting sleep time is also used to manage night awakenings. Theoretically, by restricting sleeping time, the body will respond by staying in deeper sleep more of the night. To do this, the parent first tracks the child’s sleeping patterns for several nights. The total number of hours asleep is calculated, not counting the time the child spent lying awake in bed. The parent then adjusts the total sleep time to only allow 90% of the usual sleep time. Reducing sleep in the morning is preferable as it is easier to fade back once the intervention is working. During this process, if the child is found lying awake in bed, allow the child up for a period of time, and then put him/her back to sleep. Once the night awakenings have resolved, the sleep restriction is gradually lifted by allowing the child 15 more minutes of sleep each day.

Additional Considerations

When thinking about a plan to help resolve sleep issues, also consider:
  • Psychosocial issues: Consider psychosocial circumstances that may impact sleep training including crowded sleeping area, noise, unsafe environment, homelessness, parents working at night, etc. For example, it would be more difficult for a family sharing a bedroom to endure a “cry-it-out” approach to sleep training. Consider a social work consult when resources are limited.
  • Safety: If the child wakes up during the night and wanders, advise parents to use room gates and/or door alarms to ensure the child remains safe.
  • Sleep logs: Also known as sleep diaries or trackers, these can be used to track different behaviors such as getting ready for bed, electronics use, caffeine consumption, as well as documenting hours of sleep and night awakenings. Multiple versions are available; see Resources, below. Sleep logs can be reviewed by the clinician or sleep specialist to identify concerning patterns.
  • Consultation: Families can consult with a sleep specialist for additional family education and support. There are some online consulting services to coach families through sleep training, and there are pediatric sleep medicine specialists (typically pulmonologists with specialized training) who can work with families as well.
  • Medications: The clinician can consider medications, such as melatonin, as adjunctive therapy while initiating a behavioral program or to get the parents some needed sleep before they embark on the behavioral program.

Resources

Information & Support

For Parents and Patients

Better Sleep in Kids and Parents (Dr. Craig Canapari)
Excellent, in-depth, and easy-to-read resource about sleep training, sleep hygiene, use of melatonin, and more; developed by Dr. Craig Canapari, a Yale Pediatric Sleep Medicine physician.

Sleep for Kids (National Sleep Foundation)
Fun for children and useful for parents and teachers to understand and overcome sleep problems.

Patient Education

Sleep Hygiene for Children (CHOC Children's) (PDF Document 32 KB)
Printable, 2-page handout with 14 easy tips for good sleep hygiene in children ages 0-13; Children’s Hospital of Orange County.

Bedtime Routines Shown with Photos and Checklists (Autism Speaks) (PDF Document 2.1 MB)
Tips, sample visual bedtime routines, and a sample bedtime pass.

Sleep Tips for Adolescents (Medical Home Portal) (PDF Document 193 KB)
A 1-page printable handout with basic suggestions for improving sleep.

Sleep Tips for Children (Medical Home Portal) (PDF Document 189 KB)
A 1-page printable handout with basic suggestions for improving sleep.

Tools

Sleep History Questionnaire (PDF Document 20 KB)
A 14-day sleep tracker and 1-page questionnaire about sleep routines and behavior.

Sleep Diary (PDF Document 2.3 MB)
Includes a 1-week, kid-friendly version for school-aged children who are able to communicate in writing and/or verbally.

Adolescent Sleep & Comfort Log (PDF Document 205 KB)
Features a 16-day sleep-time log and comfort tracker for teens to fill out on their own.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: February 2019
Current Authors and Reviewers:
Author: Jennifer Goldman, MD, MRP, FAAP

Page Bibliography

Honaker SM, Schwichtenberg AJ, Kreps TA, Mindell JA.
Real-World Implementation of Infant Behavioral Sleep Interventions: Results of a Parental Survey.
J Pediatr. 2018;199:106-111.e2. PubMed abstract / Full Text
Study examining parental practices in successfully implementing different behavioral sleep intervention (BSI) outside a clinical setting and duration until improved sleep.