Clinician Administered Treatment Resources

Most parents and children benefit from basic education about normal sleep (may reduce patient's anxiety about sleep) and sleep hygiene (activities that help promote sleep).¹ Research has shown that children's sleep difficulties are often related to behavioral problems and how their parents interact with them at bedtime.² Therefore, behavior therapy can be helpful for a variety of sleep difficulties.

Treatment Recommendations for Specific Sleep Disturbances

• Insomnia
• Hypersomnia
• Narcolepsy
• Breathing-Related Disorder
• Circadian Rhythm Disorder
• Sleep Terror Disorder
• Nightmare Disorder
• Sleep Walking Disorder
• Bedtime Refusal
• Enuresis (Bedwetting)

More Provider Resources

A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems
J. A. Mindell & J. A. Owens

Empirically Supported Treatments in Pediatric Psychology: Nocturnal Enuresis
M. W. Mellon & M. L. McGrath

Bedwetting Store
Online store for ordering urine alarms.

Insomnia

Sleep hygiene is an important component to any treatment package.³ Parents and children can work together to develop healthy sleep-related habits, such as not engaging in stimulating activity before bed, awakening at a consistent time each day, avoiding caffeine or stimulating medications before bed, etc. Other useful behavioral interventions include:⁴

• Relaxation—any number of relaxation skills can be helpful for children and adolescents who are experiencing stress or anxiety that impacts their ability to sleep.
• Bedtime fading—identify a time when the child consistently falls asleep, then gradually move that time up by about 15 minutes until the child is falling asleep at the desired time. This is helpful when children are having difficulty following a consistent sleep-wake schedule.
• Establishing a consistent bedtime routine—parents learn to establish a consistent bedtime routine, which is initiated about 30 minutes before bedtime. The routine can consist of reading, teeth brushing, bath, etc. This can help children learn to wind down and fall asleep.
• Extinction—this is useful if the child is throwing tantrums related to going to bed or staying in bed. The parent learns to check on the child gradually less often until he or she learns to go to sleep and stay asleep on their own.
• Stimulus Control—only allowing the child or adolescent to sleep in bed and requiring that other activities (e.g., reading, homework, watching television) occur elsewhere. The young person is instructed to get out of bed if not sleeping (e.g., play with toys quietly on the floor, read in a chair, etc.), and avoid going back to bed until feeling sleepy again. This teaches the child to associate the bed with "sleep" as opposed to other activities. This is useful for young people who lie awake tossing and turning and have trouble falling asleep in their own bed.
• Paradoxical intention—telling the child to try to lie in bed and stay awake as long as possible. This is sometimes useful for children who have anxiety about being able to go to sleep, as it takes the focus away from their anxiety.
  Several cognitive-behavioral strategies are more appropriate for older children and adolescents, such as: ⁴
• Cognitive restructuring—identify unrealistic beliefs about sleeping (e.g., "If I don't sleep I will die."), and help the young person alter their beliefs. This is useful when a child or adolescent worries about not sleeping, which in turn makes it more difficult to sleep.
• Meditation or imagery—use these techniques to help the young person relax before bedtime. This is useful if the child or adolescent is experiencing stress or anxiety, which contributes to difficulty falling asleep.

A behavior therapist can help parents implement these techniques at home if they need addition help applying these procedures.²

Many practitioners do prescribe a variety of medications for pediatric insomnia, such as antihistamines, certain anti-depressants, and other sedative-hypnotic medications. However, there are few studies that have examined the use of medications to aid sleep in children, and currently there are no medications approved for use as hypnotics in children by the U.S. Food and Drug Administration.³ If insomnia is secondary to, or caused by another disorder (e.g., depression, medical illness), that disorder should be treated first. If symptoms of insomnia do not improve a referral to sleep specialist may be helpful.⁵

Hypersomnia

If hypersomnia is secondary to, or caused by another disorder (e.g., depression, medical illness), that disorder should be treated first. Poor sleep hygiene may contribute to hypersomnia. It is important to implement habits to promote sleeping at night and staying awake during the day, such as avoiding activities that delay bed time and avoiding caffeine.⁶ More

Narcolepsy

Stimulant medications, such as Ritalin, are effective for the treatment of Narcolepsy in children.⁷Taking scheduled naps in addition to medication is recommended. ⁸ More

Breathing-Related Disorder

For patients with obstructive sleep apnea, treatment may include weight loss when children and adolescents are obese⁹, surgical interventions (removing the tonsils or adenoids), and the use of a continuous positive airway pressure (CPAP) device. ¹⁰ A C-PAP is a machine that blows air into your nose via a nose mask, keeping the airway open and unobstructed. More

Circadian Rhythm Disorder

Light therapy (properly timed exposure to bright light to promote a normal sleep-wake cycle and decrease sleep disturbances) and behavioral interventions may be beneficial in the treatment of Circadian Rhythm Disorder. ¹¹ Behavioral interventions include implementing habits to promote normal sleep/wake cycles and gradually shifting the time of sleep. ¹⁵More

Sleep Terror Disorder

Before beginning treatment it is recommended that sleep terrors be waited out to see if they resolve. ¹³ Sleep terrors may be impacted by a failure to get enough sleep, therefore getting more sleep might be helpful.  Scheduled awakening may also be beneficial for the treatment of sleep terrors. ¹³ Scheduled awakening involves waking the person approximately 30 minutes before the he or she normally awakens, then slowly eliminating the scheduled awakenings as spontaneous awakenings decrease.¹³If the problem persists, a trial of antidepressants or antianxiety medications may be beneficial, however the effectiveness of these drugs has not been clearly demonstrated. ¹³ More

Nightmare Disorder

Behavioral interventions may be beneficial in the treatment of recurrent nightmares.^{14, 15} Treatment may include imagery rehearsal for nightmares (practice of how to respond to the event without actually experiencing it) and sleep hygiene (implementing habits that promote good sleep). More

Sleep Walking Disorder

Sleep walking does not necessarily require treatment, and may go away on its own. It is important to implement habits to promote good sleep and treat any underlying medical conditions that may impact sleep problems.¹⁶ Safety measures may be necessary to prevent injury, including locking windows and doors, removing obstacles in the room, adding alarms, or blocking stairways.¹⁵ Medications, such as certain sedatives or antidepressants, may be helpful, particular if the potential risk for injury is great, if other interventions have not been helpful, or if the individual is experiencing excessive daytime sleepiness.¹⁶ Behavioral techniques, such as relaxation and scheduled awakening may also be beneficial for the treatment of sleep walking.¹⁵ Scheduled awakening involves waking the person up approximately 15-20 minutes before the usual time her or she sleep walks and then keeping him or her awake through the time during which the episodes usually occur.¹⁶ More

Bedtime Refusal

A number of behavioral interventions, such as establishing healthy sleep habits, rewarding compliance with bedtime routines, and ignoring tantrums associated with going to bed, are effective when a child is exhibiting bedtime refusal/resistance. If the young person is having difficulty staying in bed because of a Sleep Disorder or Enuresis, it is important to get treatment for these problems first or along with treatment for bedtime refusal. More

Enuresis (Bedwetting)

According to Division 12 of the American Psychological Association, behavioral treatment is well-established as a beneficial treatment for enuresis. Behavioral treatment usually involves the use of a urine alarm device and parent education.^{17, 18} More

Desmopressin and Imipramine have been used to treat enuresis. Medications may have side-effects and do not teach continence skills. When children stop taking medications symptoms will generally reemerge. When medications do work the effects tend to be seen fairly quickly, therefore medication can be a useful adjunct to behavior therapy.¹⁸ More

¹ McCrae, C. S., Sidney, D. N., Taylor, D. J., & Lichstein, K. L. (in press). Insomnia. In J. Fisher and W. O'Donohue (Eds.), Practice guidelines for evidence based psychotherapy.  New York: Kluwer Academic Publications.

² Moore, B. (in press).Pediatric insomnia.In J. E. Fisher & W. O'Donohue (Eds.). Practitioner's guidelines for evidence based psychotherapy. New York: Kluwer.

³Owens, J. (2005). Insomnia in Children and Adolescents. Journal of Clinical Sleep Medicine, 1, 4, e454-e458. Accessed 4/27/06.

⁴ Durand, V. M., Mindell, J., Mapstone, E., & Gernert-Dott, P. (1998). Sleep problems. In. T. S. Watson & F. M. Gresham (Eds.). Handbook of child behavior therapy (pp. 203-219). New York: Plenum Press.

⁵ McCrae, C. S., Sidney, D. N., Taylor, D. J., & Lichstein, K. L. (in press). Insomnia. In J. Fisher and W. O'Donohue (Eds.), Practice guidelines for evidence based psychotherapy. New York: Kluwer Academic Publications.

⁶ National Institutes of Health, National Institutes of Neurological Disorders and Stroke. NIDS Hypersomnia Information Page. Updated 1/14/06. Accessed 2/26/06.

⁷ American Academy of Child and Adolescent Psychiatry (2002).Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. Journal of the American Academy of Child Adolescent Psychiatry, 41, 2 Suppl, 26S-49S.

⁸ Littner, M., Johnson, S. F., McCall, W. V., McDowell Anderson, W., Davila, D., K. Hartse, Kushida, C. A., et al. (2001).  Practice Parameters for the Treatment of Narcolepsy: An Update for 2000. Sleep, 24, 4, 451-466.

⁹ Chan, J., Edman, J. C., & Koltai, P. J. (2004). Obstructive sleep apnea in children.American Family Physician, 69, 5.

¹⁰ American Academy of Pediatrics (2002). Clinical practice guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics, 109, 4, 704-712.

¹¹ Cataletto, M. E., & Hertz, G. (2005). Sleeplessness and Circadian Rhythm Disorder. Updated 9/27/05. Accessed 2/26/06.

¹² Heussler, H. (2005).Common causes of sleep disruption and daytime sleepiness: childhood sleep disorders II. Medical Journal of Australia, 182, 9, 484-489.

¹³ Durand, V. M. (in press). Sleep Terrors. In J. E. Fisher & W. O'Donohue (Eds.). Practitioner's guidelines for evidence based psychotherapy. New York: Kluwer.

¹⁴Krakow, B., Johnston, L., Melendrez, D., Hollifield, M., Warner, T. D., Chavez-Kennedy, D., & Herlan, M. J. (2001). An Open-Label Trial of Evidence-Based Cognitive Behavior Therapy for Nightmares and Insomnia in Crime Victims With PTSD. American Journal of Psychiatry, 158, 2043-2047.

¹⁵ Pagel, J. F. (2000).Nightmares and Disorders of Dreaming. American Family Physician, 61, 7, 2037-2050.

¹⁶ Sharp, S. J., & D'Cruz, O. F. (2006). Somnambulism (Sleep Walking). Updated 1/3/06. Accessed 2/26/06.

¹⁷ Houts, A.C. (1996).Behavioral treatment of enuresis. The Clinical Psychologist, 49, 1, 5-6.

¹⁸ Friman, P. C., & Jones, K. M. (1998). Elimination disorders in children. In. T. S. Watson & F. M. Gresham (Eds.). Handbook of child behavior therapy (pp. 239-260). New York: Plenum Press.

¹⁹ American Academy of Child and Adolescent Psychiatry (2004). Psychiatric medication for children and adolescents part II: Types of medications. Fact Sheets for Families, 29.Accessed 4/26/06.