Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children An American Academy of Sleep Medicine Review

BEDTIME PROBLEMS AND FREQUENT NIGHT WAKINGS ARE HIGHLY PREVALENT IN YOUNG CHILDREN, OCCURRING IN APPROXIMATELY 20% TO 30% of infants, toddlers, and preschoolers.1-7 In addition, longitudinal studies have demonstrated that sleep problems first presenting in infancy may persist into the preschool and school-aged years and become chronic.8-11 Furthermore, the impact of disturbed and inadequate sleep in young children can be both significant and extensive.12 There is increasing evidence that sleep disruption and/or insufficient sleep has deleterious effects on children’s cognitive development (e.g., learning, memory consolidation, executive function), mood regulation (e.g., chronic irritability, poor modulation of affect), attention, and behavior (e.g., aggressiveness, hyperactivity, poor impulse control), as well as health (e.g., metabolic and immune function, accidental injuries) and overall quality of life.13-16 In addition, studies have documented secondary effects on parentsa (e.g., maternal depression), as well as on family functioning.17-19 Finally, the economic burden related to healthcare costs for sleep problems in infants and young children has been estimated to be considerable.20,21 A number of treatment strategies for bedtime behavior problems and night wakings in children exist, including behavioral management techniques, parent education, and medication. In contrast to the paucity of data that exists regarding pharmacologic treatment,22-24 there is now a solid body of literature supporting empirically based behavioral treatments of bedtime problems and night wakings in infants, toddlers, and preschoolers. In addition, studies have also demonstrated that these strategies, compared to pharmacological treatments, are often more effective, may be more acceptable to both parents and practitioners,25-28 and avoid potential harmful side effects associated with medication use. Behavioral sleep management strategies have the further advantage of potentially generalizing to the management of daytime issues. Given the impact of sleep disturbances in infants and young children, and the availability of empirically supported treatment strategies, the development of clinical guidelines for the management of bedtime resistance and night wakings in young children is important and necessary. As the basis for developing those clinical guidelines, and building on several previous thorough reviews of empirically-based non-pharmacologic treatments of behavioral insomnias of childhood,29-31 we present an updated critical summary of the current literature. A brief discussion of the issues pertaining to the definition and diagnosis of behavioral insomnia of childhood is included.