PEDIATRIC SLEEP Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Closer to our Customers… Young Children (but don’t just take our word for it.) An American Academy of Sleep Medicine Review Jodi A. Mindell, PhD1,4; Brett Kuhn, PhD2; Daniel S. Lewin, PhD3; Lisa J. Meltzer, PhD4; Avi Sadeh, DSc5 1Department of Psychology, Saint Joseph’s University, Philadelphia, PA; 2University of Nebraska Medical Center, Omaha, NE; 3Children’s National ” Our relationship with Embla, formerly Medcare, has been “ The Xactrace Belts are the best Medical Center, George Washington University School of Medicine, Washington, DC; 4Children’s Hospital of Pennsylvania, Philadelphia, PA; 5Depart- mutually beneficial both educationally and professionally. way to measure breathing effort ment of Psychology, Tel Aviv University, Tel Aviv, Israel Every piece of our future 30 bed facility will be networked and are smoothly interfaced with Abstract: This paper reviews the evidence regarding the effi cacy of be- tinction and preventive parent education. In addition, support is provided together and they have helped us towards our pending 1st the Rembrandt Sleep system”. havioral treatments for bedtime problems and night wakings in young for graduated extinction, bedtime fading/positive routines, and scheduled CoA PSG Accredited sleep program”. – Andy Desrosiers, Holy – Jim Wilcox, RPSGT/CRT, children. It is based on a review of 52 treatment studies by a task force awakenings. Additional research is needed to examine delivery methods of treatment, longer-term effi cacy, and the role of pharmacological agents. Family Hospital , Massachusetts, USA All Children’s Hospital, appointed by the American Academy of Sleep Medicine to develop prac- tice parameters on behavioral treatments for the clinical management of Furthermore, pediatric sleep researchers are strongly encouraged to de- St. Petersburg, Florida, USA bedtime problems and night wakings in young children. The fi ndings in- velop standardized diagnostic criteria and more objective measures, and “The Embletta is a powerful diagnostic tool. It dicate that behavioral therapies produce reliable and durable changes. to come to a consensus on critical outcome variables. provides a wealth of information and a great “I have been using Embla, formerly Medcare, equipment since Across all studies, 94% report that behavioral interventions were effi ca- Keywords: Bedtime problems, night wakings, behavioral insomnia of deal of detail. At the same time it is easy to 2001. Starting out with 2 beds, we are currently running 10 cious, with over 80% of children treated demonstrating clinically signifi - childhood, treatment, behavioral treatment learn and simple to use with excellent reliability. beds. I have used Artisan, Monet and the Embla cant improvement that was maintained for 3 to 6 months. In particular, Citation: A Review by Mindell JA, Kuhn B, Lewin DS et al. Behavioral empirical evidence from controlled group studies utilizing Sackett criteria treatment of bedtime problems and night wakings in infants and young Once we received our first Embletta, we stored our N7000, and have been amazed by their for evidence-based treatment provides strong support for unmodifi ed ex- children. SLEEP 2006;29(10):1263-1276. other devices on the shelf”. – Paul R. Murphy, RPSGT, reliability and ease of operation. Scoring Sahlgrenska University Hospital, Gotaborg, Sweden and analysis modules are friendly and 20,21 flexible and I would highly recommend 1. INTRODUCTION estimated to be considerable. A number of treatment strategies “ At Scansleep, we use for bedtime behavior problems and night wakings in children ex- all of the products we have used from Embla”. – BEDTIME PROBLEMS AND FREQUENT NIGHT WAKINGS Embla, Embletta, ist, including behavioral management techniques, parent educa- Michael D. McDannold, RPSGT,CRT ARE HIGHLY PREVALENT IN YOUNG CHILDREN, OC- tion, and medication. In contrast to the paucity of data that exists Somnologica and Enterprise in all our clinics. Vermont Medical SDC, Vermont, USA CURRING IN APPROXIMATELY 20% TO 30% of infants, tod- regarding pharmacologic treatment,22-24 there is now a solid body 1-7 All of the hardware has been extremely stable and user- dlers, and preschoolers. In addition, longitudinal studies have of literature supporting empirically based behavioral treatments friendly. We are also enthusiastic users of the software demonstrated that sleep problems first presenting in infancy may of bedtime problems and night wakings in infants, toddlers, and To learn how we can get closer to you too, please call applications”. – Soren Berg, M.D. PhD, Copenhagen, Denmark persist into the preschool and school-aged years and become preschoolers. In addition, studies have also demonstrated that 8-11 us at 1.888.662.7632 or visit us at www.embla.com chronic. Furthermore, the impact of disturbed and inadequate these strategies, compared to pharmacological treatments, are of- 12 sleep in young children can be both significant and extensive. ten more effective, may be more acceptable to both parents and There is increasing evidence that sleep disruption and/or insuf- practitioners,25-28 and avoid potential harmful side effects associ- ficient sleep has deleterious effects on children’s cognitive de- ated with medication use. Behavioral sleep management strate- velopment (e.g., learning, memory consolidation, executive func- gies have the further advantage of potentially generalizing to the tion), mood regulation (e.g., chronic irritability, poor modulation management of daytime issues. of affect), attention, and behavior (e.g., aggressiveness, hyperac- Given the impact of sleep disturbances in infants and young tivity, poor impulse control), as well as health (e.g., metabolic children, and the availability of empirically supported treatment and immune function, accidental injuries) and overall quality of strategies, the development of clinical guidelines for the manage- 13-16 life. In addition, studies have documented secondary effects ment of bedtime resistance and night wakings in young children is a on parents (e.g., maternal depression), as well as on family func- important and necessary. As the basis for developing those clini- 17-19 tioning. Finally, the economic burden related to healthcare cal guidelines, and building on several previous thorough reviews costs for sleep problems in infants and young children has been of empirically-based non-pharmacologic treatments of behavioral insomnias of childhood,29-31 we present an updated critical sum- a global leader in sleep diagnostic systems mary of the current literature. A brief discussion of the issues per- a The term “parents” is used throughout the paper for stylistic reasons to denote taining to the definition and diagnosis of behavioral insomnia of any type of guardian or caregiver (e.g., grandparent). childhood is included. Global Headquarters: 11001 W. 120th Ave., Broomfield, CO 80021 Disclosure Statement 1.1 Definition of Disorder and Prevalence This was not an industry supported study. Drs. Mindell and Sadeh serve as PH: 303.962.1800 FX: 303.962.1810 consultants for Johnson & Johnson. Drs. Kuhn, Lewin, and Meltzer have To clarify the definitions used in this review, it is important www.embla.com www.shopembla.com indicated no fi nancial confl icts of interest. to make a distinction between the clinical diagnoses applicable to bedtime problems and night wakings in children, and the re- Address correspondence to: Jodi A. Mindell, PhD, Department of Psychol- search definitions used in studies of children with these sleep ogy, Saint Joseph’s University, 5600 City Avenue, Philadelphia, PA 19131; problems. First, within the clinical realm, the 1997 International Tel: (610) 660-1806; Fax: (610) 660-1819; E-mail: [email protected] Classification of Sleep Disorders32 separates bedtime problems SLEEP, Vol. 29, No. 10, 2006 1263 Review of Bedtime Problems in Children—Mindell et al 1EM101_ad5_8-15.indd 1 8/15/06 2:31:44 PM and night wakings into two distinct diagnostic categories: Sleep context of normal physical, cognitive, and emotional changes oc- Onset Association Disorder and Limit Setting Sleep Disorder. The curring at various developmental stages. Furthermore, parental most recent revision of the International Classification of Sleep recognition and reporting of sleep problems in children also var- Disorders33 uses similar terminology, but subsumes both of these ies across childhood, with parents of infants and toddlers more clinical entities under the new clinical diagnostic category of Be- likely to be aware of sleep concerns than those of school-aged havioral Insomnia of Childhood, which is further classified as children and adolescents. In addition, culturally-based values and sleep-onset association type, limit-setting type, or combined type. beliefs regarding the meaning, importance, and role of sleep in From a clinical standpoint, it should also be emphasized that the daily life, as well as culturally-based differences in sleep prac- diagnostic criteria for a sleep disorder require a specific constel- tices (e.g., sleeping space and environment, solitary sleep vs. co- lation of symptoms of a defined severity level to be present for sleeping, use of transitional objects) have a profound effect not a specified time and to result in some significant impairment in only on how a parent defines a sleep “problem” but on the relative functioning either in the child or in the parent(s) or family. As acceptability of various treatment strategies.