Chapter 22: Sleep Disorders

CHAPTER 22

Sleep Disorders

Judith Owens Melissa M. Burnham

Although the term “sleeping like a baby” con- searchers generally agree that sleep states are ventionally implies certain characteristics, such evident in the last trimester of the prenatal pe- as sleeping deeply and for long, uninterrupted riod. Mirmiran, Maas, and Ariagno (2003), in bouts, developmental sleep researchers—and a review of this work, reported that both active anyone who has ever lived with an infant—have and quiet sleep can be differentiated as early long understood that “typical” infant sleep is as 32 weeks’ gestation, and that quiet sleep in- characterized by a variety of different behav- creases from 32 to 40 weeks’ gestation, with a iors and patterns, as well as a number of struc- concomitant decrease in indeterminate sleep. tural features (“sleep architecture”) unique to Active sleep (AS), however, appears to remain sleep in early life. Furthermore, the regulation relatively constant during the last weeks of of sleep, which involves the interaction between gestation. Similar results are found in preterm the homeostatic “sleep drive” and circadian- infants of the same postconceptional age. The based timing, undergoes substantial develop- high proportion of AS during late gestation par- mental changes across the first 3 years of life, allels rapid brain maturation that is occurring and infants often experience either transitory or at this time, implicating AS as potentially play- longer-lasting disturbances in their sleep during a role in brain development (Mirmiran et ing this period. In this chapter, we review the al., 2003). In addition to these changes in sleep typical course of sleep–wake state development architecture during the prenatal period of life, across the first 3 years of life, discuss the most circadian rhythms also are evident in the last common sleep disturbances seen during this trimester of gestation. Mirmiran and Lunshof period, describe sleep problems in the context (1996) and Lunshof and colleagues (1998) have of other disorders, and provide an overview of reported a circadian fetal heart rate rhythm that common interventions used to treat infant–tod- is entrained to maternal rest–activity, cortisol, dler sleep problems. melatonin, body temperature, and heart rate rhythms. Thus, even during prenatal life, the circadian clock appears to be functional. Ontogenetic Course of Sleep Across Following the prenatal period, dramatic the First 3 Years changes in sleep occur during the first 3 years of life, including average sleep duration, sleep Although the focus of this chapter is on post- architecture, and timing of sleep and wakeful-

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. natal development, it should be noted that re- ness across the 24-hour day. At birth, the typi-

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cal infant spends significantly more time asleep In addition to changes in the total amount of than awake, has a disproportionately higher per- sleep, substantial changes occur in the night- centage of active versus quiet sleep, and sleeps time architecture of sleep as well. For instance, about the same amount during the day and night although the typical adult enters sleep at the (Kleitman & Englemann, 1953; Roffwarg, De- beginning of the night through non-REM (non- ment, & Fisher, 1964). By age 3, all of this has rapid eye movement) sleep stages (then pro- changed, such that the average 3-year-old has gressing through Stages 1–4), very young in- consolidated sleep into one lengthy nighttime fants enter sleep in an active (or “REM-like”) bout and one daytime nap, is starting to ex- sleep state. AS onset occurs prenatally and hibit adult proportions of active and quiet sleep, generally declines during the early months of and sleeps for an average of about 12 hours per life. Coons and Guilleminault (1984) report a 24-hour day (Galland, Taylor, Elder, & Herbi- significant decrease in AS-onset sleep periods son, 2012; Jacklin, Snow, Gahart, & Maccoby, between ages 3 and 6 weeks, and again be- 1980). We discuss in turn each of these trans- tween ages 4 and 6 months. In addition to the formations. entry into AS, young infants also experience Detailed studies of infant sleep in the mid- much higher proportions of total sleep time portion of the previous century served to in- in AS compared to adults and older children form some general misperceptions that existed (Ficca, Fagioli, & Salzarulo, 2000; Jenni, Bor- at the time. For example, it was discovered that bély, & Achermann, 2004; Kurth, Olini, Huber, during the newborn period, the average child & LeBourgeois, 2015). The decline in the per- sleeps approximately 16–17 hours per day, in centage of the night spent in AS across the first sharp contrast to the 20–22 hours reported in year of life is accompanied by a concomitant pediatric textbooks prior to the 1950s (Kleit- increase in quiet (or “slow wave-like”) sleep man & Englemann, 1953; Parmelee, Schulz, & (Anders et al., 1985; Burnham et al., 2002; Disbrow, 1961). Also, it had been generally ac- Dittrichová, 1966; Kurth et al., 2015; Louis, cepted that the total amount of sleep declines Cannard, Bastuji, & Challamel, 1997). For in- early in infancy. The seminal longitudinal work stance, Jenni and colleagues (2004) reported of Kleitman and Engelmann (1953), however, that 2-week-olds spend approximately 51% of indicated that the total duration of sleep did not the night in AS and 39% of the night in quiet differ over the first 3 months of life; rather, it sleep; these percentages gradually change to 30 is the distribution of sleep across the 24-hour and 70%, respectively, by 9 months of age. As day that changes, so that more sleep becomes mentioned in the section on prenatal develop- prominent (or “consolidated”) during the night- ment, the proclivity for AS during early devel- time hours. This finding has been substantiated opment is thought to play a role in healthy brain in subsequent investigations (e.g., Anders & development (Kurth et al., 2015; Peirano, Al- Keener, 1985; Coons & Guilleminault, 1984). garín, & Uauy, 2003). The cycle length of each Total sleep time across 24 hours does decline AS–quiet sleep bout is also shorter in infancy somewhat beyond the 3-month mark, but most and early childhood compared to the 90-minute infants continue to sleep between 12 and 14 cycle characteristic of adult sleep architecture. hours per day through the age of 2 years. The This so-called “ultradian cycle” is closer to 60 longest uninterrupted sleep period at night con- minutes in infancy (Aserinsky & Kleitman, tinues to increase until it levels off sometime 1955; Dittrichová, 1966; Harper et al., 1981), between ages 3 and 6 months for the remainder with the adult cycle pattern thought to emerge of the first year of life (Anders & Keener, 1985; sometime during middle childhood (Roffwarg Burnham, Goodlin-Jones, Gaylor, & Anders, et al., 1964). 2002; Galland et al., 2012). Notwithstanding Perhaps the most striking developmental these changes, it should be noted that “sleeping sleep change that occurs during early infancy is through the night” is a misnomer for most in- the maturation of the circadian system and the fants and toddlers across the first 3 years of life. infant’s gradual synchronization (or “entrain- Most young children continue to wake up dur- ment”) to the 24-hour light–dark cycle. The ing the night; a substantial proportion, however, bulk of research to date suggests that in new- learn to self-soothe (“regulate” sleep) and put borns, there is no clear relationship between themselves back to sleep independently upon sleep and wakefulness and time of day. Rather, such awakenings (e.g., Burnham et al., 2002; sleep patterns are largely dependent on hunger

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. Keener, Zeanah, & Anders, 1988). and satiety, and feeding schedules. Thus, sleep

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is distributed for the young infant almost equal- Sleep Disturbances ly between night and day. Young infants typi- Definition cally sleep for 3- to 4-hour periods (which may be shorter in breastfed infants) separated by 1–2 As described earlier, the definition of a sleep hours of wakefulness. Remarkably, by about 3 “problem” in infants and toddlers is complicat- months of age, most infants have established ed by the existence of considerable variability consolidated sleep periods that occur during the in individuals’ “normal” sleep. There are addi- nighttime hours (Bamford et al., 1990; Burn- tional complicating factors as well. Factors such ham, 2007; McMillen, Kok, Adamson, Deay- as inter- and intracultural variation in what is ton, & Nowak, 1991; St. James-Roberts, Rob- considered “normal,” extreme developmental erts, Hovish, & Owen, 2015). changes that are occurring during this age pe- Although often ignored in discussions of riod, the fact that sleep disturbances occur in “average” or “typical” sleep, there is a great the context of parent–child relationships, and deal of individual variability in total sleep the existence of various systems for clinically amount, in the timing of sleep–wake rhythmic- classifying sleep “disorders” are all involved ity, in the proportion of time spent in each sleep in complicating the definition of sleep prob- state during sleep itself, and in the longest pe- lems in this age group. For example, culturally riod of consolidated sleep, among other sleep– based values and beliefs regarding the mean- wake variables (e.g., Anders, Halpern, & Hua, ing, importance, and role of sleep in daily life, 1992; Emde & Walker, 1976; Fazzi et al., 2006; as well as culturally based differences in sleep Galland et al., 2012; Louis et al., 1997; Navelet, practices (e.g., sleeping space and environment, Benoit, & Bouard, 1982; Sadeh, Hauri, Kripke, solitary sleep vs. cosleeping, use of transitional & Lavie, 1995; St. James-Roberts & Plewis, objects) have a profound effect on not only how 1996). For example, an epidemiological study a parent defines a sleep “problem” but also the of 493 children ages 1 month to 16 years in relative acceptability of various treatment strat- Switzerland revealed significant variability in egies. total sleep duration, nighttime sleep duration, Thus, parental concerns and subjective ob- and daytime sleep duration (Iglowstein, Jenni, servations regarding their child’s sleep patterns Molinari, & Largo, 2003). In a longitudinal and behaviors often define what constitutes a study of almost 3,000 children from birth to sleep “disturbance” in the clinical context. Cer- 6–7 years, Magee, Gordon, and Caputi (2014) tainly, the two are intertwined. For example, in found four different developmental trajectories a recent study, parental sleeping problems were in regards to sleep duration: typical sleepers associated with more frequent reporting of chil- (40.6%), initially short sleepers (45.2%), poor dren’s sleeping problems in 2- to 6-year-olds sleepers (2.5%), and persistent short sleepers (Rönnlund, Elovainio, Virtanen, Matomäki, (11.6%). Some of the differences were associ- & Lapinleimu, 2016). Of course, when an in- ated with environmental, parental, and child fant wakes up, parents’ sleep may be disrupted. factors. A more recent study of over 700 par- Thus, the definition of a sleep problem in an ent–child pairs showed a higher interindividual infant is at least partly characterized by paren- variability in sleep patterns until age 6 months, tal sleep disruption. Parental recognition and then little variability in bedtime, sleep latency, reporting of sleep problems in children also and sleep duration from 6–12 months (Bruni varies across childhood, with parents of infants et al., 2014). Although researchers are begin- and toddlers more likely to be aware of sleep ning to recognize and examine these individual concerns than those of school-age children, for differences and possible etiological factors in example. Medical concerns in an infant, such a older children (e.g., Buckhalt, El-Sheikh, & prematurity, or congenital conditions, such as Keller, 2007) and adults (Tucker, Dinges, & Down syndrome (Bassell, Phan, Leu, Kronk, & Von Dongen, 2007), more research into in- Visootsak, 2015) may predispose to both paren- dividual differences at earlier ages is needed. tal and subsequent child insomnia (Blomqvist, These interindividual differences are important Nygvist, Rubertsson, & Funkquist, 2017). Fi- partly because they illuminate the complexity nally, the daytime sequelae of inadequate or involved in clearly defining the boundary be- disrupted sleep may also be less easily recog- tween normal and pathological sleep in young nized in infants, as excessive daytime sleepi- children, and in recognizing and evaluating ness in children is frequently manifested as

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. sleep disturbance in this population. behavioral and/or mood dysregulation or neu-

rocognitive dysfunction. Interestingly, Kocev- Clinicians often rely exclusively on parent ska and colleagues (2017) reported that parent- report of a problem in order to diagnose and identified sleep problems prior to age 2 years treat a sleep disturbance in an infant or toddler. was not associated with later adverse impacts Indeed, sleep problems in infants and toddlers on brain morphology. Sleep problems reported have been found to be correlated with mater- by parents after the age of 2, however, were as- nal postpartum depression (Hairston, Solnik- sociated with smaller gray-matter volume at age Menilo, Deviri, & Handelzalts, 2016), paternal 7. Clinicians, then, need to exercise caution in depression, increased anger and stress (Cook et diagnosing and treating sleep problems in very al., 2017; Millikovsky-Ayalon, Atzaba-Poria, & young children and must consider the many Meiri, 2015), parental fatigue, lower levels of contextual and developmental factors that may tolerance to crying (Sadeh et al., 2016), lower be contributing to what is perceived as a “sleep parental health literacy (Bathory et al., 2016), disturbance.” general disruptions to family life, poor maternal mental and physical health, and lower lev- Prevalence els of parental well-being (e.g., Bayer, Hiscock, Hampton, & Wake, 2007). Many parents clearly Despite the difficulty in delineating a clear, uni- do find disruptions in their child’s sleep to be versally accepted definition of “problem sleep” problematic, but individual tolerance levels and in the infant–toddler population, concerns with expectations differ greatly; furthermore, the sleep are among the most common complaints of threshold for seeking “professional help” from parents during well-baby visits (Thiedke, 2001). a variety of health care providers (e.g., primary For example, in a study of over 700 parent– care pediatricians, mental health specialists, child dyads including infants from birth to age and behavioral sleep medicine specialists, as 12 months, almost 10% of infants had parent- well as other sources, such as “sleep coaches”) reported sleep problems, defined as difficulty likely varies greatly and is influenced by myri- settling and problematic night wakings (Bruni ad factors ranging from culturally based values et al., 2014). In a large-scale study of over 2,000 to the presence of social support networks, to children from birth to age 36 months in Aus- insurance coverage and access to health care in tralia and New Zealand, over 30% of parents a given community. Not only does this complex reported their infants’ sleep to be problematic relationship likely profoundly reduce preva- (Teng, Bartle, Sadeh, & Mindell, 2012). Dur- lence rates (which are frequently based on diag- ing infancy and toddlerhood, the most frequent nostic coding and billing in the health care sys- caregiver complaints were excessive night wak- tem), but it also very probably underestimates ing and settling problems at bedtime, with the the impact on sleep problems on both young former being more prevalent earlier in life and children and families. the latter in toddlerhood and beyond (Mindell, 1993). Prevalence rates are largely determined Problematic Night Waking by parental report, although some studies have shown similar rates using objective measures of As discussed earlier, the most common sleep sleep and a priori established research criteria complaint in the infant–toddler population is (e.g., sleep onset ≥ 30 minutes, occurring ≥ 5 night waking. Despite research evidence sug- nights/week for ≥ 3 weeks; Gaylor, Goodlin- gesting that sleep problems may be different Jones, & Anders, 2001). The most commonly in very young children compared to how they reported overall prevalence rate of any type present in adults, the most recent version of the of sleep problem in the infant–toddler popu- Diagnostic and Statistical Manual of Mental lation is around 25% (Lozoff, Wolf, & Davis, Disorders (DSM-5; American Psychiatric As- 1985; Richman, 1981; Teng et al., 2012). How- sociation, 2013) and the third edition of the In- ever, in a poll, the National Sleep Foundation ternational Classification of Sleep Disorders (2004) found that only 6% of parents of infants (ICSD-3; American Academy of Sleep Medi- and 11% of parents of toddlers reported a sleep cine, 2014) do not distinguish between child- problem in their child. Thus, it is important to hood and adulthood sleep disorders. Night-wak- conduct more population-based studies and to ing problems are classified under the broad term use consistent definitions, in order to determine “dysomnia,” or difficulty initiating or maintain- clear and accurate prevalence rates. ing sleep. The DSM-5 classification has limited Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

usefulness in the infancy period because spe- ability to self-soothe has been clearly shown to cific criteria for young children are not distin- be associated with the practice of putting the guished, and young children rarely meet the infant to bed while drowsy but still awake (i.e., impairment and/or severity criteria for the adult avoiding associating sleep onset with parental diagnosis. Most night waking during infancy is intervention). In addition, parental responses to thought to occur because the infant has learned night wakings in and of themselves may be re- to depend on or need specific circumstances or inforcing (e.g., feeding, prolonged interactions). objects (“sleep-onset associations”) introduced While sleep-onset associations are certainly by a caregiver (e.g., rocking, nursing, or a paci- an important contributor to night waking, there fier) in order to fall asleep. These are typically are apparently other reasons that nighttime available to the child at bedtime; however, these waking develops. For example, in one study, same sleep-onset associations are also often active physical comforting at bedtime only needed by the child in order to fall back to sleep explained 3% of the variance in infant sleep after normal arousals or awakenings during the problems at 1 year when examined with other night. Thus, when the child wakes at night and variables such as maternal cognitions, tempera- these circumstances or objects are not present, ment, and maternal anxiety/depression, but it the parent must reintroduce them in order for did explain more variance in the continuity of the child to reinitiate sleep. As infants and chil- problematic sleep from the first to the second dren typically arouse briefly on average four to year of life (Morrell & Steele, 2003). Clearly, six times throughout the night as a result of the more research is needed to fully explain the rea- normal ultradian rhythm of sleep cycles, these sons behind night waking in the infant–toddler night wakings (or, more accurately, these fail- period. ures to fall back to sleep) may occur as often as every 90–120 minutes. Settling Difficulties Night waking is only considered a disorder in the presence of “a specific constellation of The second most common sleep disorder found symptoms of a defined severity level to be pres- in the infant–toddler population is also con- ent for a specified time and to result in some sidered a “dyssomnia” in DSM-5 (American significant impairment in functioning either in Psychiatric Association, 2013). “Settling diffi- the child or in the parent(s) or family” (Mindell culties” are defined as delaying or resisting bed- et al., 2006, p. 1264). In the absence of these time. Although it was referred to as “behavioral criteria, presenting complaints that do not meet insomnia of childhood, limit setting subtype” in the definition of “a disorder” are not diagnosed. ICSD-2, ICSD-3 eliminated this classification. As noted earlier, not all parents find it disturb- However, because it is important to distinguish ing that their infants or toddlers need their as- between night waking and settling difficulties sistance to fall asleep. Thus, two children may in the infancy period, in this chapter we refer to present with the exact same symptoms, but only the limit-setting subtype despite its official (but the child whose parents find the pattern prob- lamented) demise. Bedtime resistance generally lematic, or who is experiencing impairment develops in children ages 2 years and older, as in daytime functioning, can be formally diag- children gain more independence and experi- nosed with a “sleep disorder.” ence more developmentally normal fears, and Problematic night waking is thought to re- is manifested by prolonged bedtime routines sult largely from parents’ providing bedtime and strong resistance to going to bed (Crowell, environment conditions (i.e., sleep-onset as- Keener, Ginsburg, & Anders, 1987; Jenkins, sociations such as nursing, rocking) that can- Owen, Bax, & Hart, 1984; Salzarulo & Che- not be reliably reproduced by the infant after valier, 1983). Settling difficulties are thought waking up in the middle of the night and re- to be exacerbated by parents’ inadequately en- quire parental intervention. Fehlings, Weiss, forcing bedtimes and/or responding to (and thus and Stephens (2001) found that 6-month-old to reinforcing) children’s “curtain calls” (requests, 4-year-old children who had been referred from after bedtime, for one more story, one more a sleep clinic and who experienced these types drink of water, one more hug, 5 more minutes, of “nonadaptive sleep associations” had signifi- and the like). The most robust research in this cantly higher odds of night waking compared area comes from older children, but it demon- to a matched control group. In particular, the strates a significant correlation between bed- Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

time resistance and overall daytime resistance Sleep Problems and Bed Sharing to parental behaviors (Bates, Viken, Alexander, It should be noted that in a number of studies Beyers, & Stockton, 2002). Both daytime and (e.g., Hysing, Harvey, et al., 2014) bed sharing bedtime resistance are considered the result of has been associated with increased sleep prob- parents’ inability to set clear limits. lems in infants and toddlers. This is a highly Nevertheless, these problems also may reflect a mismatch between the parents’ expecta- controversial topic for a number of reasons, tions and the child’s predisposed sleep patterns ranging from cultural and socioeconomic dif- (Mindell et al., 2006). In particular, prolonged ferences in typical sleeping practices to poten- sleep onset and/or night waking may indicate tial issues regarding infant attachment to safety that caregiver expectations regarding “time in concerns (Burnham, 2013; Sadeh, Mindell, bed” may exceed the child’s sleep needs, re- & Owens, 2011). In a recent review of the lit- sulting in delayed sleep onset, prolonged night erature, Mileva-Seitz, Bakermans-Kranenburg, waking or early morning awakening, or some Battaini, and Luijk (2017) found general design combination of these. limitations in studies and a lack of convinc- Many children, of course, have symptoms of ing empirical evidence that precluded mak- both night waking and sleep-onset difficulties; ing strong generalizations either for or against thus, a clear distinction is not always feasible. bed sharing. Distinctions should also be made From a practical standpoint, the appropriate regarding bed sharing, sharing of other sleep- diagnosis should be based on the predominant ing spaces (e.g., a couch), room sharing, and symptom pattern for the previous 3 months proximate sleeping of caregivers and infants. whenever possible. For example, the American Academy of Pediat- There are also a number of precipitating and rics (2016) has recently revised their guidelines perpetuating factors associated with night- on safe infant sleeping environments, which waking and settling difficulties in infants and include room sharing but not bed-sharing, ide- toddlers, which include both extrinsic (e.g., en- ally for the first 12 months, as a means of re- vironmental situations, parental issues) and inducing risk of sudden unexpected infant death trinsic (e.g., temperament, medical issues) fac- syndrome. tors, and often represent a combination of these issues. Bedtime problems are often associated Other Sleep Disorders with child temperament (Carey, 1974; Keener et al., 1988; Sadeh, Lavie, & Scher, 1994; Sorondo Other sleep disorders that disrupt sleep, such & Reeb-Sutherland, 2015; Van Tassel, 1985). as obstructive sleep apnea and restless legs For example, “fussy” or temperamentally chal- syndrome/periodic limb movement disorder, lenging children may require a particular type may also delay sleep onset and trigger night of soothing/sleep-inducing technique, resist- wakings, and should also be considered in the ing any alternative that is less dependent on the differential diagnosis if symptoms and risk fac- caregiver. Sleep problems in typically develop- tors are present (e.g., snoring, adenotonsillar ing infants and toddlers have also been linked to hypertrophy, positive family history). Primary sensory processing issues (Vasak, Williamson, sleep disorders may also coexist with the more Garden, & Zwicker, 2015). Some caregivers behaviorally based insomnias, potentially exac- may have their own intrinsic and extrinsic is- erbating daytime sequelae. For example, sleep sues (e.g., depression, anxiety, long work hours) terrors may be a cause of nocturnal awaken- that interfere with their ability to set clear lim- ings characterized by agitation and high levels its both during the day and at bedtime. In other of arousal in young children, but they are much cases, there is a “mismatch” between parental less common (prevalence of about 1–3%) than expectations regarding sleep behaviors and the problematic sleep-onset associations. They typ- normal developmental trajectory of sleep pat- ically first present in the preschool age range, terns. Finally, environmental factors, such as and there is frequently a family history of sleep living accommodations that require a child to terrors or sleepwalking. Sleep terrors are char- share a bedroom with a sibling, parent, or ad- acterized by extreme levels of agitation, a high ditional family members (e.g., grandparents) arousal threshold, resistance to comforting, residing in the home, may also contribute to lack of recognition of caregivers, incoherent poor limit setting or negative sleep onset asso- and/or nonsense verbalizations, and a rapid re-

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first third of the night, when slow-wave sleep mind that it is difficult to tease apart the poten- predominates. The child has no memory of tial direction of effect in these investigations. It the event, and daytime sequelae are extremely is entirely possible that some of these correlates rare. “Transient sleep disturbances,” also called either precede the child’s sleep disruption or the “adjustment sleep disorders,” usually occur two are related to a completely different, un- in a child with prior normal sleep. Transient studied factor. One prospective study did find night wakings can be the result of a stressful that persistent sleep disruptions across the first life event, disruption of sleep schedule (e.g., 2 to 24 months of life were uncommon (6%) a trip, jet lag), or an illness. Short-term sleep but were associated with maternal depression disturbances, however, can become chronic if and parenting stress at 24 months (Wake et al., parents respond in a way (e.g., reinforcement of 2006). In contrast, in at least one investigation, the night wakings) that fosters poor sleep habits. Bayer and colleagues (2007) indicated that once they controlled for maternal sleep quality, the Impairments relationship between infant sleep problems and maternal mental health was eliminated. In most It is clear that two main sleep problems exist of these investigations, both child sleep and pa- during the infant–toddler period, that some par- rental well-being were measured by parent re- ents find these problems disturbing while others port, which potentially confounds any reported do not, and that sleep problems occur within a relationships. complex context of factors that affect their definition, diagnosis, and outcomes. There is also Child evidence that the aforementioned sleep problems may have a significant impact on some As discussed earlier, infant–toddler sleep dis- families, and there is research to suggest that ruptions are correlated with, and indeed may they may have an impact on the children who cause, several negative family outcomes. Less experience them, as well. However, due to the clear is whether there is a negative impact on fact that research in this area is relatively new the child him- or herself. While studies of and generally has not used experimental de- older children and adolescents have indicated signs or sophisticated data-analytic techniques, relationships between sleep problems and day- we use the term “correlate” to discuss purport- time behavior (e.g., Owens-Stively et al., 1997; ed impacts of sleep problems on children and Smedje, Broman, & Hetta, 2001; Wolfson & families. Thus, the issues we discuss below are Carskadon, 1998), fewer data are available on clearly bidirectional, in that they both increase the infant–toddler population. the risk (including heightened parental percep- A clear elucidation of the potential impact of tion) of sleep problems in infants and may be sleep problems on infants and toddlers is par- consequences of sleep problems in infants. ticularly challenging because these children take regular naps during the day. Daytime be- Family havioral effects of a nighttime sleep problem may be diminished by the child’s use of daytime As we noted earlier, some of the correlates of in- sleep to “make up for” a restless or short night. fant–toddler sleep problems in families include More recent studies have suggested that there maternal depression, anxiety, parental fatigue, may be an association between sleep problems general disruptions to family life, poor mater- such as settling difficulties and social–emo- nal mental and physical health, and less parental tional problems in toddlers (Hysing, Sivertsen, well-being (Bayer et al., 2007; Eckerberg, 2004; Garthus-Niegel, & Eberhard-Gran, 2016); sleep Hall, Clauson, Carty, Janssen, & Saunders, problems in infants and later deficits in self- 2006; Lam, Hiscock, & Wake, 2003; Meijer & regulation (Williams, Berthelsen, Walker, & van den Wittenboer, 2007; Meltzer & Mindell, Nicholson, 2017) and social–emotional adjust- 2007; Petzoldt, Wittchen, Einsle, & Martini, ment to school (Williams, Nicholson, Walker, & 2016; Wake et al., 2006). Hall and colleagues Berthelsen, 2016; Williams & Sciberras, 2016), (2006) reported that resolving the sleep prob- infant sleep problems, and parental ratings of lems of 6- to 12-month-old infants resulted in infant mood (Mindell & Lee, 2015); infant sleep significant improvement in parents’ sleep qual- problems and attentional dysregulation and be- ity, cognitions about infant sleep, depression, havior problems at ages 3–4 years (Sadeh et al.,

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. and marital harmony. It is important to keep in 2015); infant sleep duration and efficiency and

both externalizing and autism spectrum be- Although some of the above studies were con- haviors, which may be gender-specific (Saenz, founded by the fact that parents provided infor- Yaugher, & Alexander, 2015); and sleep prob- mation on both sleep and behavior, others (e.g., lems at 18 months and social–emotional prob- Randazzo et al., 1998) used objective measures. lems at 5 years (Sivertsen et al., 2015). Most evidence for a link between poor sleep Although there is growing evidence to sup- and daytime behavioral impairment, however, port objective daytime behavioral sequelae comes from studies with older children. Finally, for infants and toddlers who experience sleep it should be emphasized that other postulated problems, animal research has confirmed a health outcomes of inadequate sleep in children compelling relationship between sleep and de- include potential deleterious effects on the car- velopment of the brain. For example, there is diovascular, immune, and various metabolic some evidence that REM sleep helps consoli- systems, including glucose metabolism and en- date memory and promotes advanced cogni- docrine function, and an increase in accidental tive functioning (Stickgold, 2005); in addition, injuries. For example, shorter periods of night- REM sleep may provide an “endogenous source time sleep at 3 years have been linked to obesity of activation” with implications for neural de- during middle childhood (Reilly et al., 2005). velopment (Kurth et al., 2015, p. 65). Sleep also Some studies have indicated modest relation- may be involved in promoting brain plastic- ships between disturbed sleep and later behav- ity (Frank, Issa, & Stryker, 2001; Kurth et al., ior problems in very young children (e.g., Dear- 2015). Indeed, the same patterns of developing, McCartney, Marshall, & Warner, 2001; ment are seen among slow-wave activity, synap- Gregory, Eley, O’Connor, & Plomin, 2004), tic density, and energy consumption in both hu- although factors other than disturbed sleep mans and rats from birth through adolescence clearly contribute to the appearance of later be- (Kurth et al., 2015). These lines of evidence havior problems as well. Scher, Zukerman, and point to the possibility that sleep provides the Epstein (2005), for example, found that night foundation for neurocognitive development and waking in infancy predicted only 3% of the growth (Cheour et al., 2002; Gómez & Edgin, variance in behavioral scores at 42 months. Per- 2015; Kurth et al., 2015; Stickgold, Whidbee, sistent night waking and/or settling problems Schirmer, Patel, & Hobson, 2000). Thus, it were better predictors of later negative behav- would follow that any problem that results in ior than was night waking during the infancy significant sleep loss during development may period. Wake and colleagues (2006) also found impact cognitive functioning. that persistent, rather than transient, problems A robust body of research indicates asso- during the infant–toddler period related to sub- ciations between the quality of older children’s sequent child behavior problems. Recent work sleep and their cognitive and emotional func- has supported this relationship between persis- tioning and physical well-being. Sleep loss tent sleep problems in early life and later behav- and sleep fragmentation are known to directly ioral and academic problems (e.g., Williams, impact mood (increased irritability, decreased Nicholson, Walker, & Berthelsen, 2016). Thus, positive mood, poor affect modulation). Behav- it appears likely that severe, persistent sleep ioral manifestations of sleepiness in children problems during the infant–toddler period can are varied, and range from externalizing behav- impact daytime behavior; less clear is the po- iors, such as increased impulsivity, hyperactiv- tential impact of less severe or transient sleep ity, and aggressiveness, to mood lability and in- problems. attentiveness (Smedje et al., 2001). For instance, sleep loss has been related to maladjustment in preschoolers (Bates et al., 2002) and in impaired Sleep Disturbances in the Context daytime cognitive and behavioral functioning of Other Disorders in school-age children (Sadeh, Gruber, & Raviv, 2003). Sleepiness may also result in observable The high prevalence rates for sleep problems neurocognitive performance deficits, includ- found in children with neurodevelopmental dis- ing decreased cognitive flexibility and verbal orders, ranging from 13 to 85%, may be related creativity, poor abstract reasoning, impaired to any number of factors, including intrinsic motor skills, decreased attention and vigilance, abnormalities in sleep regulation and circadian and memory impairments (Dahl, 1996; Ran- rhythms, sensory deficits, and medications used

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. dazzo, Muehlbach, Schweitzer, & Walsh, 1998). to treat associated symptoms (Johnson, 1996;

Wiggs, 2001). In children with special needs, dren younger than 2 years old, and none, to our sleep problems are often chronic and unlikely to knowledge, has been conducted in infants less resolve without aggressive treatment. In addi- than 12 months old. tion, sleep disturbances in these children often Parents of young children with attention-def- have a profound effect on the quality of life of icit/hyperactivity disorder (ADHD) frequently the entire family. These children also frequently report sleep disturbances, especially difficulty have multiple sleep disorders occurring simul- initiating sleep and restless and disturbed sleep taneously or in succession. Higher degrees of (Sung, Hiscock, Sciberras, & Efron, 2008; Tsai, cognitive impairment tend to be associated with Hsu, & Huang, 2016; Yoon, Jain, & Shapiro, more frequent and severe sleep problems. 2012). Surveys of parents and children with It has been estimated that significant sleep ADHD compared to typically developing chil- problems occur in 30–80% of children with se- dren consistently report an increased preva- vere mental retardation and in at least half of lence of sleep problems, including delayed sleep children with less severe cognitive impairment. onset, poor sleep quality, frequent night wak- Estimates of sleep problems in children with ings, and shortened sleep duration that includes autism and pervasive developmental disorder infants later diagnosed with ADHD (Williams are similarly in the 50–70% range (Owens, & Sciberras, 2016). Although there are no stud- 2007). The types of sleep disorders that occur ies of sleep in very young children with ADHD in these children are generally not unique; rath- using more objective methods (e.g., polysom- er, they are more frequent and more severe than nography, actigraphy), studies in preschool those in the general population, and typically children, for example, have demonstrated in- reflect the child’s developmental level rather creased levels of nocturnal activity and more than chronological age. Significant problems night-to-night variability in sleep parameters with initiation and maintenance of sleep, short- (Melegari et al., 2016). Sleep problems in chil- ened sleep duration, irregular sleeping pat- dren with ADHD are likely to be multifactorial terns, and early morning waking, for example, in nature, and potential etiologies range from have been reported in a variety of different psychostimulant-mediated sleep-onset delay in neurodevelopmental disorders, including au- some children to bedtime resistance related to a tism spectrum disorders, Angelman syndrome, comorbid anxiety in some or oppositional defi- Rett syndrome, Smith–Magenis syndrome, and ant disorder in others. In some children, settling Williams syndrome. difficulties at bedtime may be related to deficits Basic principles of sleep hygiene are par- in sensory integration associated with ADHD, ticularly important to consider in preventing while in others, a circadian phase delay may be and treating sleep problems in children with the primary etiological factor in bedtime resis- developmental delays (Didden, Curfs, van tance (Tsai et al., 2016). Driel, & de Moor, 2002). Ensuring the safety Underlying medical conditions may also ac- of these children, especially if night waking is count for difficulties falling asleep and stay- a problem or there is a history of self-injurious ing asleep, including gastroesophageal reflux, behavior, also needs to be a key consideration allergies and atopic dermatitis, asthma, milk in management. A range of behavioral manage- intolerance, chronic gastrointestinal disorders, ment strategies used in typically developing seizures, and pain (e.g., otitis media). In addi- children for night wakings and bedtime resis- tion, in those conditions that typically require tance, such as graduated extinction procedures nighttime parental intervention (e.g., colic), it and positive reinforcement, may also be applied may be difficult for parents to differentiate be- effectively in children with developmental de- tween night wakings due to ongoing physical lays. Collaboration with a behavioral therapist symptoms and those related to learned behav- may be needed if there are complex, chronic, or iors (e.g., parental attention to crying). Parents multiple sleep problems, or if initial behavioral of children with a current or past history of med- strategies have failed. Finally, the use of phar- ical problems may also have difficulty setting macological intervention, including melatonin, limits, whether because of guilt, a sense that the in conjunction with behavioral techniques, also child is “vulnerable,” or concerns about doing has been shown to be effective in selected cases; psychological harm. Medication effects may however, few randomized controlled trials of also lead to disrupted sleep and night wakings. melatonin in children with neurodevelopmen- A number of patient and environmental factors

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family dynamics, underlying disease process- cost, positive reinforcement, and parent edu- es, comorbid mood and anxiety disorders, and cation–prevention programs. Some of the in- concurrent medications are clearly important terventions described below are tailored more to consider in assessing the bidirectional rela- specifically toward either bedtime problems or tionship of sleep problems and chronic illness night wakings, but since these two issues often in children. coexist, all treatment modalities are included. Unmodified extinction and parent education– prevention programs are the two behavioral Interventions for Sleep-Related Disturbances interventions that have the strongest empirical support. See Table 22.1 for a detailed list of the Behavioral interventions are the mainstay treat- pros and cons of each intervention strategy, ment of bedtime struggles and night wakings in from a clinical perspective. infants and toddlers. Consistent with the conclusions of two previous reviews (Kuhn & El- Extinction Procedures liott, 2003; Mindell, 1999), more recent reviews indicate that behavioral therapies produce reli- “Extinction” procedures in general involve the able and durable changes for both bedtime re- elimination of parental attention as a reinforcer sistance and night wakings in young children for undesired behaviors (e.g., crying, scream- (Crichton & Symon, 2016; Meltzer & Mindell, ing). The goal of extinction in the case of prob- 2014; Mindell et al., 2006). The bulk of the evi- lematic night wakings is to enable a child to dence supports the efficacy of behavioral thera- develop “self-soothing” skills in order to fall pies in reducing sleep latency and the number asleep independently, without continued need and duration of awakenings (Meltzer & Mind- for parental presence. ell, 2014), including one review that found efficacy in infants under age 6 months (Crichton Unmodified Extinction & Symon, 2016). However, Douglas and Hill’s (2013) review concluded that behavioral inter- The “cry it out” approach involves having the ventions in the first 6 months do not decrease parents put the child to bed at a designated bed- crying or reduce later sleep problems, and they time, then ignore the child’s protest behaviors may have unintended consequences (increased such as crying, tantrums, and calling for the crying, worsened maternal mood). Given the parents (with the exception of illness, injury, inconsistent evidence in very young infants, etc.), until a preset time the next morning. The clinicians should use caution in recommending biggest obstacles associated with extinction are aggressive forms of sleep training in this age the requirement for strict parental consistency group. with the intervention, since inconsistent care- Studies of behavioral interventions demon- giver response provides intermittent reinforce- strate that treatment-related changes across most ment and maintains the awakenings and the types of interventions were maintained at short likelihood of postextinction “response bursts” ( < 6 months), intermediate (6–12 months) and (temporary intensification of protest behavior long-range follow-up ( > 12 months). A number immediately after the intervention is instituted). of studies also found positive effects of sleep in- From a clinical standpoint, the major drawbacks terventions on secondary child-related outcome of unmodified extinction procedures are that variables, such as parent-reported daytime be- they are stressful for parents and infants, and havior (e.g., crying, irritability, detachment, many parents are unable to ignore crying long self-esteem, or emotional well-being). Sleep- enough for the procedure to be effective. related behavioral intervention also led to improvement in the well-being of the parents (e.g., Extinction with Parental Presence related to fatigue, sleep, mood, stress, marital satisfaction) in a number of studies (e.g., Hall et A modification of the extinction approach that al., 2015; Symon & Crichton, 2017). is similar to the previous procedure involves Most of the interventions described in be- having the parents stay in the child’s room at havioral treatment studies may be placed in the bedtime but ignore the child and his or her following categories: extinction and its variants protest behavior. It is often recommended that (see below), positive bedtime routines, sched- parents gradually withdraw from the room each

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TABLE 22.1. Pros and Cons of Four Behavioral Interventions Intervention Pros Cons Unmodified •• Solid empirical evidence for •• May be less effective or developmentally appropriate extinction efficacy if implemented prior to 6 months of age •• Generally effective within 1–2 •• Unacceptable to many families weeks in uncomplicated cases •• Significant cultural barriers •• Time frame may be appropriate •• May be challenging for other family members, for some families (i.e., imminent neighbors birth of another child) •• Requires high level of consistency and parental •• Instructions to caregivers simple cooperation to avoid intermittent reinforcement and straightforward •• Typically involves “extinction burst” •• Most feasible before child is able to climb out of crib

Modified or •• Solid empirical evidence for •• Typically takes longer than unmodified extinction graduated efficacy •• Requires high level of consistency and parental extinction •• Generally effective within 1–2 cooperation to avoid intermittent reinforcement weeks in uncomplicated cases •• Typically involves “extinction burst” •• More acceptable to families •• Most feasible before child is able to climb out of crib •• Treatment protocol can be •• “Check-ins” must not be reinforcing individualized •• Intermittent parental presence may be activating/ •• Allows parents to provide upsetting for some children reassurance to child

Positive routines/ •• Good empirical support for both •• Bedtime routines may be challenging to coordinate bedtime fading •• Bedtime routines generally easy with parent work schedules, multiple caregivers to implement and reinforcing for •• Bedtime routines should not involve electronic both caregivers and child media, which may be difficult for some families •• Bedtime fading matches bedtime •• Bedtime fading involves a temporary later bedtime with child’s natural fall-asleep and thus a longer period of parental involvement in time and reduces sleep onset and the evening protest behavior •• Generally less stressful for parents than extinction

Scheduled •• Some empirical support •• Requires parents to “preemptively” awaken a awakenings •• Focuses on increasing duration sleeping child of consolidated sleep •• Difficult to convince caregivers of rationale •• Based on child’s spontaneous •• Limited utility in clinical practice night waking times

Graduated Extinction the parents comforting their child for a brief pe- “Sleep training” refers to a variety of tech- riod, usually 15 seconds to 1 minute. The par- niques. Typically, parents are instructed to ig- ents are instructed to minimize any interactions nore bedtime crying and tantrums for specified during check-ins that may reinforce their child’s periods of time, tailored to the child’s age and attention-seeking behavior. temperament, as well as the parents’ judgment of how long they can tolerate the child’s crying. Positive Routines and Bedtime Fading Parents employ a fixed schedule (e.g., 5 min- with Response Cost utes) or one that involves progressively longer intervals (e.g., 5 minutes, 10 minutes, then 15 Similar to extinction techniques, these ap- minutes) of waiting before checking on their proaches match the child’s bedtime with his or child. With incremental graduated extinction, her natural sleep-onset time and rely heavily the intervals increase across successive checks on stimulus control techniques as the primary within the same night or across successive agent of behavior change. In contrast to extinc-

Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. nights. The checking procedure itself involves tion strategies, both of these treatments aim to

increase appropriate behaviors and control of of parent sleep education programs often in- affective and physiological arousal, rather than clude the following: focusing on reduction of inappropriate behaviors. Positive routines involve the parents de- • Institution of a set bedtime and regular sleep veloping a set bedtime routine characterized schedule that ensures adequate sleep, as sleep by quiet and calming activities that the child deprivation will result in increased nighttime enjoys. Bedtime fading with response cost in- arousals. A bedtime should be set that is ap- volves taking the child out of bed for prescribed propriate for the child’s age and provides ade- periods of time when the child does not fall quate sleep at night. A consistent nightly bed- asleep. Bedtime is also temporarily delayed to time will also help to set the circadian clock ensure rapid sleep initiation. Once the behav- and enable the child to fall asleep more easily. ioral chain is well established and the child is • Establishment of a consistent bedtime routine falling asleep quickly, the bedtime is moved that lasts approximately 20–45 minutes and earlier by 15–30 minutes over successive nights includes three to four soothing activities (e.g., (“fading”) until a preestablished bedtime goal bath, pajamas, stories) that does not include is achieved. stimulating activities such as television view- ing. Regular nightly bedtime routines have Scheduled Awakenings Technique been found to be associated with improved sleep in children ages 1–5 years (Mindell, Li, This approach focuses on increasing the dura- Sadeh, Kwon, & Goh, 2015). tion of consolidated sleep. The intervention in- • Maintenance of daytime sleep (naps) at least volves parents awakening and consoling their through the age of 3–3½ years, to avoid sleep child approximately 15–30 minutes before a deprivation. typical spontaneous awakening. Caregivers • Use of transitional objects, such as a blanket, must first establish a baseline of the usual num- doll, or stuffed animal, that will be readily ber and timing of spontaneous nighttime awak- available to the child during the night. enings, then schedule preemptive awakenings. Scheduled awakenings are then gradually faded For all of these behavioral strategies, it is out, by systematically increasing the time span critical that parents are consistent in applying between awakenings. behavioral programs to avoid inadvertent inter- Of course, all of the behavioral interven- mittent reinforcement of night wakings. They tions described earlier, especially in children also should be forewarned that frequently pro- preschool age and older, may be combined with test behavior temporarily escalates at the begin- positive reinforcement strategies (e.g., sticker ning of treatment (“postextinction burst”). charts) to increase the likelihood of desired be- While behavioral interventions for sleep haviors (e.g., staying in bed). problems in infants and toddlers have considerable empirical support, concerns have been Parent Education Programs raised both by professional and public groups regarding possible negative impact on chil- These approaches generally focus on early es- dren’s social and emotional development, and tablishment of positive sleep habits, and are attachment (Etherton, Blunden, & Hauck, 2016; often preventive rather than intervention strat- Hiscock & Fisher, 2015). However, recent re- egies per se. Parent sleep education programs views (Symon & Crichton, 2017) and several have been shown to be effective not only in randomized controlled trials of behavioral in- treating but also in preventing infant sleep prob- terventions (graduated extinction, bedtime fad- lems (Hiscock et al., 2014). Strategies typically ing) in infants showed no adverse long-term target bedtime routines, developing a consis- stress responses or long-term effects on par- tent sleep schedule, parental behavior during ent–child attachment or child emotions and sleep initiation, and parental response to night- behavior at 12 months (Gradisar et al., 2016) time awakenings. Almost all programs include or on outcomes related to child mental health, the recommendation that infants be put to bed psychosocial functioning, stress regulation, and “drowsy but awake” starting at around 3–4 child–parent relationship assessed 5 years after months of age to help them develop independent the intervention (Price, Wake, Ukoumunne, & sleep initiation skills at bedtime. Other features Hiscock, 2012). Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

Pharmacological Interventions Wasdell, Bomben, Rea, & Freeman, 2006), is generally well tolerated and appears to be an ac- Sedatives/hypnotics should not be considered ceptable choice for caregivers (Waldron, Spark, the first line in the management of sleep onset & Dennis, 2016); however, the risk of long-term or sleep maintenance insomnia in young chil- side effects, especially when melatonin is ad- dren. If recommended in very selected clinical ministered to infants and young children, is circumstances (e.g., inpatient hospitalization, unknown. Alpha agonists such as clonidine at special needs populations), these drugs should bedtime are commonly used in clinical prac- always be combined with behavioral therapy. tice to manage prolonged sleep-onset delay in Only a handful of studies has examined the ef- children with ADHD (Klein-Schwartz, 2002; fect of pharmacological treatment of bedtime Prince, Wilens, Biederman, Spencer, & Woz- problems and night wakings in infants and niak, 1996); however, it should be pointed out young children, and with mixed results; one ran- that there is little empirical evidence regard- domized controlled trial of diphenhydramine ing efficacy and safety, particularly in younger in six 15-month-olds, for example, showed no children. advantage with regard to efficacy over placebo (Merenstein, Diener-West, Halbower, Krist, & Rubin, 2006). Despite this, pharmacological Other Approaches interventions such as nonprescription sedating Alternative treatments, such as infant massage, antihistamines are commonly used in clinical may be safe and simple adjuncts in the treat- practice for sleep problems, even in young chil- ment of infant sleep problems. Infant massage dren (Owens, Rosen, & Mindell, 2003). In ad- is commonly used in many areas of the world, dition, pharmacological strategies are not nec- especially Africa, India, and Asia. Although essarily specifically targeted toward improving the effects of infant massage on pediatric sleep parental adherence to a concurrent behavioral have not been extensively studied, some studies treatment, and thus may not have long-lasting have shown that massage in the newborn pe- effects. Overall, the evidence suggests that be- riod may have a long-term effect on melatonin havioral strategies are equally or more effec- synthesis and the development of normal circa- tive, are more acceptable to both parents and dian rhythms (Ferber, Laudon, Kuint, Weller, & practitioners, and avoid potential harmful side Zisapel, 2002). The positive effects of massage effects associated with medication use. Behav- may also target many of the problems associat- ioral sleep management strategies have the fur- ed with prolonged bedtime struggles, including ther advantage of potentially generalizing to the high infant arousal, parent tension, and negative management of daytime issues. parent–child interactions. The few studies that For clinicians, an important treatment goal have looked at massage as an intervention for in managing individual children with special pediatric sleep problems have reported short- needs, such as ADHD, or other neuropsychiat- ened sleep-onset latency, fewer night wakings, ric conditions, such as autism, should be evalu- and improved daytime alertness/behavior fol- ation of any comorbid sleep problems, followed lowing regular bedtime massage (Field & Her- by appropriate diagnostically driven behavioral nandez-Reif, 2001; Field, Kilmer, Hernandez- and/or pharmacological intervention. For ex- Reif, & Burman, 1996). ample, difficulty falling asleep in children with ADHD related to psychostimulant use may respond to adjustments in the dosing schedule; Conclusions in some children, the sleep-onset delay is due to a “rebound” effect of the medication wear- In summary, our basic understanding of the ing off coincident with bedtime, rather than a normal trajectory of sleep development in the direct stimulatory effect of the medication it- first few years of life, and of the etiology and self. Melatonin has demonstrated reductions treatment of disordered sleep in infancy, is in sleep latency when given at bedtime both in evolving rapidly. The recognition that sleep is a typically developing children and in children fundamental human function that both mirrors with ADHD and other neurodevelopmental dis- and impacts other important areas of maturation orders (Smits et al., 2003; van Maanen, Meijer, (social, emotional, cognitive, etc.) in the young Smits, van der Heijden, & Oort, 2017; Weiss, child has led to an increasingly sound body of Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

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EBSCO : eBook Collection (EBSCOhost) - printed on 7/2/2019 3:13 PM via TUFTS UNIV AN: 1843598 ; Zeanah, Charles H..; Handbook of Infant Mental Health, Fourth Edition Account: s3579704.main.ehost