Samponerix

When Children Dont Sleep Well
--
David H. Barlow, PhD
Anne Marie Albano, PhD
Gillian Butler, PhD
David M. Clark, PhD
Edna B. Foa, PhD
Paul J. Frick, PhD
Jack M. Gorman, MD
Kirk Heilbrun, PhD

Programs
Robert J. McMahon, PhD
Peter E. Nathan, PhD
Christine Maguth Nezu, PhD
Matthew K. Nock, PhD
Paul Salkovskis, PhD
Bonnie Spring, PhD
Gail Steketee, PhD
John R. Weisz, PhD
G. Terence Wilson, PhD

When Children
Dont Sleep Well
Interventions for Pediatric Sleep Disorders
P a r e n t W o r k b o o k
V. Mark Durand
1
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About ProgramsThatWork
One of the most dicult problems confronting the parents of chil-

dren with various disorders and diseases is nding the best help avail-
able. Everyone is aware of friends or family who have sought treat-
ment from a seemingly reputable practitioner, only to nd out later
from another doctor that the original diagnosis was wrong or the
treatments recommended were inappropriate or perhaps even harm-
ful. Most parents or family members address this problem by read-
ing everything they can about their childrens symptoms, seeking out
information on the Internet, or aggressively asking around to tap
knowledge from friends and acquaintances. Governments and health-
care policymakers are also aware that people in need dont always get
the best treatmentssomething they refer to as variability in
healthcare practices.
Now healthcare systems around the world are attempting to correct

this variability by introducing evidence-based practice. This simply
means that it is in everyones interest that patients of all ages get the
most up-to-date and eective care for a particular problem. Health-
care policymakers have also recognized that it is very useful to give
consumers of healthcare as much information as possible, so that they
can make intelligent decisions in a collaborative eort to improve
health and mental health. This series, ProgramsThatWork, is de-
signed to accomplish just that for children suering from behavioral
health problems. Only the latest and most eective interventions for
particular problems are described in user-friendly language. To be in-
cluded in this series, each treatment program must pass the highest
standards of evidence available, as determined by a scientic advi-
sory board. Thus, when parents or family members of children suf-
fering from these problems seek out an expert clinician who is
familiar with these interventions and decide that they are appropri-
ate, they will have condence that they are receiving the best care
available. Of course, only your healthcare professional can decide on
the right mix of treatments for your child.
This workbook is designed to help you manage your childs sleep
problems. When children have diculty sleeping, it can aect how
well they function during the day. A childs sleep problems can also
be disruptive to the entire family. While medications are often pre-
scribed, their safety and eectiveness in children has not been estab-
lished. Fortunately, there are steps you can take to improve your childs
sleep without the use of drugs. This workbook outlines eective in-
terventions for a variety of sleep problems. This program is most
eectively applied by working in collaboration with your clinician.
David H. Barlow, Editor-in-Chief

ProgramsThatWork
Boston, Massachusetts
vi
Contents
Chapter Overview
Chapter Pre-Intervention Assessment and Planning
Chapter Good Sleep Habits
Chapter Bedtime
Chapter Night Waking
Chapter Nightmares and Sleep Terrors
Chapter Bedwetting
Chapter Other Sleep-Related Issues
Chapter Age-Related and Parental Sleep Concerns
Albany Sleep Problems Scale (ASPS)
Sleep Diary Forms
Behavior Log Forms
Bedwetting Recording Sheet Forms

This page intentionally left blank
Chapter 1 Overview
Introduction
Having a child with sleep problems can be dicult and exhausting.

There are many ways, fortunately, to improve your childs sleep.
Each module of this workbook presents a sleep problem and de-
scribes options for intervention, including step-by-step instruction.
Since interventions must be carried out at night, you will be taking
the primary role in treating your childs sleep problem.
Your therapist will work with you to determine your childs sleep
problem and to select a suitable intervention for your family. The
rst two sessions of therapy will be spent assessing your childs sleep
problem and planning for intervention. The nature and number of
the remaining sessions depend on your childs sleep problem(s) and
progress. Throughout therapy, this workbook will assist you in mon-
itoring your childs sleep and carrying out interventions.
It is important to be patient during the assessment period. A great deal

of information is needed to properly design an eective plan. At the
same time, the plans can take from several days to several weeks to be
successful. Your persistence will be needed in order for your child to
sleep better. Discuss with your therapist any family situations that may
interfere with your ability to fully carry out the interventions.
To begin, it is helpful to learn more about sleep and problems related

to sleep.
Nature of Sleep
Sleep is as necessary as food and drink. It aects learning, memory,

and even physical health. In general, adults need about hours of
sleep per night, but the needs of children are greater (about hours
for infants, hours for -year-olds, and hours for teenagers). Sleep
1
progresses through a series of stages throughout the night, including
deep sleep (where it is dicult to awaken someone) and dream sleep.
The patterns of sleep are biological, but they can be inuenced by
the environment. What we do during the dayfor example, drink-
ing caeine, nappingwill change our sleep patterns at night. And,
how parents respond to the sleep patterns of their childrenwhile
not the cause of sleep problemscan aect how quickly they can be
resolved.
Sleep Problems
Sleep problems are very common among children as well as adults,

with up to % of people having signicantly disrupted sleep, re-
gardless of age. The types of sleep problems can dier signicantly,
even when the problems seem similar. The most often reported
problems surrounding the sleep of children include bedtime di-
culties and night waking problems. However, these are only a few of
the many dierent sleep problems that are observed in children. A
sleep problem is usually dened by how it aects the child or the
family. Not sleeping a full hours is not considered a sleep problem
unless it results in excessive sleepiness during the day or disruption
surrounding sleep.
Often, sleep problems are due to a combination of the childs genet-
ics and learned patterns. For example, a child who is naturally a
light sleeper gets used to always falling asleep with a parent nearby.
The child then has diculty falling back asleep when waking up at
night without the parent present. The sleep interventions described
in this book take advantage of the role of the environment to help
children generally sleep better at night.
Interventions for Sleep Problems
There are a number of interventions that can be helpful, although

sometimes sleep problems are not cured but managed. This is be-
cause we as yet are not able to change our sleep biologyeven with
medications. Furthermore, many medications have not been well
2
studied in children and may have serious side eects. Fortunately, re-
search points to the success of improving childrens sleep without the
use of drugs. The interventions outlined in this workbook have been
found eective in treating childrens sleep problems.
Children who are very susceptible to disturbed sleep may continue

to have diculties as they grow older. It is important to continue
with good sleep habits even after your childs sleep has improved. If
sleep problems recur or a new sleep problem develops, another
round of intervention may be necessary. This workbook can be used
as a resource as you manage your childs sleep problems at dierent
ages. It also includes suggestions if you suer from your own sleep
problems.
3
Chapter 2 Pre-Intervention Assessment and Planning
FIRST SESSION: Sleep Interview and Assessment Tools
Goals
To assess your childs sleep problems
To start recording your childs sleep pattern
Albany Sleep Problems Scale
Your therapist will use your answers to the Albany Sleep Problems
Scale (ASPS) to help identify your childs sleep problem and its causes.
A description of the importance and relevance of each item on the
ASPS follows. Scoring for each question gives instructions for ob-
taining additional information in this workbook. (See the blank
copy of the ASPS in an appendix for the score key.)
Sleep Habits Questions
. Does the child have a fairly regular bedtime and time that he or
she awakens?
Having a regular bedtime and a regular time to awaken is crucial for

children with sleep problems. Children (and adults) associate sleep
with certain times and situations. Keeping a regular schedule will
help your child fall asleep more easily. Your therapist will assist you
in selecting the best times based on your childs, and familys, needs.
If necessary, your therapist will also suggest how to adapt these
schedules for weekends or holidays.
Scoring: If you selected a or less (i.e., less than every night), your
therapist may refer you to Chapter : Good Sleep Habits for inter-
vention suggestions on creating sleep schedules.
5
. Does the child have a bedtime routine that is the same each
evening?
Bedtime routines help signal the brain that bedtime is approaching

and can actually aid with sleep. Using the same routine each night
sets up a series of these signals and can improve bedtime problems.
Your therapist can assist you in establishing routines that are relaxing
and help your child sleep better.
Scoring: If you selected a or less (i.e., less than every night), your
therapist may refer you to Chapter : Good Sleep Habits for inter-
vention suggestions on establishing bedtime routines.
. Does the child work or play in bed often right up to the time he
or she goes to bed?
Just as bedtime routines can signal the onset of sleep, using the bed
for other activities can signal play or work. It is dicult for children
to turn o thoughts about the game they were playing in bed, for
example, just because it is now time for sleep. For children who have
diculty falling asleep, it is recommended that the bed only be a
place for sleep.
Scoring: If you selected a or more (i.e., one or more times per

week), your therapist may refer you to Chapter : Good Sleep
Habits.
. Does the child sleep poorly in his or her own bed, but better
away from it?
Poor sleep in ones own bed can be a sign that the bed signals things
other than sleep. This could be the playing or work mentioned in the
previous question or anxious thoughts about school or not falling
asleep.
Scoring: If you answered Yes, your therapist may refer you to

Chapter : Good Sleep Habits.
. Does the child consume caeine in any form?
Caeine is a stimulant that can aect the ability to fall asleep. Be-
cause caeine can remain in ones system for up to hours, drinking
a caeinated drink at dinner may be enough to interfere with bedtime.
6
week), your therapist may refer you to Chapter : Good Sleep Habits
for suggestions on identifying and consuming caeine.
. Does the child engage in vigorous activity in the hours before

bedtime?
Vigorous (or aerobic) activity just before bedtimein contrast to

what you may thinkcan interfere with sleep. Rather than tire out
the child, such exercise can increase the childs internal body tem-
perature and make him or her more alert.

week), your therapist may refer you to Chapter : Good Sleep Habits
for suggestions on the appropriate use of exercise.
Bedtime and Night Waking Questions
. Does the child resist going to bed?
Disruption at bedtime can be caused by a number of dierent prob-

lems. Additional information is needed to select the best method for
reducing your childs particular problem.

week), your therapist may refer you to Chapter : Bedtime for in-
tervention suggestions.
Does the child take more than an hour to fall asleep but does not
resist?
A childs inability to fall asleep despite his or her best eorts can be up-
setting. This situation can be the result of several dierent problems.

week), your therapist may refer you to Chapter : Bedtime for in-
tervention suggestions, especially for sleep restriction.
. Does the child awaken during the night but remain quiet and in
bed?
Interrupted sleep often involves a child having acquired the habit of

waking at the wrong times. What causes children to wake up in the
7
middle of the night is not completely understood, but can be helped
with several dierent techniques.

week), your therapist may refer you to Chapter : Night Waking for
intervention suggestions, especially for sleep restriction or sched-
uled awakening.
. Does the child awaken during the night and is he or she dis-
ruptive (e.g., tantrums, oppositional)?
Interrupted sleep accompanied by behavioral outbursts is also not

well understood. It can certainly be disruptive to the child and the
whole family. There are several options for reducing these nighttime
problems.
week), your therapist may refer you to Chapter : Night Waking for
intervention suggestions.
Sleepiness Questions
. Does the child take naps during the day?
Napping can be helpful for children who need to catch up on their

sleep. However, if naps cause the child to later have problems going to
bed, it may be necessary to reduce or eliminate this daytime sleeping.

week) and bedtime is a problem, your therapist may refer you to
Chapter : Bedtime for intervention suggestions. If you selected a
or more (i.e., one or more times per week) and night waking is a
problem, your therapist may refer you to Chapter : Night Waking
for intervention suggestions.
. Does the child often feel exhausted during the day because of
lack of sleep?
The number of hours a child sleeps may not be a problem if he or

she is alert and functions well during the day. If, however, a child ap-
pears sleepy on most days, then it needs to be determined if the child
is getting enough good sleep, and if not, what might be causing this
problem.
8
week) and bedtime is a problem, your therapist may refer you to
Chapter : Bedtime for intervention suggestions. If you selected a
or more (i.e., one or more times per week) and night waking is a
problem, your therapist may refer you to Chapter : Night Waking
for intervention suggestions. If you selected a or more (i.e., one
or more times per week) and neither bedtime nor night waking is a
problem, your therapist may refer you to Chapter : Other Sleep-
Related Issues for guidance and intervention suggestions.
. Has the child ever had an accident or near accident because of

sleepiness from not being able to sleep the night before?
Sleepiness can result in problems with motor coordination and con-

centration. If the child is so tired that accidents have occurred, this
is a sign of a serious interruption of sleep that needs to be addressed.
Scoring: If you answered Yes and bedtime is a problem, your ther-

apist may refer you to Chapter : Bedtime for intervention sugges-
tions. If you answered Yes and night waking is a problem, your
therapist may refer you to Chapter : Night Waking for intervention
suggestions. If you answered Yes and neither bedtime nor night
waking is a problem, your therapist may refer you to Chapter :
Other Sleep-Related Issues for guidance and intervention suggestions.
Medication Use Questions
. Does the child ever use prescription drugs or over-the-counter

medications to help him or her sleep?
Using medications to help with most sleep problems is not recom-

mended for long-term use (more than weeks). In most cases,
sleep professionals view medication as a temporary measure to be
used until a more formal plan is designed.
. Has the child found that sleep medication doesnt work as well
as it did when he or she rst started taking it?
One of the downsides of using sleep medication is that it often loses

its eectiveness with continued use. When used for too long, chil-
dren (and adults) begin to tolerate sleep medication so that they
need more of it to be eective.
9
. If taking sleep medication, does the child nd that he or she
cant sleep on nights without it?
Sometimes, stopping medication can have a negative eect on sleep.

This phenomenon is known as rebound insomnia and can create
major problems when discontinuing use of these drugs.

week) or answered Yes to any of the questions in this section, you
should discuss with your therapist how to carefully reduce the use of
these medications. Your family physician or pediatrician needs to be
involved in this decision and plan.
Sleep Schedule Questions
. Does the child fall asleep early in the evening and awaken too
early in the morning?
Sometimes sleep is a problem because it occurs at the wrong times.

This can be the result of a sleep habit or other diculty and it can
be helped with several dierent interventions.
. Does the child have diculty falling asleep until a very late
hour and diculty awakening early in the morning?
Troubles at bedtime can sometimes be the result of sleeping at the

wrong times rather than an unwillingness of a child to go to bed.
Again, this can be the result of a sleep habit or other diculty and it
can be helped with several dierent interventions.

week) to either of these questions and bedtime is a problem, your
therapist may refer you to Chapter : Bedtime for intervention sug-
gestions. If you selected a or more (i.e., one or more times per
week) to either of these questions and night waking is a problem, your
therapist may refer you to Chapter : Night Waking for intervention
suggestions. If you selected a or more (i.e., one or more times per
week) to either of these questions and neither bedtime nor night wak-
ing is a problem, your therapist may refer you to Chapter : Other
Sleep-Related Issues for guidance and intervention suggestions.
10
Nightmare Questions
. Does the child wake up in the middle of the night upset?
Waking up at night upset can be a simple night waking episode or a

nightmare. If your child is screaming but is not awake, this is prob-
ably a sleep terror and will require a dierent approach to treatment.

week), or a but you are very concerned, further information is
needed. It is important to dierentiate nightmareswhich are dis-
turbing dreamsfrom sleep terrors. Your therapist may refer you to
Chapter : Nightmare and Sleep Terrors, which includes separate in-
terventions for nightmares and for sleep terrors.
. Is the child relatively easy to comfort during these episodes?
One way to dierentiate nightmares from sleep terrors is by how eas-

ily the child settles after these events. Sleep terrors occur while the
child is asleep and he or she will resist being comforted, while a child
having a nightmare often seeks this reassurance.

Chapter : Nightmare and Sleep Terrors for intervention suggestions
for nightmares. If you answered No, your therapist may also refer
you to Chapter , but for intervention suggestions for sleep terrors.
Sleep Terror Questions
. Does the child have episodes during sleep where he or she

screams loudly for several minutes but is not fully awake?
Sleep terrors occur while a child is in deep sleep. Although he or she

may appear to be having a nightmare, nightmares and sleep terrors
are dierent types of sleep problems.

week), or a but you are very concerned, your therapist may refer
you to Chapter : Nightmare and Sleep Terrors for intervention sug-
gestions for sleep terrors.
11
. Is the child dicult to comfort during these episodes?
Again, because sleep terrors occur while a child is in very deep sleep,
it will be dicult to awaken him or her and the child will resist
eorts at comforting.

Chapter : Nightmare and Sleep Terrors for intervention suggestions
for sleep terrors. If you answered No, your therapist may also refer
you to Chapter , but for intervention suggestions for nightmares.
Hypersomnia and Narcolepsy Questions
. Does the child experience sleep attacks (falling asleep almost

immediately and without warning) during the day?
Although rare, some children and adults experience episodes where

they fall asleep almost immediately and without warning. This can
be the sign of a very specic type of sleep problemperhaps hyper-
somnia or narcolepsy.
Scoring: If you selected a or more, it is recommended that your

child be evaluated by a physician or a sleep specialist if any of these
problems are suspected.
. Does the child experience excessive daytime sleepiness that is

not due to an inadequate amount of sleep?
Sometimes a child can seem to have enough hours of sleep but still
appear tired during the day. There can be a number of sources of
sleep disruption such as problems with breathing or excessive
movement of arms and legsthat can awaken a child throughout
the night, even if he or she does not remember these events. If a child
seems tired during the day or if frequent night waking is a problem
and hypersomnia, limb movement disorders, and/or breathing-related
disorders are a suspected cause, the child should be evaluated by a
physician or a sleep specialist.
Scoring: If you selected a or more, your therapist may refer you

to Chapter : Other Sleep-Related Issues for more information on
hypersomnia, limb movement disorders, and breathing-related dis-
orders.
12
Breathing-Related Questions
. Does the child snore when asleep?
One sign that a childs breathing may be interrupted during sleep is

the presence of snoring.

week), your therapist may refer you to Chapter : Other Sleep-
Related Issues for information on breathing problems.
. Does the child sometimes stop breathing for a few seconds dur-
ing sleep?
Sleep apneaor brief interruptions in breathing during sleepis a

serious concern. It will cause the person to be tired during the day
and can cause other medical problems.
Scoring: If you selected a or more (i.e., less than once per week
but more than never), your child should be evaluated by a physician
or a sleep specialist.
. Does the child have trouble breathing?
Breathing problems during the day may signal the possibility of

breathing problems at night. If this is the case, the child may have
disturbed sleep yet not be aware of it.
Scoring: If you selected a or more (i.e., less than once per week
but more than never), your child should be evaluated by a physician
or a sleep specialist.
. Is the child overweight?
Being overweight can signicantly increase the risk for sleep apnea
and other breathing diculties during sleep. If the child is over-
weight and has diculty waking up in the morning, these could be
clues to identifying a breathing problem.
Scoring: If you answered Yes, and breathing problems are a sus-

pected cause of tiredness, your child should be evaluated by a physi-
cian or a sleep specialist.
13
Sleepwalking and Sleeptalking Questions
. Has the child often walked when asleep?
Sleepwalking is usually not a serious problem but can be a sign of a
child not getting enough sleep.
. Does the child talk while asleep?
As with sleepwalking, sleeptalking is usually not a serious problem
but also can be a sign of a child not getting enough sleep.
week) on either of these questions, your therapist may refer you to
Chapter : Other Sleep-Related Issues for information and interven-
tion suggestions for sleepwalking and related problems.
Limb Movement and Rhythmic Movement Questions

. Are the childs sheets and blankets in extreme disarray in the
morning when he or she wakes up?
Some childrens sleep can be disrupted by their frequent movements
throughout the night. Like interrupted breathing, these movements
can awaken children multiple times without their knowledge. One
sign of this excessive movement may be sheets and blankets moved
around each morning.
week), your therapist may refer you to Chapter : Other Sleep-
Related Issues for information on limb movement problems.
. Does the child wake up at night because of kicking legs?
Again, frequent limb movements at night can disrupt sleep and
cause daytime tiredness.
week), your child should be evaluated by a physician or a sleep spe-
cialist.
. While lying down, does the child ever experience unpleasant

sensations in the legs?
Strange feelings in the legs could be the sign of restless legs syn-
drome, which can interfere with falling asleep at night.
14
Scoring: If you answered Yes, your child should be evaluated by a
physician or a sleep specialist.
. Does the child rock back and forth or bang a body part (e.g.,
head) to fall asleep?
Some children soothe themselves to sleep by rocking or engaging in

other similar behavior. These types of rhythmic movements are com-
mon, even in some adults. When they begin to cause injury, as with
some children who bang their heads, intervention is recommended;
often, however, this is not serious enough to treat.

week), or a but you are very concerned, your therapist may refer
you to Chapter : Other Sleep-Related Issues for information on
rhythmic movement disorder.
Bedwetting Questions
. Does the child wet the bed?
Although bedwetting is not a sleep problem, it may be of concern.

Up until the age of about years, bedwetting is not considered a
problem. However, after that age, children should be sleeping
through the night without accidents.

week), or a but are very concerned, your therapist may refer you to
Chapter : Bedwetting for information and intervention suggestions.
Teeth Grinding Questions
. Does the child grind his or her teeth at night?
Teeth grinding at night can be a concern for some children, al-

though, like bedwetting, is not a sleep disorder.

week), your child should be evaluated by a pediatrician.
15
Anxiety and Depression Questions
. Does the child sleep well when it doesnt matter, such as on

weekends, but sleeps poorly when he or she must sleep well,
such as when a busy day at school is ahead?
Anxiety and depression can sometimes interfere with sleep and may
be detected by looking at when a childs sleep is disrupted.
. Does the child often have feelings of apprehension, anxiety, or

dread when he or she is getting ready for bed?
Anxiety or depression can also interfere with falling asleep, and older
children should be asked about what they are thinking around bed-
time.
. Does the child worry in bed?
Again, it is important to assess if emotional diculties are interfer-

ing with a childs sleep.
. Does the child often have depressing thoughts, or do tomor-

rows worries or plans buzz through his or her mind when her
or she wants to go to sleep?
This is one more in the series of questions to assess if anxiety or de-

pression is interfering with a childs ability to fall asleep.
. Does the child have feelings of frustration when he or she cant

sleep?
This is one more in the series of questions to assess if anxiety or de-

pression is interfering with a childs ability to fall asleep.
. Has the child experienced a relatively recent change in eating

habits?
Changes in eatingalong with changes in sleep patternscan be a

sign of depression, and this information is important when deter-
mining the inuences on sleep.
Scoring: If you answered Yes, or selected a or more (i.e., one

or more times per week) to any of the questions in this section, your
therapist may refer you to Chapter : Other Sleep-Related Issues for
information and intervention suggestions for anxiety and depression.
16
Daytime Behavior Problem Questions
. Does the child have behavior problems at times other than bed-
time or upon awakening?
This question is included because ) getting a handle on daytime be-

havior problems can often help with bedtime problems and, ) day-
time behavior problems and sleep problems are often related, and it
is important to consider them together. If you answered Yes to this
question, your therapist will work with you to address these behavior
problems.
Other Causes
. When did the childs primary diculty with sleep begin?
Answers here may provide additional information about the poten-

tial causes of disrupted sleep (e.g., problems at school). Your thera-
pist will take this information into account when assessing your
childs sleep problems.
. What was happening in the childs life at that time, or a few

months before?
Again, answers here may provide your therapist with additional in-
formation about the potential causes of disrupted sleep (e.g., illness
or vacations that preceded the current problems).
. Is the child under a physicians care for any medical condition?
It is important to know if medical conditions or the treatments for

these problems (e.g., medications) are contributing to the childs
sleep diculties. Make sure to inform your therapist about your
childs medical history.
Introduction of Sleep Diary and Behavior Log
To begin understanding your childs sleep pattern, you should keep

a Sleep Diary for weeks. This tool measures basic information such
as the time the child was put in bed and approximately what time
the child fell asleep. This will give you an idea about how long your
17
child takes to fall asleep each night. The Sleep Diary also indicates if
and how many times the child may have awakened during the night.
Finally, the Sleep Diary includes the time the child wakes up each
morning and any naps. This information tells you about any sched-
ule problems (for example, the child wakes up too early), and the
way sleep is or is not spread out during the day. You can calculate the
total amount of sleep time by adding up the number of shaded
boxes.
See Figure . for an example of a Sleep Diary. A blank form is pro-

vided at the end of this chapter. Additional blank forms are included
in an appendix at the back of the book.
If night waking and/or bedtime are issues, you should also record
your childs behavior at bedtime and during the night in a Behavior
Log, as well as keep a Sleep Diary. This helps determine the extent
and nature of behavior problems associated with sleep. See Figure .
for an example of a Behavior Log. A blank form is provided at the
end of this chapter. Additional blank forms are included in an ap-
pendix at the back of the book.
Homework
Complete the Sleep Diary on a daily basis.

Complete the Behavior Log as needed.
18
SLEEP DIARY for Ethan
Instructions: Shade in the times when the child is asleep. Mark bedtime with a down arrow and time awake with an up arrow.
A.M. P.M.
Day Date 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 Noon 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00

Tuesday Aug 22

Wednesday Aug 23

Thursday Aug 24

Friday Aug 25

Saturday Aug 26

Sunday Aug 27

Monday Aug 28

Tuesday Aug 29
Figure 2.1.
Example of Completed Sleep Diary for Ethan
19
20
BEHAVIOR LOG for Emma
Date Time Behavior at Bedtime Your Response Behavior During Awakenings Your Response
3/19 9:15 Crying, throwing toys Told her to stop, let her fall
asleep on the couch
3/20 9:30 Crying, screaming Let her fall asleep in my lap
3/20 12:30 Crying Mommy! Let her come into our bed
3/21 9:15 Whining Let her watch TV until she

fell asleep in the TV room
Figure 2.2
Example of Completed Behavior Log for Emma
SECOND SESSION: Treatment Planning
Goals
To identify the nature of your childs sleep problems
To review your childs sleep schedules and habits
To assess problems you may have with carrying out interventions
To decide on the next step for treatment
The Nature of Your Childs Sleep Problems
In this session, your responses from the ASPS will be used to help
identify the nature of your childs sleep problems. Your therapist will
summarize the dierent types of sleep problems and those that seem
to be applicable to your child. Where appropriatefor example,
when breathing-related problems are suspectedyou may be referred
to your pediatrician or family physician for follow-up.
Review of Sleep Diary
By this session, you should have a partially completed Sleep Diary.

This will be used to calculate how long, on average, your child sleeps
each day (combining both nighttime and daytime sleeping). Infor-
mation from the Sleep Diary may suggest that napping is interfering
with nighttime sleep. It may also make clear that your child does not
have a consistent bedtime and/or time to awaken.
Review of Behavior Log
If appropriate, you may also be keeping a Behavior Log. This log will
help indicate how disruptive your child is around sleep. If your
childs behavior is also disruptive to others (e.g., siblings, neighbors),
21
you may need a consistent way to handle disturbances. Your thera-
pist may help you choose a specic crisis intervention technique.
Sleep Schedules and Habits
Almost % of sleep problems can be resolved with good sleep habits

or sleep hygiene. Your child should have a regular time to go to bed
and a regular time to wake up. It is important to keep to the sleep
schedule, especially on weekends.
Other sleep habits include bedtime routines, caeine use, diet, and
exercise. If any of these are problematic, see Chapter : Good Sleep
Habits.
Sleep Intervention Questionnaire (SIQ)
Many families experience signicant guilt when trying to address

their childs sleep problem. Even though you may recognize the need
for your child to fall asleep or go back to sleep alone, you may have
a hard time carrying out certain interventions. The questions on the
next page will be used to help narrow the types of intervention
choices suitable for your family.
Results of the SIQ
Your therapist will go over your answers to the questionnaire with

you and discuss any issues you may have that might interfere with
your ability to intervene with your child. You will be working to-
gether to select an intervention that works for your family.
Next Steps
If your child has multiple needs, your therapist will help you to pri-
oritize sleep problems. For example, if both bedtime and night wak-
ing are problems, it is usually best to rst intervene with bedtime
22
Sleep Intervention Questionnaire (SIQ)
Disruption Tolerance
. Does your child misbehave at bedtime or when waking up at night in a way that is too serious or up-
setting to ignore?
Yes No
. Would it be dicult or impossible for you to listen to your child being upset for long periods of time
(more than a few minutes)?
Yes No
. Do you nd it too dicult to put your child back in bed once he or she gets up?
Yes No
Schedule Tolerance
. Are you, or another member of your family, willing to stay up later at night to put a sleep plan into
action?
Yes No
. Are you, or another member of your family, willing to get up earlier in the morning to put a sleep
plan into action?
Yes No
Attitudinal Barriers
. Do you feel emotionally unable to deal directly with your childs sleep problem?
Yes No
. Do you feel guilty making your child go to bed (or go back to bed) when he or she does not want to?
Yes No
. Do you think it would be emotionally damaging to your child if you tried to change the way he or
she slept?
Yes No
23
problems. A resolution to bedtime problems also typically brings a
resolution to night waking. The Decision-Tree for Sleep Interven-
tions (Figure .) outlines the treatment plan. Your therapist will se-
lect the next module based on your childs needs.
Homework
Continue completing the Sleep Diary on a daily basis.

Continue completing the Behavior Log as needed.
24
Pre-intervention Assessment
and Planning
Assess nature of
Is sleep
sleep problem
See Chapter 3 Yes hygiene a No
using ASPS, diary
problem?
and logs
Is sleep
still a Yes Is bedtime a
problem? problem?
Yes
See Chapter 4
No
No
Conclude Is night waking

sessions a problem?
Yes
No See Chapter 5 No
Are there Are nightmares

remaining problems No Is bedwetting No or sleep terrors
around sleep? a problem? a problem?
Yes Yes Yes
See Chapter 8 See Chapter 7 See Chapter 6
Figure 2.3
Decision Tree for Sleep Interventions
25
26
SLEEP DIARY for
A.M. P.M.
Day Date 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 Noon 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00
BEHAVIOR LOG for
27
Chapter 3 Good Sleep Habits
Goals
To understand the importance of good sleep habits
To gure out how much sleep your child needs
To identify problems with your childs sleep habits
To make changes to improve your childs sleep habits
Importance of Good Sleep Habits
A number of habits can aect sleep:

What and when we eat and drink
When we exercise
Bedroom temperature
Any noise
What we do in bed (e.g., watching TV, playing games)
Everyday activities that we tend to take for granted can impact on

how well we fall to sleep and if we stay asleep. This is especially true
for children with sleep problems. You may need to provide more
structure to establish good sleep habits for your child.
Age-Related Sleep Needs
First, it is important to make sure that your child is getting enough

sleep; however, childrens sleep needs vary. By months, all children
should be able to sleep through the night without being fed and fall
asleep on their own. As children grow older, they need less and less
29
Table 3.1 Sleep Needs by Age
Age Average Sleep Needs (approximate)
months years hours

years hours
years hours
years . hours (no longer taking naps)
years hours
years . hours
sleep. Table . can be used to estimate the average sleep need for a
child of a certain age.
Keep in mind, though, that some children need more or less sleep
than the average. If your child functions well during the day and
does not seem tired, she may be getting enough sleep even if it is less
than the average amount for her age. On the other hand, if your
child is getting the average amount of sleep for her age and is still
tired, she may require more sleep.
Improving Sleep Habits
There are changes you can make to improve your childs sleep. The
following suggestions address each of the issues from the checklist.
. If your child does not have a fairly regular bedtime and time
when she awakens:
Estimate the approximate number of hours of sleep for
the goal (based on your childs sleep needs)
Determine a good wake time that ts with your familys
and your childs schedule
Move backwards from the desired wake time the num-
ber of optimal sleep hours to nd the best bedtime
(e.g., .. minus hours .. bedtime)
Try to stay with this sleep-wake schedule each day
even on weekends
30
Sleep Habits Checklist
Use the following checklist to help assess your childs sleep habits. If you check No to an item, this
issue may be contributing to your childs sleep problem.
My child: Yes No
. Has a fairly regular bedtime and time to awaken
. Has a regular bedtime routine
. Does not work or play in bed
. Does not sleep better away from her own bed
. Does not consume caeine
. Does not engage in vigorous activity before bedtime
. Does not take more than an hour to fall asleep and does not awaken at night
. Has a good diet
. Has a good bedroom environment (e.g., lack of noise and light, comfortable
temperature)
31
. If your child does not have a bedtime routine that is the same
each evening:
Make the last minutes before bedtime a regular
routine
Include calming activities such as dressing for sleep,
washing, and reading
Keep the order and timing of the activities about the
same each night
Do not include activities that could cause conict (e.g.,
picking out clothes for school, organizing homework)
Avoid television watching during this time, which can
interfere with sleep
Avoid extending the time for the bedtime routine (i.e.,
do not allow bedtime activities to take up more time
than allotted)
. If your child works or plays in bed, often right up to the time

when she goes to bed:
Avoid any activity in bed other than sleeping or routines
leading up to sleeping
. If your child sleeps poorly in her own bed but better away
from it:
Avoid any activity in bed other than sleeping or routines
leading up to sleeping
Follow bedtime routines and the other good sleep habits
. If your child consumes caeine in any form:

Reduce the amount of caeine used by your child dur-
ing the day (including soda, chocolate, nonprescription
drugs)
Eliminate all intake of caeine at least hours before
bedtime
. If your child engages in vigorous activity in the hours before

bedtime:
Try to establish a daily exercise regime for your child
Consult with a physician before starting any new exer-
cise programs
32
Encourage your child to engage in aerobic exercise
hours before bedtime
Discourage your child from exercising or engaging in
vigorous activity right before bedtime
If appropriate, look for ways to decrease boredom and
increase activity throughout the day
. If your child takes more than an hour to fall asleep but does
not resist, or if your child awakens at night but remains quiet
and in bed:
Consider a later bedtime
Encourage your child to get out of bed if she cannot
fall asleep within minutes
Have your child sit somewhere else in the room and
read or engage in some other quiet activity until she is
tired, then go back to bed and try to fall asleep again
Consider sleep restriction for bedtime (Chapter ) or
night waking (Chapter ) problems
. If your childs diet does not encourage good sleeping:

Consider milk before bedtime (but not so much that it
leads to toileting problems)
Consider low-fat foods at dinner and prior to bedtime
to reduce stomach distress
. If your childs bedroom discourages sleep because of noise,

lights, or temperature:
Keep the household relatively quiet at bedtime if noise
can be heard in the bedroom
Minimize light in the bedroom, using a nightlight if
necessary
Keep the room temperature comfortable (not too hot
or cold)
If your child has several problems with sleep habits, your therapist
will help you to decide which issues to address rst. However, you
can try making simple changes (for example, reducing caeine use)
immediately. Table . summarizes many of the dos and donts of
good sleep habits. Look through the list periodically to see if you are
following all of the recommended strategies.
33
Table 3.2 Dos and Donts of Good Sleep Habits
Do establish a regular bedtime and a regular time Dont let your child stay up or sleep in on a regular
to awaken basis
Do have a regular bedtime routine of minutes, Dont extend the time for the bedtime routine
keeping the timing and order of activities
consistent
Do include activities to help your child get ready Dont include activities that could cause conict
for bed (e.g., putting on pajamas, brushing
teeth, etc.)
Do restrict activities in bed to those that help Dont let your child watch television before bed
induce sleep (e.g., reading a bedtime story,
listening to music, etc.)
Do make sure your child gets regular exercise Dont let your child exercise or engage in physical
during the day activity before bed
Do reduce noise and light in the bedroom, and Dont let your child consume food or drink
keep the bedroom at a consistent temperature containing caeine hours before bedtime
Schedule Modications for the Weekend
If you nd it dicult to follow bedtimes and wake times during the

weekend, some modication is permissible. You can look for a time
halfway between the regular wake time and the time your child
would typically awaken on her own. That is, if a childs wake time
during the week is : .., and she usually sleeps in until :
.. on the weekend, the new weekend wake time should be around
: .. Similarly, a modied weekend bedtime is allowable. How-
ever, bedtime on the weekend should be no later than one hour past
the typical bedtime.
Homework
Use the suggestions in this chapter to improve your childs

sleep habits as needed and continue to complete the Sleep
Diary on a daily basis.
If establishing a bedtime routine, record the results using a

Sleep Diary and Behavior Log.
34
Chapter 4 Bedtime
Goals
To understand the intervention options for improving bedtime
To select the appropriate intervention for your family
To carry out steps for graduated extinction (if selected inter-

vention)
To carry out steps for sleep restriction (if selected intervention)
To watch out for obstacles to successful intervention
Intervention Options
At this point, you may have already worked on establishing better

sleep habits for your child. If bedtime behavior is a still a problem,
the next step is to try one of two interventions for bedtime problems:
graduated extinction and sleep restriction. A brief description of
each of these interventions follows. Table . lists the advantages and
disadvantages of each approach.
Graduated Extinction
Graduated extinction involves spending increasingly longer amounts

of time ignoring the cries and protests of a child at bedtime. The
goal of this treatment is to fade the amount of time parents attend
to their child around bedtime. At the same time, it gives parents the
opportunity to check on their child. This method appears to work
by forcing the child to learn to fall asleep on his own.
35
Table 4.1 Pros and Cons of Graduated Extinction and Sleep Restriction
Pros Cons
Graduated Extinction Begins during regular bedtime Long bouts of crying/tantrums

Allows for checking on the child Can be a temporary increase in
crying/tantrums
Not useful for nondisruptive sleep-
initiation problems
Sleep Restriction Avoids most crying/tantrums Requires family member to stay up

later with the child
Can be used for nondisruptive
sleep-initiation problems Can be dicult to keep child awake
for new bedtime
Sleep Restriction
Sleep restriction involves reducing the amount of time the child

sleeps and then gradually increasing the time to a healthy amount.
This can involve moving bedtime later in the evening or waking the
child up earlier in the morning. The goal of this treatment is to make
the child drowsy in order to decrease the likelihood of bedtime dis-
turbances. It seems the childs tiredness may make it easier for the
child to practice falling asleep without parents present.
Intervention Selection
Before you select an approach, it is important to identify reasons

why you might have a hard time using one of these interventions.
Your therapist will raise the following issues and help you decide how
they might impact the sleep plan for your child.
Graduated extinction may not be the best option for your family if:
Your child misbehaves at bedtime in a way that is too seri-

ous or upsetting to ignore
36
It would be dicult or impossible for you to listen to your
child being upset for long periods of time (more than a few
minutes)
You nd it too dicult to put your child back in bed once

he gets up
Schedule Tolerance
You may need to consider which intervention would be the least dis-
ruptive to the family if you, or another member of your family, are:
Not willing to stay up later at night to put a sleep plan into

action
Not willing to get up earlier in the morning to put a sleep

plan into action
You may need to work on your thoughts and feelings about your
childs sleep in order to prepare for intervention. Talk to your thera-
pist further if you:
Feel emotionally unable to deal directly with your childs

sleep problem
Feel guilty making your child go to bed (or go back to bed)

when he does not want to
Think it would be emotionally damaging to your child if

you tried to change the way he slept
Your therapist can help you challenge self-talk that interferes with
successful intervention. (For example, you may think My child will
be angry with me if I make him sleep alone, or I am a bad parent
if my child is upset at bedtime.)
37
Steps for Graduated Extinction
If graduated extinction is selected as the treatment of choice, follow

these steps:
. Maintain a regular bedtime routine.
. Set a bedtime that will not change over the course of the inter-
vention.
. Decide on the amount of time to wait before going in to check

on the child. A typical time would be between minutes the
rst night.
. Pick the night to begin the plan. Assume no one will have a
good nights sleep that evening. Because of this, most families
begin on a Friday night.
. On the rst night, follow the bedtime routine and put the
child to bed at the regular bedtime. Leave the room and then
wait the agreed upon time (e.g., minutes) before checking on
the child.
. If after waiting the full amount of time the child is still crying,
you can go into the room, tell him to go to bed, then leave.
You should not pick up the child, give him food or a drink, or
engage in extensive conversation.
. Wait the same amount of time (e.g., minutes) before going

back into the room each time. Continue this pattern until the
child is asleep. Or, if you feel comfortable, start to wait longer
between visits.
. On each subsequent night, wait another or minutes be-

tween visits. Continue using the same procedure as in step
when returning to the childs room.
38
Steps for Sleep Restriction
If sleep restriction is selected as the treatment of choice, follow these

steps:
. Select a bedtime when the child is likely to fall asleep with little
diculty and within about minutes. To determine this bed-
time, use the Sleep Diary to nd a time when the child falls
asleep if left alone (e.g., ..), then add minutes to this
time (e.g, new bedtime : ..).
. If the child falls asleep within minutes of being put to bed at

this new bedtime and without resistance for successive nights,
move the bedtime back by minutes (e.g., from : .. to
: ..).
. Keep the child awake before the new bedtime, even if he seems
to want to fall asleep.
. If the child does not fall asleep within about minutes after
being put to bed, have him leave the bedroom and extend the
bedtime for one more hour.
. Continue to move the bedtime back (e.g., from : .. to

: ..) until the desired bedtime is reached.
. Maintain a regular time to awaken the child and resist letting

the child sleep in.
Common Obstacles
You will need to watch out for obstacles to successful bedtime inter-
vention. Common problems include:
Lying down with the child until he falls asleep
Letting the child take naps during the day
Extended discussions with the child over the rationale for

the plan at bedtime
Interruptions due to illness or other changes (e.g., sleeping

away from home)
39
Giving in to delay tactics (e.g., asking for another story or
something more to drink, etc.)
Guilt over the childs distressespecially when using grad-

uated extinction
If any of these occur, go back to following the planned steps. The

goal is to keep making progress. If you are having diculty carrying
out the selected intervention, discuss modifying the plan with your
therapist.
Homework
Implement the selected intervention as discussed during the

session.
Continue to complete the Sleep Diary on a daily basis.

Continue to complete the Behavior Log on a daily basis.
Address obstacles as needed or make modications to the plan
as decided with your therapist.
40
Chapter 5 Night Waking
Goals
To understand the intervention options for reducing night

waking
To carry out steps for graduated extinction (if selected

intervention)
To carry out steps for sleep restriction (if selected intervention)
To carry out steps for scheduled awaking (if selected intervention)
If modifying sleep habits (especially bedtime routines and sleep-

wake schedule) has not been successful in improving night waking
problems, the next step is to try graduated extinction, sleep restric-
tion, or scheduled awakening. A brief description of each of these
interventions follows. Table . outlines the advantages and disad-
vantages of each approach.
Graduated Extinction
Graduated extinction involves spending increasingly longer amounts

of time ignoring the cries and protests of a child who awakens from
sleep. The goal of this treatment is to fade the amount of time par-
ents attend to their child around night waking. At the same time, it
gives parents the opportunity to check on their child. This method
appears to work by forcing the child to learn to fall back to sleep on
her own.
41
Sleep Restriction
Sleep restriction involves reducing the amount of time the child

sleeps and then gradually increasing the time back to a healthy
amount. This can involve moving bedtime later in the evening or
waking the child up earlier in the morning. The goal of this treat-
ment is to make the child drowsy and decrease the likelihood of bed-
time disturbances. It seems the childs tiredness may make it easier
for the child to practice falling back to sleep without parents present.
Scheduled Awakening
Scheduled awakening involves waking the child some period of time

just prior to the time she usually awakens. The goal of this interven-
tion is to have the child fall back asleep from this brief awakening
without parental involvement. Why it works is unclear, but it may
involve reprogramming the sleep cycle to a more regular sleep-
wake schedule. It may also give the child experience in falling asleep
alone while drowsy.
Table 5.1 Pros and Cons of Graduated Extinction, Sleep Restriction, and Scheduled
Awakening
Pros Cons
Graduated Extinction Only needed if and when child Long bouts of crying/tantrums
awakens
Can be a temporary increase in
Allows for checking on the child crying/tantrums
Not useful for nondisruptive sleep
awakening
Sleep Restriction Avoids most crying/tantrums Requires family member to stay up
later with the child
sleep-initiation problems Can be dicult to keep child awake
for new bedtime
Scheduled Awakening Avoids most crying/tantrums Requires family member to awaken
or stay up later to awaken child
sleep-initiation problems Requires that the night waking(s)
occurs at about the same time(s)
each evening
42
Before you select an approach, it is important to identify reasons

why you might have a hard time using one of these interventions.
Your therapist will raise the following issues and help you decide how
they might impact the sleep plan for your child.
Graduated extinction may not be the best option for your family if:
Your child misbehaves when waking up at night in a way

that is too serious or upsetting to ignore
It would be dicult or impossible for you to listen to your

child being upset for long periods of time (more than a few
minutes)
You nd it too dicult to put your child back in bed once

she gets up
Schedule Tolerance
You may need to consider which intervention would be the least dis-
ruptive to the family if you, or another member of your family are:
Not willing to stay up later at night to put a sleep plan into

action
Not willing to get up earlier in the morning to put a sleep

plan into action
You may need to work on your thoughts and feelings about your
childs sleep in order to prepare for intervention. Talk to your thera-
pist further if you:

sleep problem
43
when she does not want to

you tried to change the way she slept
successful intervention. (For example, you may think My child will
be angry with me if I ignore her cries, or I am a bad parent if my
child is upset during the night.)
Steps for Graduated Extinction
If graduated extinction is selected as the treatment of choice, follow

these steps:
vention.
. Decide on the amount of time to wait before going in to check

on the child. A typical time would be between minutes the
rst night.
. Pick the night to begin the plan. Assume no one will have a
good nights sleep that evening. Because of this, most families
begin on a Friday night.
. On the rst night, wait the agreed upon time (e.g., minutes)
before checking on the child following a night waking.
. If after waiting the full amount of time the child is still crying
upon awakening, you can go into the room, tell her to go to
bed, then leave. You should not pick up the child, give her food
or a drink, or engage in extensive conversation.
. Wait the same amount of time (e.g., minutes) before going

back into the room each time. Continue this pattern until the
child is asleep. Or, if you feel comfortable, start to wait longer
between visits.
44
. On each subsequent night, wait another or minutes be-
tween visits. Continue using the same procedure as in step
when returning to the childs room.
Steps for Sleep Restriction
If sleep restriction is selected as the treatment of choice, follow these

steps:
time (e.g, new bedtime : ..).
. If the child falls asleep within minutes of being put to bed at
this new bedtime and without resistance for successive nights,
move the bedtime back by minutes (e.g., from : .. to
: ..).
. Keep the child awake before the new bedtime, even if she
seems to want to fall asleep.
being put to bed, have her leave the bedroom and extend the
the child sleep in.
Steps for Scheduled Awakening
If scheduled awakening is selected as the treatment of choice, follow

these steps:
. Use the Sleep Diary to determine the time or times that the
child typically awakens during the night.
. On the night that you begin the plan, awaken the child
approximately minutes prior to the typical awakening
45
time. For example, if the child usually has a night waking at
: .., wake up the child at : .. If the child seems
to awaken very easily, move the time back by minutes
(: ..) the next night and on all subsequent nights.
. If there is a broad range in the times the child awakens (for ex-
ample, from : .. to : ..), awaken the child about
minutes prior to the earliest time (in this case, : ..).
. Do not fully awaken the child. Gently touch and/or talk to the
child until she opens her eyes, then let her fall back to sleep.
. Repeat this plan each night until the child goes for a full
nights without a waking. If the child has achieved this level of
success, skip one night (that is, no scheduled waking) during
the next week. If the child has awakenings, go back to awaken-
ing the child every night. Slowly reduce the number of nights
with scheduled awakenings until the child is no longer waking
during the night.
Common Obstacles
You will need to watch out for obstacles to successful bedtime inter-
vention. Common problems include:
Lying down with the child until she falls back to sleep
Letting the child take naps during the day
Extended discussions with the child over the rationale for

the plan upon awakening

away from home)
Giving in to avoidance tactics (e.g., asking to sleep in par-

ents bed)
Guilt over the childs distressespecially when using grad-

uated extinction

goal is to keep making progress. If you are having diculty carrying
46
out the selected intervention, discuss modifying the plan with your
therapist.
Homework

session.

Continue to complete the Behavior Log as night waking occurs.
47
Chapter 6 Nightmares and Sleep Terrors
Goals
To understand the dierence between nightmares and sleep

terrors
To understand the intervention options for reducing night-

mares and/or sleep terrors
To carry out steps for using magic (if selected intervention

for nightmares)
To carry out steps for relaxation (if selected intervention for

nightmares)
To carry out steps for paradoxical intention (if selected inter-

vention for nightmares)
To carry out steps for scheduled awakening (if selected inter-

vention for sleep terrors)
Nightmares versus Sleep Terrors
Nightmares and sleep terrors are sometimes confused for one an-
other. However, the two sleep disturbances are dierent (see Table
.) and require dierent interventions.
Based on the results of the Albany Sleep Problems Scale (ASPS),

your therapist will discuss with you whether your child is experienc-
ing nightmares or sleep terrors. For interventions for each, see the
corresponding sections in this chapter.
49
Table 6.1 Differences between Nightmares and Sleep Terrors
NIGHTMARES SLEEP TERRORS
Child awakens Child asleep

Child can recall details Child has no recall
Child can be comforted Child is dicult to comfort
Child has limited movement or Child may sit up, walk around,
vocalizations until after waking or talk during event
Before you select an approach, you may need to work on your

thoughts and feelings about your childs sleep in order to prepare for
intervention. Talk to your therapist further if you:

sleep problem

when he does not want to

you tried to change the way he slept
successful intervention. (For example, you may think I must be
doing something wrong if my child has nightmares/sleep terrors.)
Intervention OptionsNightmares
Intervention options for nightmares depend on the age of the child.

For young children (up to about years of age), magic can be used.
For older children, relaxation or paradoxical intervention may be
more appropriate. A brief description of each of these interventions
follows.
50
Magic
This intervention uses magic to help allay fears the child may have
regarding sleep or the content of nightmares. For example, a magic
wand is used to provide protection against feared objects or per-
sons in a nightmare. Believing that the magical object will be eec-
tive appears to relieve the childs anxiety.
Relaxation
Relaxation involves using a technique called progressive muscle re-

laxation (PMR) before bedtime. The goal of this treatment is to re-
duce anxiety around sleep or nightmares.
Paradoxical Intention
Paradoxical intention involves providing instruction to the child or

adolescent to stay awake rather than try to fall asleep. Providing per-
mission to stay awake may reduce anxiety surrounding sleep or the
anticipation of nightmares.
Steps for Magic
If magic is selected as the treatment of choice, follow these steps:

vention.
. Find an age-appropriate item (for example, magic wand, toy

sword, magic dust) that might help the child feel more in
control (for example, by using a sword to ght o monsters).
. Introduce the magic item each evening, emphasizing how

powerful it is and that it will, eventually, help the child deal
with scary dreams.
. Encourage the child to discuss the magic item and how it could
help him.
51
Steps for Relaxation
If relaxation is selected as the treatment of choice, follow these steps:
vention.
. Make relaxation training the last part of the bedtime routine.
. Begin by telling the child to lie back on his bed. Arms and legs
should be limp as well as the head. If the child is holding up
his head, this means that the muscles of the neck are tensing
and he cannot be completely relaxed.
. For younger children, or children who seem to have a problem

following the directions, a simple instruction such as act like
a wet noodle may be enough to help them visualize what is
needed.
. Begin with the facial muscles, asking the child to slowly and
carefully tense the muscles. The tension of the muscles should
last for about seconds.
. Following the tension of a set of muscles, have the child relax

the muscles, and give him seconds to experience the good
feeling of relaxation.
. Remember to talk to the child using a soothing and calming

voice. Take your time.
. The exercise moves from the facial muscles to the jaw (clench-
ing and relaxing the jaw), then to the neck and shoulders, arms
and hands, chest, stomach, thighs, legs, and feet.
. Have the child tell you if he experiences any pain or discom-

fort. You may need to instruct him not to tense the muscles too
tightly, or you may want to avoid certain muscle groups.
. Have the child practice until he can run through it alone.
. Use the technique at bedtime and any time the child feels tense
or anxious.
52
Steps for Paradoxical Intention
If paradoxical intention is selected as the treatment of choice, follow

these steps:
vention.
. Make paradoxical intention the last part of the bedtime routine.
. Begin by telling the child or adolescent to lie back on his bed.
. Inform the child or adolescent that you want him to try to stay
awake, but if he falls asleep, thats okay. You dont want the
child or adolescent to be anxious that he will fall asleep.
. The child or adolescent should remain in bed in the dark, lying

still and relaxed with his eyes closed.
. Try to assess how much sleep the child or adolescent received

each night.
Common Obstacles
You will need to watch out for obstacles when implementing a pro-
gram for nightmares. Common problems include:
Lying down with the child until he falls asleep or falls back
to sleep

away from home)
Guilt over the childs distress
Expecting change too quickly
If any of these occur, go back to following the planned steps. The goal
is to keep making progress. Also, keep in mind that there is no evi-
dence of any lasting negative consequences for occasional nightmares.
53
Modications
If you are having problems carrying out the intervention, discuss

with your therapist. Treatment-specic modications may need to
be made to each approach as follows.
Magic
If you and your child selected an object or routine that does not
seem to work, try brainstorming alternative strategies. Sometimes
the second try works best.
Relaxation
Your child or adolescent may have trouble relaxingespecially if he

cannot turn o his thoughts. If this is the case, try the use of sooth-
ing music to accompany the muscle relaxation.
Paradoxical Intention
If your child or adolescent is anxious about trying to stay awake,

consider switching to relaxation.
Intervention OptionsSleep Terrors
Sleep terrors are assumed to be a sign of inadequate sleep. Interven-

tion typically takes the form of improving sleep through reducing
bedtime problems (see Chapter ), reducing night waking (see Chap-
ter ), or allowing naps if that does not disrupt the usual sleep pat-
tern. When improving sleep is not successful or cannot be changed
quickly, scheduled awakening is used.
54
Scheduled Awakening
Scheduled awakening involves waking the child up before the time

he usually has a sleep terror. The goal of this intervention is have the
child fall back asleep from this brief awakening without parental in-
volvement. It is unclear why this works, but may involve repro-
gramming the sleep cycle to a more regular sleep-wake schedule.

these steps:
. Use the Sleep Diary to determine the time or times that the
child typically has a sleep terror.
. On the night that you are to begin the plan, awaken the child
approximately minutes prior to the typical time for a sleep
terror. For example, if the child usually has a sleep terror at
: .., wake up the child at : .. If the child seems
to awaken very easily, move the time back by minutes
(: ..) the next night and on all subsequent nights.
. If there is a broad range in the times the child has sleep ter-
rors (for example, from : .. to : ..), awaken the
child about minutes prior to the earliest time (in this case,
: ..).
child until he opens his eyes, then let him fall back to sleep.
nights without a sleep terror. If the child has achieved this level
of success, skip one night (that is, no scheduled waking) dur-
ing the next week. If the child has sleep terrors, go back to
awakening the child every night. Slowly reduce the number of
nights with scheduled awakenings until the child is no longer
experiencing sleep terrors.
55
Common Obstacles
Common problems with using scheduled awakening include:

Skipping scheduled awakenings because of diculty get-
ting up or reluctance to awaken the child

away from home)
Guilt over the childs distress

goal is to keep making progress.
Modications
If you are having problems carrying out the intervention, discuss

with your therapist. Treatment-specic modications for scheduled
awakening may need to be made.
If your child fully awakens and does not go back to sleep following
awakenings, move the scheduled awakening time back by minutes
for the next episode.
If you miss more than an occasional scheduled awakening because

you cannot stay awake or get up to awaken your child, consult
your therapist about switching to another technique. For example,
other techniques may be used to improve overall sleep (such as sleep
restrictionsee Chapter ).
Homework

session.

Continue to complete the Behavior Log as needed.
56
Chapter 7 Bedwetting
Goals
To understand the causes of bedwetting
To take initial steps to reduce bedwetting
To carry out steps for the bell and pad technique (if selected
intervention)
To carry out steps for dry bed training (if selected intervention)
To carry out steps for full-spectrum home training (if selected

intervention)
Nature and Causes of Bedwetting
Though bedwetting is not classied as a sleep problem, we address it

in this book because it is a common nighttime occurrence. Success-
ful toilet training typically occurs between the ages of 1 2 and . It
is normal for young children to have occasional incidents of bed-
wetting; however, by age , children should be able to sleep through
the night without accidents.
Causes of bedwetting may be physical or psychological and can in-

volve:
Urinary tract infections and other medical conditions
Chronic constipation
Lack of antidiuretic hormone or ADH
Stress and emotional upset
Because of the possible role of medical causes of bedwetting, your

child should be screened by a physician prior to developing a plan.
57
Initial Steps
Before trying any specic techniques, the following steps are usually
suggested:
Limit the childs uids prior to bedtime and cut down

on drinks or foods with caeine, which can cause more
urination.
Have the child stop in the bathroom right before going to

sleep.
Punishment, in the form of yelling, nagging, or ridicule,

should not be used for accidents. This can make the prob-
lem worse.
If an accident occurs, have the child participate in the

clean-up. It is important to remember that this should not
be done in a punishing way.
If these small steps are not enough, then you and the therapist will
select from several more formal techniques for bedwetting during
the second session.
Introduction of Bedwetting Recording Sheet
Use a Bedwetting Recording Sheet to help you keep track of how

often your child wets the bed. In addition, space is available to record
how you respond to accidents. See Figure . for an example. A blank
form is provided at the end of this chapter. Additional blank forms
are included in an appendix at the back of the book. Two weeks of
recording is an ideal length for observing any patterns. If bedwetting
occurs reliablysuch as every nightthen one weeks worth of in-
formation may be enough information for the therapist.
If no physical problems are present and the initial steps to reduce

bedwetting have not solved the problem, there are several dierent
58
Bedwetting Recording Sheet
Childs Name: Michael
Dates of Recording: September 39
Day of the Time of

Week Bedwetting Response
Monday 1:30 a.m. Helped him wash up and change his clothes and sheets - he slept in
our bed
Tuesday 12:15 a.m. Changed his clothes and sheets and comforted him
Wednesday No bedwetting
Thursday
Friday
Saturday
Sunday
Figure 7.1
Example of Completed Bedwetting Recording Sheet
techniques that can be tried. These include the bell and pad tech-
nique, dry bed training, and full-spectrum home training.
The Bell and Pad Technique
A urine alarm, or the bell and pad, is one of the oldest techniques
for helping children with bedwetting. This commercially available
device consists of a pad that goes underneath the childs sheet. If the
59
pad gets wet, it sets o an alarm that is loud enough to wake the child
(and the family). The child is directed to nish urinating in the bath-
room. Parents then help the child clean her clothes and bed (clean-
liness training).
Dry Bed Training
Dry bed training includes the use of the bell and pad, and cleanli-
ness training. It also involves steps for awakening the child during
the night. In addition, a positive practice procedure is used in which
parents ask their child to lie in bed, count up to , and then get up,
go into the bathroom, and try to urinate.
Full-Spectrum Home Training
Full-spectrum home training (FSHT ) includes the use of the bell

and pad, and cleanliness training. It also uses two additional tech-
niques to try to help the child stay dry once the program is com-
pleted. A retention control training procedure is taught to the
child during the day in a manner similar to the positive practice part
of dry bed training. The nal part of the FSHT package is an over-
learning component. Following weeks of consecutive dry nights,
the child is given uids before bedtime to help strengthen the ability
to stay dry overnight.
Your therapist will work with you to choose the approach that ts
best with your family. Typically, the simplest approach (the bell and
pad) is introduced rst, followed by the other procedures. There are
also several medications that can reduce bedwetting. If you are in-
terested in these, speak to your pediatrician or doctor.
If you have feelings of guilt surrounding your childs bedwetting

problems, discuss these with your therapist. Your therapist can help
you challenge self-talk that interferes with successful intervention. (For
example, you may think My child will be angry with me if I make
her change clothes, or I am a bad parent if my child wets the bed.)
60
Steps for the Bell and Pad Technique
You can purchase the equipment for the bell and pad technique from
a number of dierent online sources (for example, http://www.bed
wettingstore.com). It is also sometimes available at department
stores such as Sears. Follow these steps:
. Hook up the alarm yourself each night and test it by touching
the sensors (its safe) with a wet nger.
. Listen for the alarm carefully and respond to it quickly.
. Have a night-light or ashlight nearby so you will be able to
see what you are doing when the alarm sounds.
. As soon as you hear the alarm, get out of bed and turn o the
alarm.
. Have the child go to the bathroom and nish urinating.
. Once nished, help the child clean her clothes and bed.
. Use the alarm every night until the child experiences or
consecutive weeks without bedwetting. This can take to
months, so be patient.
Steps for Dry Bed Training
The basic steps for dry bed training are as follows:

. Establish a nightly waking schedule. On the rst night, wake
the child each and every hour. On the second night, wake the
child hours after going to bed. If the child is dry for the re-
mainder of that night, then move the waking back to 1 2 hours
after bedtime. Continue to move the waking time back for
each dry night until it is hour after bedtime. If the child wets
the bed or more times in week, restart the schedule.
. Upon awaking the child, bring her to the bathroom and ask
her to urinate.
. After the bathroom trip, give the child some uids to drink and
ask her to try to hold it in until the next awakening.
. Allow the child to return to bed until the next awakening.
61
Positive Practice Procedure
At the same time, begin a positive practice procedure. Ask the child
to lie in bed, count up to , and then get up, go into the bathroom,
and try to urinate. This should be repeated timesboth right after
each instance of wetting the bed and again the next night at bedtime.
Bell and Pad Procedure and Cleanliness Training
On the second night of the waking schedule, install the bell and pad.
If the child wets the bed after the rst night of use and the alarm goes
o, instruct the child to change the wet clothes and remove the wet
sheets from the bed. Then direct the child to get dressed and make
the bed. This last step is repeated times for each instance of bed-
wetting before the child can go back to sleep. Repeatedly taking o
and putting on clothes and remaking the bed is unpleasant and is
thought to help the child avoid accidents.
Steps for Full-Spectrum Home Training
Bell and Pad Procedure and Cleanliness Training
Install the bell and pad and begin procedure. If the child wets the
bed after the rst night of use and the alarm goes o, have the child
change out of her wet clothes and remove the wet sheets from the
bed. Then direct the child to get dressed and make the bed. This last
step is repeated times for each instance of bedwetting before the
child can go back to sleep.
Retention Control Training
At the same time as starting the bell and pad procedure, give the
child a large amount of uids at bedtime. Then when the child in-
dicates that she has to urinate, ask her to hold it for minutes. Af-
terwards, give the child some tangible reward (such as money or
some other prize) for successfully holding urination. Increase the
time by minutes each day until the child can hold her urination for
minutes, at which point training ends. If the child fails on one
day, repeat the same amount of time the next day.
62
Overlearning Component
After consecutive successful (dry) nights, start the overlearning

component of training. The steps are as follows:
. Give the child ounces of water in the minutes before bed-

time on the rst night, and add ounces for each consecutive
dry nights.
. If the child has an accident, the amount of water should be cut

back by ounces.
. Stop adding more water when the maximum for the child is
reached. The maximum number of ounces is determined by
adding to the childs age in years (e..g., if the child is years
old, the maximum number of ounces is ).
. Overlearning ends when the child has had consecutive dry

nights while drinking the maximum uids prior to bedtime.
Obstacles
If you run into problems carrying out the selected intervention, con-
sult with your therapist about how to address these obstacles or try-
ing other approaches to dealing with bedwetting.
Homework
Have your child screened by a physician for possible medical

causes of bedwetting.
Take initial steps for handling bedwetting.

Complete the Bedwetting Recording Sheet.
session.
Address obstacles as needed or try a new intervention plan as

decided with your therapist.
63
Childs Name:
Dates of Recording:
Day of the Time of

64
Chapter 8 Other Sleep-Related Issues
Goals
To learn about other sleep-related problems
To take steps to reduce sleepwalking and related problems (if

relevant)
To take steps to improve problems related to sleeping at the

wrong times (if relevant)
To take steps to improve problems related to excessive sleepi-

ness (if relevant)
To take steps to improve other nighttime problems or concerns

(if relevant)
Intervention OptionsSleepwalking and Related Problems
This category includes sleepwalking, sleeptalking, and other related

problems (for example, sleepeating). These sleep disturbances most
often occur during non-dream or NREM sleep, usually within the
rst few hours after falling asleep at night. In children, the causes of
these active sleep events have been thought to include anxiety, a lack
of sleep, and fatigue. They have also been linked to seizure disorders,
which should be ruled out by a physician. For the most part, these
sleep events should not be a source of concern. However, there are
occasional reports of people harming themselves or others during
sleepwalking. If your child frequently sleepwalks, some precautions
should be taken. Strategies to reduce these problem sleep events
include:
Encourage more sleep and generally try to make sure that

the child is fully rested
Identify and address potential sources of stress or anxiety
65
If more sleep is not possible or eective, a trial of sched-
uled awakening may prove helpful

these steps:
. Use the Sleep Diary to determine the time(s) that the child
typically awakens during the night with these sleep events.
. On the night that you are to begin the plan, awaken the child
approximately minutes prior to the typical time for the sleep
episode. For example, if the child usually walks in his sleep at
: .., wake up the child at : .. If the child seems to
awaken very easily, move the time back by minutes the next
night and on all subsequent nights (: ..).
. If there is a broad range in the times for the sleep episode (for
example, from : .. to : ..), awaken the child about
minutes prior to the earliest time (in this case, : ..).
child until he opens his eyes, then let him fall back to sleep.
nights without the sleep disturbance. If the child has achieved
this level of success, skip one night (that is, no scheduled wak-
ing) during the next week. If the child has another episode, go
back to awakening the child every night. Slowly reduce the
number of nights with scheduled awakenings until the child is
no longer experiencing problems.
Intervention OptionsSleeping at the Wrong Times
Some children have diculty falling asleep at the desired time in the
evening and waking up at the right time the next morning. Rather
than resistance to sleep, this may be a result of the childs biological
clock being out of synch with the external world. Generally referred
66
to as circadian rhythm disorders, these diculties can be particularly
disruptive and include:
Delayed Sleep Phase Syndromeinability to fall asleep at night, stay-

ing up later and waking up later than usual
Advanced Sleep Phase Syndromefalling asleep too early and waking

up earlier than desired in the morning
Non--Hour Sleep-Wake Cycleshaving a sleep-wake cycle not fol-

lowing the typical -hour period, causing a gradual shift in sleep-
wake times (for example, falling asleep later and later each night
until the child is sleeping during the day and awake at night)
General Strategies
First, work on improving the childs sleep habits (described in Chap-

ter ). If this is not successful in realigning the childs sleep times, try
the following strategies. However, consult a sleep expert for more se-
rious or treatment-resistant sleep cycle problems.
Arrange daily activity cues. All typical daily activities (e,g,, meals,
bathing, homework, etc.) should occur during normal times. Do not
adapt these schedules to meet the needs of the childs disrupted
sleepsuch as allowing the child to eat dinner at .. Daily ac-
tivity cues will help the child readjust his sleep schedule.
Experiment with melatonin. In consultation with the childs pediatri-

cian, give the child melatonin about minutes prior to the desired
bedtime. This can sometimes help reset the biological clock such
that the child sleeps on a more regular schedule.
Bright light therapy. A typical bright light therapy plan involves hav-
ing the child sit in front of a bank of lights for several hours after
awaking. The lights must provide more light than is typical in a
home or at school because they have to produce approximately the
amount of light provided by the sun. Light boxes are now com-
mercially available and usually include about six orescent light
tubes. The child sits facing these lights and can work or carry on
other activities at the same time. Using these lights has helped some
people regulate their sleep cycles toward one that better matches a
typical schedule.
67
If these steps are unsuccessful, two other approachessleep restric-
tion and chronotherapycan be useful. Note that chronotherapy
requires a major time commitment on the part of the family and is
usually the approach of last resort. These two approaches are de-
scribed next.
Sleep Restriction
Sleep restriction involves reducing the amount of time the child sleeps
and then gradually increasing the time back to a healthy amount.
This can involve moving bedtime later in the evening or waking the
child up earlier in the morning. This technique works by resetting
the childs biological clock. Follow these steps:
time (new bedtime : ..).
. If the child falls asleep within minutes of being put to bed

at this new bedtime and without resistance for successive
nights, move the bedtime back by minutes (from : ..
to : ..).
. Keep the child awake before the new bedtime, even if he seems
to want to fall asleep.
being put to bed, have him leave the bedroom and extend the


the child sleep in.
Chronotherapy
Chronotherapy essentially involves keeping the child awake later

and later on successive nights, until he achieves the desired new sleep
68
schedule. If chronotherapy is selected as the treatment of choice, fol-
low these steps:
Use the Sleep Diary to identify the typical sleep-wake

schedule for the child.
On the night you are to begin the plan, keep the child
awake approximately hours after his typical bedtime. For
example, if the child usually falls asleep at : .., keep
the child up until : ..
Do not allow the child to sleep at times other than the

scheduled onesthat is, no naps.
Each successive night, move the bedtime ahead by another

hours (for example, from : .. to : ..).
Keep this schedule until the childs new bedtime approxi-

mates the desired bedtime (for example, : ..).
Excessive Sleepiness
Sleepiness can be excessive to the point that it interferes with daily

activities. If this cannot be attributed to other sleep problems (such
as night waking or insucient sleep), the child should be assessed by
a sleep or other medical professional. The scores on specic ques-
tions of the Albany Sleep Problems Scale (ASPS) can point to one
of the following concerns: hypersomnia, narcolepsy, breathing-related
sleep disorders, or limb movement disorders.
Hypersomnia and Narcolepsy
Hypersomnia is a problem of sleeping too much. Despite getting a

full nights sleep each evening, some children (and adults) nd
themselves falling asleep several times each day. Narcolepsy is a seri-
ous sleep problem that includes uncontrollable sleep attacks as well
as daytime sleepiness. People with narcolepsy experience cataplexy,
or a sudden loss of muscle tone. These are not seizures, but instead
are involuntary sleep attacks.
69
Breathing-Related Sleep Disorders
Diculties in breathing can result in numerous brief arousals

throughout the night. As a result, the child does not feel rested even
after or hours asleep. At the extreme end, sleep apnea involves
periods where the child stops breathing completelyagain, inter-
rupting sleep. Often, there is no recollection of these breathing
problems upon waking.
Limb Movement Disorders
Physical movements, such as leg and arm twitching, that continue

throughout most of the night may interrupt sleep. These movements
may occur even without the child being aware of them. Two types of
movement-related sleep problems are relatively common causes of
daytime sleepiness: periodic limb movements and restless legs syn-
drome. Medical evaluation and intervention is recommended for
these problems.
Other Nighttime Problems
Responses on the Albany Sleep Problems Scale (ASPS) can be used

to identify other nighttime problems that may require intervention.
Some of these concerns are outlined here.
Problems with Anxiety
Being anxious can have a direct impact on how a child sleeps and can
include:
. Anxiety about daytime issues (for example, school)
. Anxiety about not being able to sleep
Anxiety about sleeping itself can be helped by using a form of para-

doxical instruction. Go through the usual bedtime routine, but tell
the child that falling asleep is not that important. The child should
be in bed, with the lights out, and with eyes closed. However, the
child should be told to try to remain awake without opening his eyes
or moving around too much. If the child is anxious about not being
70
able to sleep, giving him permission to stay awake can help relieve
these fears and paradoxically help the child fall asleep.
Problems with Depression
Being depressed can seriously interfere with sleepeither causing

too much sleep or not enough. If depression is suspected as interfer-
ing with sleep, seek a referral for treatment.
Sleep-Related Headaches
Some children experience headaches when they wake up in the

morning. There are at least three possible causes for early morning
headaches: breathing diculties, caeine withdrawal, or sleep depri-
vation. Specic interventions for each of these causes should be ex-
plored with your therapist and/or pediatrician.
Rhythmic Movement Disorder
Some children rock back and forth in their beds before going to
sleep. Sometimes this rocking includes head banging against the wall
or the side of the crib. The rocking or head banging usually seems to
be soothing to the child and helps him fall asleep. These types of be-
haviors are more formally referred to as rhythmic movement disor-
der. They are fairly common (in their less injurious forms) among
infants and toddlers. Often no intervention is necessary. If treatment
is desired, sleep restriction can be helpful (see steps for sleep restric-
tion under Intervention OptionsSleeping at the Wrong Times).
Nighttime Teeth Grinding
This includes all forms of teeth clenching and grinding that occur
during sleep. This does not seem to be a serious sleep concern on its
own; however, if frequent, the grinding down of the teeth can be-
come serious. In addition, people who grind their teeth are more
likely to have jaw pain and headaches than those who have no teeth
grinding. Evaluation by a pediatrician is recommended.
71
Homework

session.
Seek an evaluation by a sleep expert or pediatrician if necessary.

Continue to complete the Behavior Log as needed.
72
Chapter 9 Age-Related and Parental Sleep Concerns
Age-Related Concerns
Children have dierent sleep needs at dierent ages. Table . in

Chapter provides a broad guideline for the average number of hours
of sleep children need at dierent ages. You can use this as a rule of
thumb for gauging how much or how little your child should sleep.
It also helps to be aware of several milestones related to the develop-
ment of children.
3 Months: Fading Nighttime Feedings
Most children do not need to be fed during the night after the age of
about months. Unfortunately, nighttime feedings can lead to con-
tinued night waking because the child becomes conditioned to
awaken at these times and, in turn, is conditioned to need the feed-
ing to fall back asleep. Nighttime feedings after the age of months
can be faded according to the following schedule.
Fading Nighttime Feedings:
. On the rst night, give the child feedings of ounces (if bottle
fed) or minutes (if breast fed) with hours between feedings.
. On each subsequent night, reduce feedings by ounce or

minute (for example, the second night would be ounces or
minutes). Also increase the time between feedings by min-
utes (for example, from hours to 1 2 hours).
. Remember that a crying child may be hungry, but does not

need the nourishment.
. By the eighth night, the child should no longer be fed at bed-

time or in the middle of the night.
73
6 Months: Sleeping Through the Night
Most infants can sleep through the night without awakening by the
age of months. If your child continues to awaken one or more
times at night after having fallen asleep, and she is at least months
old, refer back to the previous chapters for help in dealing with this
problem.
5 years: Fading Daytime Naps
By age , children should be able to have an active morning without

a nap. And somewhere between the ages of and , most children
no longer need an afternoon nap. Remember children are dierent
when it comes to sleep needs. Some children and adults can nap dur-
ing the day, and this does not negatively impact on their sleep. In
contrast, other individuals who nap even for a short period of time
can have trouble falling asleep at night or may awaken earlier than
desired. At about the age of , if a child is still napping and this is in-
terfering with sleep, then it may be time to begin to phase out this
daytime sleeping.
One helpful suggestion is if you are going to awaken your child early
from a nap, do it just before some favorite or fun activity (for ex-
ample, lunch time or play time). This can help reduce your childs
irritability in these situations.
Teen Years: Accommodating Changes in Sleep Patterns
It has been estimated that after puberty, teens get about 1 2 hours of
sleep each night, yet they need more than . At this time in develop-
ment, the timing of sleep changes such that the pattern becomes de-
layed. Teens naturally begin to fall asleep later, and this is not just the
result of late-night television watching or computer use. Unfortu-
nately, most school districts schedule high school classes to begin at an
early time, at the very point in development when this is problematic.
This change in sleep patterns makes good sleep habits very impor-
tant during your childs teen years. Follow the steps in Chapter
especially the use of regular bedtimes and regular times to awaken.
74
Parental Sleep Concerns
Many sleep disorders are genetic and you may nd that you also have
signicant sleep disturbances. At the same time, having your child
continually disrupt your sleep can lead to more persistent sleep dis-
ruption in your own sleep. Fortunately, the same interventions used
for children can be eective for improving parental sleep problems.
Establishing good sleep habits is the rst step in addressing adult

sleep problems. Try the suggestions in Chapter for improving your
sleep.
In addition, do not consume alcohol before bedtime. Alcohol use can

increase episodes of partial waking. It can also increase interrupted
breathing during sleep, which contributes to daytime drowsiness.
Also, assess your smoking patterns to see if they are interfering with
your disturbed sleep. The nicotine in cigarettes is a stimulant and,
like caeine, serves to stimulate the nervous system. Smoking right
before bedtime can result in an overstimulation of the brain, which
will interfere with sleep. Another problem for people who smoke is
that to maintain their x of nicotine, they need to smoke fairly
often throughout the day. The problem they have with sleep is that
they can experience withdrawal during the night, and this can dis-
rupt sleep. It is not surprising that many smokers light up almost as
soon as they wake up in the morning because their brains are crav-
ing nicotine.
75
Albany Sleep Problems Scale (ASPS)
ALBANY SLEEP PROBLEMS SCALE (ASPS)
Name: Date of Birth:
Diagnoses: Sex:
Name of Respondent: Date Adm:
Instructions: Circle one number that best represents the frequency of the behavior.
Never
Less than once per week
One to two times per week
Three to six times per week
Nightly
. Does the child have a fairly regular bedtime and time that he or she awakens?
. Does the child have a bedtime routine that is the same each evening?
. Does the child work or play in bed often right up to the time he or she goes
to bed?
. Does the child sleep poorly in his or her own bed, but better away from it? Yes No
. Does the child consume caeine in any form?
. Does the child engage in vigorous activity in the hours before bedtime?
. Does the child resist going to bed?
. Does the child take more than hour to fall asleep but does not resist?
. Does the child awaken during the night but remain quiet and in bed?
. Does the child awaken during the night and is he or she disruptive
(e.g., tantrums, oppositional)?
. Does the child take naps during the day?
. Does the child often feel exhausted during the day because of lack of sleep?
. Has the child ever had an accident or near accident because of sleepiness Yes No
from not being able to sleep the night before?
. Does the child ever use prescription drugs or over-the-counter medications
to help him or her sleep?
. Has the child found that sleep medication doesnt work as well as it did Yes No/NA
when he or she rst started taking it?
. If taking sleep medication, does the child nd that he or she cant sleep on Yes No/NA
nights without it?
78
ALBANY SLEEP PROBLEMS SCALE (ASPS) continued
. Does the child fall asleep early in the evening and awaken too early in the
morning?
. Does the child have diculty falling asleep until a very late hour and
diculty awakening early in the morning?
. Does the child wake up in the middle of the night upset?
.Is the child relatively easy to comfort during these episodes? Yes No/NA
. Does the child have episodes during sleep where he or she screams loudly
for several minutes but is not fully awake?
. Is the child dicult to comfort during these episodes? Yes No/NA
. Does the child experience sleep attacks (falling asleep almost immediately
and without warning) during the day?
. Does the child experience excessive daytime sleepiness that is not due to an
inadequate amount of sleep?
. Does the child snore when asleep?
.Does the child sometimes stop breathing for a few seconds during sleep?
. Does the child have trouble breathing?
. Is the child overweight? Yes No
. Has the child often walked when asleep?
. Does the child talk while asleep?
. Are the childs sheets and blankets in extreme disarray in the morning when
he or she wakes up?
. Does the child wake up at night because of kicking legs?
. While lying down, does the child ever experience unpleasant sensations in Yes No
the legs?
. Does the child rock back and forth or bang a body part (e.g., head) to fall
asleep?
. Does the child wet the bed?
. Does the child grind his or her teeth at night?
. Does the child sleep well when it doesnt matter, such as on weekends, but Yes No
sleeps poorly when he or she must sleep well, such as when a busy day at
school is ahead?
. Does the child often have feelings of apprehension, anxiety, or dread when
he or she is getting ready for bed?
79
ALBANY SLEEP PROBLEMS SCALE (ASPS) continued
. Does the child worry in bed?

.Does the child often have depressing thoughts, or do tomorrows worries or
plans buzz through his or her mind when he or she wants to go to sleep?
. Does the child have feelings of frustration when he or she cant sleep?
. Has the child experienced a relatively recent change in eating habits? Yes No
. Does the child have behavior problems at times other than bedtime or upon
awakening? Yes No
.When did the childs primary diculty with sleep begin?
. What was happening in the childs life at that time, or a few months before?
.Is the child under a physicians care for any medical condition? Yes No
(If yes, indicate the condition below.)
OTHER COMMENTS:
Copyright V.M. Durand, .
80
Sleep Diary Forms
82
SLEEP DIARY for
A.M. P.M.
Day Date 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 Noon 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00
SLEEP DIARY for
A.M. P.M.
Day Date 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 Noon 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00
83
84
SLEEP DIARY for
A.M. P.M.
Day Date 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 Noon 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00
Behavior Log Forms
86
BEHAVIOR LOG for
BEHAVIOR LOG for
87
88
BEHAVIOR LOG for
BEHAVIOR LOG for
89
90
BEHAVIOR LOG for
Bedwetting Recording Sheet Forms
Childs Name:
Dates of Recording:
Day of the Time of

92
Childs Name:
Dates of Recording:
Day of the Time of

93
Childs Name:
Dates of Recording:
Day of the Time of

94
Childs Name:
Dates of Recording:
Day of the Time of

95
Childs Name:
Dates of Recording:
Day of the Time of

96

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When Children Dont Sleep Well

David H. Barlow, PhD

Anne Marie Albano, PhD

Gillian Butler, PhD

David M. Clark, PhD

Edna B. Foa, PhD

Paul J. Frick, PhD

Kirk Heilbrun, PhD

Peter E. Nathan, PhD

Christine Maguth Nezu, PhD

Matthew K. Nock, PhD

Paul Salkovskis, PhD

Bonnie Spring, PhD

Gail Steketee, PhD

John R. Weisz, PhD

G. Terence Wilson, PhD

Oxford New York

Copyright by Oxford University Press, Inc.

Published by Oxford University Press, Inc.

Printed in the United States of America

One of the most dicult problems confronting the parents of chil-

Now healthcare systems around the world are attempting to correct

David H. Barlow, Editor-in-Chief

Chapter Pre-Intervention Assessment and Planning

Chapter Good Sleep Habits

Chapter Night Waking

Chapter Nightmares and Sleep Terrors

Chapter Other Sleep-Related Issues

Chapter Age-Related and Parental Sleep Concerns

Albany Sleep Problems Scale (ASPS)

Sleep Diary Forms

Behavior Log Forms

Bedwetting Recording Sheet Forms

Having a child with sleep problems can be dicult and exhausting.

It is important to be patient during the assessment period. A great deal

To begin, it is helpful to learn more about sleep and problems related

Sleep is as necessary as food and drink. It aects learning, memory,

Sleep problems are very common among children as well as adults,

Interventions for Sleep Problems

There are a number of interventions that can be helpful, although

Children who are very susceptible to disturbed sleep may continue

FIRST SESSION: Sleep Interview and Assessment Tools

To assess your childs sleep problems

To start recording your childs sleep pattern

Albany Sleep Problems Scale

Sleep Habits Questions

Having a regular bedtime and a regular time to awaken is crucial for

Bedtime routines help signal the brain that bedtime is approaching

Scoring: If you selected a or more (i.e., one or more times per

Scoring: If you answered Yes, your therapist may refer you to

. Does the child consume caeine in any form?

. Does the child engage in vigorous activity in the hours before

Vigorous (or aerobic) activity just before bedtimein contrast to

Scoring: If you selected a or more (i.e., one or more times per

Bedtime and Night Waking Questions

. Does the child resist going to bed?

Disruption at bedtime can be caused by a number of dierent prob-

Scoring: If you selected a or more (i.e., one or more times per

Scoring: If you selected a or more (i.e., one or more times per

Interrupted sleep often involves a child having acquired the habit of

Scoring: If you selected a or more (i.e., one or more times per

Interrupted sleep accompanied by behavioral outbursts is also not

. Does the child take naps during the day?