What is the role of CBT in the treatment of pediatric sleep disorders?

Updated: Oct 09, 2018
  • Author: Sufen Chiu, MD, PhD; Chief Editor: Caroly Pataki, MD  more...
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Specific interventions for sleep problems have gained the status of established evidence-based interventions. The issues that received the most attention pertain to settling problems and night awakenings in infants and toddlers. These topics have been extensively studied, with an impressive volume of well-controlled and informative clinical studies. Clinical research of all other sleep problems and in other age ranges is still very limited.

Family dynamics should be explored and redressed. Sleep patterns of parents and their adolescent children reveal similarities [12] ; for example, strained and reciprocal parent-child interactions indicate that a mother’s poor sleep may directly affect parenting style. Accordingly, adolescents’ psychological functioning and sleep are also affected.

Limit-setting problems, bedtime resistance, and frequent nightly awakenings represent common problems encountered in pediatric practice. CBT uses relatively straightforward and safe strategies for enhancing overall parenting effectiveness as well as ameliorating the aforementioned problems. Such strategies include the following:

  • Extinction technique – This technique involves the parents putting their child to bed at a designated time and ignoring the child’s or infant’s protests until an established time the next morning

  • Graduated extinction – Many parents may experience or perceive pure extinction as overly taxing or cruel; therefore, a graduated extinction technique may be used, which may include progressive time delays in responding to bedtime protests or refusals (ie, a checking technique) or may involve comforting for increasingly shorter intervals when checking on the child

  • Positive routine-stimulus control technique – This technique involves developing a consistent, pleasurable, and calming nighttime routine, with pleasurable activities being halted if the child protests or throws a tantrum; the child is then put to bed

  • Scheduled awakenings – Parents awaken the child approximately 15 minutes before his or her typical nightly awakening times; the scheduled awakenings then are gradually stopped or tapered off

In patients with nocturnal enuresis, the history and physical examination are usually sufficient to rule out a urologic abnormality. If medical causes of enuresis are ruled out, children younger than 6 years should be managed with child and family reassurance that the enuresis is developmentally normal. Older children may benefit from medication to reduce embarassment. Helpful behavioral strategies include the following:

  • Alarm clock method – An alarm is set before the most probable time of the event (as suggested by preceding enuretic episodes); the alarm may be set for a predetermined time, such as 2-3 hours after usual onset of enuresis; children eventually avoid wetting themselves before the alarm is triggered (in contrast with the bell and pad method); longer treatment duration results in a higher success rate

  • Parent education – Parents need to know that sleep hygiene practices serve as prevention of enuresis; fluid restriction, bedtime voiding, and parent awakening later are components of sleep hygiene (see Patient Education); the earlier the child begins practicing sleep hygiene, the better; individual families may require creative combinations of the aforementioned interventions

Treatment for sleep-related fears and anxiety includes relaxation training, guided imagery, positive self-talk, positive reinforcement for increasingly successful efforts, systematic desensitization, and gradual exposure to a child-determined hierarchy of sleep-related fears or anxiety. The child progresses from envisioning less threatening fears to conquering in vivo actual feared objects or situations. Exposure-response prevention is combined with relaxation techniques and positive reinforcement for treatment gains.

In patients with periodic limb movement during sleep (PLMS) or restless legs syndrome (RLS), CBT should focus alleviating stress and promoting relaxation. Pharmacologic therapy may be considered (see below).

In patients with circadian rhythm disorders, light therapy in the morning can help reset the suprachiasmatic nuclei. The individual is exposed immediately upon awakening to 8,000–10,000 lux of bright light for 20 to 30 minutes. [20] If a light box is used, it is placed at 18 to 24 inches from the face. Chronic use of a light box can lead to development of cataracts. This is the opposite of the effect of melatonin (see below), which can be used at night to help induce sleep. In manipulating the internal sleep-wake clock, gradually delaying sleep onset resynchronizes the internal clock. Sleep onset should be delayed in 3-hour increments each night until the desired sleep time is established. [20]

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