Dr. Roberta Leu

No area of pediatric sleep medicine stirs more controversy in the mainstream media than the treatment of behavioral insomnia of childhood (BIC), defined in the International Classification of Sleep Disorders (American Academy of Sleep Medicine [AASM], 2005) as difficulty falling and/or staying asleep that is behavioral in etiology and not explained by a medical or psychiatric cause.

The diagnosis, which is usually made via a caretaker report, is divided into three subtypes: limit-setting type (ie, bedtime problems), sleep-onset association type (night-wakers), and a combined type. Including all three subtypes, disease prevalence is estimated at 20% to 30% in infants, toddlers, and preschoolers (Morganthaler et al. Sleep. 2006;29[10]:1277). Though the disease has been associated with diurnal behavioral problems, it also has significant adverse effects on the parents, including sleep deprivation, maternal depression, and increased parental stress (Wake et al. Pediatrics. 2006;117[3]:836). Unfortunately, an astounding 84% of children with sleep disturbances continue to have them at 3-year follow-up, with persistent sleep fragmentation noted in as many as 18% of school-age children (Kataria et al. J Pediatr. 1987;110[4]:642; Sadeh et al. Dev Psychol. 2000;36[3]:291).

Treatment options

One likely contributor to the endurance of BIC into later childhood is the uncertainty about the optimal method of treatment. According to the AASM’s behavioral practice parameters for bedtime problems and night-waking in infants and children, the standard of care is to use the behavioral strategy of unmodified extinction, more commonly known as the "cry-it-out" method. This technique involves putting the child to bed at a designated time and not responding to the child’s protests/cries until it is time to wake up in the morning, unless there are significant safety or illness concerns.

Another practice standard is to use unmodified extinction, allowing a parent to remain in the room without reacting to the child ("extinction with parental presence"); a gentler method called "graduated extinction" or "modified extinction" allows the parent to briefly check on the child at predetermined times but with progressively longer intervals until sleep is achieved. The idea behind each of these methods is to allow the child to develop self-soothing skills so that he or she is able to fall asleep independent of parental intervention. By not providing the positive reinforcement of parental attention, the undesired behavior (crying or screaming) is extinguished.

Although a number of studies support the efficacy of these behavioral interventions in significantly reducing bedtime resistance and night-wakings (Mindel et al. Sleep. 2006;29[10]:1263), controversy understandably exists about the morality of allowing a child to cry for extended periods of time without consolation. Proponents of attachment parenting dub unmodified extinction as cruel and unusual punishment. The debate lies in whether withholding a parent’s response to a child’s cries at night results in long-term damage to the child or the parent-child relationship.

A well-written theoretical review of this practice has questioned the use of extinction techniques to help infants sleep independently (Blunden et al. Sleep Med Rev. 2011;15[5]:327), arguing that nocturnal crying has culturally been deemed undesirable, even pathological. The authors make arguments for the social and biological utility of infant crying and cite studies proposing that prolonged crying could result in increased cortisol, stress, withdrawal behaviors, attachment disorders, and potential neuronal changes. Because extinction methods are likely to involve prolonged periods of crying and thereby increase biological stress, they postulate that these methods are not completely benign, though the referenced studies of adverse outcomes of prolonged crying were not specifically related to the use of extinction therapy for BIC.

Until recently, no long-term studies had addressed the longitudinal effects of "crying-it-out," though short-term studies had shown no adverse effects. A recent publication evaluated the effects of an infant behavioral sleep program at 5-year follow-up on the child, the parent-child relationship, and maternal outcomes (Price et al. Pediatrics. 2012;130[4]:643). This study was an extension of the previously published Infant Sleep Study, a randomized controlled trial evaluating the shorter-term effects of a behavioral sleep intervention on infants who were identified by mothers as having sleep problems at 8 months of age (Hiscock et al. Arch Dis Child. 2007;92[11]:952).

Two techniques were used in this study: "controlled comforting" (graduated extinction) and "camping out." This latter technique, also known as adult fading, is similar to "extinction with parental presence," with the parent gradually distancing himself or herself from the child. Price and colleagues followed up on those children at 6 years of age, analyzing differences in intervention vs. control groups based upon parental reports and standardized questionnaires of emotional and behavioral problems, perception of sleep as a problem, clinical sleep problems, psychosocial health-related quality of life, and stress, as measured by morning cortisol levels. Additionally, researchers assessed the child-parent relationship; parenting styles; and evaluated maternal depression, anxiety, and stress. Results showed no statistically significant difference between the intervention and control groups in any of the measured outcomes, supporting the theory that behavioral sleep interventions have no long-term adverse effects on children.

Prevention strategies

Regardless of whether or not extinction methods are benign or harmful to an infant, there are parents who simply prefer noncrying methods for getting their child to sleep. In addition to extinction, the AASM practice parameters also propose parent education/prevention as a standard recommendation. This intervention focuses on preventing sleep problems by teaching parents to establish good sleep routines within their child’s first 6 months of life.

Strategies typically include developing consistent sleep schedules and providing an appropriate level of parental interaction during sleep initiation and nighttime awakenings. Putting the infant to bed in a "drowsy but awake" state can foster development of self-soothing and sleep initiation skills. Outside of these standard recommendations, two guideline recommendations are "delayed bedtime with removal from bed/positive bedtime routines" and "scheduled awakenings."

The first refers to the technique of temporarily delaying the child’s bedtime in order to increase the likelihood of the child falling asleep in the bed by increasing sleep pressure. Optionally, the child may be removed from the bed if he or she is unable to achieve sleep within a predetermined time period. Implementation of scheduled awakenings requires that parents be familiar with their child’s night waking patterns; based upon this schedule, the child is preemptively woken up 15 to 30 minutes prior to the expected spontaneous awakening and consoled in a typical manner. Gradually, these scheduled awakenings are faded out, with the intention of increasing consolidated sleep. There was insufficient evidence for the task force committee to support any one technique or combination of techniques over another.

Beyond BIC

Despite the emotional wear that extinction therapy for BIC can have on a parent, the lack of direct data suggesting harm makes it reasonable to include as a recommendation to frustrated caregivers. It is critical to be aware that underlying medical issues, which may be contributing to nighttime awakenings (eg, gastroesophageal reflux, pain due to acute illness such as hand-foot-and-mouth disease, and upper respiratory infection) must be ruled out before a behavioral sleep problem is diagnosed and treated in this fashion.

Most importantly, both providers and parents should be aware that extinction methods are not the only behavioral methods available to manage BIC. Further studies to demonstrate the efficacy of these other methods in larger populations or to develop additional methods need to be conducted, hopefully leading to and expansion of the practitioner’s toolbox for treating BIC. When a family presents for management of an infant with behavioral insomnia, the provider should practice the art of tailoring a treatment plan that considers parent and child temperaments, schedules, and social and cultural perspectives to optimize success while minimizing parental stress.

Sophia Kim, MD

Fellow, Sleep Medicine

Roberta Leu, MD

Director, Pediatric Sleep Disorders Program

Emory University School of Medicine

Atlanta, Georgia

No area of pediatric sleep medicine stirs more controversy in the mainstream media than the treatment of behavioral insomnia of childhood (BIC), defined in the International Classification of Sleep Disorders (American Academy of Sleep Medicine [AASM], 2005) as difficulty falling and/or staying asleep that is behavioral in etiology and not explained by a medical or psychiatric cause.

The diagnosis, which is usually made via a caretaker report, is divided into three subtypes: limit-setting type (ie, bedtime problems), sleep-onset association type (night-wakers), and a combined type. Including all three subtypes, disease prevalence is estimated at 20% to 30% in infants, toddlers, and preschoolers (Morganthaler et al. Sleep. 2006;29[10]:1277). Though the disease has been associated with diurnal behavioral problems, it also has significant adverse effects on the parents, including sleep deprivation, maternal depression, and increased parental stress (Wake et al. Pediatrics. 2006;117[3]:836). Unfortunately, an astounding 84% of children with sleep disturbances continue to have them at 3-year follow-up, with persistent sleep fragmentation noted in as many as 18% of school-age children (Kataria et al. J Pediatr. 1987;110[4]:642; Sadeh et al. Dev Psychol. 2000;36[3]:291).

Treatment options

One likely contributor to the endurance of BIC into later childhood is the uncertainty about the optimal method of treatment. According to the AASM’s behavioral practice parameters for bedtime problems and night-waking in infants and children, the standard of care is to use the behavioral strategy of unmodified extinction, more commonly known as the "cry-it-out" method. This technique involves putting the child to bed at a designated time and not responding to the child’s protests/cries until it is time to wake up in the morning, unless there are significant safety or illness concerns.

Another practice standard is to use unmodified extinction, allowing a parent to remain in the room without reacting to the child ("extinction with parental presence"); a gentler method called "graduated extinction" or "modified extinction" allows the parent to briefly check on the child at predetermined times but with progressively longer intervals until sleep is achieved. The idea behind each of these methods is to allow the child to develop self-soothing skills so that he or she is able to fall asleep independent of parental intervention. By not providing the positive reinforcement of parental attention, the undesired behavior (crying or screaming) is extinguished.

Although a number of studies support the efficacy of these behavioral interventions in significantly reducing bedtime resistance and night-wakings (Mindel et al. Sleep. 2006;29[10]:1263), controversy understandably exists about the morality of allowing a child to cry for extended periods of time without consolation. Proponents of attachment parenting dub unmodified extinction as cruel and unusual punishment. The debate lies in whether withholding a parent’s response to a child’s cries at night results in long-term damage to the child or the parent-child relationship.

A well-written theoretical review of this practice has questioned the use of extinction techniques to help infants sleep independently (Blunden et al. Sleep Med Rev. 2011;15[5]:327), arguing that nocturnal crying has culturally been deemed undesirable, even pathological. The authors make arguments for the social and biological utility of infant crying and cite studies proposing that prolonged crying could result in increased cortisol, stress, withdrawal behaviors, attachment disorders, and potential neuronal changes. Because extinction methods are likely to involve prolonged periods of crying and thereby increase biological stress, they postulate that these methods are not completely benign, though the referenced studies of adverse outcomes of prolonged crying were not specifically related to the use of extinction therapy for BIC.

Until recently, no long-term studies had addressed the longitudinal effects of "crying-it-out," though short-term studies had shown no adverse effects. A recent publication evaluated the effects of an infant behavioral sleep program at 5-year follow-up on the child, the parent-child relationship, and maternal outcomes (Price et al. Pediatrics. 2012;130[4]:643). This study was an extension of the previously published Infant Sleep Study, a randomized controlled trial evaluating the shorter-term effects of a behavioral sleep intervention on infants who were identified by mothers as having sleep problems at 8 months of age (Hiscock et al. Arch Dis Child. 2007;92[11]:952).

Two techniques were used in this study: "controlled comforting" (graduated extinction) and "camping out." This latter technique, also known as adult fading, is similar to "extinction with parental presence," with the parent gradually distancing himself or herself from the child. Price and colleagues followed up on those children at 6 years of age, analyzing differences in intervention vs. control groups based upon parental reports and standardized questionnaires of emotional and behavioral problems, perception of sleep as a problem, clinical sleep problems, psychosocial health-related quality of life, and stress, as measured by morning cortisol levels. Additionally, researchers assessed the child-parent relationship; parenting styles; and evaluated maternal depression, anxiety, and stress. Results showed no statistically significant difference between the intervention and control groups in any of the measured outcomes, supporting the theory that behavioral sleep interventions have no long-term adverse effects on children.

Prevention strategies

Regardless of whether or not extinction methods are benign or harmful to an infant, there are parents who simply prefer noncrying methods for getting their child to sleep. In addition to extinction, the AASM practice parameters also propose parent education/prevention as a standard recommendation. This intervention focuses on preventing sleep problems by teaching parents to establish good sleep routines within their child’s first 6 months of life.

Strategies typically include developing consistent sleep schedules and providing an appropriate level of parental interaction during sleep initiation and nighttime awakenings. Putting the infant to bed in a "drowsy but awake" state can foster development of self-soothing and sleep initiation skills. Outside of these standard recommendations, two guideline recommendations are "delayed bedtime with removal from bed/positive bedtime routines" and "scheduled awakenings."

The first refers to the technique of temporarily delaying the child’s bedtime in order to increase the likelihood of the child falling asleep in the bed by increasing sleep pressure. Optionally, the child may be removed from the bed if he or she is unable to achieve sleep within a predetermined time period. Implementation of scheduled awakenings requires that parents be familiar with their child’s night waking patterns; based upon this schedule, the child is preemptively woken up 15 to 30 minutes prior to the expected spontaneous awakening and consoled in a typical manner. Gradually, these scheduled awakenings are faded out, with the intention of increasing consolidated sleep. There was insufficient evidence for the task force committee to support any one technique or combination of techniques over another.

Beyond BIC

Despite the emotional wear that extinction therapy for BIC can have on a parent, the lack of direct data suggesting harm makes it reasonable to include as a recommendation to frustrated caregivers. It is critical to be aware that underlying medical issues, which may be contributing to nighttime awakenings (eg, gastroesophageal reflux, pain due to acute illness such as hand-foot-and-mouth disease, and upper respiratory infection) must be ruled out before a behavioral sleep problem is diagnosed and treated in this fashion.

Most importantly, both providers and parents should be aware that extinction methods are not the only behavioral methods available to manage BIC. Further studies to demonstrate the efficacy of these other methods in larger populations or to develop additional methods need to be conducted, hopefully leading to and expansion of the practitioner’s toolbox for treating BIC. When a family presents for management of an infant with behavioral insomnia, the provider should practice the art of tailoring a treatment plan that considers parent and child temperaments, schedules, and social and cultural perspectives to optimize success while minimizing parental stress.

Sophia Kim, MD

Fellow, Sleep Medicine

Roberta Leu, MD

Director, Pediatric Sleep Disorders Program

Emory University School of Medicine

Atlanta, Georgia

No area of pediatric sleep medicine stirs more controversy in the mainstream media than the treatment of behavioral insomnia of childhood (BIC), defined in the International Classification of Sleep Disorders (American Academy of Sleep Medicine [AASM], 2005) as difficulty falling and/or staying asleep that is behavioral in etiology and not explained by a medical or psychiatric cause.

The diagnosis, which is usually made via a caretaker report, is divided into three subtypes: limit-setting type (ie, bedtime problems), sleep-onset association type (night-wakers), and a combined type. Including all three subtypes, disease prevalence is estimated at 20% to 30% in infants, toddlers, and preschoolers (Morganthaler et al. Sleep. 2006;29[10]:1277). Though the disease has been associated with diurnal behavioral problems, it also has significant adverse effects on the parents, including sleep deprivation, maternal depression, and increased parental stress (Wake et al. Pediatrics. 2006;117[3]:836). Unfortunately, an astounding 84% of children with sleep disturbances continue to have them at 3-year follow-up, with persistent sleep fragmentation noted in as many as 18% of school-age children (Kataria et al. J Pediatr. 1987;110[4]:642; Sadeh et al. Dev Psychol. 2000;36[3]:291).

Treatment options

One likely contributor to the endurance of BIC into later childhood is the uncertainty about the optimal method of treatment. According to the AASM’s behavioral practice parameters for bedtime problems and night-waking in infants and children, the standard of care is to use the behavioral strategy of unmodified extinction, more commonly known as the "cry-it-out" method. This technique involves putting the child to bed at a designated time and not responding to the child’s protests/cries until it is time to wake up in the morning, unless there are significant safety or illness concerns.

Another practice standard is to use unmodified extinction, allowing a parent to remain in the room without reacting to the child ("extinction with parental presence"); a gentler method called "graduated extinction" or "modified extinction" allows the parent to briefly check on the child at predetermined times but with progressively longer intervals until sleep is achieved. The idea behind each of these methods is to allow the child to develop self-soothing skills so that he or she is able to fall asleep independent of parental intervention. By not providing the positive reinforcement of parental attention, the undesired behavior (crying or screaming) is extinguished.

Although a number of studies support the efficacy of these behavioral interventions in significantly reducing bedtime resistance and night-wakings (Mindel et al. Sleep. 2006;29[10]:1263), controversy understandably exists about the morality of allowing a child to cry for extended periods of time without consolation. Proponents of attachment parenting dub unmodified extinction as cruel and unusual punishment. The debate lies in whether withholding a parent’s response to a child’s cries at night results in long-term damage to the child or the parent-child relationship.

A well-written theoretical review of this practice has questioned the use of extinction techniques to help infants sleep independently (Blunden et al. Sleep Med Rev. 2011;15[5]:327), arguing that nocturnal crying has culturally been deemed undesirable, even pathological. The authors make arguments for the social and biological utility of infant crying and cite studies proposing that prolonged crying could result in increased cortisol, stress, withdrawal behaviors, attachment disorders, and potential neuronal changes. Because extinction methods are likely to involve prolonged periods of crying and thereby increase biological stress, they postulate that these methods are not completely benign, though the referenced studies of adverse outcomes of prolonged crying were not specifically related to the use of extinction therapy for BIC.

Until recently, no long-term studies had addressed the longitudinal effects of "crying-it-out," though short-term studies had shown no adverse effects. A recent publication evaluated the effects of an infant behavioral sleep program at 5-year follow-up on the child, the parent-child relationship, and maternal outcomes (Price et al. Pediatrics. 2012;130[4]:643). This study was an extension of the previously published Infant Sleep Study, a randomized controlled trial evaluating the shorter-term effects of a behavioral sleep intervention on infants who were identified by mothers as having sleep problems at 8 months of age (Hiscock et al. Arch Dis Child. 2007;92[11]:952).

Two techniques were used in this study: "controlled comforting" (graduated extinction) and "camping out." This latter technique, also known as adult fading, is similar to "extinction with parental presence," with the parent gradually distancing himself or herself from the child. Price and colleagues followed up on those children at 6 years of age, analyzing differences in intervention vs. control groups based upon parental reports and standardized questionnaires of emotional and behavioral problems, perception of sleep as a problem, clinical sleep problems, psychosocial health-related quality of life, and stress, as measured by morning cortisol levels. Additionally, researchers assessed the child-parent relationship; parenting styles; and evaluated maternal depression, anxiety, and stress. Results showed no statistically significant difference between the intervention and control groups in any of the measured outcomes, supporting the theory that behavioral sleep interventions have no long-term adverse effects on children.

Prevention strategies

Regardless of whether or not extinction methods are benign or harmful to an infant, there are parents who simply prefer noncrying methods for getting their child to sleep. In addition to extinction, the AASM practice parameters also propose parent education/prevention as a standard recommendation. This intervention focuses on preventing sleep problems by teaching parents to establish good sleep routines within their child’s first 6 months of life.

Strategies typically include developing consistent sleep schedules and providing an appropriate level of parental interaction during sleep initiation and nighttime awakenings. Putting the infant to bed in a "drowsy but awake" state can foster development of self-soothing and sleep initiation skills. Outside of these standard recommendations, two guideline recommendations are "delayed bedtime with removal from bed/positive bedtime routines" and "scheduled awakenings."

The first refers to the technique of temporarily delaying the child’s bedtime in order to increase the likelihood of the child falling asleep in the bed by increasing sleep pressure. Optionally, the child may be removed from the bed if he or she is unable to achieve sleep within a predetermined time period. Implementation of scheduled awakenings requires that parents be familiar with their child’s night waking patterns; based upon this schedule, the child is preemptively woken up 15 to 30 minutes prior to the expected spontaneous awakening and consoled in a typical manner. Gradually, these scheduled awakenings are faded out, with the intention of increasing consolidated sleep. There was insufficient evidence for the task force committee to support any one technique or combination of techniques over another.

Beyond BIC

Despite the emotional wear that extinction therapy for BIC can have on a parent, the lack of direct data suggesting harm makes it reasonable to include as a recommendation to frustrated caregivers. It is critical to be aware that underlying medical issues, which may be contributing to nighttime awakenings (eg, gastroesophageal reflux, pain due to acute illness such as hand-foot-and-mouth disease, and upper respiratory infection) must be ruled out before a behavioral sleep problem is diagnosed and treated in this fashion.

Most importantly, both providers and parents should be aware that extinction methods are not the only behavioral methods available to manage BIC. Further studies to demonstrate the efficacy of these other methods in larger populations or to develop additional methods need to be conducted, hopefully leading to and expansion of the practitioner’s toolbox for treating BIC. When a family presents for management of an infant with behavioral insomnia, the provider should practice the art of tailoring a treatment plan that considers parent and child temperaments, schedules, and social and cultural perspectives to optimize success while minimizing parental stress.

Sophia Kim, MD

Fellow, Sleep Medicine

Roberta Leu, MD

Director, Pediatric Sleep Disorders Program

Emory University School of Medicine

Atlanta, Georgia