1. health and fitness
2. disorders

Journal of Psychosomatic Research 54 (2003) 587 – 597
Please note that this paper was intended to be published as part of the Special Issue of
Behavioral Sleep Medicine 54(1), but due to an administrative oversight it was not included
Treatment efficacy in behavioral pediatric sleep medicine
Brett R. Kuhn a,*, Amy J. Elliottb
a
Department of Psychology, Munroe-Meyer Institute, 985450 University of Nebraska Medical Center, Omaha, NE 68198-5450, USA
b
Center for Disabilities, University of South Dakota School of Medicine, Vermillion, SD, USA
Abstract
Behavioral interventions have been identified as the treatment
of choice for many forms of pediatric sleep disturbance. We adopt
criteria established by the Task Force on Promotion and Dissemination of Psychological Procedures (1996) to evaluate the literature
base describing behavioral interventions for pediatric sleep disturbance. Three well-established interventions, one promising intervention and one probably efficacious intervention, have emerged
for bedtime refusal and frequent nighttime awakenings. Only one
intervention for sleep terrors and sleepwalking has sufficient empirical support to be considered promising. Behavioral interventions
targeting circadian rhythm disorders (e.g., delayed sleep phase),
nightmares and rhythmic movement disorder (RMD) have not
been researched sufficiently to be considered empirically supported.
D 2003 Elsevier Inc. All rights reserved.
Keywords: Behavior management; Children; Parenting; Pediatric; Sleep; Treatment
Introduction
Disturbed sleep has been identified consistently among
the most common concerns presented in clinical settings
for children [1 – 3]. Recent evidence indicates that a
good night’s sleep plays a critical role in early brain
development, learning, and memory consolidation [4,5],
while disrupted sleep has been linked to behavior problems
and poor emotional regulation [6,7]. Although some
pediatric sleep disorders demand medical attention (e.g.,
obstructive sleep apnea, narcolepsy), the majority require
clinical assessment and intervention skills that specialists in
behavioral medicine are ideally suited to provide. The
purpose of this article is to evaluate the efficacy of behavioral interventions for common pediatric sleep disturbances,
specifically bedtime resistance, night waking, sleep schedule disorders and parasomnias.
In 1996, an American Psychological Association task
group developed specific criteria, frequently referred to as
the Chambless criteria, to evaluate psychological treatments
based on the weight of the empirical support behind an
intervention [8]. These criteria have become the ‘gold
standard’ for evaluating the efficacy of an intervention.
The Chambless criteria outline the type of support necessary
* Corresponding author.
E-mail address: [email protected] (B.R. Kuhn).
0022-3999/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0022-3999(03)00061-8
for a research study to be considered ‘well-established’ or
‘probably efficacious.’ The primary distinction between
these two categories is that a ‘well-established’ intervention
has been shown to produce benefits that exceed another
treatment or placebo condition that controlled for attention
and expectancy variables. We also included a category of
‘promising’ interventions that the Society of Pediatric Psychology Task Force recently added to the Chambless criteria
[9]. These interventions have shown some initial empirical
support and make sense conceptually, but they lack the
methodological rigor necessary to meet the standards of the
Chambless criteria.
Bedtime resistance and frequent night waking
Sometimes referred to as pediatric ‘‘insomnia,’’ the
hallmark of pediatric sleep disturbance among infants and
toddlers involves bedtime resistance and frequent night
waking [10]. Like the outdated term ‘‘dyslexia,’’ use of
the term ‘‘pediatric insomnia’’ has fallen into recent disfavor. The preferred term, ‘‘pediatric sleep disturbance,’’
avoids potential overlap and confusion with the adult
insomnia literature. Pediatric sleep medicine is a distinctive
field with unique causal and maintaining variables and
different interventions. For example, adults with insomnia
complain of difficulty falling asleep despite their best
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B.R. Kuhn, A.J. Elliott / Journal of Psychosomatic Research 54 (2003) 587–597
efforts, while young children are likely to actively resist
falling to sleep despite their parents’ best efforts. In this
section, we consider bedtime disturbance and frequent night
waking together because the two often coexist [11], and
treatments that target one symptom often generalize to the
other [12]. These findings may be explained by the fact that
sleep initiation is required not just at bedtime, but also
following brief nighttime awakenings that are part of a
child’s normal sleep cycle [13]. Therefore, children who rely
on ‘nonadaptive’ sleep associations (e.g., feeding, rocking,
parental presence), which the child cannot recreate by himor herself, will require assistance several times per night
[14,15]. Because Mindell [16] recently published a comprehensive review of this area, we will keep our coverage brief.
‘Well-established’ interventions
Extinction
As applied to pediatric sleep disturbance, extinction
involves placing the child in bed and then ignoring inappropriate child behavior (e.g., unreasonable requests, crying) until morning. Exceptions to ignoring are made in the
possibility of illness or danger to the child. Extinction has
been evaluated in more clinical outcome studies than any
other single treatment for pediatric sleep disturbance. The
procedure is easy for parents to understand and the underlying operant theory is well-established. Specifically, termination of the reinforcement contingency that maintains a
given response (e.g., crying) will reduce or eliminate the
occurrence of that response over time [17]. The earliest
reports of using extinction to target bedtime problems
consist of uncontrolled case studies [18,19]. These early
reports were followed by numerous controlled, withinsubject designs [20 –22] and larger between-groups experimental studies [23 –27]. The procedure now has been shown
to be efficacious in five large-scale studies by four separate
investigatory teams. Consequently, extinction clearly meets
criteria as a ‘well-established’ intervention for bedtime
disturbance and frequent night waking [16]. The primary
drawback of extinction is the potential for postextinction
response bursts and spontaneous recovery of the problematic
response [17]. France and Blampied [28] present recent
evidence suggesting that response bursts may be more
frequent in children undergoing extinction (unmodified),
compared to graduated extinction or extinction with parental
presence. Parents who are unaware of the potential of
response bursts may inadvertently resume reinforcing
(e.g., attending) the problem behavior, creating an intermittent reinforcement schedule and thereby increasing resistance to future extinction procedures [29].
Graduated extinction
Graduated extinction was first described by Douglas and
Richman [30], and later popularized by Ferber [31] in his
popular self-help book entitled Solve Your Child’s Sleep
Problems. Different versions of the checking procedure
have been described, but all rely on extinction combined
with occasional parental checks that are usually faded over
time. Lawton et al. [29] found successful results with
decremental graduated extinction [32], in which parents
responded immediately but systematically reduced the
duration of parental attention by 1/7th every 4 days over
the 28-day intervention. The most common version is
incremental graduated extinction, which involves ignoring
inappropriate child behavior for successively longer periods
of time (e.g., 5, 10, 15 min) across successive checks within
the same night [12,33] or across successive nights [34].
With the addition of two recent studies, there are now three
randomized, well-controlled group experiments to support
the efficacy of graduated extinction [25,35,36]. Because
these studies were published by three separate investigatory
teams, there now is sufficient support to qualify incremental
graduated extinction as a ‘well-established’ treatment for
bedtime resistance and frequent night waking.
There is some indication that incremental increases
between the checks may not be critical to successful outcomes. A slight modification, termed the ‘‘quick check’’ or
‘‘minimal check’’ [32,37] is virtually identical to incremental gradual extinction, except that the periods between
parental checks are maintained at a constant interval (e.g.,
every 10 min). This version has produced successful outcomes in one uncontrolled clinical outcome study [38], one
multiple-baseline study [28] and one group comparison
study [39]. Many professionals strongly advocate these
checking procedures as a ‘‘friendly’’ alternative to unmodified extinction. Recent data, however, suggest that compared with unmodified extinction, checking procedures may
result in more, not less, crying and infant distress [28]. This
may be because the mere appearance of the parent at regular
intervals is sufficient to reinforce the very behavior (i.e.,
crying) that parents are trying to extinguish.
Early intervention/parent education
Providing early intervention services in an effort to prevent sleep disturbances from occurring presents an enticing
alternative to treating problems after they are firmly
entrenched. A variety of behavioral interventions have been
used in an educative manner to promote the early establishment of healthy sleep patterns. Strategies typically target
sleep routines, parental handling during sleep initiation, and
parental response during night awakenings. The one consistent recommendation has been to place infants in their cribs
sleepy but still awake, to promote independent sleep initiation
skills at bedtime which allow infants to return to sleep after
waking. One small-scale study [40] and three large-scale
studies attest to the efficacy of early intervention [41 – 43].
After reviewing the empirical data, Mindell [16] aptly concluded that parent education as a prevention strategy meets
criteria as a ‘well-established’ intervention. Interestingly, the
most impressive prevention study conducted to date is yet to
be published. Symon et al. [44] randomly assigned 268
infants to early intervention or control at 2– 3 weeks of age.
B.R. Kuhn, A.J. Elliott / Journal of Psychosomatic Research 54 (2003) 587–597
The intervention required only 45 min of contact time and
focused on teaching parental handling skills to promote infant
independent sleep achievement skills. By 6 weeks of age,
infants in the intervention group averaged nearly 9 h more
sleep per week than infants in the control group. Group
differences persisted through 12 weeks and collection of
long-term data is currently underway. These data may help
address the primary weakness of existing studies in this area,
which has been failure to collect follow-up data in order to
establish the true preventive nature of early intervention.
‘Probably efficacious’ interventions
Scheduled awakenings
Scheduled awakenings first were used for frequent night
waking by McGarr and Hovel [45] in a single-case, reversal
design. The procedure since has been evaluated in two
multiple-baseline studies [46,47] and one large group comparison study [24]. The procedure calls for establishing a
baseline of spontaneous nighttime wakings, then scheduling
preemptive awakenings 15 – 30 min prior to the usual time
of the child’s spontaneous wakings. With each parentinduced scheduled awakening, the child is provided with
the ‘‘usual’’ responses (e.g., feeding, rocking, soothing) as if
the child had awakened spontaneously. The time span
between awakenings is increased systematically (e.g., by
30 min) until the awakenings can be eliminated and the
child sleeps through the night. Scheduled awakenings
appear to systematically increase the duration of children’s
sleep periods while eliminating spontaneous waking and
excessive crying. Rickert and Johnson [24] compared
scheduled awakening with unmodified extinction and found
that, while both techniques were effective in reducing night
wakings, extinction produced the most rapid results.
‘Promising’ interventions
Extinction with parental presence
This more recent modification to extinction is based on
the assumption that children experience bedtime problems
due to separation anxiety [32]. The approach calls for a
parent to sleep in the child’s bedroom, but not in the same
bed for 1 week while ‘‘feigning’’ sleep and ignoring
inappropriate child behaviors (extinction). After 1 week,
the parent resumes sleeping in a separate room. The
assumption is that the child’s awareness of parental presence
will be reassuring and promote quick sleep onset. Parents
also may find the procedure more acceptable, leading to
better adherence than unmodified extinction. Parental presence has proven efficacious in one large group study,
showing comparable results to the quick check procedure
in eliminating children’s bedtime disturbance [39]. France
and Blampied [28] recently conducted a multiple-baseline
evaluation of extinction, extinction with minimal check and
extinction with parental presence. They concluded that
parental presence produced rapid resolution of night waking
589
and crying with fewer postextinction response bursts, making it the ‘‘treatment of choice’’ [28].
Positive routines/faded bedtime with response cost
Positive routines and faded bedtime are similar strategies
that rely heavily on stimulus control as the primary agent of
behavior change. Critics of behavioral reductive procedures
point out that extinction-based procedures may reduce or
eliminate inappropriate behaviors, however, they fail to
teach or reinforce adaptive replacement behaviors. Positive
bedtime routines can be conceptualized in part as a differential reinforcement procedure designed to teach children
appropriate pre-bedtime behaviors and sleep onset skills.
The procedure involves temporarily delaying bedtime to
ensure rapid sleep initiation, then establishing appropriate
cues for sleep onset (e.g., consistent prebedtime routine)
that are chained and paired with positive parent – child
interactions. Once the behavioral chain is well-established
and the child is falling asleep quickly, the bedtime is
gradually moved earlier in the evening until reaching the
pre-established bedtime goal.
Positive bedtime routines first were used to eliminate
bedtime tantrum behaviors of 3 children in a within-subject,
A – B – C design [48]. The intervention was effective in
gaining voluntary bedtime compliance in all three cases.
Like many studies in this area, the authors collected behavioral data (e.g., bedtime resistance) but did not address the
children’s actual sleep patterns [48]. Two large group
studies also reported beneficial results with positive routines
[35,49]. One of these studies [35] used a well-defined
protocol and randomized group design, placing positive
routines in the ‘promising’ intervention category.
Piazza and Fisher [50,51] used a variation of positive
routines to eliminate severe sleep disturbances and increase
appropriate sleep in children. Faded bedtime involves first
delaying the child’s bedtime by approximately 30 min. If the
child does not fall to sleep quickly (e.g., within 15 –30 min),
a response cost procedure can be added, during which the
child is taken out of bed and kept awake for 30– 60 min
before being allowed to return to bed. This procedure
continues until the child falls to sleep quickly. If the child
achieves quick sleep onset, the bedtime is set 30 min earlier
the next night and continually ‘‘faded’’ according to these
criteria until reaching the agreed upon bedtime goal. Sleep is
scheduled and restricted, as the child is awakened at the
same time each day and is not allowed to sleep outside of
prescribed sleep times.
Faded bedtime and positive routines share the common
components of temporarily delaying the bedtime and bedtime fading. However, as Piazza and Fisher [51] point out,
positive routines require a wider repertoire of responses
from the parent such as instituting a particular routine,
praising each component of the routine, and repeatedly
returning the child to bed if they come out. Faded bedtime,
both with and without response cost, has been evaluated in
five treatment outcome studies employing well-controlled,
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within-subject designs [50 – 54]. At this point, bedtime
fading with response cost may be the most promising
alternative to extinction-based procedures and is a prime
target for a randomized large group comparison study.
Interestingly, the procedure closely resembles a combination
of two behavioral interventions, sleep restriction and stimulus control instructions, which have the strongest treatment
efficacy for chronic adult insomnia [55].
Treatment effect sizes
One weakness in using descriptive criteria such as
Chambless et al. [8] when evaluating treatment efficacy is
the overreliance on statistical significance; to select outcomes. Larger samples usually produce a greater likelihood
of statistical significance, however, one cannot use statistical
significance to conclude that an intervention yields more
powerful, or clinically meaningful results. Consequently,
treatment effect sizes have been recommended for inclusion
in reviews of empirically supported interventions rather than
sole reliance on statistical significance [56].
Compared to research on adult insomnia, the area of
pediatric sleep disorders is still in its relative ‘‘infancy’’
[57]. While dozens of published intervention studies exist
for insomnia, with relatively consistent outcome variables
(e.g., sleep latency, number of awakenings, total sleep time)
[58], the pediatric sleep literature consists of only a handful
of randomized group studies with little consistency in
outcome variables. We were able to identify several randomized or partially randomized treatment outcome studies from
the pediatric sleep literature. Effect sizes, however, could
not be calculated for several studies due to the use of
combined interventions [23,59], pooling of data from more
than one intervention group [38,39], or failing to report
statistical outcome data [36]. We were able to calculate
effect sizes from four randomized group studies [24,25,
27,35] that evaluated the efficacy of four different behavioral interventions (extinction, graduated extinction, scheduled awakenings, positive routines) across six outcome
measures (frequency and duration of awakenings, frequency
and duration of bedtime tantrums, ‘‘good bedtimes,’’ ‘‘good
nighttimes’’). Effect sizes varied considerably depending on
the study, the outcome variables assessed and the time of
measurement (see Table 1). Based on direct comparison
studies, Extinction, Graduated Extinction and Positive Routines were found to produce comparable results, with
combined average effect sizes, d, of 1.58, 1.55, and 1.35,
respectively. It should be noted that for most outcome
variables, all four behavioral interventions surpassed
d = 0.80 (see Table 1), indicating a large treatment effect
[60]. These effect sizes for children with bedtime disturbance compare quite favorably to the effect sizes found for
adult insomnia. For example, Morin et al. [55] calculated
effect sizes for behavioral interventions combined, including
z = 0.88 for sleep onset latency, z = 0.92 for time awake after
sleep onset and z = 0.53 for number of nighttime awaken-
Table 1
Treatment effect sizes for RTC studies evaluating behavioral interventions
for bedtime resistance and night waking
Intervention
Study/outcome variables
Extinction
Rickert and Johnson [24]a
Number of Awakenings
d = 2.31
Adams and Rickert [35]a
Frequency Bedtime Tantrums
Duration Bedtime Tantrums
Graduated Scheduled Positive
extinction awakenings routines
d = 1.11
d = 0.75
d = 1.50
Seymour et al. [27]b
Number of Awakenings
Minutes Awake
d = 0.68
d = 1.00
Reid et al. [25]c
Good Bedtimesd
Good Nighttimese
d = 2.63
d = 1.29
d = 0.88
d = 1.83
d = 1.93
d = 2.03
All studies employed a RTC design, therefore, between-groups effect sizes
were computed on posttreatment scores.
a
Six weeks posttreatment.
b
Four weeks posttreatment.
c
Three weeks posttreatment.
d
Settled alone in less than 10 min.
e
Slept through night without sleeping with or waking the parents.
ings. Two subsequent meta-analytic reviews found similar
results [58,61]. Smith et al. [58] found a mean effect size of
0.96 across five outcome variables for behavioral interventions. Caution must be exercised in comparing the pediatric
and adult literatures, however, because few similarities exist
in chosen outcome variables. For example, treatment outcome studies for pediatric bedtime resistance and frequent
night waking often target bedtime behaviors (e.g., compliance, tantrums, crying) without including sleep-related
variables such as sleep onset, number and duration of
awakenings, or total sleep time.
Circadian rhythm disorders
Circadian rhythm disorders involve a misalignment
between an individual’s sleep pattern and the sleep pattern
that is desired or regarded as the societal norm [62]. This
review focuses on the three most common circadian sleep
disorders encountered in children and adolescents: advanced
sleep phase syndrome (ASPS); delayed sleep phase syndrome (DSPS); and irregular sleep –wake pattern. ASPS is
believed to be most common in infants, toddlers and elderly
individuals [63,64]. In ASPS, the major sleep episode is
advanced in relation to the desired clock time, resulting in
symptoms of compelling evening sleepiness, early sleep
onset and an awakening that is earlier than desired [62].
There are few reports of ASPS in the literature. Although
there is one report of phase advance chronotherapy being
successful in an older adult [65], we found no published
treatment studies targeting children or adolescents.
B.R. Kuhn, A.J. Elliott / Journal of Psychosomatic Research 54 (2003) 587–597
The most common circadian sleep disturbance among
older children and adolescents is DSPS [66,67]. In DSPS,
the major sleep episode is delayed in relation to the desired
clock time that results in symptoms of sleep-onset insomnia
and/or difficulty in awakening at the desired time [62].
DSPS initially was described with reference to adults;
however, most adults report that their difficulties originated
in childhood or adolescence [68 –70].
Behavioral treatments for DSPS typically include one or
more of three primary components: stabilization of the sleep
schedule; gradual realignment to a desired sleep schedule
through either phase advance or phase delay chronotherapy;
and rewards or behavioral contracts to facilitate maintenance
of treatment effects. Unfortunately, there are few data to
support these treatment components for children. In fact, at
the time of this writing, there is not a single behavioral
intervention for DSPS that has sufficient empirical support
to be classified by the Chambless criteria. In order to
facilitate additional research in the area, we will briefly
describe those interventions that have received attention in
the literature.
Behavioral treatment of DSPS primarily has focused on
either advancing or systematically delaying the child’s sleep
phase until the desired sleep – wake schedule is achieved.
Ferber and Boyle [71] have advocated using phase advance
with younger children with DSPS, which involves gradually
advancing the waking time followed by a gradual advance
of the child’s bedtime, although there has been no research
evaluating this approach with children. Attempts to phase
advance with adolescents and adults with DSPS have not
been successful [67,72,73].
Phase delay chronotherapy [74] involves first stabilizing the child’s sleep schedule, then ‘‘lengthening’’ the
day by delaying both bedtime and wake time by 3 h each
day over successive days until the desired sleep phase
is reached. Once the desired sleep – wake schedule is
achieved, bedtimes and wake times must be closely adhered to throughout the week or children will drift back
to their previous sleep –wake schedule. Although chronotherapy has been used primarily with adults [75], there are
a few published studies that have targeted child participants [76 –78]. Dahl et al. [76] used chronotherapy and a
behavioral intervention (extinction) to treat the sleep problems of a 10-year-old girl diagnosed with DSPS and
Attention Deficit Hyperactivity Disorder (ADHD). The
intervention package, which took 1 week to implement,
produced an increase in total sleep time from 7.2 to 9.0 h
per night. Pre- and post-intervention behavioral measures
and teacher ratings indicated significant improvement in
peer interactions, increased productivity on a timed arithmetic task and increased completion of academic seatwork.
Although ADHD symptomatology persisted, the improvement in sleep reportedly produced a significant reduction
in the severity of symptoms and clinical impairment.
Despite the fact that chronotherapy has received widespread billing as a treatment for DSPS, there has been
591
surprisingly little research on the procedure since it was
first introduced in 1981.
Thorpy et al. [67] devised an interesting alternative to
daily progressive chronotherapy that reportedly was less
disruptive to participants’ weekly school schedule. Sleep
deprivation with phase advance (SDPA) involves keeping
a regular sleep schedule for 6 days, followed by one night
of total sleep deprivation on the weekend. Bedtime on
the following night is advanced 90 min earlier than the
previous 6 days, and the new sleep schedule is maintained
for the next 6 days. The process is repeated on successive
weekends until the desired schedule is attained. SDPA
‘‘appeared to be helpful’’ for the group of adolescents
described, however, the protocol still awaits formal empirical evaluation.
Irregular sleep – wake patterns consist of temporally
disorganized and variable episodes of sleeping and waking
behavior [62]. Irregular sleep schedules appear to occur
more often in young children with inconsistent bedtimes
and wake times and adolescents who demonstrate large
discrepancies between their weekday and weekend sleep
schedule [79]. Mindell et al. [80] successfully treated a 2year-old blind child with an irregular sleep schedule. A
strict sleeping and feeding schedule was introduced to
increase the likelihood the child would be tired at bedtime
and fall asleep quickly. Although this procedure did not
systematically advance the bedtime, the same effect was
achieved. This report was an uncontrolled pre-/posttreatment study, but observable effects of the schedule were
immediate and lasting. The authors postulated that imposing strict schedule changes is likely to be more successful
in young children who still have polyphasic sleep patterns.
Piazza et al. [78] used chronotherapy to effectively treat
an 8-year-old female with developmental disabilities and a
disrupted sleep – wake schedule characterized by irregular
sleep onset times, variable wake times, inappropriate day
sleep and reduced total sleep time. Immediate improvements in the child’s sleep pattern were observed after
chronotherapy was introduced, achieving an age-appropriate bedtime within 11 days. Four months of follow-up
data indicated that the improvements were maintained.
These results suggest that the utility of phase delay
chronotherapy may extend beyond DSPS to other sleep
schedule disturbances.
Parasomnias
The term parasomnia is used to describe a group of
undesirable behaviors that occur during sleep or are exacerbated by sleep [62]. Common forms include sleepwalking,
sleep terrors, nightmares and rhythmic movement disorder
(RMD). Because there is limited research attesting to the
efficacy of behavioral interventions for most parasomnias in
children, this section will outline clinical approaches that
need to be subjected to empirical study.
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Sleep terrors and sleepwalking
Nightmares
Sleepwalking (somnambulism) and sleep terrors (pavor
nocturnus) are N-REM partial arousal parasomnias, reflecting incomplete arousal from sleep. Sleepwalking consists of
a series of complex behaviors initiated from slow-wave
sleep that result in walking during sleep. Sleep terrors also
are characterized by a sudden arousal from slow-wave
sleep, but the behavioral presentation typically consists of
a piercing scream or cry accompanied by autonomic and
behavioral manifestations of intense fear [62].
Partial arousal parasomnias usually occur during the
first few hours of sleep, toward the end of the first sleep
cycle as the child transitions out of slow wave (i.e., deep)
sleep. Genetic factors are thought to be highly predisposing, but expression of the trait may be influenced
by environmental factors [81]. Event frequency appears to
increase with factors that amplify a child’s homeostatic
‘‘pressure,’’ such as insufficient sleep resulting from an
irregular sleep schedule, staying up late, giving up a
daily nap, or waking early in the morning [82]. Children
with primary sleep disorders (e.g., obstructive sleep
apnea) are at increased risk for partial arousal parasomnias due to sleep fragmentation, as are children with
behavioral sleep disturbances that compromise total sleep
time [83,84].
Nightmares are frightening dreams that usually awaken
the sleeper from REM sleep [62]. They typically involve an
episode of sudden awakening from sleep with intense
anxiety or fear of harm. One way nightmares can be
distinguished from sleep terrors is that upon awakening,
the child is usually alert with little confusion or disorientation. Furthermore, most children seek parental reassurance,
describe vivid details of the frightening images and have
difficulty returning to sleep. The timing of events is important, because in contrast to sleep terrors, which occur
during slow-wave N-REM sleep, nightmares take place
during REM sleep, which is more prominent during the last
half of the night.
The clinical approach for children who experience occasional nightmares usually involves nothing more than education that nightmares are an unavoidable part of growing
up and reassurance that they do not necessarily signify
emotional disturbance. Nightmares that occur frequently or
contain extremely disturbing content may warrant professional attention.
Surprisingly, there is no solid research to guide professionals in their efforts to assist children who experience
frequent or disturbing nightmares. To date, the empirical
literature on behavioral interventions for children with
nightmares consists of two nonrandomized group studies
[89,90], one quasi-experimental case report [91], and a
handful of nonexperimental case descriptions [92 – 95].
Consequently, the current state of the empirical research
fails to support a single intervention as ‘promising’ according to our adopted criteria.
Wile [89] published the largest, albeit uncontrolled,
group study with 25 children between the ages of 6 and
14 years. Group 1 comprised 11 children who were taught to
‘‘think of positive dreams in the place of nightmares.’’
Group 2 consisted of 11 children who were provided
therapeutic suggestion (e.g., ‘‘I am going to sleep quietly
tonight’’), while Group 3 included 3 children who were
encouraged to engage in dream-relevant content coping
tasks during the day. Although termed ‘‘indirect suggestion,’’ this intervention obviously consisted of in vivo
exposure. For example, a child who had nightmares of
horses after seeing a dead horse was taken to visit horses
and encouraged to learn about them, while another child
whose nightmare content involved skeletons was taken to
a museum of natural history to see numerous skeletons.
The median time for the nightmares to ‘‘disappear’’ was
3 months for Group 1, 5 months for Group 2 and 2 months
for Group 3. Although the work of Wile [89] comprises the
largest study to date, the method of subject assignment was
not described, statistical tests were not used, a control group
was not included, and only 3 children participated in the
third group. Nonetheless, the study pioneered systematic
evaluation of focused interventions to reduce nightmares in
children, which was a radical departure from the Freudian
‘Promising’ interventions
Scheduled awakenings. Scheduled awakenings involve
the parent waking the child 15 – 30 min prior to an expected
partial arousal event. Although initially used to treat nighttime awakenings, scheduled awakenings gained popularity
as an intervention for parasomnias after the publication of
uncontrolled reports proclaiming the elimination of sleepwalking [85] and sleep terrors [86]. The recent publication
of two successful multiple-baseline studies [87,88] places
scheduled awakenings within the classification of a ‘promising’ intervention.
The mechanism underlying scheduled awakening’s utility in decreasing partial arousal parasomnias in children is
unclear. One possibility is that the awakenings alter the
child’s sleep patterns so as to eliminate the disruption in
slow-wave sleep [85,87]. Alternatively, scheduled awakenings may condition the child for self-arousal just prior to
an event, thereby avoiding it altogether. Finally, it could
be that scheduled awakenings indirectly reduce partial
arousal events by increasing the child’s total sleep time.
As mentioned previously, scheduled awakenings are used
for children with frequent nighttime awakenings and have
been found to systematically increase the length of children’s sleep periods. Durand and Mindell [87] noted an
unexpected and unexplained increase in total sleep time
for all 3 of their participants after implementing scheduled awakenings, which presents a confound of the independent variable.
B.R. Kuhn, A.J. Elliott / Journal of Psychosomatic Research 54 (2003) 587–597
era in which dreams were considered symbolic discharges of
repressed sexual conflict.
The first and only controlled group study to date was
published recently by Krakow et al. [90], who are wellknown for their work with adult nightmare sufferers [96,97].
Nineteen adolescent females (aged 13 – 18 years) with
chronic nightmares were assigned to waitlist control or to
active intervention consisting of a 6-h workshop on imagery
rehearsal therapy (IRT). The IRT intervention consisted of
three steps: (a) self-selecting a nightmare; (b) changing the
nightmare ‘‘anyway you wish’’; and (c) rehearsing the new
version 5– 20 min each day. At 3 months, retrospective
report indicated that nightmare frequency decreased significantly in the treatment group with no change in the
control group. The authors recognized the limitations of
their study, including small sample size, nonrandomized
subject assignment, a selective population (residential facility) and instruments not standardized for use with adolescents. In addition, nightmare frequency was measured via
retrospective report, which has been shown to be less
reliable than daily logs [98].
Researchers interested in pediatric sleep should find the
treatment of nightmares a ripe area to make one’s ‘‘mark.’’
There are several important points to take into account.
First, accurate identification and measurement of nightmares
in young children is challenging. Unlike the behavioral
manifestations of sleepwalking, night terrors and enuresis,
nightmare episodes may not be accompanied by external
manifestations that are readily apparent to parents sleeping
in another room [99]. Second, the existing literature contains differences in the operational definition of nightmares,
which leads to uncertainty regarding the epidemiology,
etiology, diagnosis, and treatment of nightmares in children
[100]. The pediatric sleep literature is fraught with confusion regarding nightmares and sleep terrors, often using
the terms interchangeably [101 –104]. Finally, nightmares as
‘‘frightening dreams that awaken the child from REM
sleep’’ must be clearly distinguished from a child’s verbal
report of a ‘‘nightmare’’ following a normal nighttime
awakening that is selectively reinforced (e.g., serves as the
child’s admission ticket into the parents’ bed).
In summary, there is surprisingly little quality research
supporting clinical intervention for children who experience
frequent or disturbing nightmares. The empirical support
that does exist suggests that exposure-based therapies may
be a fertile area for future research.
Rhythmic movement disorder
RMD is a sleep –wake transition disorder that comprises
a group of stereotyped, repetitive movements involving
large muscles, usually of the head and neck [62]. These
movements typically occur prior to sleep initiation and into
light sleep, then again during the night as the child returns
to sleep following normal awakenings. The topography of
the movements varies along a broad spectrum (e.g., head
593
banging, head rolling and body rocking) [105]. Head banging (jactatio capitis nocturna) is the most commonly recognized form, characterized by repeated lifting of the head or
upper torso and forcible banging of the head into the pillow,
mattress, headboard or wall.
The etiology of RMD is unknown. It most likely represents the final common pathway derived from multiple
etiologies. The diagnosis of RMD can be challenging in
certain cases, yet relatively straightforward in others. For
most children, RMD represents a stereotypic movement/
habit disorder with the essential feature involving ‘‘motor
behavior that is repetitive, often seemingly driven and nonfunctional’’ [106]. Habit behaviors like RMD can often be
distinguished from organically based movements because
the former can be produced voluntarily, can be temporarily
suppressed, and can be modified by distractions or special
attention [107]. Medical etiology should always be ruled out,
especially when RMD presents for the first time after early
childhood [108]. Accurate diagnosis can be greatly aided by
having parents videotape the nocturnal events or through
split-screen video-polysomnographic analysis [109].
Upon reviewing the treatment literature, one quickly
discovers considerable confusion regarding the definition
of RMD. Many studies cited to have targeted RMD instead
addressed daytime self-injurious behavior, usually in individuals with mental disabilities [110– 112]. Using a consistent definition and diagnostic criteria of RMD, such as the
one used by the International Classification of Sleep Disorders [62], will be a critical step toward advancing the
scientific literature in this area.
To date, there have been no randomized group treatment
studies published. In addition, no two studies have evaluated the same treatment protocol, leaving the area without
a single ‘promising’ intervention. The entire literature on
behavioral interventions for RMD in children consists of
eight published articles that base their results on anecdotal
reports, uncontrolled (e.g., A – B design) single-subject
studies and quasi-experimental single-subject designs.
Although the state of the empirical literature cannot be
construed to provide strong support for using behavioral
interventions, the case for using psychopharmacological
agents is even weaker. The medication literature consists
of a few uncontrolled anecdotal reports, with no measurement of RMD activity at pre- or posttreatment. In contrast,
there is a handful of quasi-experimental studies with preand posttreatment frequency data to show that behavioral
interventions can produce rapid and substantial reductions
in RMD, with durable and lasting effects [113– 117].
Several studies have incorporated immediate detection
and feedback for the presence of rhythmic behavior, by
using verbal prompts from all night observers, a contingent light signal or audible alarms attached to the bed
[113,115 – 118]. Because rhythmic movement is often
highly conditioned to the sleep onset process, teaching replacement behaviors has been a primary goal. Some intervention packages explicitly taught alternative sleep initiation
594
B.R. Kuhn, A.J. Elliott / Journal of Psychosomatic Research 54 (2003) 587–597
behaviors, while children in other studies appeared to
develop replacement behaviors on their own, such as learning to sleep on one’s back rather than front, mild rocking
from side to side as opposed to violent head banging or
‘‘grinding’’ one’s head into the pillow rather than banging it
[113,116,118]. Strauss et al. [116] used a positive practice
procedure to teach a 7-year-old girl to repeatedly stop her
head just prior to striking the bed, then lay down calmly.
Contingency management using star charts, tangibles or
financial rewards has been used to reinforce alternative
sleep-initiation behaviors, or the cessation of rhythmic
behavior [113,116,119]. Mild punishments such as response
cost also have been used, including waking the child or
having the child walk around for a brief time before being
allowed to return to bed [114,115]. A couple of studies
used professionals to deliver the intervention within a
hospital setting before teaching parents to utilize the protocol
at home [114,118].
Conclusions
The past decade has witnessed heightened interest and
increased recognition of the impact that sleep has on children’s development, learning, mood and behavior. The field
of pediatric sleep medicine has witnessed a proliferation of
recent activity including the publication of review articles
[10,16,32,120], clinical practice guidelines [121,122] and
self-help books [123,124]. With the exception of bedtime
refusal and night waking, however, there are surprisingly
few empirically supported interventions for pediatric sleep
problems. Uncontrolled case reports far outnumber experimental studies, and the majority of the randomized studies
have recruited subjects through newspaper advertisements,
limiting the external validity of the findings to clinical
populations. Sample sizes have been small with short-term
data collection, and there has been little agreement on
relevant outcome variables. Some studies included behavioral outcome variables (e.g., duration of crying, frequency
out of bedroom), while others used sleep-related variables
(e.g., sleep latency, frequency/duration of awakenings, total
sleep time). A select number of studies incorporated both
behavioral and sleep-related variables, but some major
studies included neither. Confusion surrounding the definition of certain disorders (e.g., nightmares vs. sleep terrors,
RMD vs. self injurious behavior) may be resolved by
adopting formal diagnostic criteria, such as those published
by the American Academy of Sleep Medicine (formerly the
American Sleep Disorders Association) [62].
In conclusion, we hope that this review will provide
guidance to clinicians working with families, and encouragement and direction to researchers in the field. While
some readers may view the glass as ‘‘half empty,’’ we
perceive a rapidly developing field with abundant opportunities to forge an empirical foundation for novel or
promising interventions. Treatment outcome studies are
desperately needed to allow professionals to adopt a consumer-driven model that allows parents to make informed
decisions after learning about various treatment options,
their efficacy, advantages, disadvantages and potential side
effects [28].
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