Extrinsic Dyssomnias

Night waking and/or reluctance to go to bed are the most common sleep complaints of parents about their infants and young children. These disruptions in sleep might better be classified as extrinsic “proto” or “potential” dyssomnias. Night-waking problems begin to cause concern in the last 3 months of the child’s first year of life and become more prominent in the second year (Anders et al. 2000). Before the child is 9 months old, night waking is tolerated as “normal” (Ferber 1999; Goodlin-Jones et al. 2000). Moore and Ucko (1957) defined night waking as a “disorder” when a child awakens and cries one or more times between midnight and 5 a.m. on at least 4 of 7 nights, for at least 4 consecutive weeks. By age 1 year, 50% of infants who had previously slept through the night were reported as experiencing night waking. Moore and Ucko reported a further transient increase in problem night awakenings during the second year of life. In other studies, nearly 20% of toddlers were described as experiencing night waking (Bernal 1973; Jenkins et al. 1980). The prevalence decreases to 1%-5% in school-age children (Gass and Straugh 1984; Richman et al. 1982).

In this regard, it is important to acknowledge that there are significant family, community, and cultural determinants in the definitions of infant sleep problems. Some families and some cultures tolerate sleep disruptions better for longer periods (Lee 1992). Similarly, some families and cultures are more flexible in devising workable solutions. For example, having an infant sleep alone seems to be highly valued in our culture. Yet, infants’ sleeping alone is a custom that is relatively new in the span of human evolution and is characteristic of only a small segment of our global society (Caudill and Plath 1966; Lozoff et al. 1984; McKenna et al. 1990; Thevenin 1987). The use of a sleep aid has cultural, community, and family implications as well. For some parents, use of sleep aids is viewed as unhealthy and is discouraged. Community and family values must be considered in evaluating problems and prescribing treatments.

Little is known about the outcomes of “proto” dyssomnias in regard to their progression to genuine dyssomnias with daytime impairment. Zuckerman and colleagues (1987) followed up 8-month-old infants with sleep problems and found that 41% of them still had problems when they were 3 years old. Only 26% of the children with sleep problems at age 3 years had not manifested them when they were 8 months old. Kataria and colleagues (1987) found that in their sample, 84% of 3-year-olds still had their sleep problems 3 years later. Richman and colleagues (1982) found that almost half of 3-year-old children who experienced night waking had had their problem from birth, and 40% of the children who had sleep problems at 8 years had had problems at least from the time they were 3 years old. Although some studies attribute the origins of these problems to intrinsic factors related to temperament (Carey 1974; Schaefer 1990; Weissbluth et al. 1984), others have emphasized the importance of extrinsic factors such as nutritional and allergenic factors, stress, and states of physical discomfort (Beal 1969; Kahn et al. 1989; Wright et al. 1983). Parental conflict, maternal personality, and maternal depression have also been identified as contributing factors (Field 1994; Guedeney and Kreisler 1987; Zuckerman et al. 1987). When the disturbance is severe, ICSD-CDM diagnostic labels such as “inadequate sleep hygiene,” “environmental sleep disorder,” “insufficient sleep syndrome,” “limit setting sleep disorder,” “sleep-onset association disorder,” and “food allergy insomnia” may be appropriate (see

Table 17-1).

Treatment

Pharmacological and behavioral regimens, alone or in combination, are the most commonly used approaches to treating extrinsic dyssomnias. Hypnotics are prescribed most often by pediatricians and family physicians for both night waking and problems in falling asleep, and behavioral interventions are attempted more by mental health professionals. Ounsted and Hendrick (1977) summarized survey data that indicated that 25% of children had received a sleep medication by age 18 months. The widespread use of medication persists even though research conducted to test efficacy has been limited and support for the therapeutic benefit of such medication is marginal. Positive benefits have been short-lived. Moreover, evidence from studies with adults shows significant negative effects from long-term use of sedating medication.

Behavioral interventions derive from the hypothesis that sleep problems result from habitual, learned, interactional patterns involving child and caregiver. Extinction attempts to eliminate the positive reinforcement of the parent’s presence by instructing the parent to ignore attention-seeking behaviors. These instructions are applicable to both night-waking problems and protests around going to bed. Such an intervention may be too difficult for some parents, and some children do not return to sleep even after exhausting bouts of crying. A less abrupt variant prescribes gradual withdrawal of parental involvement by incremental periods of longer waiting following response to the child’s crying (Ferber 1999).

Another approach to treating night waking is to schedule awakenings before the time of the expected spontaneous awakening (Rickert and Johnson 1988). This approach, too, is aimed at preventing the rewarding association between night waking, crying, and parental intervention. The method has been difficult for many parents to follow. Conjoint sleeping, as an approach to treatment, derives from the cross-cultural observations that co-sleeping is common in most non-Western societies. Conjoint sleeping provides the continuous presence of a parent sleeping on a cot in the child’s bedroom without direct parental contact (Sadeh 1990).

The behavioral technique of reframing attempts to shift the focus of the intervention (Sadeh and Anders 1993). For example, night awakenings that occur several times each night are frequently associated with difficulties in separating from the parent at sleep onset. Even though the parent’s concern may be directed at the nightly awakenings, the intervention focuses on presleep interaction at bedtime and naptime, and not on the symptom of night waking. The parent is instructed to develop a consistent ritual around bedtime or naptime that avoids feeding or rocking to sleep. A bedtime ritual such as reading, singing, or playing a quiet game is often suggested. Then, the parent is encouraged to put the child in his or her own bed while the child is still awake and to remain in close proximity until the child falls asleep. It may be necessary, at first, for the parent to sit by the bedside, in physical contact with the child, or even lying next to the child on an adjacent bed (conjoint sleeping). Subsequently, after the child is able to fall asleep on his or her own, the parent gradually moves ever farther away during sleep onset. Finally, the parent is instructed to leave the child’s bedroom following the bedtime ritual but before the child is asleep. If the child protests or cries, the parent responds, after a brief wait, by reentering and restoring the child to a sleeping position. Such reentries are repeated at brief intervals as long as the child protests.

During the time that the intervention focuses on going to bed, parents should respond to night awakenings in their customary manner. They comfort their crying infant and sometimes return to conjoint sleeping. Ferber (1985), in a modification of this procedure, recommends a gradual, progressive lengthening of the period between times of reentering. If the separation problem at naptime and bedtime can be resolved, the awakenings in the middle of the night most often end.

In general, behavioral strategies have been reported to be effective in treating most extrinsic, some intrinsic, and most sleep-wake schedule dyssomnias of infants, children, and adolescents, even in severe cases of retardation and autism (Howlin 1984). Jones and Verduyn (1983) reported an 84% success rate in 19 children with sleep problems treated with behavioral methods. These results were maintained during a follow-up period 6 months after termination of treatment. Graziano and Mooney (1982) were successful in using behavioral methods with children who had nighttime fears. Richman et al. (1985) reported a 77% improvement in 35 children ages 1-5 years. Treatment was based on training the parents in the use of behavioral strategies tailored specifically to the individual needs or problems of their child. Sadeh (1990) used an activity monitor to objectively measure changes in sleep patterns of sleep-disturbed infants. He reported that the “checking” procedure (Richman et al. 1985) and conjoint sleeping for a defined period were equally effective in producing a marked improvement in sleep.