Behavioural interventions for children’s sleep problems

• Doctors
• Psychologists
• Social workers
• Childhood nurses
• Behaviour intervention specialists.

These health professionals teach strategies to help change children’s sleep behaviour. Cerebral Palsy Alliance also offers a service where our health professionals can help decide if these behavioural interventions are the right choice for children and their families.

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Fees will apply and will depend on the provider and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing or therapist travel.

Ask health care providers if you are eligible for funding to assist with fees. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

The amount of time families will need to spend using the strategies will vary. At first they will need to be used every day until good sleep habits are developed.

The most common sleep problems for children with cerebral palsy include difficulties settling and getting
to sleep, waking up during the night, breathing problems, and being sleepy or over-aroused during the
day because they are over-tired^2,3.

All young children have disrupted sleep from time to time, and this is completely normal. However, as many as one in five⁴ infants, toddlers and children with cerebral palsy have learnt unhealthy sleep habits that have a negative impact on the whole family⁵. There are a variety of complex causes, including:

• Pain, which may be due to stomach problems like gastro-oesophageal reflux, muscle spasms, or pressure on the skin because children cannot reposition easily in bed
• Breathing difficulties
• Epilepsy
• Vision impairment^2,3,6
• Family factors
• Other childhood illnesses

Sleep is essential for the physical and emotional health of all people. Sleep problems can impact on the wellbeing, learning and day-to-day functioning of a child with cerebral palsy⁷ as well as the daily function and wellbeing of their family⁵.

There are a variety of health professionals and services that use behavioural interventions to help children with cerebral palsy sleep better. There are also many things a family can do to help their child. These interventions have potential to not only improve the sleeping habits of the infant, toddler or child, but also help the whole family get a good night’s sleep. The strategies will depend on the child and the nature of their problems. These techniques will need to be used every day, usually around bed and sleep time, to help children change their behaviours. Examples include:

Sleep routines

A calming bedtime routine gives children time to relax and prepare for sleep. The first step is to
create an environment that encourages sleep – a darkened, calm bedroom without any stimulating
activities such as television or computers. While every family is different, a bedtime routine may include a
set time for play, dinner, bath, story, teeth, toilet, bed and wake-up. Above all, it must be consistent so
that children learn to get ready for bed in the same way each night, preparing them to go to sleep and
stay asleep.

Other options to consider

Here are some other techniques health professionals may suggest:

• Using a sleep diary to track a child’s sleep and identify any issues
• Reward children for good sleep habits
• Bedtime pass – children are given a card called a bedtime pass. They can use the card once to leave their bedroom after bedtime, whether to go to the toilet, have a drink or get one final hug
• Teach children ways to relax
• Practice graduated extinction, also known as controlled crying. This technique is generally used when an infant is over six months old and involves allowing a child to cry after going to bed but reassuring them at regular intervals.

Take a team approach

It is important that families and health professionals work together to choose the right approach. Reversing unhealthy sleep habits can be more challenging than with typically developing children.

There is no proven one way that will help children to sleep better and the behavioural interventions used will depend on the child’s age, family situation, and the nature of the problem.

• After conducting a thorough assessment, a health professional may suggest a referral to a specialised sleep clinic or service if needed
• Along with behavioural interventions, children’s treatment programs may include other interventions such as sedative medications or melatonin, analgesics, light therapy, breathing equipment or a specialised sleep positioning system

Raising Children Network – The Australian Parenting Website http://raisingchildren.net.au/
Sleep Health Foundation. http://www.sleephealthfoundation.org.au/

A detailed assessment is critical to determine whether a behavioural intervention is appropriate, which techniques will be most effective and what other forms of intervention are required. The health professional may ask families to complete questionnaires and track their children’s sleep in a diary to help understand the nature of the sleep difficulty.

The second type of assessment is to measure the outcome of the intervention, to ensure behavioural interventions are effective.

We searched the medical, allied health and psychology literature to find research evaluating the outcomes of behavioural interventions for children with cerebral palsy who have difficulties with sleeping.

We aimed to find the best available evidence about whether this intervention reduces sleep difficulties and behavioural problems in children. Research evaluating the effects of medications on sleep was not included.

No studies were found including only children with cerebral palsy. The literature was then searched for high level evidence found in systematic reviews (Level 1) and randomised controlled trials (RCTs) (Level 2) evaluating behavioural interventions for all children, including typically developing children and children with other conditions.

The best available evidence was a systematic reviews evaluating behavioural interventions for sleep difficulty in typically developing children, and children with Autism or Down Syndrome⁸. Three additional randomised controlled trials (RCTs) of behavioural interventions for children with intellectual disability were also located^10-11. There were only a few children with cerebral palsy within these studies.

The evidence for behavioural interventions for typically developing children, aged 0 to 13 years, is considered to be high quality. Behavioural interventions are effective for these children. The effects of behavioural interventions were short-lived after the end of intervention, suggesting that efforts to manage sleep need to be persistent or repeated⁷.

The evidence for children with disabilities was not conclusive. One study found sleep improved after behavioural interventions¹⁰, other studies sound no change in sleep⁹.

Overall, the evidence for the effects of behavioural interventions for addressing sleep difficulties in children with cerebral palsy is considered low quality. This is because, firstly, the evidence is mainly from typically developing children and we cannot be certain that children with cerebral palsy will respond to behavioural interventions in the same way as typically developing children. Secondly, the evidence for children with disabilities was conflicting so we are not able to draw clear conclusions about the effectiveness of behavioural interventions. It is important to note that the participants in the studies of children with disabilities had intellectual disabilities. The sleep difficulties of children with cerebral palsy may be due to a number of causes which are likely to be different for each child. The research evidence does not provide clear guidance as to whether or not a child with cerebral palsy will respond to behavioural interventions. Health professionals should work together with children and their families to identify appropriate ways of assisting with sleep difficulties and to carefully monitor whether the interventions are effective.

Reduction in time taken to fall asleep in typically developing younger children

Moderate quality evidence from the RCTs included in the systematic review⁸ suggests that behavioural interventions are effective for reducing the time taken for typically developing young children (0 – 5 years) to fall asleep (known as sleep onset latency). The behavioural interventions included giving advice and support to families, structured bedtime routines and bedtime passes. These interventions were effective whether delivered face-to-face by a health professional with the family or online. Behavioural intervention worked up to 3 months, but not at 12 months, after intervention finished.

Less night waking for typically developing children

Moderate quality evidence from RCTs included in the systematic review⁸ suggests that a range of behavioural interventions delivered face-to-face or online are effective in reducing how often and for how long typically developing young children wake during the night. The interventions included structured bedtime routines, parent education and support groups, information booklets and an online program which gives personalised advice on helping to achieve better sleep (called a customised sleep profile). The effects were noted up to 3 months, but not up to 6 or 12 months after intervention finished.

Cognitive behaviour intervention may help typically developing older children

Low quality evidence suggests that face-to-face cognitive behaviour intervention is effective for reducing time to get to sleep (one RCT⁸) and reducing the duration of night time waking (two RCTs⁸) in older children aged seven to 13 years. The effect was up to 3 months, but not as long as 12 months after the intervention finished.

Results are inconclusive for children with developmental disabilities including cerebral palsy

The results were mixed and, therefore, inconclusive for children with developmental disabilities such as Autism, Down syndrome, intellectual impairment and various disabilities, including a few children with cerebral palsy. Three RCTs included in the systematic review⁸ and an additional RCT⁹ found that behavioural interventions were not effective for children with developmental disabilities. The interventions included sleep education delivered face-to-face or by booklet, and a cognitive behavioural program with and without melatonin (a medication used to help with sleep difficulties). Another RCT¹⁰, however, found overall sleep disturbance was reduced following face-to-behavioural intervention with telephone support.

Behavioural interventions may increase sleep of mothers

One study¹⁰ also reported increased sleep for mothers of children who had behavioural interventions. Challenging behaviours such as irritability, hyperactivity, non-compliance and aggression decreased whether the child had behavioural intervention or no intervention¹¹. The children in this study had various disabilities including cerebral palsy and all had intellectual impairment and daytime challenging behaviour.