Night awakenings
If a child is having trouble with sleep onset, approach this first with a behavioral protocol (exception: you may approach
both problems at the same time if you intend to use a graduated extinction program). A large percentage of children will no
longer wake at night once they have appropriate sleep associations. If behavioral night awakenings persist and the family
wishes to intervene, the following options are available.
Determine, by history, if the night awakenings are full or partial awakenings.
If partial awakenings:
- Provide the family guidance about not intervening so that the child may return to deep sleep.
- If partial awakenings persist, try a program of rousting the child 30-40 minutes before the expected wakening for several weeks. This may extinguish the pattern.
If full awakenings:
- If the child is getting up and wandering about the house in an unsafe manner, institute mechanisms for safety such as a gate at the bedroom door or a bell on the door. Ensuring safety is important even if the parents desire not to intervene. To do an intervention program, the parents must be aware of when the child wakes (thus the bell on the door). Bed and door alarms can be purchased if necessary.
Options for behavioral interventions
- Graduated extinction program: This option is similar to that used to help a child learn to fall asleep at bedtime.
- Scheduled awakening: In this option, the parent tracks the pattern of the awakenings for several nights and, if predictable, begins to gently rouse the child 30-45 minutes before to reset the sleep cycle. While counter-intuitive, this works because the parent is rousing the child during deep sleep when the child will have an easy time going back to sleep and. By rousing the child, the parent resets the sleep cycle avoiding the passage into light sleep and full wakening. (If the child has trouble going back to sleep after the parent rouses him/her, this means the child had already moved into light sleep and, on subsequent nights, the parents should wake the child earlier.) Once the night awakenings have resolved, the family gradually weans the scheduled rousing (e.g., stop doing it 1-2 nights per week).
- Restrict sleeping time: Theoretically, by restricting sleeping time, the body will respond by staying in deeper sleep more of the night. To do this, the parent tracks the child’s sleeping patterns for a period of time. The total number of hours asleep is calculated. Do not include the time spent lying awake in bed. Subsequently, adjust the morning waking time so that the child is only allowed 90% of the usual sleep time (one can also adjust night bedtime, but morning is preferable as it is easier to fade back once the intervention is working). If the child is found lying awake in bed, allow the child up for a period of time and then put him/her back to sleep. Once the night awakenings have resolved, the sleep restriction is gradually lifted by allowing the child 15 more minutes of sleep each day.
Pros and Cons of the Three Approaches
Graduated Extinction
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Sleep Restriction
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Scheduled Awakening
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