Table 2.

Behavioral treatments for insomnia of childhood

TREATMENT METHOD	MOST RELEVANT POPULATION	DESCRIPTION
Age appropriate and consistent bedtime and sleep schedule	All children	Child is put to bed at developmentally appropriate bedtime consistently 7 days a week with minimal variation
Bedtime routine	All children	A series of subsequent steps taken in the half hour prior to bedtime. Steps are completed in same manner each night to “cue” that initiation of sleep time is approaching. Should be no longer than 30 minutes with 2–3 relaxing activities (bath, story) and end in the bedroom. For younger children or developmentally delayed children, incorporate picture charts. Can also check off boxes and earn stickers for completion of each step of the routine or completion of the entire routine.
Extinction	Young children	“Cry it out” method. Child is placed in bed or crib while still awake, then parents are instructed not to respond to cries or protests. Must warn parents of extinction burst, as protests will first increase prior to decreasing.
Graduated extinction	Young children	Child is placed in bed or crib while still awake, then parents leave the room and wait increasing numbers of minutes before re-entering the room for a brief, neutral interaction with the child. After each re-entry, the number of minutes before the next entry is gradually increased after each trial and over the course of several days.
		Also used to fade parental presence to teach child to fall asleep independently. Rather than leave the room, the parent moves further away from the child every few nights. In both cases, warn parents of extinction burst that may occur within first few nights.
Positive routines	Young children	Implement bedtime routine that is positive and enjoyable parent-child interaction with one or two of child's preferred activities. Parent provides consistent praise, but if child refuses a step or tantrums, the routine is ended, child is put to bed, and interaction ceases.
Faded bedtime	Young children, young children with late bedtime	Child is put to bed close to time he or she is most likely to fall asleep. Once falling asleep within 15–20 minutes, bedtime is moved 15 minutes earlier every 2–3 nights until desired bedtime is reached.
Faded bedtime with response cost	Young children, children with developmental delays	Child is put to bed close to time he or she is most likely to fall asleep. Once falling asleep within 15–20 minutes, bedtime is moved 15 minutes earlier every 2–3 nights until desired bedtime is reached. Once in bed, if child does not fall asleep quickly within a set period of time, child is removed from the bed for a specific period of time.
Scheduled awakenings	Young children	Establish baseline pattern of awakenings using sleep diary. Within 15–30 minutes prior to the typical night waking determined from sleep diary, parent preemptively awakens the child by shaking them lightly and asking them to awaken. Once the child responds by opening eyes slightly or mumbling, the parent allows the child to fall back asleep or provides a “typical” response to soothe the child back to sleep (i.e., rocking, feeding, patting). Procedure is implemented on a nightly basis for 2–4 weeks.
Parent education	All children	Education regarding sleep hygiene measures, good sleep promoting habits, reduced caffeine, consistent and developmentally appropriate sleep-wake times.
Cognitive behavioral therapy	Children approximately age 8 or above	Methods include progressive muscle relaxation, deep-breathing exercises, imagery, cognitive techniques to decrease negative thoughts at bedtime, or keeping a worry journal, all of which can be used independently or as a package together to reduce level of arousal and anxiety at bedtime, increasing likelihood of ability to initiate sleep.