SLEEP, Vol. 29, No. 10, 2006 1263
BEDTIME PROBLEMS AND FREQUENT NIGHT WAKINGS
ARE HIGHLY PREVALENT IN YOUNG CHILDREN, OC-
CURRING IN APPROXIMATELY 20% TO 30% of infants, tod-
dlers, and preschoolers.1-7 In addition, longitudinal studies have
demonstrated that sleep problems first presenting in infancy may
persist into the preschool and school-aged years and become
chronic.8-11 Furthermore, the impact of disturbed and inadequate
sleep in young children can be both significant and extensive.12
There is increasing evidence that sleep disruption and/or insuf-
ficient sleep has deleterious effects on children’s cognitive de-
velopment (e.g., learning, memory consolidation, executive func-
tion), mood regulation (e.g., chronic irritability, poor modulation
of affect), attention, and behavior (e.g., aggressiveness, hyperac-
tivity, poor impulse control), as well as health (e.g., metabolic
and immune function, accidental injuries) and overall quality of
life.13-16 In addition, studies have documented secondary effects
on parentsa (e.g., maternal depression), as well as on family func-
tioning.17-19 Finally, the economic burden related to healthcare
costs for sleep problems in infants and young children has been
estimated to be considerable.20,21 A number of treatment strategies
for bedtime behavior problems and night wakings in children ex-
ist, including behavioral management techniques, parent educa-
tion, and medication. In contrast to the paucity of data that exists
regarding pharmacologic treatment,22-24 there is now a solid body
of literature supporting empirically based behavioral treatments
of bedtime problems and night wakings in infants, toddlers, and
preschoolers. In addition, studies have also demonstrated that
these strategies, compared to pharmacological treatments, are of-
ten more effective, may be more acceptable to both parents and
practitioners,25-28 and avoid potential harmful side effects associ-
ated with medication use. Behavioral sleep management strate-
gies have the further advantage of potentially generalizing to the
management of daytime issues.
Given the impact of sleep disturbances in infants and young
children, and the availability of empirically supported treatment
strategies, the development of clinical guidelines for the manage-
ment of bedtime resistance and night wakings in young children is
important and necessary. As the basis for developing those clini-
cal guidelines, and building on several previous thorough reviews
of empirically-based non-pharmacologic treatments of behavioral
insomnias of childhood,29-31 we present an updated critical sum-
mary of the current literature. A brief discussion of the issues per-
taining to the definition and diagnosis of behavioral insomnia of
childhood is included.
1.1 Definition of Disorder and Prevalence
To clarify the definitions used in this review, it is important
to make a distinction between the clinical diagnoses applicable
to bedtime problems and night wakings in children, and the re-
search definitions used in studies of children with these sleep
problems. First, within the clinical realm, the 1997 International
Classification of Sleep Disorders32 separates bedtime problems
Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and
An American Academy of Sleep Medicine Review
Jodi A. Mindell, PhD1,4; Brett Kuhn, PhD2; Daniel S. Lewin, PhD3; Lisa J. Meltzer, PhD4; Avi Sadeh, DSc5
1Department of Psychology, Saint Joseph’s University, Philadelphia, PA; 2University of Nebraska Medical Center, Omaha, NE; 3Children’s National
Medical Center, George Washington University School of Medicine, Washington, DC; 4Children’s Hospital of Pennsylvania, Philadelphia, PA; 5Depart-
ment of Psychology, Tel Aviv University, Tel Aviv, Israel
Review of Bedtime Problems in Children—Mindell et al
a The term “parents” is used throughout the paper for stylistic reasons to denote
any type of guardian or caregiver (e.g., grandparent).
This was not an industry supported study. Drs. Mindell and Sadeh serve as
consultants for Johnson & Johnson. Drs. Kuhn, Lewin, and Meltzer have
indicated no ﬁ nancial conﬂ icts of interest.
Address correspondence to: Jodi A. Mindell, PhD, Department of Psychol-
ogy, Saint Joseph’s University, 5600 City Avenue, Philadelphia, PA 19131;
Tel: (610) 660-1806; Fax: (610) 660-1819; E-mail: email@example.com
Abstract: This paper reviews the evidence regarding the efﬁ cacy of be-
havioral treatments for bedtime problems and night wakings in young
children. It is based on a review of 52 treatment studies by a task force
appointed by the American Academy of Sleep Medicine to develop prac-
tice parameters on behavioral treatments for the clinical management of
bedtime problems and night wakings in young children. The ﬁ ndings in-
dicate that behavioral therapies produce reliable and durable changes.
Across all studies, 94% report that behavioral interventions were efﬁ ca-
cious, with over 80% of children treated demonstrating clinically signiﬁ -
cant improvement that was maintained for 3 to 6 months. In particular,
empirical evidence from controlled group studies utilizing Sackett criteria
for evidence-based treatment provides strong support for unmodiﬁ ed ex-
tinction and preventive parent education. In addition, support is provided
for graduated extinction, bedtime fading/positive routines, and scheduled
awakenings. Additional research is needed to examine delivery methods
of treatment, longer-term efﬁ cacy, and the role of pharmacological agents.
Furthermore, pediatric sleep researchers are strongly encouraged to de-
velop standardized diagnostic criteria and more objective measures, and
to come to a consensus on critical outcome variables.
Keywords: Bedtime problems, night wakings, behavioral insomnia of
childhood, treatment, behavioral treatment
Citation: A Review by Mindell JA, Kuhn B, Lewin DS et al. Behavioral
treatment of bedtime problems and night wakings in infants and young
children. SLEEP 2006;29(10):1263-1276.
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and night wakings into two distinct diagnostic categories: Sleep
Onset Association Disorder and Limit Setting Sleep Disorder. The
most recent revision of the International Classification of Sleep
Disorders33 uses similar terminology, but subsumes both of these
clinical entities under the new clinical diagnostic category of Be-
havioral Insomnia of Childhood, which is further classified as
sleep-onset association type, limit-setting type, or combined type.
From a clinical standpoint, it should also be emphasized that the
diagnostic criteria for a sleep disorder require a specific constel-
lation of symptoms of a defined severity level to be present for
a specified time and to result in some significant impairment in
functioning either in the child or in the parent(s) or family. As
with all psychiatric disorders, mild and transient symptoms do not
necessarily constitute a sleep disorder. Bedtime problems, primar-
ily seen in children 2 years of age and older, include bedtime stall-
ing and bedtime refusal. Bedtime refusal behaviors are typically
described as stalling, verbal protests, crying, clinging, refusing
to go to bed, getting out of bed, attention-seeking behaviors, and
multiple requests for food, drinks, and stories (“curtain calls”).
This constellation of sleep behaviors generally falls within the di-
agnostic category of behavioral insomnia of childhood, limit-set-
ting type, in which parents demonstrate difficulties in adequately
enforcing bedtime limits (e.g., inconsistent or inappropriate bed-
time for the child’s age, conceding to multiple requests for atten-
tion after bedtime). In general, night wakings fall within the diag-
nostic category of behavioral insomnia of childhood, sleep onset
association type, with most children relying on sleep onset as-
sociations (e.g., rocking, feeding, parental presence) to fall asleep
at bedtime. During the course of normal nighttime arousals, these
children are then unable to recreate this sleep association, requir-
ing parental assistance to return to sleep.4 Night wakings are typi-
cally viewed as problematic by caregivers only when they involve
“signaling” (e.g., accompanied by crying, protesting, or getting
out of bed), and are frequent and/or prolonged.
It should be noted, however, that essentially no empirical stud-
ies of “sleep problems” in children have utilized these specific
clinical definitions. Rather, intervention studies have employed a
number of different research criteria (see below) that are closely re-
lated to criteria for defining a sleep disorder but do not completely
parallel the diagnostic criteria to define “problematic” sleep onset
and maintenance-related behaviors. In addition, because bedtime
resistance and frequent night wakings commonly coexist, thus are
often “lumped” together for the purposes of defining inclusion
criteria for studies and assessing treatment outcomes.7 Further-
more, most studies do not distinguish between bedtime resistance
and delayed sleep onset, which although often associated are not
always interchangeable in terms of etiology or treatment.
In any discussion of research definitions of sleep problems in
children, it should be noted that defining a sleep disorder in chil-
dren, compared to adults, is more complex and challenging for
several reasons. First, virtually all behavioral problems in young
children, including bedtime problems and night wakings, are de-
fined primarily by caregivers, and thus the definition is influenced
by a host of variables, including parent education level, parental
psychopathology, family dynamics, household composition, and
parenting styles. Even those studies that have utilized a strict “re-
search definition” of sleep problems have relied largely on parent-
report data, which are subject to a number of reporting biases. The
definition of these sleep problems may also be developmentally
based, namely transient problems that can be understood in the
context of normal physical, cognitive, and emotional changes oc-
curring at various developmental stages. Furthermore, parental
recognition and reporting of sleep problems in children also var-
ies across childhood, with parents of infants and toddlers more
likely to be aware of sleep concerns than those of school-aged
children and adolescents. In addition, culturally-based values and
beliefs regarding the meaning, importance, and role of sleep in
daily life, as well as culturally-based differences in sleep prac-
tices (e.g., sleeping space and environment, solitary sleep vs. co-
sleeping, use of transitional objects) have a profound effect not
only on how a parent defines a sleep “problem” but on the relative
acceptability of various treatment strategies. However, although
it is clear from the above discussion that bedtime problems and
night wakings are defined by a number of subjective complaints
arising from parent’s perception of behavior as well as the effects
of sleep disruption (e.g., irritability and inattention), it should be
emphasized that this is also the case for other broadly accepted
childhood psychiatric disorders (e.g., oppositional defiant disor-
der, enuresis, attention-deficit/hyperactivity disorder).
While the research criteria used in the literature to define bed-
time problems and night wakings are not consistent across stud-
ies, a number of researchers have attempted to operationalize and
standardize the definition of sleep problems in infants and young
children. These definitions generally include parameters related
to some combination of frequency (e.g., number of wakings per
night, nights per week with bedtime resistance), severity (e.g., du-
ration of night wakings), and chronicity (e.g., weeks to months)
of behaviors. For the purposes of this review, we have attempted
to be consistent with the current existing literature, using the no-
sology of bedtime problems/resistance and night wakings to refer
to “sleep problems” in infants and young children.
The identified prevalence of “problematic” bedtime resistance
and frequent night wakings is remarkably similar across studies,
even when comparing studies across cultures. It is estimated that
overall 20% to 30% of young children in cross-sectional studies
are reported to have significant bedtime problems and/or night
wakings.1-5 For infants and toddlers, night wakings are one of
the most common sleep problems, with 25% to 50% of children
over the age of 6 months continuing to awaken during the night.30
However, because these 2 sleep complaints frequently co-exist
and similar treatments strategies may be used for both, many
studies do not approach them as separate concerns and thus indi-
vidual prevalence rates are difficult to estimate.7,34
The etiology of bedtime resistance and night wakings in child-
hood involves a multifactorial pathophysiologic mechanism and
represents a complex combination of biological, circadian, and
neurodevelopmental factors that are influenced by, but not solely
attributable to, environmental and behavioral variables (such as
sleeping arrangements and parenting styles).22,35 Thus, bedtime
resistance and night wakings in childhood may be viewed as aris-
ing within a similar paradigm as psychophysiological insomnia in
adults, and involve predisposing, precipitating, and perpetuating
factors. The predisposing factors for these problems are grounded
in circadian and homeostatic perturbations that form the neuro-
biological substrate upon which these sleep problems are super-
Review of Bedtime Problems in Children—Mindell et al
SLEEP, Vol. 29, No. 10, 2006 1265
imposed. The inability to “sleep through the night” and “settling”
problems at bedtime/failure to “self-soothe” after night wakings
essentially represent a delay in the emergence or a regression of
behaviors associated with the neurodevelopmental processes of
sleep consolidation and sleep regulation, respectively, that occur
over the first few years of life.3,4,36-38 Although the evolution of
sleep consolidation and sleep regulation in childhood is governed
principally by maturation of neural and circadian mechanisms,
like many other neurodevelopmental processes (e.g., emergence
of language, bowel and bladder control), it is also influenced by
the context and environment in which they occur.37,39,40 Thus, these
sleep problems by definition involve some elements of learned
behavior that are then amenable to modification by behavioral
The precipitating and perpetuating factors associated with bed-
time resistance and night wakings are myriad, and include both
extrinsic (e.g., environmental situations, parental issues) and in-
trinsic (e.g., temperament, medical issues) factors and often rep-
resent a combination of these issues. Bedtime problems are often
associated with child temperament or challenges related to calm-
ing a child.41-45 For example, “fussy” children may insist on a par-
ticular type of soothing/sleep-inducing technique, resisting any
alternative that is less dependent on the caregiver. Some caregiv-
ers may have problems of their own (e.g., depression, alcoholism,
long work hours) that interfere with their ability to set clear limits
both during the day and at bedtime. Caregivers of children with
current medical issues, or a history of a serious illness, may also
have difficulty setting limits, due to guilt, a sense that the child
is “vulnerable,” or concerns about doing psychological harm to
the child. Furthermore, other sleep disorders such as obstructive
sleep apnea have been shown to be associated with increased bed-
time behavior problems.46,47 In other cases, there is a “mismatch”
between parental expectations regarding sleep behaviors and the
normal developmental trajectory. Finally, environmental factors,
such as living accommodations that require a child to share a bed-
room with a sibling, parent, or additional family members (e.g.,
grandparents) residing in the home, may also contribute to poor
limit setting or negative sleep onset associations. Caution, though,
must be exercised in the interpretation of some of these factors.
For example, sleep proximity within the home and parent expecta-
tions may be determined by cultural, ethnic, and socio-economic
The clinical impact of bedtime resistance and night wakings
usually involves identifiable alterations in an infant or child’s
behavior. However, any discussion of the significance of pedi-
atric sleep problems must also underscore the importance of the
relationships between sleep problems and mood, development,
learning, performance, and health. A wealth of empirical evi-
dence clearly indicates that significant performance impairments
and mood dysfunction are associated with daytime sleepiness re-
sulting from insufficient or interrupted sleep.16,48,49 Higher-level
cognitive functions regulated by the prefrontal cortex, such as
cognitive flexibility and the ability to reason and think abstractly,
appear to be particularly sensitive to the effects of disturbed, in-
sufficient, and/or irregular sleep.16,50-52 Furthermore, these sleep
problems appear to be an important precursor and potential early
indicator of future anxiety, depression, and substance use disor-
ders.49,53-55 Sleep problems also place a significant burden on par-
ents and the parent-child relationship. Finally, health outcomes
of inadequate sleep include potential deleterious effects on the
cardiovascular, immune, and various metabolic systems, includ-
ing glucose metabolism and endocrine function.
The primary objective of this paper is to provide a review of
the empirical evidence regarding the efficacy of behavioral in-
terventions for the clinical management of bedtime problems
and night wakings in infants and children. Secondary objectives
include an evaluation of the impact of behavioral interventions
on the child and parent and the durability of outcomes (short-
term and long-term). The primary interventions reviewed here
are standard behavioral treatment techniques that include: 1) ex-
tinction (unmodified extinction, Graduated Extinction, extinction
with parental presence); 2) positive bedtime routines/faded bed-
time with response cost; 3) scheduled awakenings; and 4) parent
3.1 Identification and Selection of Treatment Studies
Treatment studies selected for review in this paper were identi-
fied through PsycLIT and MEDLINE searches (1970-2005) using
the following keywords: (1) sleep problem-disorder- disturbance-
disruption-patterns-sleeplessness; (2) bedtime problems-resis-
tance-struggles-refusal-tantrums; (3) dyssomnias-insomnia; (4)
limit setting sleep disorder-settling problems; (5) night waking-
nighttime awakenings-sleep onset association disorder; (6) treat-
behavioral-parent training- parenting- mother-infant interaction-
anticipatory-guidance-prevention-primary-care intervention; (7)
The criteria for inclusion of a study were as follows: (a) study
included any child between the ages of 0 - 4 years 11 months (old-
er children included in any study were excluded from the analy-
ses; most studies including older children were case reports and
single-case designs); (b) intervention study of any behavioral or
psychoeducational treatment that involved behavioral principles;
and (c) focus was on bedtime problems, night wakings, or a be-
haviorally-based sleep problem (all other sleep disorders were ex-
cluded, including parasomnias and nightmares). Exclusion crite-
ria included: (a) no behavioral intervention or behaviorally-based
psychoeducational component, (b) sleep problem associated with
a primary medical or psychiatric condition (including known
developmental disabilities), and (c) study was not published in
a peer-reviewed publication, such as a dissertation. All types of
studies, including case studies and single-subject designs, were
included in the analyses.
A total of 3,008 abstracts were considered from the initial
search that included all articles published through January 2005.
The large majority of these were excluded because they did not
meet inclusion criteria, with 92 articles selected for full review.
Following full review, 35 articles were excluded primarily be-
cause the study population included children with developmen-
tal disabilities or the treatment was exclusively pharmacological.
“Pearling,” the process of manually scanning the captured arti-
Review of Bedtime Problems in Children—Mindell et al
SLEEP, Vol. 29, No. 10, 2006 1266
cles’ bibliography for additional relevant references not detected
by Medline, netted an additional 5 citations.
The present paper is based on evidence from 52 individual
studies (n > 2,500 subjects) that met inclusion criteria; these stud-
ies are denoted by an asterisk in the reference list. Each article
was reviewed and rated by 2 task force members. Any disagree-
ments were resolved by discussion and consensus among task
3.2 Treatment Procedures: Description and rationale
Interventions for bedtime problems and night wakings consist
primarily of time-limited parent training strategies that incorpo-
rate behaviorally-based interventions, founded on principles of
learning and behavior (e.g., reinforcement, extinction, shaping).
Parent training typically involves a therapist “coaching” the par-
ents to become the active agents of change to address their child’s
problematic sleep patterns, habits, or sleep-related behaviors.
Among the many forms of behavioral health services for young
children, no other treatment has been more thoroughly investi-
gated or widely applied as parent management training.56
The first studies that were conducted on the treatment of early
childhood sleep problems focused on the use of extinction 57. Un-
modified extinction procedures for sleep problems involve having
the parents put the child to bed at a designated bedtime and then
ignoring the child until a set time the next morning (although par-
ents continue to monitor for illness, injury, etc). Behaviors that are
ignored include crying, tantrums, and calling for the parents. Ex-
ceptions to ignoring the child include any concerns that the child
is hurt, ill, or in danger. The biggest obstacle associated with ex-
tinction is lack of parental consistency. Parents must ignore their
child’s cries every night, no matter how long it lasts. If parents
respond after a certain amount of time, the child will only learn
to cry longer the next time. Parents are also instructed that post-
extinction response bursts may occur. That is, often at some later
date there is a return of the original problematic behavior. Parents
are instructed to avoid inadvertently reinforcing this inappropriate
behavior following such an extinction burst. The common term
used in the media and self-help books to describe unmodified ex-
tinction techniques is the “cry it out” approach.58
The major drawback of unmodified extinction procedures is
that it is stressful for parents. Many parents are unable to ignore
crying long enough for the procedure to be effective. As a variant
to unmodified extinction, some studies have utilized extinction
with parental presence. This procedure involves the parents stay-
ing in the child’s room at bedtime but ignoring the child and his/
her behavior. Some parents find this approach more acceptable
and are able to be more consistent.
Rather than having the child cry for extended periods, Grad-
uated Extinction procedures have been developed. The term
“Graduated Extinction” refers to a variety of techniques. Typi-
cally, parents are instructed to ignore bedtime crying and tantrums
for specified periods. The duration or interval between check-ins
with the child is often tailored to the child’s age and temperament,
as well as the parents’ judgment of how long they can tolerate the
child’s crying. Either parents can employ a fixed schedule (e.g.,
every 5 minutes) or they can wait progressively longer intervals
(e.g., 5 minutes, 10 minutes, then 15 minutes) before checking on
their child. With incremental Graduated Extinction, the intervals
increase across successive checks within the same night or across
successive nights. The checking procedure itself involves the par-
ents comforting their child for a brief period, usually 15 seconds
to a minute. The parents are instructed to minimize interactions
during check-ins that may reinforce their child’s attention-seek-
The goal of Graduated Extinction is to enable a child to de-
velop “self-soothing” skills in order for the child to fall asleep in-
dependently without undesirable sleep associations (e.g., nursing,
drinking from a bottle, rocking by parent). Once these skills are
established, the child should be able to independently fall asleep
at bedtime and return to sleep following normal nighttime arous-
als. In the popular literature, this type of intervention is often re-
ferred to as “sleep training.”59
Positive Routines/Faded Bedtime with Response Cost
Positive routines involve the parents developing a set bedtime
routine characterized by quiet activities that the child enjoys.
Faded bedtime with response cost involves taking the child out
of bed for prescribed periods of time when the child does not fall
asleep. Bedtime is also delayed to ensure rapid sleep initiation
and that appropriate cues for sleep onset are paired with posi-
tive parent-child interactions. Once the behavioral chain is well
established and the child is falling asleep quickly, the bedtime is
moved earlier by 15 to 30 minutes over successive nights until a
pre-established bedtime goal is achieved. A scheduled wake time
Review of Bedtime Problems in Children—Mindell et al
Table 1— Diagnostic Criteria of Behavioral Insomnia of Childhood
A. A child’s symptoms meet the criteria for insomnia based upon
reports of parents or other adult caregivers.
B. The child shows a pattern consistent with either the sleep-onset
association type or limit-setting type of insomnia described be-
i. Sleep-onset association type includes each of the following:
1. Falling asleep is an extended process that requires special
2. Sleep-onset associations are highly problematic or demand-
3. In the absence of the associated conditions, sleep onset is
signiﬁcantly delayed or sleep is otherwise disrupted.
4. Nighttime awakenings require caregiver intervention for the
child to return to sleep.
ii. Limit-setting type includes each of the following:
1. The individual has difﬁculty initiating or maintaining sleep.
2. The individual stalls or refuses to go to bed at an appropriate
time or refuses to return to bed following a nighttime awak-
3. The caregiver demonstrates insufﬁcient or inappropriate
limit setting to establish appropriate sleeping behavior in the
C. The sleep disturbance is not better explained by another sleep dis-
order, medical or neurological disorder, mental disorder, or medi-
American Academy of Sleep Medicine. The International Classiﬁ-
cation of Sleep Disorders, 2nd ed.: Diagnostic and Coding Manual.
Westchester, IL: 2005.33
SLEEP, Vol. 29, No. 10, 2006 1267
is established and daytime sleep is not allowed, with the exception
of age-appropriate naps.
These two strategies are similar in that they match the child’s
bedtime with his/her natural sleep onset time and rely heavily
on stimulus control techniques as the primary agent of behavior
change. Both treatments aim to increase appropriate behaviors
and control of affective and physiological arousal, rather than fo-
cusing on reducing inappropriate behaviors, as is done with the
previously described extinction strategies.
Scheduled awakenings involve parents awakening and consol-
ing their child approximately 15 to 30 minutes before a typical
spontaneous awakening. This strategy begins with establishing a
baseline of the number and time of spontaneous nighttime awaken-
ings. Preemptive awakenings are then scheduled. Parent-induced
scheduled awakenings are typically followed by the parents’ usual
response to a spontaneous awakening, such as rocking or nursing
the child back to sleep. Scheduled awakenings are then faded out,
by systematically increasing the time span between awakenings.
These scheduled awakenings appear to increase the duration of
One approach to treatment of sleep disturbances is to prevent
their occurrence. A number of behavioral interventions have been
incorporated into these parent education programs, with a focus
on early establishment of positive sleep habits. Strategies typical-
ly target bedtime routines, developing a consistent sleep schedule,
parental handling during sleep initiation, and parental response
to nighttime awakenings. Almost all programs have incorporated
the recommendation that babies should be put to bed “drowsy but
awake” to help them develop independent sleep initiation skills at
bedtime, and enabling them to return to sleep without intervention
following naturally occurring nighttime arousals.
Many parent education programs have targeted soon-to-be-par-
ents, as well as parents of newborns. For this review, preventive
education was designated for parent education that was conducted
during the prenatal period or during the first 6 months. This strat-
egy focuses on a prevention model rather than an intervention
model, as denoted by the above behavioral treatments. In contrast,
general parent education was defined as occurring after 6 months
of age and involved provision of information about normal sleep.
4.0 SUMMARY OF RESULTS
Table 2 (which can be accessed on the web at http://www.
aasmnet.org/), summarizes the 11 studies included in the pres-
ent review that meet Sackett evidence Levels I and II, based on
criteria described in the method section. The following section
summarizes the magnitude of changes obtained on infant/toddler
behavior (e.g., bedtime crying) and sleep parameters, the clini-
cal significance of those changes, the durability of improvements
over time, and the comparative efficacy of single and combined
4.1 General findings
More than 2,500 infants and toddlers participated across the 52
selected studies that evaluated behavioral interventions for bed-
time struggles and frequent night waking. Nearly half of the sub-
ject pool (n=1,135) participated in the methodologically strongest
studies employing a randomized controlled trial (RCT) design.
In the 40 studies that identified the gender of the subjects, 760
out of 1359 subjects were male (56%). Thirty-six studies provid-
ed the mean age of the subjects. The average age of the subjects
in these studies was 20 months. The age range of the total pool
of participants spanned from 1 week to 10 years (although only
participants under 5 years of age were considered in this paper).
Seven studies indicated race; 67% of the 858 of subjects in
these 7 studies were Caucasian. The remaining 33% of subjects,
in those studies in which race was identified, were African-Amer-
ican, Asian, or the study did not provide this information. Nine-
teen studies were conducted in the United States, 10 in England,
7 in Australia, and 4 in New Zealand, with the remaining taking
place in Canada, Iceland, Israel, Scotland, Sweden, Switzerland,
or other European countries.
Of the total participant pool, 731 subjects (29%) across 28
studies were clinically referred by a professional (n=579) or self-
referred (n=152) for sleep problems. A significant percentage of
children (52%) across 14 studies were recruited specifically to
participate in the research study, often during routine medical ap-
pointments or by posting community advertisements. It should be
noted that 7 of the 9 studies in Evidence Level I recruited their
research participants, whereas studies using small “n” multiple
baseline designs were more likely to involve participants who
were clinically referred.
Table 3 summarizes the guidelines by which the classification
of evidence was evaluated, as adapted from Sackett.60 Of the 52
selected studies, 8 (15%) represented RCTs that were classified
as Level I.17,18,20,61-65 Three studies (6%) were classified as Level
II.66-68 Twenty-six (50%) met criteria as a Level III study,7,19,21,69-
91 many of which used a multiple-baseline research design. The
remaining 15 (29%) fell into Levels IV92-94 or V.57,95-103
These 52 studies assessed the efficacy of a number of behavior-
al interventions that varied greatly in procedural delivery. Despite
these differences, most of the interventions can be placed into the
following categories: extinction and its variants (i.e., unmodified
extinction, extinction with parental presence, Graduated Extinc-
tion), positive bedtime routines, scheduled awakenings, bedtime
fading with response-cost, Positive Reinforcement, and parent
This empirical literature includes a wide range of outcome vari-
ables. Many researchers collected data on sleep-related variables
(e.g., sleep onset latency, frequency and duration of awakenings,
total sleep time), whereas others focused more on child behav-
ior outcomes (e.g., duration of crying, frequency of leaving the
bedroom, and callouts to parents). Behavioral and sleep related
variables were both measured in only a few studies; some major
studies included no child outcome variables, choosing instead to
focus on parent sleep or emotional adjustment.
Among the studies summarized, 11% identified bedtime re-
sistance as the primary dependent variable,17,57,76,86,88,103 whereas
frequent awakenings were the main focus in 27% of the stud-
ies.19,21,63,64,66,72,75,78,79,82,89,92,97,104 Exactly 50% of the studies tar-
geted the “clinical dyad” of bedtime resistance and night wak-
ing.7,20,61,62,65,67-71,73,77,80,81,85,87,90,91,93-96,98,101,102,105 One study was
unique in that it targeted bedtime fears,83 whereas 5 studies ad-
dressed nonspecific “sleep problems.”17,18,84,99,100 Consistent with
previous reviews (e.g.,5,29,31), as discussed above, we chose to
consider bedtime disturbance and frequent night waking together.
The 2 sleep disturbances frequently coexist,34 and treatments that
Review of Bedtime Problems in Children—Mindell et al
SLEEP, Vol. 29, No. 10, 2006 1268
target 1 often generalize to the other.7
4.2 Specific behavioral interventions
In his 1959 study, Williams57 appears to have been the first to
formally apply Unmodified Extinction to problematic bedtime
behavior. Extinction has a strong record of accomplishment, now
having been evaluated in 19 separate research studies involving
552 participants.b With the exception of 2 studies68,85, in 17 stud-
ies the procedure has proven highly effective in eliminating bed-
time problems and night wakings, and improving sleep continu-
Graduated Extinction was first devised by Rolider and Van-
Houten86 as a more parent-friendly alternative to Unmodified
Extinction. The protocol was modified slightly and popularized
by Ferber in his 1985 self-help book58, as well as by Douglas in
1989106. This variation on the extinction theme has now been eval-
uated in 14 studies and 748 participants. All 14 reported positive
treatment outcomes as indicated by a reduction in bedtime prob-
lems and/or night wakings.7,16-19,21,62,72,73,81,84,86,99,105 An additional 5
studies relied on the same underlying behavioral principle (i.e.,
gradual removal of parental attention or physical proximity) with-
out using the formal checking procedure outlined in the original
protocol.23,68,90,96,100 It appears safe to conclude that Graduated Ex-
tinction, as applied to bedtime problems and night waking, now
stands on equal empirical footing as its predecessor.
Extinction with Parental Presence is a more recent variant of
extinction. The procedure is more popular in England but appears
to be making its way to the U.S. Four research studies involving
290 children found the procedure to be effective.18,84,98,104
Positive Routines were first used by Milan in 1981107 to address
bedtime tantrums of three children with severe handicaps. Two
studies17,77 have since evaluated the protocol with 81 typically de-
veloping children, and both concluded that the procedure is rapid
and effective. Positive Routines provides a positive, albeit less
tested, alternative to extinction that may reduce the undesirable
post-extinction response burst that many parents have difficulty
Scheduled Awakenings was first described by McGarr and
Hovell in 198082, then more formally evaluated by a series of
three studies by Johnson and colleagues.63,78,79 Forty-four children
have participated across 4 studies. The outcome data indicate
that Scheduled Awakenings afford another treatment option for
frequent nighttime awakenings. Compared with extinction, the
procedure is slightly more complicated to carry out, and studies
suggest that results may take several weeks rather than several
days. Furthermore, scheduled awakenings are not an appropriate
treatment for young children with bedtime struggles.
Having an infant or young child participate in a nightly Standard-
ized Bedtime Routine has become a universal, “common sense”
recommendation. This intervention component was included in no
fewer than 14 of the selected studies.28,62,67,68,70,75,84,88,89,96,97,99,101,105
However, it was always included as part of a multi-component
treatment package, and has yet to be systematically evaluated as
a stand-alone intervention. The same can be said for Positive Re-
inforcement, which was included as part of the treatment package
in 15 studies28,62,67,68,70,83,87-89,95-97,99-101 yet was never evaluated as
the sole intervention.
Finally, outcomes from 5 large-scale studies provide evidence
that Parent Education/Prevention may set the standard as the
most economical and time efficient approach to behaviorally-
based pediatric sleep problems. More than 1,000 parents across
5 studies20,61,65,66,92 have received sleep education and prevention
strategies during their prenatal period or the first 6 months of
infancy. Results have proven to be not only statistically signifi-
cant, but also clinically meaningful to parents who want to teach
their newborn essential sleep skills, although given that no stud-
ies have done follow-up longer than six months the durability of
effects is not yet established. For example, Pinilla66 was able to
teach 100% of infants to “sleep through the night” by 8 weeks of
age, whereas only 23% of control infants accomplished this goal.
Wolfson20 used only 4 sessions to help 72% of infants to “sleep
through the night” by 3 weeks post-birth, compared to 48% of
control infants. Prevention strategies afford the ability to impact
large numbers of infants and young children without a great deal
Review of Bedtime Problems in Children—Mindell et al
Table 3—AASM Classiﬁcation of Evidence
Recommendation Evidence Levels Study Design Studies
A I Large, well-designed, randomized, and blinded 9 studies:17,18,20,61-65,104
controlled study with statistically signiﬁcant
conclusions on relevant variables
B II Smaller, well-designed, randomized and blinded, 4 studies:66-68,105
controlled study with statistically signiﬁcant
conclusions on relevant variables
C III Well-designed, non-randomized prospective 26 studies:7,19,21,69-88,90,91,101
study with control group
C IV Well-designed, large prospective study with 3 studies:23,92,94
historical controls or careful attention to
confounding effects or small prospective study
with control group
C V Small prospective study or case series without 10 studies:57,95-103
Adapted from Sackett60 Total: 52 studies
b The number of subjects represent the total number participating in a given study,
not necessarily the number of subjects who received that particular intervention
SLEEP, Vol. 29, No. 10, 2006 1269
of monetary or time investment. Adair92 was able to reduce fre-
quent night waking by half simply by incorporating written in-
formation regarding sleep habits and behavior management into
2 routine well-child medical visits. One potential disadvantage of
large scale, less personalized interventions is that parents may not
implement the treatment as intended, or at all. St. James-Roberts65
incorporated Pinilla’s successful treatment package into an educa-
tional brochure, and attained only a modest increase (10%) in the
number of infants who slept through the night at 12 weeks of age.
Group comparison data indicated that the intervention group did
not implement the essential treatment components.
4.3 Overall Efficacy
Based on authors’ conclusions from their own data, 94% (49
of 52) reported that behavioral interventions produced clinically
significant reductions in bedtime resistance and night wakings.
Three studies reported equivocal findings,64,68,85 and no study re-
ported detrimental effects. The percentage of participants who
improved on relevant outcome measures was reported in a few
studies. The average percentage of subjects who improved was
82% (range 10% - 100%), however, the timing of this determina-
tion varied considerably.
The 11 studies with the strongest research methodologies (Lev-
els I and II) evaluated the outcomes of 9 different behavioral in-
terventions, either alone, comparatively, or in combination. The
interventions most commonly evaluated in the strongest studies
included Unmodified Extinction (4 studies), Parent Education/
Prevention (4 studies), and Graduated Extinction (3 studies).
Standard Bedtime Routines (2 studies) and Positive Reinforce-
ment (2 studies) were also evaluated, but were always included
as part of a larger treatment package. Nine17,18,20,61-63,65-67 of the 11
studies found positive intervention effects and 264,68 were equivo-
cal. Overall, the weight of the evidence from controlled group
studies supports two behavioral interventions: Extinction and Par-
ent Education/Prevention, with clear support for Graduated Ex-
We conclude that infants and toddlers who exhibit bedtime
resistance and nighttime awakenings respond favorably to be-
havioral interventions. Unmodified extinction and Parent Edu-
cation/Prevention are the two treatment modalities that have the
strongest empirical support. Graduated Extinction, bedtime fad-
ing/positive routines, and scheduled awakenings were also sup-
4.4 Comparative Efficacy of Treatment Modalities
The studies selected for this review varied greatly in methodol-
ogies, therefore it may be difficult to compare “apples to oranges”
in selecting among available treatments. Studies used different
outcome variables and methods of assessment. Most involved
multi-component treatment packages, therefore few data are
available directly comparing one pure treatment to another. For
example, Reid62 published an excellent study comparing Extinc-
tion to Graduated Extinction. Each intervention, however, also
included 2 other treatment components (door closing if the child
came out of the bedroom more than once and praise/rewards for
a successful night), making it more difficult to directly compare
Despite the methodological differences, there are a few con-
clusions that can be drawn based on the handful of studies that
conducted head-to-head comparisons of 2 or more treatments. In
drawing these conclusions, only the impact on sleep-related vari-
ables were considered. One clear finding in these studies is that
children participating in an active behavioral sleep intervention
demonstrated more rapid and significant resolution to their sleep
disturbance than those who did not receive treatment.17,62,63 These
findings support previous work suggesting that pediatric sleep
disturbances often become chronic, with few children outgrow-
ing the problem.9,11
The direct comparison studies provide little evidence to sug-
gest that any 1 behavioral protocol is vastly superior to another.
Positive Routines, Unmodified Extinction, Graduated Extinction,
Extinction with Parental Presence, and Scheduled Awakenings
were all included in 1 or more comparison studies. All 5 studies
that directly compared behavioral treatments found no apprecia-
ble differences in long-term efficacy.17,62,63,74,104 There is evidence
that Unmodified Extinction may produce faster improvement
than Scheduled Awakenings63, and that combining sedative medi-
cation (antihistamine) with Extinction may produce a more im-
mediate response with reduced infant distress.74
Unmodified Extinction and its recent variants (Graduated;
with Parental Presence) appear to be on level playing ground,
along with Positive Routines. One study concluded that com-
pared to Graduated Extinction, “positive routines produced the
fastest improvement in decreasing the tantrum behavior.”17 The
data, however, appeared equivalent until approximately week 4
of treatment when Positive Routines continued to produce ad-
ditional improvement as Extinction reached a plateau. Positive
Routines and a variant, Faded Bedtime, appear to provide prom-
ising alternatives to more traditional extinction-based protocols.
Although the 2 protocols were evaluated in only 3 of the selected
studies,17,69,77 Faded Bedtime with/without response-cost has been
studied more extensively in children with developmental dis-
abilities. Notably, Positive Routines and Faded Bedtime closely
resemble a combination of 2 behavioral interventions (sleep re-
striction and stimulus control instructions) that have received the
strongest research support in the treatment of adult insomnia.108
Review of Bedtime Problems in Children—Mindell et al
Table 4 —Frequency and Percent of Studies Reporting Durability of
< 6 6-12 >12 No
months months months follow-up
Extinction 20 (59%) 8 (23%) 3 (9%) 3 (9%)
Standardized Bedtime 11 (79%) 1 (7%) 1 (7%) 1 (7%)
Positive Routines 1 (50%) 1 (50%)
Scheduled 3 (75%) 1 (25%)
Bedtime Fading/ 1 (100%)
Response Cost (n=1)
Positive 10 (66.7%) 3 (20%) 2 (13.3%)
Education (n=15) 9 (60%) 1 (7%) 1 (7%) 4 (26%)
General Behavioral 2 (50%) 1 (25%) 1 (25%)
Other (n=12) 5 (41.6%) 5 (41.6%) 2 (16.7%)
Total (n=101) 61 (60%) 20 (20%) 5 (5%) 15 (15%)
SLEEP, Vol. 29, No. 10, 2006 1270
Three of the five direct comparison studies provided sufficient
original data that Kuhn and Elliott29 were able to calculate treat-
ment effect sizes. Unmodified Extinction produced a larger effect
size (d = 2.31) than Scheduled Awakenings (d = 1.11) on number
of awakenings at 6 weeks post-treatment.63 Effect sizes for fre-
quency and the duration of bedtime tantrums were comparable
for Graduated Extinction (d =0.75; duration= 1.50) and Positive
Routines (d =0.88; duration=1.83).17 At 3 weeks post-treatment,
Unmodified Extinction produced a slightly larger effect size (d =
2.63) than Graduated Extinction (d = 1.93) on “good bedtimes”
(settled alone in less than 10 minutes), but the results were re-
versed for “good nighttimes” (slept through night without sleep-
ing with or waking parents) with Graduated Extinction (d = 2.03)
slightly outperforming Unmodified Extinction (d = 1.29).62 Most
importantly, the effect sizes for all four interventions surpassed d
= 0.80, which reflects a large treatment effect.109 Overall, these ef-
fect sizes indicate that Positive Routines, Unmodified Extinction,
Graduated Extinction, and to a lesser degree Scheduled Awaken-
ings, all represent effective treatment options for the treatment of
pediatric bedtime problems and frequent night waking.
4.5 Source of Outcome Assessment
Nine studies (17%) employed at least 1 objective outcome
measure such as direct observations, videotapes, audiotapes, or
actigraphy data.7,21,69,84,85,88,97,103,104 Seven studies (13%) used a
standardized rating scale to assess outcomes related to child be-
havior or infant security.62,66,70,74,83,84,88 However, the overwhelming
majority of intervention studies (77%) relied on parent complet-
ed daily diaries as the primary outcome measure. These diaries
most frequently assessed child sleep (56%), however a few (8%)
tracked bedtime behavior such as crying, tantrums, or leaving the
bedroom. Seven studies (13%) used diaries to collect data on both
child sleep and bedtime behavior.21,65,70,71,83,86,103
Parent completed sleep diaries typically include daily record-
ings for nightly bedtime, time asleep, the number, timing, and du-
ration of any night wakings, the time of morning waking, and the
duration of any daytime sleep. Although there are some limitations
to parent-report measures, they are the most widely used mea-
sure of sleep in clinical settings and therefore tend to have high
content and face validity. For infants and toddlers, sleep related
complaints come from the parents rather than from the child110;
therefore parents are the most obvious source of information for
their child’s sleep behavior.111 Parent completed sleep diaries
possess reasonable validity, high internal consistency, and good
agreement (> 90%) with video or voice activated recordings, and
actigraphic measures of children’s sleep-wake patterns.7,42,75,82,112-
115 Parents of sleep disturbed infants have been shown to be good
reporters on sleep schedule measures, but do more poorly on sleep
4.6 Secondary Outcomes
A number of studies assessed the effects of sleep interven-
tions on secondary outcome variables, such as daytime behav-
ior. These studies addressed possible adverse effects of behav-
ioral interventions, as well as the potential beneficial effects on
daytime behavior. A total of 13 studies selected for this review
reported results pertaining to child daytime functioning such as
crying, irritability, detachment, self esteem, or emotional well-
being.17,28,62,66,70,73,74,83,84,88-90,101 Five studies17,88-90,101 based their
conclusions solely on subjective retrospective parental report,
whereas 8 studies.28,62,66,70,73,74,83,84 collected formal data such as
standardized rating scales or observations of parent-child interac-
Adverse secondary effects as the result of participating in be-
haviorally based sleep programs were not identified in any of the
studies. On the contrary, infants who participated in sleep inter-
ventions were found to be more secure74,117,118c predictable,66 less
irritable,90 and to cry and fuss less following treatment.73 Mothers
indicated that behaviorally-based sleep interventions had no ef-
fect on maintaining the practice of breast feeding or on infant’s
total daily fluid intake.66,92 In a number of studies, parents of older
children reported improvements in their children’s daytime be-
havior after participation.28,70,83,84,89,101 For example, Seymour89
reported that 73% of parents reported positive changes in their
child’s daytime behavior. There are several potential mechanisms
to account for these findings, but 1 likely factor is the increased
total sleep time and improved sleep quality that children and their
parents experience following effective treatment.
It is important to indicate that sleep related behavioral inter-
vention also led to improvement in the well-being of the parents
beyond the specific benefits in sleep patterns in the children.
Twelve studies collected outcome measures on parent mood,
stress, or marital satisfaction.7,17-21,28,62,64,73,74,105 A few studies col-
lected data on fathers, however the majority focused on mothers
who tended to demonstrate elevated levels of depressed mood
and more disturbed sleep at pre-treatment, probably because they
assumed the most responsibility in caring for a sleep disturbed
infant or toddler. The results were remarkably consistent across
studies. Following intervention for their child’s sleep disturbance,
parents exhibited rapid and dramatic improvements in their over-
all mental health status,64,105 reporting fewer symptoms of depres-
sion.7,18,19,21 They reported an increased sense of parenting effi-
cacy,20 enhanced marital satisfaction,7,17,21 and reduced parenting
stress.62,117 For instance, Eckerberg117 reported that following suc-
cessful implementation of a behavioral intervention that led to
significant improvement of their infant sleep, the parents reported
improvements of their own mood, stress level, and fatigue. Simi-
larly, Hiscock18 reported a 45% decrease in depression scores at
2 and 4 months post-treatment in depressed mothers after par-
ticipating in a behavioral infant sleep program. The only factor
that predicted an increase in maternal depression scores was per-
sistent infant sleep problems18. Another study reported that 70%
of participating mothers fell above the cutoff score for clinical
depression at baseline, but only 10% were still depressed fol-
lowing intervention for their sleep disturbed infant.19 Finally, in
a prevention study, Wolfson20 provided sleep education to parents
before and after the birth of their infant. Parents who received
the sleep education reported feeling an increased sense of compe-
tence, whereas parents in the control group reported higher stress
Given the strong association between chronic sleep distur-
bance and risk for depression,119,120 it is possible that the observed
reduction in parental depression is mediated by the improved
parental sleep patterns once infant and toddler sleep problems
are ameliorated. Three of the selected studies7,21,95 collected sec-
ondary outcome data on parent sleep variables following child
Review of Bedtime Problems in Children—Mindell et al
c France, 1992 and Eckerberg, 2004 were not selected to be included in this re-
view, however the outcome data from these studies were based on previous stud-
ies that were selected.
SLEEP, Vol. 29, No. 10, 2006 1271
participation in a behavioral sleep intervention. One found only
minor improvement in parental sleep variables.21 Mindell,7 how-
ever, reported an 80% reduction in the frequency of parental night
waking and less time awake at 1 month post-treatment.
4.7 Durability of Sleep Improvements
As seen in Table 4, 85% of the studies reviewed in this paper
examined the maintenance of treatment effects over time. These
studies demonstrated that treatment related changes across most
types of interventions were maintained at short (< 6 months), inter-
mediate (6 - 12 months) and long range follow-up (> 12 months).
Of the studies that reported improvements in either bedtime be-
haviors or a decrease in night wakings, 89% reported success in
all of the participants at follow-up; the other 11% reported contin-
ued treatment gains for over two-thirds of their participants.
In the majority of the studies (60%) the follow-up assessment
occurred less than 6 months after treatment ended. In fact, only
5% of the studies reviewed reported the maintenance of treatment
effects more than 1 year after the intervention ended. The durabil-
ity of treatment effects should thus be interpreted with caution.
5.0 TREATMENT INTEGRATION
5.1 Multi-Faceted Interventions
Two or more types of interventions, or multi-faceted interven-
tions (MFI), were used in 58% (n=30) of the reviewed studies.
Concurrent implementation of multiple interventions was used in
the majority of these studies whereas multiple baseline designs, or
serial implementation of interventions, were reported in 30% (n
= 9) of the 30 MFI studies. Only 4 of these articles were graded
as evidence levels I or II,20,62,65,68 and 16 were graded as evidence
level III. The remaining 10 were graded as evidence Levels IV or
The types of intervention strategies varied a great deal across
studies. The most common MFI interventions paired either Posi-
tive Reinforcement (n = 14) and/or Standard Bedtimes Routines
(n = 17) with either Extinction or Graduated Extinction. In 3 MFI
studies, there was reference to a behavioral intervention, but the
type of intervention was not specified. Other behavioral tech-
niques, such as somatic relaxation and deep breathing, time out,
punishment, response cost, and a children’s bedtime story, were
used in 1 or 2 studies each in combination with 1 or more of the
more common interventions.
Some form of parent education, either regarding sleep train-
ing (behavioral techniques, limit setting, elimination of noctur-
nal feeding) or general information about sleep (developmental
changes in sleep across the first several years of life) was used in
11 of the MFI studies. Although these 11 studies explicitly stated
that parent education was a component of the intervention, it is
highly likely that a much larger percentage of studies used some
form of written or verbal education. Several studies were consid-
ered MFI20,65,72,91,92 because they explicitly stated that parents were
instructed in written materials to implement multiple techniques.
Finally, in 4 of these studies20,65,72,92 written material alone was
compared to therapist-guided interventions, and as discussed be-
low, head-to-head comparisons tended to favor therapist interven-
Eight of the MFI studies reported tailoring treatments for the
individual child and family. In each of these studies, the types
of interventions were discussed, but the specific approach to in-
dividualizing the treatments was not specified. Tailoring a treat-
ment to a specific patient’s needs is the norm in clinical settings,
but this approach establishes several confounds that can limit the
ability to generalize study findings, as well as the claims that the
treatment is efficacious.
In a similar vein, the strength of the MFI studies lies in their
high ecological validity, namely, most clinicians are likely to
combine intervention strategies with their patients rather than
rely on a single approach. The obvious weakness of the studies
using MFI is that the efficacy of individual interventions cannot
be analyzed. Multiple baseline or ABAB designs pose even more
complexity in testing efficacy as there are carry over effects of
the initial intervention strategy. While counter-balancing different
interventions helps to control for carry over effects, only 1 study
reported the sequence of the intervention and counterbalancing
was not reported.88
The reported efficacy of the MFI interventions was high, be-
tween 50% and 100% of subjects had improved partially or com-
pletely, with all but 4 studies reporting between 75% and 100%
improvement in bedtime behavior problems and nighttime awak-
enings. Thus, while there are several weaknesses and confounds
inherent in this subgroup of studies that used MFI and tailored
interventions, taken as a whole there was generally a large mag-
nitude of positive change in all but 2 studies.65,68 The strength of
these studies lies in the high ecological validity of both tailored
and MFI treatment approaches.
5.2 Combining Behavioral and Pharmacological Therapies
Only 1 of the articles74 reviewed here combined behavioral in-
tervention with pharmacotherapy. Although there are numerous
studies of combined behavioral and pharmacologic treatments of
adult insomnia, this is the only identified publication in the Eng-
lish language literature on children. The study involved a double
blind, placebo controlled trial of trimeprazine (a sedating antihis-
tamine). Thirty-five children aged 7 - 27 months were assigned
to groups receiving training in extinction and were administered
trimeprazine or placebo. The group receiving active medication
improved more quickly, but relapsed slightly upon withdrawal,
resulting in no group differences at follow-up. This finding is con-
sistent with studies in adults121 showing a faster response when
pharmacologic agents are combined with behavioral treatments.
While the focus of this paper is on behavioral interventions and
not pharmacotherapy it is important to address the issue of medi-
cations because of their widespread use in clinical practice26 and
there may be specific cases in which it is justifiable to initiate a
combined behavioral and pharmacological therapy.122
6.0 TREATMENT RESPONSE AND MODERATING VARIABLES
The role of key factors such as the length of the therapy and
patient and parent characteristics has not been systematically as-
sessed. However, a number of studies have assessed differences
in therapist discipline (e.g., psychologist versus nurse practitio-
ner) and the manner in which the interventions were delivered
(written materials versus direct patient therapist contact).
6.1 Child and parent characteristics
There are no systematic reports on patient and parent charac-
Review of Bedtime Problems in Children—Mindell et al
SLEEP, Vol. 29, No. 10, 2006 1272
teristics vis-à-vis the outcomes of the interventions. Carpenter96
in a study of group intervention found that 73% of the parents re-
ported improvement and suggested that marital problems, parental
depression, and similar problems accounted for the failure of the
intervention in the other parents. Similarly, Jones and Verduyn98
reported 84% success in resolving sleep problems using a behav-
ioral management program, and indicated that the sleep problems
were less likely to resolve if marital discord was involved or if
only 1 parent attended therapy. In another study,62 positive out-
come of 1 of the interventions (standard ignoring) was associated
with maternal characteristics, namely, mothers who were less de-
pressed, less distressed about parenting, and made less disciplin-
ary mistakes were more likely to achieve better outcomes.
6.2 Treatment format
The format of the interventions for sleep problems in early
childhood has varied considerably across studies. Although most
studies have been based on therapist-parent sessions as the main
mode of delivery, studies have explored other more economic
modes of delivery, such as interventions by para-professionals or
interventions based on an information booklet only.
Eckerberg72 compared the effects of interventions based on ad-
vice and support to interventions based on written information
only. The therapeutic approach in both interventions was based on
Graduated Extinction. Both interventions reduced protesting and
sleep latency, reduced the number of night wakings, and extended
sleep duration. The results failed to support differential effects of
the treatment format. Scott and Richards64 compared 3 types of
interventions: advice, advice and support, and a booklet group.
All 3 groups gradually improved with time.
St. James-Roberts65 assessed the effects of 3 intervention for-
mats: (1) a behavioral group that received written material and
discussed the topic with a clinician; (2) an educational group
that received written guide with general guidelines but no spe-
cific behavioral instructions; (3) and a control group that received
normal health services that were available to the other 2 groups.
The behavioral intervention led to a modest (10%) increase in
the number of infants who met the criteria for sleeping through
the night (5 hours or more) at 12 weeks of age. The educational
intervention produced no noticeable differences compared to the
control group. It is impossible to determine if the contact with the
clinicians or the specific behavioral instructions led to the limited
outcome differences between the groups.
Seymour67 compared the effects of written information with
and without therapist contact. A waiting list group served as an ad-
ditional comparison group. Both treatments (written information
with or without therapist contact) led to a significant improvement
after 4 weeks of treatment. The results were achieved faster in the
group with therapist contact. However, after 4 weeks of treatment
there were no significant differences between the 2 interventions.
The positive outcomes were maintained at a 3-month post treat-
Finally, Weymouth94 performed 3 studies with different modes
of delivery. In study 1, the intervention included a booklet, clini-
cal support, and clinical support with therapists. In study 2, the
intervention included a booklet and reduced contacts with the
therapist, and in study 3 the intervention included only the book-
let. The author concluded that some parents could succeed with a
booklet alone, whereas others require additional clinical support.
The results of these studies provide limited support for the
cost-effectiveness of using clinical sessions as part of the inter-
vention model for sleep problems in early childhood. In a tele-
phone survey of parents of 12 to 35 month old children123 it was
reported that many parents have used interventions methods
based on information provided by the media (e.g., books, parent-
ing magazines, TV) with high rates of success (above 70% for
some popular interventions). These results also suggest that many
parents can successfully utilize information on sleep related be-
havioral interventions with no need for professional help.
Another consideration of cost-effectiveness is the potential use
of group rather than individual sessions. Only 3 studies assessed
the use of parent group sessions and none of them compared
group versus individual session format. Reid,62 Carpenter,96 and
Szyndler91 reported positive outcomes for group interventions.
Research comparing the outcomes of individual versus group ses-
sion format is needed to assess the possible advantage over more
costly individual sessions.
In summary, the mode of delivery varied across studies, with
some studies finding little increased benefit for face-to-face inter-
ventions. Several factors, such as symptom chronicity and sever-
ity, parental mental health and coping skills, are likely moderat-
ing factors. The quality and content of the interventions is also a
key consideration that requires further assessment.
6.3 Treatment duration
The duration of the interventions varied considerably among
published studies. However, there are no published studies com-
paring structured treatment programs of different durations. Most
interventions ranged between 2 weeks and 2 months. The findings
suggest that even relatively short interventions (1 - 3 sessions)
can be very effective in improving sleep in early childhood. More
research is needed to assess the value of more extended treatment
programs in terms of short- versus long-term effects on the child’s
evolving sleep patterns.
7.1 General conclusions
This review of 52 treatment studies indicates that several
well-defined behavioral approaches produce reliable and durable
changes in bedtime problems and night wakings in infants and
young children. Across all studies, 94% report that behavioral
interventions produced clinically significant improvements in
bedtime problems and/or night wakings. Approximately 82% of
children benefit from treatment and the majority maintain these
results for 3 to 6 months. Empirical evidence from controlled
group studies strongly supports unmodified extinction, Gradu-
ated Extinction, and preventive parent education about sleep. In
addition, the majority of studies also included a consistent bed-
time routine, Positive Reinforcement, and general parent educa-
tion about sleep.
These findings are consistent with the conclusions of 2 pre-
vious reviews5,29 that used previously established criteria in the
field of clinical psychology124 to evaluate the empirical support
for behavioral interventions. Mindell5, in 1999, found that extinc-
tion and parent education on the prevention of sleep problems to
be well-established treatments. Furthermore, Graduated Extinc-
tion and scheduled awakenings were probably efficacious, with
Review of Bedtime Problems in Children—Mindell et al
SLEEP, Vol. 29, No. 10, 2006 1273
positive routines a promising intervention. An updated review by
Kuhn and Elliott29 in 2003 found extinction, Graduated Extinction,
and early intervention/parent education to be well-established in-
terventions. Scheduled awakenings were considered probably ef-
ficacious, whereas extinction with parental presence and positive
routines/faded bedtime with response cost were promising inter-
7.2 Methodological issues
The outcomes of the research on the efficacy of clinical in-
terventions for early childhood sleep problems have been very
positive. However, clearly some notable methodological limita-
tions need to be considered. The lack of standard definitions and
criteria for sleep problems in early childhood limits the possibility
of comparisons between studies and sometimes even for differ-
ent interventions within studies. A similar problem is the lack of
standardized outcome measures that would enable comparisons
Another potential concern in this area is the inclusion of single-
case design studies, rather than sole reliance on RCTs as empirical
evidence for these behavioral interventions. The primary limita-
tion in studying a single-case is that the results from that partic-
ular case may not be relevant to other cases (external validity).
However, larger samples producing statistically significant find-
ings do not necessarily mean that such effects are more power-
ful or clinically significant.125 Experimental single-case research
designs (e.g., ABAB, multiple baseline) are stronger than large
group designs at isolating mechanisms of change (internal valid-
ity), and are therefore used more commonly in applied behavioral
research, thus highly applicable to the question at hand.
Advances in technology have led to new objective methods
to assess sleep in young children. These relatively non-intrusive
techniques (e.g., time-lapse video, actigraphy, see Thoman and
Acebo126 for review) may provide clinicians an opportunity to
objectively assess target symptoms or problems in addition to
parental subjective reports. It has been suggested that inflated
improvement effects could result from parental fatigue when par-
ents are asked to document each night-waking on a daily basis for
extended periods.104 However, there are clear benefits to parental
report and the combination of subjective and objective measures.
Parental subjective experience of the sleep problem is clearly
valuable. Furthermore, objective measures may capture nighttime
awakenings that are not indicative of sleep disruption, providing
a better understanding of children’s sleep in general. A combina-
tion of these measures is necessary to identify those children with
clinically significant sleep problems.
The scarcity of studies comparing different delivery methods
(e.g., clinical session versus booklet information) and their con-
flicting results makes it difficult to assess the essential compo-
nents needed for an effective intervention. Some of these questions
could be answered by traditional outcome research (comparisons
between groups). Another approach is the use of process research
to assess the contributions of specific elements of interventions
(e.g., discussing parental fears and anxieties prior to the behav-
ioral coaching). The complementary role of process research has
not been well recognized and implemented in the study of behav-
ioral interventions for sleep problems (see Shirk and Russell127 for
a review of these methodological issues).
Another crucial issue is the assessment of the long-term effi-
cacy of the interventions. Most studies reviewed here had a fol-
low-up period of 6 months or shorter. Recently, the long-term
maintenance of positive outcomes of cognitive-behavioral inter-
ventions has been questioned in different areas of psychopathol-
ogy in adults.128 Future research should include longer follow-up
periods than those that have been traditionally used.
7.3 Future research
It is clear that there are many crucial questions that remain to be
answered regarding the treatment of bedtime problems and night
wakings in young children. For instance, in light of the wide-
range efficacy demonstrated by different intervention methods,
what are the actual curative factors or the essential ingredients of
these interventions? Other intriguing questions include: What are
the outcome changes in actual sleep patterns as opposed to those
reported sleep patterns? How long are these positive outcomes
maintained? What are the negative side effects, if any?
Additional research is also needed on the impact of interven-
tions on mood, behavior, and development. Specific child and
parent characteristics need further study, such as child (e.g., tem-
perament, age) and parent (e.g., depression, parenting style) vari-
ables related to treatment success.
In addition to the above methodological concerns, future re-
search should move toward the use of standardized research diag-
nostic criteria, as well as standardized assessment measures. The
use of standardized diaries and questionnaires would allow com-
parison across studies and their outcomes, enabling meta-analytic
studies in this area. Furthermore, the addition of objective assess-
ment tools, such as actigraphy, would be highly beneficial.
Another primary area in need of further research is the role
of pharmacological agents, either alone or in combination with
behavioral interventions, in the treatment of sleep issues in young
children. These agents are frequently prescribed by pediatricians
and child psychiatrists26,129, however, there is limited research on
their efficacy, risks, benefits, and limitations. With the advent of
many new hypnotics and the potential risks associated with medi-
cations in young children, this research becomes even more cru-
cial. Finally, research is needed to evaluate the efficacy of alterna-
tive treatment modalities such as infant massage and nutritional
After an extensive review of the pediatric sleep literature, we
found that two behavioral interventions for bedtime problems and
night wakings in young children, specifically Unmodified Extinc-
tion (including Extinction with Parental Presence) and Preventive
Parent Education, have received strong empirical support across
the highest-level of studies. In addition, support is provided
for graduated extinction, bedtime fading/positive routines, and
scheduled awakenings. An overwhelming majority of children
respond favorably to these behavioral techniques, resulting in
not only better sleep, but also improvements in child and family
well-being. Although significant advances have been made in the
behavioral management of these common sleep problems, clearly
additional research is necessary and there are more questions to
be answered. It is essential that future studies use standardized re-
search diagnostic criteria, include more objective measures, and
that pediatric sleep researchers develop a consensus on critical
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