Night wakings and bedtime struggles are the two most prominent sleep problems in children, according to Jodi Mindell, Ph.D., associate professor of psychology at St. Joseph’s University in Philadelphia. She spoke at a symposium on behavioral treatment for sleep disorders at the annual joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society in Las Vegas in June.

Some children who fall asleep normally have great difficulty returning to sleep when they awaken in the night. Known as sleep onset association disorder, this problem typically occurs in children aged 6 months to 3 years. Babies and toddlers usually awaken three to five times a night, Mindell said. The problem is not that they wake up, she noted, but that they don’t go back to sleep on their own.

Parents need to teach babies how to self-soothe, she said. If parents always rock the baby to sleep, take it for a ride in the car if it frets, or otherwise step in to offer comfort, the baby likely will continue to need them. Difficulty with night wakings is most common in firstborns, she observed. "Only new parents," she said, "have two hours to rock a baby to sleep." Teaching a child self-soothing skills, she said, may require allowing a child to cry a few minutes. Parents need reassurance that fretting behavior will soon stop.

Bedtime stalling is common in young children. While requests for another drink or another kiss usually subside within a few minutes, children with limit setting sleep disorder actively fight going to bed and may take two to three hours to fall asleep.

The first step in treatment, Mindell said, is to make sure the child has an appropriate bedtime, generally 7:30 p.m. to 8:30 p.m. "Parents often delay bedtime if they know it is going to be problematic," she said. "But soon the baby becomes tired and wired."

The best bedtime routine, she said, ends the same way every night, with a positive activity such as reading a favorite story. This process should take 20 to 30 minutes at most. Establishing a routine can start in the first months of life. Parents need to tailor the routine to their child, she added. If the child hates to take a bath, they should bathe the child at another time. If the child won’t sit still for stories, parents may try singing. The routine should end, she said, in the bedroom where the child sleeps.

Once parents leave the room, Mindell said, the sleep environment should be the same as it will be at 2 a.m. If lights in the hall will be off in the middle of the night, they should be turned off at bedtime. Parents need to reinforce appropriate bedtime behavior, she said, and not allow the child to get out of bed to watch television or have a cookie. For children aged 3 and up, sticker charts can encourage success. A parent might first give the child a sticker just for getting in bed, she said, and later up the ante.

Sleep terrors, sleepwalking, and nightmares, all common in young children, sometimes disrupt the entire family’s sleep, according to Brett Kuhn, Ph.D., of the University of Nebraska Medical Center in Omaha. Sleep terrors—episodes of screaming and agitation in which a child is hard to console—and sleepwalking likely are both behavioral manifestations of the same process, he said. Both almost always in nondreaming sleep in the first third of the night. Neither suggests psychopathology.

There is no reason to jolt the child awake, he said. Indeed, children with these problems often prove excessively sleepy and benefit from getting more sleep. Parents may need to move the child’s bedtime earlier, and cut reinforcements for early awakening by installing black-out curtains and taping early morning cartoons for later viewing. Parents should avoid discussing nighttime behavior with the child the next day. Helping youngsters to air their fears in the daytime, however, often is beneficial.

If a child who sleepwalks is worried about wetting the bed, Kuhn said, a parent may be able to steer him to the bathroom to void without awakening him. Since sleep terrors and sleepwalking often occur about the same time each night, awakening the child about 15 minutes before the expected event may prevent it. Just calling the child’s name may be sufficient to lighten sleep.

Sleep laboratory studies usually are not needed. The use of benzodiazepines in children is controversial, he said. These disorders usually are self-limiting, although a small percentage of adults still manifest them.

Frequent nightmares, Kuhn said, need to be distinguished from sleep terrors. While children seldom remember sleep terrors in the morning, reports of frequent anxiety-filled dreams suggest a child’s overall difficulty with adaptation and coping. A parent can help the child to examine the story of the dream, discuss the disturbing issues, and rescript more satisfying outcomes.