Services 1300 888 378

Behavioural interventions for children’s sleep problems

Last update: 25 Feb 2016

Behavioural interventions can help infants, toddlers and children to develop good sleep habits

A number of strategies can be combined to suit the needs of children with cerebral palsy and their families

These interventions need to be used every day to help children learn to change their sleep behaviours.

Who are these for?

Behavioural interventions for sleep can be used by families of the following children:
Mobility : GMFCS I, GMFCS II, GMFCS III, GMFCS IV, GMFCS V

Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

GMFCS Level I
Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

GMFCS Level II
Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

GMFCS Level III
Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

GMFCS Level IV
Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

GMFCS Level V
Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.

See full glossary

Arm ability : MACS I, MACS II, MACS III, MACS IV, MACS V

Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

MACS Level II
Handles most objects but with somewhat reduced quality and/or speed of achievement.

MACS Level III
Handles objects with difficulty; needs help to prepare and/or modify activities.

MACS Level IV
Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

See full glossary

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

CFCS Level II
Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

CFCS Level III
Effective Sender and Receiver with familiar partners.

CFCS Level IV
Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

See full glossary

Movement disorder : Ataxia, Athetosis, Dystonia, Hypotonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability, Severe intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

See full glossary

  • 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.

Find a Cerebral Palsy Alliance service

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.

More about behavioural interventions

Behavioural interventions are techniques or strategies children and their families use to learn,
change and maintain healthy sleep habits1. They can be learnt with a health professional, on the internet or using books and brochures.
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-tired2,3.
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 impairment2,3,6
  • 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/

Assessments

There are two types of assessments required to address a child’s sleep difficulties:
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.

Best available research evidence

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 located10-11. 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.

Date of literature searches: September 2014

  1. Meltzer, L. & Mindell, J. (2008). Behavioural sleep disorders in children and adolescents. Sleep Medicine Clinics, 3, 269-279.
  2. Newman, C. J., O’Regan, M., & Hensey, O. (2006). Sleep disorders in children with cerebral palsy. Developmental Medicine and Child Neurology, 48(7), 564-568.
  3. Wayte, S., McCaughey, E., Holley, S., Annaz, D., & Hill, C. M. (2012). Sleep problems in children with cerebral palsy and their relationship with maternal sleep and depression. Acta Paediatrica, 101, 618-623. See abstract
  4. Novak, I., Hines, M., Goldsmith, S., & Barclay, R. (2012). Clinical prognostic messages from a systematic review on cerebral palsy. Pediatrics, 130(5), 1-28.
  5. Meltzer, L. J, & Mindell, J. A. (2007). Relationship between child sleep disturbances and maternal sleep, mood, and parenting stress: A pilot study. Journal of Family Psychology, 21, 67-73. See abstract
  6. Hemmingsson, H., Stenhammar, A. M., & Paulsson, K. (2009). Sleep problems and the need for parental night-time attention in children with physical disabilities. Child: Care, Health and Development, 35, 89-95. See abstract
  7. Beebe, D. W. (2011) Cognitive, behavioural and functional consequences of inadequate sleep in children and adolescents. Pediatrics Clinics of North America, 58, 649-665.
  8. Meltzer, L. J, & Mindell, J. A. (2014). Systematic review and meta-analysis of behavioural interventions for pediatric insomnia. Journal of Pediatric Psychology, 39, 932-948.
  9. Montgomery, P., Stores, G., & Wiggs, L. (2014). The relative efficacy of two brief treatments for sleep problems in young learning disabled (mentally retarded) children: A randomised controlled trial. Archives of Disease in Childhood, 89, 125-130.
  10. Wiggs, L. & Stores, G. (1998). Behavioural treatment for sleep problems in children with severe learning disabilities and challenging daytime behaviour: Effect on sleep patterns of mother and child. Journal of Sleep Research, 7, 119-126.
  11. Wiggs, L. & Stores, G. (1999). Behavioural treatment for sleep problems in children with severe learning disabilities and challenging daytime behaviour: Effect on daytime behaviour. Journal of Child Psychology and Psychiatry, 40, 627-635. See abstract
Find out about CP Check-Up™

Cerebral Palsy Alliance offers a service called CP Check-Up™ which provides ongoing surveillance of the health and well-being of our clients aged 0-18 years.
The information on this page was developed using the best research evidence combined with the expertise of clinicians and people with cerebral palsy and their families. It is provided to help people with cerebral palsy, their families and caregivers, clinicians and service providers make decisions about suitable interventions. This information is intended to support, but not replace, information exchanged, and decisions made, between people with cerebral palsy, their families and health professionals.