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Pediatric Behavioral Sleep Medicine: Sleep as a Superpower

September 1, 2020

The north wall of my office is strategically adorned with pictures of various superheroes. I often point to the many superpowers featured along this wall as I describe behavioral sleep medicine to a child. Teaching children how to take control of their sleep and make it their own superpower is the essence of pediatric behavioral sleep medicine. Through the use of evidence-based psychological interventions, pediatric behavioral sleep medicine helps children address behaviorally based sleeping difficulties when an underlying medical explanation has been ruled out. Fortunately for pediatricians, many of these behavioral interventions are simple, practical, and easily implemented during a brief office visit. Below I describe three specific evidence-based interventions in the field. 

The Bedtime Pass

Bedtime can be a stressful time for children and parents alike. Bedtime is often rife with an array of behavioral and emotional challenges including defiance, stalling, anxiety and general distress.  The child’s distress level can intensify once he or she is in bed and separated from caregivers.  Not surprisingly, such children tend to get out of bed multiple times to seek some form of parental attention, which often leads to delayed sleep onset. The bedtime pass is a useful tool that helps young children stay in bed and initiate sleep independently. Depending on the severity of the bedtime protests, the child is given 1-3 bedtime passes each night. The child is permitted to use the pass to get out of bed and summon parents for any reasonable request (e.g., an extra goodnight hug, etc.). The bedtime pass helps by providing the child with a greater sense of control and therefore alleviating much of the distress associated with bedtime. To further motivate a child to stay in bed, I advise parents to allow their child to exchange any unused bedtime passes for a reward the next morning. 

The Flashlight Scavenger Hunt

Darkness is one of the most common fears among younger children. When children cannot see, their imagination can seamlessly fill the opacity of darkness with malign content. From a spooky monster in the closet to an intruder lurking in the shadows, such worries can delay sleep onset and/or lead to unhealthy sleeping habits (e.g., sleeping with the lights on). The flashlight scavenger hunt is a fun way to help kids develop a greater comfort level with darkness and overcome their fear. In the flashlight scavenger hunt, the child is tasked with finding hidden items (by the parent) in his/her dark bedroom using only a flashlight. I typically advise parents to begin by hiding one item in a simple location, and gradually add more items in more difficult-to-find locations as their child’s comfort level increases. 

Flipping the Script on Recurrent Nightmares

Nightmares are a common phenomenon in young children and typically do not necessitate structured clinical intervention. For some children, however, more frequent nightmares can lead to a variety of additional sleep related problems (e.g., difficulty with sleep-onset, co-sleeping with caregivers, etc.). Imagery Rehearsal Therapy (IRT) is an evidence-based intervention that helps children develop a sense of control over their recurrent nightmares. Applying IRT, I first have the child vividly describe the nightmare (either in writing or drawings depending upon the child’s age). Next, I help the child write or draw a new dream that contains similar themes but with more benign content. Crucial to the efficacy of IRT, the child is instructed to rehearse this new dream multiple times throughout the day and immediately following a nightmare. 

 

Sam Marzouk, Ph.D., L.P. is a pediatric psychologist and owner of Promethean Psychology in Edina. In addition to his work in behavioral sleep medicine, Dr. Marzouk also specializes in adolescent mental health.

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