Clinical Management, pediatric

Question 1

What are considered healthy sleep habits in children?

Answer 1

Practice promoting sleep regulation (circadian and sleep drive
Practices that promote sleep conditions
Reduce arousal and promote relaxation
Practices that promote adequate sleep quantity and quality

Question 2

What are practices that promote sleep regulation in pediatrics?

Answer 2

Maintain consistent sleep-wake cycle
Set and enforce consistent bedtime weekdays and weekends
Set and enforce a consistent wake time weekdays and weekends
Keep regular daily schedules of activities, including meals
Avoid bright light in bedroom at his and during night
Increase light exposure in morning
Establish appropriate napping schedule

Question 3

What are practices that promote sleep conditions in pediatrics?

Answer 3

Establish regular and consistent bedtime routine
Limit activities that promote wakefulness
Don’t use bed for punishment
Avoid sleeping in environments other than bedroom

Question 4

What practices reduce arousal and promote relaxation for children?

Answer 4

Electronics out of the bedroom
Reduce stimulating play at bedtime
Avoid heavy meals 1-2 hrs before bed
Reduce cognitive and emotional stimulation before bedtime
Limit or eliminate caffeine consumption

Question 5

What are practices that promote adequate sleep quantity and quality for children?

Answer 5

Set an age-appropriate bedtime and wake time to ensure adequate sleep
Maintain a safe and comfortable sleeping environment

Question 6

What is the definition of Extinction?

What is it used for?

Answer 6

Behavioral medicine principles:
Behavioral theory’s principle of elimination a previously reinforced behavioral response

Extinction is effective in reducing inappropriate bedtime behaviors
e.g. crying, tantrums, repeatedly getting OOB

Question 7

What results in maintenance of inappropriate bedtime behaviors

Answer 7

Behaviors are often maintained by reinforcement of parent attention and insufficient limit setting

Question 8

What are the procedures of approach with Extinction?

Answer 8

Time out from positive reinforcement (e.g. parent attention)
Planned ignoring (of attention maintained disruptive behaviors)
Extinction of escape and avoidance behaviors

Question 9

What are the steps involved in the Extinction approach?

Answer 9

Assessment
Information
Bedtime routine
Reinforcement for appropriate behaviors and unmodified extinction

Question 10

How is Standard/unmodified extinction carried out?

Answer 10

Extinguishing infant crying at bedtime by discontinuing the reinforcement of child crying via parental attention/presence

Parents have been reinforcing the child’s crying at bedtime (e.g. staying or returning to comfort the child when crying.)

Std extinction = putting the infant to bed while drowsy w/adequate need for sleep, remotely monitor for safety. Do not return to comfort child.

Requires parent to tolerate child crying. Need strong support system.

During first 3-5 nights of intervention, therapist and parent have daily phone/email contact. Therapist provides parents support.

Extinction doesn’t lead to worsening of parent-child relationship

Question 11

What is an extinction burst?

Answer 11

Frequency and severity of inappropriate bedtimes behavior may increase during the first night of treatment

Question 12

What is spontaneous recovery?

Answer 12

Reoccurrence of problems that usually occurs with a change in environment

Question 13

What is the data to support standard extinction?

Answer 13

Large treatment effect size
Effectiveness in children w/ dev. Disabilities
+ effects on parental well-being and child’s daytime behavior

Question 14

What are indications for Graduated Extinction w/ and w/o parent

Answer 14

For bedtime problems and night time wakening’s involving inappropriate sleep associations and/or limit- setting problems, in young children (ages 6 mos to 5 years)
Indicated for insomnia

Question 15

What is sleep onset insomnia in children?

Answer 15

Typically seen in children >= 6 months

Caused by neg. Sleep onset associations that interfere w/ falling asleep and going back to sleep independently at night

Question 16

What is limit-setting insomnia in children?

Answer 16

Avoidance of bedtime
Frequent requests after lights out
Refusal to go to bed or stay in bed

Question 17

What is combined type of insomnia in children?

Answer 17

Both SOA and limit setting

Often difficulties with limit setting leads to development of negative sleep onset assoc.

Question 18

What are contraindications to Extinction procedures?

Answer 18

Severe anxiety d/o
Children w/ past trauma
Prolonged crying is medically contraindicated (cardiac condition)

Question 19

What percent of children experience bedtime problems and night awakenings?

Answer 19

20-30% of children experience bedtime problems and night awakenings

Question 20

What is a sleep onset association in children?

Answer 20

Conditions that must be present to help a child fall asleep and return to sleep

Positive=one w/o assistance such as thumb sucking, pacifier, stuffed animals (able to self soothe)
Negative=another person, nursing, being rocked

Question 21

General parent education

Answer 21

Night wakings are normal

Bedtime behavior problems are often difficult to manage

Question 22

What is graduated extinction?

Answer 22

It is an effective treatment and often more tolerable for parents than standard extinction
Remove reinforcement over time
Treatment: putting to bed when drowsy and then checking in at regular intervals (fixed or incremental scale).
Not tied to whether child is crying
Problem as to whether you are still reinforcing in some way

Question 23

What is Extinction with parental presence?

Answer 23

Ignoring the child’s crying but remaining near the child (in the same room).
Also called “parental presence” or “camping out”
Parent staying in child’s room, but not attending to them when crying

Other terms are “planned ignoring”
Parent is present; gradually fades involvement
Amount of physical contact
Proximity to infant

Question 24

What is an Extinction Burst?

Answer 24

Reappearance of a previously extinguished behavior (crying)

It should be ignored to prevent the problem from reoccurring due to parental reinforcement

Question 25

What is the major barrier to implementing extinction treatments?

Answer 25

Parental resistance is the major barrier.

Question 26

What are alternatives to Extinction treatments?

Answer 26

Positive routines | Bedtime fading

Question 27

Normal sleep and development for newborns (0-3 months)

Answer 27

10-18 hrs/day (longer premature infants) No designated sleep time (45 min-4hr) across 24 hr span 8-12 weeks, sleep patterns begin to consolidate, differentiation between day and night, more predictable sleep/wake schedule

Question 28

Normal sleep and child development for Infants (3-12 months)

Answer 28

12-13 hrs (9-10 hrs at night and up to 4 hrs during day w/naps) Individual variability Sleep consolidation continues Most 6 month old sleep through night (at least 6-8 hrs) and 2-3 daytime naps

Question 29

Normal sleep and development for toddlers (12 mos - 3 yrs)

Answer 29

TST= 12-14 hrs 9-12 hrs at night, 2-4 hrs w/naps By 18 months most toddlers have transitioned to 1 nap

Question 30

Normal sleep and development for Preschoolers (3-5 years)

Answer 30

Decreased sleep needs due to phasing out of daytime naps Average 11-13 hrs of sleep per 24 hrs by age 5, only 25% of children continue to nap during the day (increased napping in black children, possibly due to not enough sleep at night, socioeconomic reasons)

Question 31

How should a parent establish a sleep schedule and bedtime schedule? What is Bedtime fading?

Answer 31

Ensure child is falling asleep at consistent and age appropriate time 7:30pm for infants 7:30-8:30 pm for toddlers/preschoolers If child is put into bed at 7pm, but doesn’t fall asleep until 9pm; place child in bed at 9pm and slowly fade (add 15 min. Every 3-4 nights). This is Bedtime Fading Keep consistent bed and wake up times Consistent bedtime routines can reduce bedtime resistance and increase sleep consolidation (3-4 soothing activities that occur on nightly basis (bath, books, prayers, bed) for total of 30-40 min. Consistent bedtime routine and sleep schedule is needed prior to continuing with graduated extinction

Question 32

Other factors involved in childhood sleep and using Extinction treatments

Answer 32

Stabilize parent behaviors and sleep location at bedtime and during the night Set a global or targeted approach: Based on child temperament and parent tolerance Decide to do both bedtime and night awakening or one at a time REsearch indicates that intervention at bedtime often transfers in 2 weeks time to night time awakenings and targeted approach is usually more tolerated by parents

Question 33

How is Graduated Extinction implemented?

Answer 33

1-2 weeks of bedtime routine Bedtime and parent behaviors have been consistent Next step is to gradually remove the negative sleep onset association (e.g., nursing parent lying next to child) Each step is followed for at least 3 nights, but more often 4-7 nights until behavior has stabilized Problem-solve barriers to treatment adherence

Question 34

How is Positive Routines done as a procedure | Bedtime Routine

Answer 34

Involve positive and rewarding bedtime interactions with the caregiver Help children to establish cues for sleep onset Typical improvements within 1-2 weeks, treatment last 2-6 sessions 3-4 quiet activities, such as bath/washing, massage/lotion, stories, cuddling/rocking No electronics Same order and time each night. Effective as stand alone intervention Dose-dependent relationship

Question 35

What are the details of Bedtime Fading?

Answer 35

Start with initially later bedtime Move it earlier slowly over time Useful for settling problems Move child’s bedtime to typical sleep onset time Positive, quiet routines After 2 nights, if child has SOL <15 min, advance bedtime by 15 min If child has SOL>15 min, delay bedtime by 15 min. Maintain regular rise time Classical conditioning/sleep hygiene Power struggles eliminated (child is exhausted at bedtime) Can combine with standard bedtime routines and positive reinforcement to adjunct For teens, use token economy to trade in for larger reward

Question 36

What are BSM principles for Bedtime fading?

Answer 36

Starting out w/initially later bedtime results in buildup of sleep pressure Support behavioral strategies of removing parental involvement at sleep onset Working toward more normal SOL of 20-30 min and determining need for sleep Behavioral Tx works best when wake-up time is anchored. An initial later bedtime is selected based upon when child is typically falling asleep (or within 30 min. Of this time) Then bedtime is gradually moved earlier

Question 37

What is the Bedtime Pass?

Answer 37

Moore, 2007 journal of ped psychology Child is given a “bedroom pass” with his/her name written on it that can be used for one brief trip out of the bedroom to get another hug, drink of water. The pass is surrendered to the parent when used Behav. Med. Principles: the bedroom pass is used to set limits to “curtain calls” at bedtime or leaving the bedroom at wake-up’s to seek parental attention/comfort (limit setting) The use of the pass just one time can be reinforced by child earning reward in morning (sticker, small prize from treasure chest) or a privilege (i.e. positive reinforcement)

Question 38

What is exposure with response prevention?

Answer 38

Backbone of anxiety interventions Create hierarchy of anxiety-provoking steps toward going to bed and sleeping independently Flashlight treasure hunts (fear of the dark) Positive self-talk

Question 39

What is cognitive restructuring?

Answer 39

``` Identify automatic thoughts Look at evidence for and against that thought Rate associated feeling and intensity Other thoughts/helpful coping strategies Rate feelings with new thought ```

Question 40

What is positive reinforcement (operant conditioning)?

Answer 40

``` Behavior is encouraged by rewards Positive punishment= an undesirable stimulus is introduced to discourage the behavior Negative reinforcement= undesirable stimulus is removed to encourage the behavior Negative punishment (extinction)= a desirable stimulus is removed to discourage the behavior ```

Question 41

How is the behavioral technique Scheduled Awakenings carried out?

Answer 41

It is a behavioral technique that is mostly successful in situations in which episodes occur (arousal d/o) on nightly basis Children w/frequent d/o of arousal that occur highly predictive time, scheduled awakening can be highly effective Involves having parent wake child ~15-30 min prior to time of night episode typically occurs First keep sleep diary Parent begins waking child on nightly basis just prior to event-just to point of arousal (e.g. child changes position or mumbles) Do over 2-4 weeks

Question 42

Nocturnal enuresis

Answer 42

Common parasomnia affecting 5-7 million children annually- mostly inherited 15-20% of 5 yr old children As many as 10% remain wet at 10 yrs old Higher incidence for boys

Question 43

What is the best evidence based treatment for nocturnal enuresis

Answer 43

Moisture alarm Indicated for children with primary enuresis (not fully continent for at least 6 mos) Indicated for secondary enuresis (continent for 6+ months, but then relapse) Most alarms are for 5+ yrs old Treatment often deferred until 6-7 Enuresis shows steady decline w/age and has spontaneous remission rates of ~15%

Question 44

What medications are used for Nocturnal enuresis?

Answer 44

``` Medication is not a front line treatment Medications include: desmopressin tolerodine imipramine oxybutynin ```

Question 45

What are the intervention steps for evaluating nocturnal enuresis in children?

Answer 45

``` Pick a right time by age Prelim. Eval by MD: look for UTI, comorbid conditions (Diab insipidis, spina bifida, or spinal cord trauma Education and demystification Interview by behav. Health staff Moisture alarm procedural checklist ``` Important supplies: alarm that has a salient wake up cue auditory alarms have most supportive data, vibrating alarms also effective vibrating alarms may be preferred when share a bedroom

Question 46

What is Dry bed training for nocturnal enuresis?

Answer 46

Azrin Inhibiting urination training Positive reinforcement for correct urinations Training in rapid awakening Increased fluid intake vs fluid restriction Increased social motivation to be non neurotic Self-correction of accidents Practice in toileting Dry bed is considered 14 days

Question 47

What is systematic desensitization?

Answer 47

Develop a hierarchy of fear-invoking activities or thoughts from least to most frightening with the child These activities or thoughts are paired with a relaxing activity

Question 48

What relaxation therapies are used in children?

Answer 48

Deep breathing Biofeedback PMR

Question 49

Newborn sleep characteristics

Answer 49

Sleep periods separated by 1-2 hrs of wake time Cycles dependent on hunger/satiety 3 sleep states: Active (REM-like), Quiet sleep (non-REM like), Indeterminate Enter sleep through Active (REM) state Early weeks: no est. nocturnal/diurnal pattern Immaturity of circadian sleep-wake cycle results in limited rhythmicity and predictability of sleep

Question 50

More info about sleep enuresis in children

Answer 50

Criteria: 2x/wk in a child +5 for at least 3 mos Genetic component Prevalence: 22% of 5yo, 10% of 6 yo, 1-3% of 15yo 15%/yr improve without intervention Primary vs secondary Assoc w/ reduced self-esteem, self-esteem increases with successful Tx First line Tx: urine alarm

Question 51

Pediatric RLS- What’s different?

Answer 51

Children w/ untreated RLS may exhibit behaviors consistent w/ bedtime resistance Lower prevalence: 1-6% Increased prevalence in children w/ ADHD and ASD Low iron storage (serum ferritin <50) found in 70-75% of children w/ RLS. Tx is iron supplementation Child report: may include terms such as squeezing, tingling, wiggling, itchy, popping, “funny” feeling

Question 52

What is the BEARS clinical interview for children? | The Sleep Habits Assessment

Answer 52

Bedtime: routine, resistance, fears EDS: hyperactivity, irritability, difficulty waking Awakenings: call outs, partial arousal, restlessness Regularity: schedule, duration Snoring: volume, pauses in breathing

Question 53

AASM Clinical practice Guidelines | Practice parameters for behavioral Tx of bedtime problems and night wakings in infants and young children

Answer 53

Behavioral interventions are effective and recommended in the tx of bedtime problems and night awakenings in young children. (Standard)

Question 54

Extinction Txs are effective

Answer 54

``` Infant and child outcomes: Did not negatively impact breastfeeding or infant daily intake. Reduced crying after intervention Reduced irritability More predictable schedule Better overall behavior ``` ``` Parent and family outcomes: Fewer nightwakings Improved mood In depressed mothers, reduced sx Enhanced marital satisfaction Reduced parenting stress Increased parenting efficacy ```

Question 55

Faded bedtime with response cost

Answer 55

Temporarily delaying a child’s bedtime to closely coincide with their typical sleep onset time Based on principles of stimulus control bedtime is faded earlier as child falls asleep faster until a target bedtime is reached Typical rate 15-30 min. Per night Response cost involves taking the child out of bed for short periods if not falling asleep

Question 56

The Bedtime Pass, other aspects

Answer 56

Bedtime Pass is a card exchangeable for one parental visit or excused departure from the room after bedtime Subsequent bids for attention are ignored Evaluated by in 3-6 year olds and found to be effective in reducing “curtain calls” and SOL Recommended for ages 3-10

Question 57

What is Alarm therapy?

Answer 57

Bed wetting alarm, urine alarm, bell and pad Alarm alerts child in response to moisture, child leaves bed to finish urinating in bathroom May require practice to learn to wake in response to alarm. Widely recognized as optimal Tx for enuresis Superior to medication and psychological intervention Success rate 78% when used for 4-6 mos 25-40% relapse

Question 58

Dry Bed Training, details

Answer 58

``` Azrin, 1974 Treatment components: Positive practice Increased fluid intake Scheduled awakenings Alarm Positive reinforcement Cleanliness training ``` Phases: Intensive training (one night, hourly awakenings) Post-training supervision (ongoing, scheduled awakenings) Normal routine (after 7 dry nights, only positive reinforcement and cleanliness training)