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TABLE 8

Behavioral Sleep Interventions

Behavioral Sleep InterventionsDescription
Extinction (“crying it out”) Parents put the child to bed and ignore until morning (but monitor for concerns for safety or illness). 
Graduated extinction (“sleep training”) Parents put the child to bed and ignore crying and tantrums for a predetermined period of time before briefly checking on and reassuring the child. The time between checks is gradually increased. The time between checks should be determined based on the child’s temperament and the parents’ tolerance for crying. 
Fading of parental presence Parents put the child to bed and gradually fade their proximity to and interactions with the child during sleep-onset every few nights. For example, the parent can transition from lying next to the child to sitting in a chair next to the bed and progressively move the chair further from the bed every few nights until they are no longer in the room. 
Scheduled awakenings After establishing the baseline timing and number of night awakenings, parents wake the child up 15–30 min before the typical awakening and follow their typical response to spontaneous awakenings. The scheduled awakenings are then gradually faded out by increasing the time between them. 
Positive routines Parents develop a consistent bedtime routine of calm activities to establish a behavioral chain leading up to sleep onset and promote appropriate sleep associations. Use of a transitional object such as a blanket or stuffed animal can help promote appropriate sleep associations. 
Bedtime pass Parents provide the child with 1 or 2 tokens (the bedtime “pass”) that can be turned in for 1 request or contact with a parent after bedtime. If the child does not use the bedtime pass, he or she can turn it in for a positive reinforcer in the morning 
Bedtime fading The designated bedtime is temporarily delayed until it coincides with the child's usual onset of sleep. The bedtime is then gradually moved earlier. If the child fails to fall asleep as expected, he or she is taken out of bed briefly before put to bed again. 
Behavioral Sleep InterventionsDescription
Extinction (“crying it out”) Parents put the child to bed and ignore until morning (but monitor for concerns for safety or illness). 
Graduated extinction (“sleep training”) Parents put the child to bed and ignore crying and tantrums for a predetermined period of time before briefly checking on and reassuring the child. The time between checks is gradually increased. The time between checks should be determined based on the child’s temperament and the parents’ tolerance for crying. 
Fading of parental presence Parents put the child to bed and gradually fade their proximity to and interactions with the child during sleep-onset every few nights. For example, the parent can transition from lying next to the child to sitting in a chair next to the bed and progressively move the chair further from the bed every few nights until they are no longer in the room. 
Scheduled awakenings After establishing the baseline timing and number of night awakenings, parents wake the child up 15–30 min before the typical awakening and follow their typical response to spontaneous awakenings. The scheduled awakenings are then gradually faded out by increasing the time between them. 
Positive routines Parents develop a consistent bedtime routine of calm activities to establish a behavioral chain leading up to sleep onset and promote appropriate sleep associations. Use of a transitional object such as a blanket or stuffed animal can help promote appropriate sleep associations. 
Bedtime pass Parents provide the child with 1 or 2 tokens (the bedtime “pass”) that can be turned in for 1 request or contact with a parent after bedtime. If the child does not use the bedtime pass, he or she can turn it in for a positive reinforcer in the morning 
Bedtime fading The designated bedtime is temporarily delayed until it coincides with the child's usual onset of sleep. The bedtime is then gradually moved earlier. If the child fails to fall asleep as expected, he or she is taken out of bed briefly before put to bed again. 

Courtesy of K Steingass, American Academy of Pediatrics, PREP DBPeds Self-Assessment.

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