A Primer on Behavioral Sleep Treatment

Tuesday, February 22, 2022

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6 minute read | contribution authored by Keira Moore, Ph.D., BCBA-D

Sleep problems are often behavior problems. Just like jumping rope, riding a bicycle, talking, or throwing a temper tantrum, sleeping- and more specifically falling asleep- can be learned and can be changed. When good sleep habits are practiced, people learn how to be good sleepers, and these skills can last for life!

Like all other behavior, we must assess the four term contingency in order to successfully treat sleep problems. The target behavior we want to increase is falling asleep quickly when in bed. The reinforcer for this behavior is sleep. When trying to change the behavior of falling asleep quickly, we focus mostly on changing the antecedents- the motivating operations and discriminative stimuli. To assess motivating operations we look at anything that affects the value of sleep as a reinforcer (e.g., sleep deprivation, exercise, use of substances like caffeine or alcohol), and we try to increase that value. To assess discriminative stimuli we look at anything that signals that sleep is available (e.g., darkness, getting into bed, a bedtime routine, etc.), and we try to create lots of signals for sleep while decreasing signals for other available competing activities. When treating sleep problems, we also have to be careful to examine interfering behavior- that is, any behavior that is ongoing at bedtime that competes with falling asleep. First we must identify any interfering behavior that is going on (e.g., calling out, engaging with electronics, getting out of bed repeatedly, etc.), then assess the four term contingency that is supporting that behavior, so we can reduce that behavior.

Typically, good sleep depends on four key elements: a regular sleep routine before bed, developing appropriate (and removing inappropriate) sleep dependencies, decreasing behavior that interferes with falling asleep, and sticking to a regular sleep schedule. If these four elements are developed and adhered to, good sleep habits will come quickly, and last a lifetime. This goes for both children and adults!

A regular sleep routine helps to establish discriminative stimuli for sleep by doing the same things before bed every night. This could be a simple routine like taking a shower, putting on PJs, brushing your teeth, reading a book, and then getting in bed. Sticking to a set routine helps signal to your body that it should get ready for sleep, and helps decrease the time it takes to fall asleep. The more consistent you are with the sleep routine, the easier time you will have getting to sleep quickly.

Sleep dependencies are things that we need to have in order to be able to fall asleep, and are also discriminative stimuli for sleep. Some people have healthy sleep dependencies, some people have unhealthy sleep dependencies, and some people have none! It’s good to have some sleep dependencies, because like a regular sleep routine, these things signal to your body that it is time to sleep. They can also help you fall back to sleep when you wake up in the middle of the night. Healthy sleep dependencies are things that you can have with you every night, and things that remain with you all night. For example, a dark room, a special pillow, white noise, or a stuffed animal are all healthy sleep dependencies. Unhealthy sleep dependencies are things that interfere with good sleep and are not always with you or don’t stay with you all night. Things like falling asleep with a TV on a timer, falling asleep with a parent in the room who does not stay all night, falling asleep with a full belly, or falling asleep while playing on your phone are all unhealthy sleep dependencies.

Many children (and adults) engage in interfering behavior during the bedtime routine or the time they should be falling asleep, which prevents them from falling asleep quickly. A healthy sleeper will fall asleep within about 10-15 min of their head hitting their pillow. If that is not the case, chances are there is some interfering behavior going on. For many children this takes the form of calling out to parents or getting out of bed. For adults it’s often watching TV or engaging with some other electronics in bed. Interfering behavior prevents the body from going into “sleep mode” and can lead to unhealthy sleep dependencies. In addition, engaging with electronics floods our body with artificial light, tricking us into thinking it’s still day time, and changing the production of melatonin, which helps us sleep. Decreasing interfering behavior is often where children need the most work during sleep treatment. This is also the area that tends to be hardest for parents to conquer…but with time and patience it can be done!

Sticking to a regular sleep schedule is one of the most important healthy sleep habits…and also one of the hardest to adhere to. Going to bed at the same time every night, and waking up at the same time every day (yes, even on weekends) is essential for healthy sleep as it becomes an establishing operation for sleep. Being on the same schedule each night helps the body to know when it is time to sleep and time to be awake, and helps ensure an adequate amount of sleep each night.

All four of these essential healthy sleep habits are attainable (often easier than you would think) for all sleepers! For most people, a few weeks of hard work and persistence can make a lifetime of difference in sleep. Happy sleeping!