Assessment and Treatment of Behavioral Sleep Problems

Assessment and Treatment of Behavioral Sleep Problems


[MUSIC PLAYING] DR. WAYNE FUQUA: We’re very fortunate today to have Dr. Brett Kuhn, who is a nationally recognized expert in childhood behavioral sleep problems. And Brett, I was going to ask if you’d be so kind as to start off by telling us something about yourself. What is your role here at Monroe Meyer
Institute at University of Nebraska, Brett? DR. BRETT KUHN: My name is Brett Kuhn. I’m a licensed psychologist. I specialize in pediatric psychology with an even further
specialization in pediatric sleep. I’m an associate professor of pediatrics at the
Monroe Meyer Institute and University of Nebraska Medical Center. WAYNE: Brett, could you please give us an orientation
to behavioral sleep problems for children? In particular, could you talk about their prevalence,
and why they are of major concern to children and their parents? BRETT: Well, there are a variety of sleep problems,
or sleep disorders in children– anything from obstructive sleep apnea, which we maybe see in kids with certain cranial facial
abnormalities to parasomnias and then circadian rhythm disorders, problems with a sleep-wake regulation, and then finally,
behaviorally based sleep disorders where children often engage in disruptive behaviors in order to avoid bed, bedtime,
or may awaken frequently. What that leads to is they oftentimes don’t get enough sleep. And of course, when children
don’t get enough sleep, their parents don’t get enough sleep. WAYNE: That must be a major source of stress for
a number of families, in particular when the child’s sleep problems disrupt the family routine and create a source of stress
for the parents who might not themselves be getting enough sleep. BRETT: It is a major source of stress for families. I have yet to have a three-year-old child come in to me
in my clinic saying, doc, you got to help me. I can’t sleep. But yet their parents drag them in each and every day. Again, when kids don’t sleep well, parents don’t sleep well. And it just ends up sometimes being an explosive situation. WAYNE: Is this an area that’s unique or overrepresented
in children with disabilities or on the autism spectrum? Or is it something that seems to cut across the board for nearly all children regardless of diagnosis
or neurotypical, neurological development? BRETT: Studies throughout the decades and across
different countries reliably find that 25% of young children and 15% of older children, adolescents, have one diagnosable sleep disorder, at least one diagnosable sleep disorder. When you get into children with developmental disabilities, genetic syndrome handicapping conditions, you can at least double that rate. We don’t know exactly why. Obviously there are physical limitations on occasion. But in my mind, in my estimations, sometimes parents just have so much on their plate when they have a special needs child, they’re dealing with the medical issues, they’re dealing with the behavioral issues, they’re dealing with academic and learning issues. Sometimes it just takes awhile to get
around to targeting their sleep problems. WAYNE: Great. When somebody comes into your clinic
complaining about sleep problems for their children, what sort of assessments do you typically do?
What types of questions or instruments do you typically do that help inform you about the problem
and the types of treatments you might pursue? BRETT: The first thing we want to do is rule out
physiological problems related to sleep. So clearly we want to make sure that
the child is breathing OK at night and isn’t snoring, doesn’t have obstructive sleep apnea,
doesn’t have symptoms with narcolepsy. those are more rare disorders.
Children with behaviorally based sleep disorders, We don’t have an objective laboratory study.
It just doesn’t capture the type of information that we need to get. So a lot of it is a well-designed structure
or semi-structured clinical interview from a functional frame of mind to identify all those variables that are
impairing a child’s ability to sleep appropriately. WAYNE: Brett, it sounds like one of your first
steps is to try to rule out some of the physiological causes for sleep problems, perhaps
by referral to a pulmonologist. And then after you rule those out, it sounds like you
might then start pursuing questions about behavioral factors that might contribute
to sleep problems. Is that correct? BRETT: Exactly. So the majority of
the clinical interview is designed to elicit those behavioral factors that
impair and impede sleep in children. We oftentimes just open things up
to have parents describe the reason they came in. Once they’re done telling their story,
we try to identify past treatment attempts. And again, here’s where the ability to conceptualize
from a behavioral standpoint– it can be very helpful to identify why past treatment attempts didn’t work for this
individual child and make sure that you don’t go down that road again. That your treatment plan addresses those
loopholes or those gaps in those problems. The next thing we’ll look at is parents define treatment goals. I have my goals for my children and how I want them to sleep. But that may not be why this
particular parent is in the room with their child. So we want individualized, behaviorally specific,
measurable treatment goals, so that we can head true north the entire time and make progress. WAYNE: On a naive level it sounds like the goals might be
pretty standard across individuals, but I get the feeling from what you’re saying, Brett, that there might be some cultural
or familial variability in terms of what their goals might happen to be for their children and their sleep.
Is that correct? BRETT: That’s one of the reasons
we want to make sure that parents identify their own individual treatment goals. Because there are differences
in sleep practices across cultures, even within the metro
area here there are differences in a parent desires and wishes in terms of
how and where and when they want their child to sleep. We want to make sure that they’re
able to identify their treatment goals, and we’re working with
them to meet those treatment goals. A good example is the sleep program that I’m going
to describe here in a bit is really more tailored to parents who desire to teach their child to become an independent, solitary sleeper. It’s probably not as valuable for those parents who desire
to co-sleep or bed-share all night, every night as a routine practice. WAYNE: Brett, it also sounds like you ask your clients
about prior treatment experiences and successes. Can you help us understand, perhaps with an example, Brett, what information you’re looking for and how that might
inform either your assessment or your treatment strategies? BRETT: Well, one of the most difficult cases coming in our
sleep clinic door is those children who have been already through a quote “cry it out” or extinction-based procedure,
and who’ve become very tolerant or have trained persistence to where they’ve cried for long periods of time. And then the parents, for whatever reasons,
and sometimes understandable reasons, terminate the protocol, go in, and provide the reinforcements. For those children, if we simply said, OK, let’s go
straight to a cry it out or extinction-based program, we’re going to be two or three hours into the protocol
before the child recognizes a contrast in the programming. WAYNE: Could you describe in a little more detail
for the practioners the critical elements of an extinction-based protocol, such as the cry it out procedure, and in particular comment
on the strengths and limitations of that particular procedure? BRETT: Well, if you look at the empirical literature, the large majority of the research has been done on single techniques, most of them involving extinction, or extinction modifications, extinction variants. Straight extinction– when I say extinction in the sleep literature, I’m talking about ignoring, because we don’t have in the literature yet a formal way to conduct a functional analysis of behaviorally based sleep problems. We haven’t specifically or scientifically identified those controlling variables. So when I refer to extinction here, I primarily mean ignoring. But obviously extinction is difficult for parents oftentimes to execute. If they’re not warned ahead of time, they may see that post-extinction response burst, the extinction burst. They may end up caving in and reinforcing more unique
or severe occurrences of the behavior. And now you as a clinician have to be able to deal
with that and solve that with your treatment plan. Extinction-based protocols are poorly viewed by a lot of parents. And if you don’t believe me, go in and search
on the Internet “cry it out” for sleep problems. And it’s rare for a family to come into my clinic who
hasn’t already tried some variation of an extinction-based protocol. Finally, extinction does a very nice job
and is very effective and expedient at reducing problem behaviors, but it does nothing to teach, train, shape, or reinforce
replacement behaviors, which I think are critical in teaching especially young children to fall asleep
independently and maintain sleep throughout the night. WAYNE: Just for clarification, could you describe
the procedural elements of the cry it out routine? In particular, I’m assuming that you’re thinking that
the parent attention, such as coming into the room when the child is crying, is construed as the reinforcer, and now you’re trying
to arrange extinction with respect to that source of reinforcement. BRETT: Yes. So the original, unmodified extinction protocol
calls for parents to place the child in bed, turn the lights off, and walk out, and not return until the next morning unless
there’s a sense that the child may be in danger. That is a very effective, very expedient treatment protocol. Parents, again, tend not to like that approach,
so people and professionals have come up with variants. And it’s primarily check-in procedures. The classic being 1985– Dick Ferber came out with graduated extinction. Where the parent walks out, ignores, and then walks back in the room to check on the child at 5 minutes, then at 10 minutes, and then at 15 minutes. And of course, if you conceptualize behaviorally, you worry about, again, teaching the child to persist longer and longer if the reinforcement value is there when the parent enters the rooms. When I work with parents on a graduated extinction protocol, we talk a lot about minimizing the reinforcement value when they walk in that room for those checks. Behavior analysts will recognize this as a time-based
reinforcement program or some type of non-contingent reinforcement. WAYNE: Just for clarification, Brett, could you describe
in a little more detail the graduated extinction procedure? It sounds like they’re going in every five minutes,
and then eventually every 10 minutes. Part of the concern might be– is there a potential
that by going in, and if you go in at the time the child is crying, that you might accidently reinforce crying and other
potentially inappropriate behavior on the part of the child? So I guess what I’m asking is do you have
any sort of exclusionary criteria about when you might go in or not go in on the graduated extinction procedure? BRETT: Traditionally the graduated extinction protocol
increases the checking interval within a single night. There are variations on that, of course, there are
variations on all these extinction based protocols. But certainly there is the risk when parents don’t
fully understand the procedure and the purposes, that they end up going in contingent upon
child behavior as opposed to passage of time. So they could intermittently or inadvertently reinforce, again,
more severe, creative, unique forms of crying, screaming, shrieking, which then is, again, hard to extinguish later on. WAYNE: Brett, just for clarification, is the advice for parents
to go in and have minimal interaction with the child when you go in to check? Or is there a programmed interaction that might be of
a reinforcing nature between the parent and the child? BRETT: I tell parents that those checks are really for them
not for the child, because honestly when they walk in the room during the time-based check, the child looks at them and thinks,
I’m saved. You’re here to save me. You’re here to put me back to sleep. So when the parent goes in, minimizes the reinforcement value
by just checking on the child, maybe talking to them briefly. And then when they turn around,
children don’t take lightly to that, they don’t like that. And oftentimes it just ends up fueling more crying.
It ends up taking longer for them to finally settle and fall asleep. You could also do an extinction modification by simply
watching the child on today’s modern, low-light, sensitive video cameras to make sure that the child is safe, hasn’t vomited or spit up,
hasn’t accidently woven their legs between the crib rails or anything like that. WAYNE: It sounds like that’s a fairly important
component in a treatment protocol, Brett. Is that where you would typically start? Or are there other components
that are worthy of consideration and other assessment considerations, Brett? BRETT: Almost all of the pediatric research thus far, the behavioral
pediatric research thus far, has looked at the efficacy of isolated techniques. And again, most of them are extinction-based or modifications
of extinction. To my knowledge at this point, we haven’t looked at the efficacy of a multi-component treatment program or manual. However, if you look at clinical practice guidelines and experts’
review articles, they all include some fairly similar components. WAYNE: Could you talk a little more about other components
perhaps above and beyond extinction-based interventions that might be built in to a behaviorally based intervention program
for sleep problems in children? BRETT: So just to emphasize, with most behavioral sleep problems,
it is the contingency management piece or the parent-child interaction piece that is the key active ingredient. But over time and with experience
we have just found that there are other components that you can add to enhance the parent-child interaction or contingency management piece. One is simply monitoring, assessing, and maintaining
an appropriate sleep-wake schedule. So one of the things that happens is parents think well, geez,
if it takes my child an hour to fall asleep, and he’s not falling asleep till 9:00, if I just put him in bed at 7:00, he’ll be asleep by 8:00.
And then we can go watch TV or read the paper. Unfortunately sleep physiology, specifically our circadian rhythm, just doesn’t work that way. So oftentimes we go just the opposite direction. And we try to make sleep itself more reinforcing by either temporarily delaying the bedtime to take advantage of this child’s circadian rhythm and increasing homeostatic sleep drive. Or sometimes we may use a minor sleep restriction therapy leading up to the contingency management procedure to make things go more smoothly. WAYNE: So it sounds like a major component of a comprehensive
behavioral sleep program is to put your children to bed when they’re drowsy, but don’t let them fall asleep out in the living room,
but actually they go into the bedroom when they are indeed drowsy. BRETT: That is a key component especially for younger children.
Putting children into their habitual sleep environment, drowsy but awake, to allow them the opportunity to initiate sleep in the place and under
the same cues that they’re expected to maintain sleep is a key component. Easier said than done, but those children– in the sleep literature– we call that sleep onset association disorder. Where they are dependent upon parent delivered cues to initiate sleep. And it’s very common to have a child come in who is put to sleep through rocking, feeding, singing, even dancing in another room. And then once the child’s asleep, they transfer that child into their bedroom or their own crib. And then, of course, the child completes their first sleep cycle, has a brief arousal, which is perfectly normal, but instead of looking around and realizing, yeah, I’ve been here, done this– going to back to sleep they have difficulties. They have to cry out or come out of the room to recontact those familiar cues or discriminative stimuli. WAYNE: So it sounds like an important component is
to establish a sleep routine, a bedtime routine that is not completely dependent upon what you might call parent initiated cues,
such as singing or rocking, but involves putting the child in bed essentially. BRETT: For younger children and some children
with developmental disabilities, they really do have a skill deficit and are unable or have great difficulty initiating sleep
without parent assistance, presence, or help. So that’s a difficult road ahead. But the excuse me drill, that I’ll describe in a little bit,
is uniquely designed to target independent sleep initiation. We usually start at bedtime, and then once the child has
7 to 10 nights of success initiating sleep independently at bedtime, then we’ll generalize the treatment program
to other sleep opportunities, like middle of night awakenings to allow them to fall back asleep after completing a sleep cycle. And finally, we’ll target naps if those are appropriate
given the child’s age and stage of development. WAYNE: Brett, it sounds like an important component
of a package involves the parent-child interaction, in particular the contingencies that the parent brings to bear. But before you get to that stage, are there some other considerations
and other treatment components that you might want to consider? BRETT: Indeed the key component is the contingency
management piece and modifying or optimizing parent-child interactions. But there are a lot of steps that clinicians can take to prepare
the parents and the child for that step, that difficult step. The first is making sure that you have established
a sleep compatible environment– or bedroom environment in our culture. And we know that human beings initiate sleep
and maintain sleep better in a reasonably dark environment, in a place that’s quiet– although white noise is actually good–
cool and comfortable, and in an environment that is perceived as safe, so that children can let down vigilance, relax, and fall asleep. The second step is to make sure that once you’ve created
that environment, you have to actually insist that the child falls asleep there. So I’ve supervised students who quickly establish that this
child is falling asleep in a dark, quiet, pristine environment with the canopy bed and the 400 thread count sheets– great sleep environment.
But unfortunately that child was falling asleep on the mom’s lap in the living room. That doesn’t do us much good. So one of the critical first steps
is to make sure that we’re not using, for example, an extinction-based intervention by putting the child in a foreign land and not first establishing
discriminative stimuli or sleep cues to allow those replacement behaviors to occur. So we may simply, at the end of our first appointment,
recommend that parents insist or require that child to initiate sleep in their habitual sleep environment during every sleep opportunity. So initially we may allow them to help the child fall asleep
in that environment, they may stay in the room with the child. I tell parents if you have a special dance or song that works– that’s great. We’ll blend those stimuli initially and get the child comfortable,
accustomed, and confident falling asleep in that habitual sleep environment, and then we can do the parent-ectomy later. WAYNE: Parentectomy– that’s a good word. It is a very apt
description of what might actually have to happen, Brett. BRETT: The bedtime routine, although it has been shown
in one study to help, it’s probably overrated to be honest with you. I think it’s important to have a regular bedtime
routine that sets the stage for sleep onset. The parents who come in to see me in my clinic,
most of them have established a regular routine. So I typically don’t focus on that per se. If you really want to set the stage for quick sleep onset,
a consistent morning waketime combined with bright light exposure actually sets our physiology so that we’re prepared
for sleep at the same time every night. WAYNE: So establishing a consistent sleep-wake
cycle seems like it’s a very important component of kind of an overall comprehensive sleep program. BRETT: It is. In fact, one contraindication to starting
a contingency management procedure at bedtime is a family who has a chaotic lifestyle, who may have a very inconsistent
sleep-wake schedule, or placing a child in bed when they are simply physiologically not prepared to sleep, or in some cases
a parent who is just simply overwhelmed, and they may place the child in bed more for respite than based on the time
needed to allow that child to get enough sleep. WAYNE: It sounds like some sort of a consistent routine
is fairly important, Brett, but I can also imagine a number of families having pretty inconsistent sleep arrangements from
week-to-week or day-to-day even with sometimes the child sleeping at the mother’s house, sometimes at the father’s house,
sometimes with the babysitter. So those sound like they might be interesting challenges from a behavioral sleep perspective. BRETT: That can definitely be a problem. We want to before the child– again, before we establish
the contingency management procedure and pull parents out of those pre-sleep cues, we want to make sure
that the child has those replacement skills. And one of those is making sure that they’re actually
sleepy, prepared to sleep when they’re placed in bed. One other little tip is carefully choosing who
is going to implement the treatment protocol. So oftentimes in your clinical interview
you can identify different parenting styles. And there may be differences also in the child’s behavior
and the level of disruptive sleep related behaviors with one parent versus the other. When you go to a contingency management program
and you alter parent-child interactions, that can be tough on children, and it can be tough on some parents. So you want to be
careful in choosing who’s delivering that intervention. Oftentimes when you’re withdrawing reinforcement, you’re
better off selecting the parent initially who can tolerate some child distress, who doesn’t get anxious, or who will
follow through with the program initially. Once you have success and the child is developing new,
more adaptive sleep onset skills, we can blend the other parent back in to where they’re both implementing the program
and then gradually fade out the first parent, so that both parents are adept at delivering the protocol independently. WAYNE: The parents sound like they’re important
components of this, Brett. In order to make this work with the parents, can you typically simply instruct the parents,
or give them a written protocol, or do you oftentimes have to make trips to the home to provide some sort of coaching
and direction and maybe even modeling for the parents? BRETT: Ideally I would love to go to every child’s home
and observe parent-child interactions at bedtime. Practically it’s just not feasible with a busy clinic schedule. Videotapes– videotaped observations are a great way. If you can’t get the information through a semi-structured clinical interview, a lot of times with today’s camera phones and very inexpensive video recorders you can observe parent-child interactions at bedtime. Which will give you a lot more specific and important information than simply getting it through a verbal interview. WAYNE: If you do have the wherewithal to get a video recording of a bedtime routine, and it comes back to your clinic,
what do you look for in those video recordings? BRETT: When I’m observing parent-child interactions at bedtime,
I’m looking for contingency management problems. So in other words, I’m looking for a parent who is adept and able
to identify appropriate pre-sleep behaviors and who will reinforce those, and those who also don’t end up inadvertently reinforcing
intermittently problem behaviors, like coming out of the room with food, attention, five minutes of extra TV, or who
enter the room contingent upon problem behaviors– or sometimes in the case of creative children,
various things that they come up with to drag the parent into the room. It’s interesting how young children oftentimes
are not interested in having a conversation with a parent, but as soon as they’re placed in their bedroom,
they want to know the meaning of life or why the sky is blue. And again, they’re being placed in an environment–
an appropriate sleep environment is relatively devoid of reinforcement. So oftentimes young children who are
unaccustomed to that or don’t tolerate that well will generate behaviors to increase reinforcement value
and drag that parent in to bring their 15th glass of water, to request that that water have added ice from
the refrigerator, cubed not crushed, shaken not stirred. Most parents, after going in there for
the 20th time, finally realize that maybe it’s not that my child’s so thirsty, maybe it’s me that they want. WAYNE: That sounds like a familiar routine for many parents. I’m wondering also about other
sources of reinforcement beyond the parents. Do you have any advice for parents about
the presence of video games, or television, or other forms of reinforcement
in the sleep environment, Brett? BRETT: Absolutely. One of the first steps
we try to help parents accomplish is again establishing that sleep compatible environment. And sources of light, especially screens that have
the blue phase of light, have an alerting effect. And there is study after study documents
that children who have television in their bedroom do not get as much sleep as those who don’t. So we have to eliminate screen time.
We have to eliminate their top three or four more stimulating or fun toys, enjoyable toys. Again, a sleep compatible environment
is relatively devoid of stimulation. So that’s why I think it’s important to teach
parents and prompt parents to go in the room every once and a while and deliver
some social reinforcement and praise, maybe even some touch for
children who are playing by the rules. WAYNE: Brett, we’ve already covered now something
about how you establish a sleep-conducive environment, establish some sort of a sleep enhancing routine, and maybe even make sure that there’s kind of a–
I think you called it a homeostatic drive to fall asleep by having some level of
sleep deprivation or drowsiness. Can we now talk a little bit about
the other side of the coin, so to speak? What sort of contingency management
strategies might a parent bring to bear for a child that protests going to bed, that cries in bed,
that gets out of bed frequently at night? Help us a little bit with the contingency
management side that you would be recommending for parents. BRETT: So the first step you have to accomplish
is making sure that parents understand the ultimate goal. For some children, the ultimate goal at the end
of the night is–no matter what you went through– is did they independently initiate sleep without the parent
in the room or without parental assistance? For maybe older children who may have more skills
and aren’t completely reliant on parental presence or assistance, The goal may simply be to reduce the occurrence of disruptive
bedtime behaviors, frequent nighttime awakenings, or any behaviors that may interfere with the process of sleep initiation. We need to make sure that parents have their eye on the prize,
and that they know what, in the end, a successful night looks like. After that, we’re really looking at modifying or optimizing
parent-child interactions to help children learn critical pre-sleep skills. What behaviors end up getting positive attention, what behaviors
end up being extinguished or aren’t going to get any parental attention. So again, the large majority of the research has been
on extinction and its variants, but we have other protocols also that rely a little bit more on reinforcement, shaping, et cetera. WAYNE: You mentioned procedures that rely
on reinforcement and shaping. I would certainly imagine that those are more palatable and easier
to get parent compliance than treatment protocols that rely mainly on extinction. Could you talk
about some of those reinforcement and shaping routines? BRETT: We don’t have any actual formal research
studies on treatment acceptability, but there is consistent research in the daytime behavior literature that
parents tend to prefer procedures to increase appropriate behaviors than behavioral reductive procedures, like extinction. So one example is bedtime fading with response cost,
which is a very well established protocol for kids. It has been used more in institutionalized settings
with children with special needs. It relies much more heavily on increasing the value of sleep over time
and less on reducing problem behavior. If you want to think of it as a concurrent reinforcement schedule,
basically over time you are increasing the reinforcement value of sleep itself. WAYNE: Can you describe that procedure in a little more detail? BRETT: Bedtime fading with response cost–
again, what we’re going to do is temporarily delay the bedtime. That’s been done in different increments. I know in my clinic when I do a bedtime fading component,
I look at the pre-treatment or baseline sleep diary and forget about what the child’s bedtime is and actually look at their
consistent sleep initiation time. So if bedtime is at 8:00, but they’re usually falling
asleep around 9:00, I’ll move temporarily the bedtime to 9:00. Again– circadian rhythm, increase homeostatic sleep drive. The response cost piece of that protocol is if the child
doesn’t fall asleep within 15, 20, 30 minutes, depending on the study and the protocol, you actually remove the child from bed,
and at that point there is no real firm instructions on what they’re allowed to do. You’re not trying to manipulate or control their behavior
or manage their behavior, you’re not trying to minimize reinforcements. I believe you should minimize light exposure. At that point you’re basically waiting for, again,
the child to become sleepy before returning them to bed and allowing, hopefully, more quick sleep initiation. What’s interesting to me is that when you read the pediatric
sleep literature, and you look at bedtime fading with response cost, if you read the adult insomnia literature,
that protocol is almost identical to a combination of protocols that we use for adult insomnia called sleep restriction
therapy and stimulus control therapy. WAYNE: We just call them different things,
but the procedures look very similar. BRETT: It’s pretty much the same, very similar. WAYNE: Does that procedure tend to be
pretty effective for children? BRETT: It does. We have fewer research studies
on bedtime fading with response cost. There are a few in the works. But it’s been shown, at least in institutionalized settings,
to be very effective with kids who have special needs. WAYNE: You mentioned some other procedures,
including the bedtime pass, could you describe that procedure in a little bit of detail and how it might actually be used? BRETT: The bedtime pass is especially suited for older,
more skilled children who have the ability to fall asleep independently, but maybe they continually creep out of the
room in order to access parental attention. They want that extra hug.
They want that extra kiss. The bedtime pass is simply a laminated or–
it could be a piece of wood for all that matters– placed underneath the child’s pillow,
and it allows the child one permitted exit from the bedroom to gain access to something that they may want or desire. They surrender that bedtime pass at that point. And once they return to the bedroom,
we continue an extinction-based protocol. A little tweak to that is if you want to add
a reinforcement component, you can actually give them access to a grab bag,
or prize bag, or stickers the next morning if they choose to keep
that pass all night and not utilize it. WAYNE: So the bedtime pass sounds like it’s
the proverbial get-out-of-jail-free pass at least one time. Once the child has used that pass up,
what happens if they get out of bed again? What do you instruct the parents to do if they’ve
used their pass and they still continue to get out of bed? BRETT: If they leave the bedroom and they don’t
have their pass left, the goal is to basically get them back into the bed by minimizing attention, so they’re not allowed
any conversation, you might even minimize eye contact. Simply get the child back into the bedroom
and ignore any further attempts or bids for attention. WAYNE: And it sounds like the bedtime pass has
a nice reinforcement component, so that if you haven’t used your bedtime pass by getting out of bed the previous night,
when you wake up in the morning, you can cash it in for some sort of valued item or activity. Is that what I’m understanding? BRETT: Exactly. You can turn that bedtime pass into some
tangible prize the next morning, so parents tend to like that tweak. WAYNE: You made a distinction, if I heard it correctly,
Brett, between can’t do and won’t do. It almost sounded like there are some situations
where the child has the skills but won’t engage in the right skills, almost a motivational problem, and then maybe
with the situations where the child has not yet developed some of the sleep onset skills, kind of a can’t do. Is that a valuable distinction, Brett? BRETT: Oftentimes for infants and toddlers,
they just haven’t developed either the breadth of sleep cues to allow them to initiate sleep in a variety
of circumstances, or they just haven’t developed the critical sleep onset and maintenance skills. In those cases, we tend to go slow. We tend to work more on building skills before
we pull away their dependent sleep cues that involve, again, parental presence or assistance. We may reinforce more heavily, put them
on a thicker reinforcement schedule, and again, build skills before we remove the problematic sleep cues. WAYNE: And then it sounds like on the won’t do side of it– BRETT: In the won’t do, if you have a kid that has
the skills, then it’s really a performance deficit. Then we really have to tightly manage parent-child interactions
and make sure that our contingency management program is pristine. WAYNE: And that’s an interesting distinction,
at least from my perspective, from so many behavior problems for children– can’t do versus won’t do. And can’t do oftentimes requires skill acquisitioning
and training, and won’t do seems like it’s oftentimes a motivational issue, and the critical issue
is how do you motivate to do what they can do but won’t do. BRETT: Realistically, I’m a little bit of a foreigner
when I go to the pediatric sleep meetings, because oftentimes my treatment protocols or my interventions for bedtime
and in the middle of night are based on what we’ve already shown to be effective to reduce problem behavior
and increase more appropriate behavior during the day. And we’ve been using these methods for decades. WAYNE: Brett, what other sort of techniques,
above and beyond what we’ve talked about already, might a clinician or a parent need to know about
to handle some of the sleep problems for children? BRETT: Well, about 15 years ago, after struggling
mightily to get parents to adhere and implement extinction-based protocols appropriately,
I decided to tweak the intervention a little bit. One of the big problems with extinction is that it
doesn’t teach the child replacement skills or behaviors. I have yet to successfully help a parent toilet train their child,
for example, by simply ignoring what you don’t want them to do. So I had the idea– and I’ve lovingly called this
the excuse me drill for a couple of decades now– to actually have parents go in
and reinforce sleep compatible behaviors. You could use stickers. You could use trinkets.
You could use a lot of things, but with most of these behaviorally based sleep disorders, we’ve already
established that parental presence and parental attention is sufficient and salient enough to reinforce
problem behavior, why not just reverse the contingency? Why not just take what we already know as a salient
reinforcer of a child and deliver that based on sleep compatible behavior, specifically when the child
lies in bed, remains in bed, reclining position, relaxed and quiet? And we can start this reinforcement schedule
on a very thick, frequent basis, so we have parents going in there– sometimes they don’t even get out of the room. They literally say, excuse me, but I need to go
tell your dad something or tell your mom something. And they might not even get out of the threshold
of the door, and they’re back immediately to touch, praise the child for being brave, for being a big boy,
for remaining in their bed. And over time, on an intermittent basis, we’re thinking
long-term maintenance here, on an intermittent basis they continue to go back in the room, but they
fade the frequency or the reinforcement schedule basically. WAYNE: Brett, that sounds like a very effective
intervention component for a multi-component sleep protocol. Can you talk in particular about the clinical response
to these treatment protocols, in particular how effective are they? How quick do we get a response to them? And do we sometimes end up with non-responders
and treatment failures, and what do we do about those, Brett? BRETT: As long as you kind of pave the way
and establish those appropriate sleep environments and make sure that you’ve got an appropriate
sleep-wake schedule, your contingency management program to teach the child appropriate pre-sleep skills
and to get them to fall asleep more quickly oftentimes occurs within the first
three to four nights of intervention. It can be very quick. That’s why I’m in this business. It’s very reinforcing to work with young children
who have behaviorally based sleep problems. So it’s not unusual to see dramatic success
within the first three or four nights. We may have success with certain outcomes and then
need to later on target other behaviors or problems or outcomes, but initially we want independent sleep
initiation to occur the very first night. If it doesn’t, as clinicians we want to know
that the very next day and problem solve that. Once we’ve chalked up four to seven successful nights
of initiating sleep at bedtime successfully and independently, now we’re going to generalize
that to middle of night awakenings. So the entire protocol, because we tend to go slow
and identify specific target behaviors and specific sleep opportunities to help parents have success, the overall program
may take quite a while– it may take weeks. But you should see child response,
and you should see improvement with each step of the way within a matter of two or three nights. WAYNE: It sounds like a relatively quick response
to these treatment protocols, Brett. That’s wonderful. It must be a fantastic relief to parents
once they’ve started implementing them. Now, you also mentioned something, though,
about middle of the night awakenings. What advice do you have for parents about managing
middle of the night awakenings and efforts to get out of bed? BRETT: If parents choose to target bedtime only with
their contingency management program– because they have five children, and it’s a dual career family,
and they just can’t be awake all night managing a sleep problem– we can target bedtime only
and later on hit the middle of night awakenings. While we’re targeting bedtime only, my recommendation
is typically in the middle of night when the child wakes up normally, calls out, comes out– respond to that
immediately and do what they normally do. So go ahead and just give the child whatever they’re
expecting, whatever they need to facilitate sleep re-initiation. That way once we do generalize an extinction-based
protocol or change a contingency management procedure in the middle of night awakenings, the contrast is there,
the child recognizes it right way, and we get quicker response. WAYNE: Great. Sounds good. BRETT: The reason we tend to target bedtime first
is just simply because we have the greatest homeostatic sleep drive. So children because of brain development and the way
their sleep-wake schedules work, they oftentimes profit handsomely from a four-hour power nap in the middle of night, and it’s more
difficult to change things in the middle of night than it would be at bedtime. Naptimes are our final target,
because it just tends to be more difficult. So we want things going pretty smoothly.
We want the child to be very skilled. We want the parent to be very skilled
once we finally go in and target naptimes. WAYNE: Brett, you mentioned naptime. Many children, by the way, are in daycares
where there is a scheduled naptime behavior. Can you offer any advice as to how to promote
appropriate sleep behavior at naptime? BRETT: The biggest issue I see with naptimes,
first of all, is parents who want to eliminate or restrict naps because the child is not going to bed well
at night or has disruptive behaviors. They’re thinking that the child is just simply
not sleepy at night, when in reality they’re engaging in all kinds of disruptive behaviors that just simply
interfere with that sleep initiation. So most children under four years of age
really need a short period of daytime sleep. If they don’t get that, you’re likely to see problems with mood, sometimes of even behavior, aggression, attention span in the later afternoon. I oftentimes work with parents to reinstitute naps for those poor kids who aren’t getting them, because it’s not an effective treatment for disruptive bedtime behaviors. In daycares what I oftentimes see, first of all, is many of them hire
people to come in and pat backs in order to put the child to sleep or in order to calm a child during naptime. And of course, they’re not trained in behavioral methods,
and they don’t understand contingency management. So they end up, of course, patting those
backs of the children who wiggle the most. So oftentimes it’s just a matter of changing
the contingency, so that they’re over reinforcing, again, those children who are remaining quiet, lying still. The other issue I occasionally see
in daycares is that it’s kind of a one-size-fits-all. So you’ve got four-year-olds on the same
nap schedule as maybe an 18-month-old. And again, throughout brain development,
you see children as they age they’re able to maintain alertness for longer and longer periods of time. So they’ll put a four-year-old child down
for a nap when they simply are not sleepy. And that sets the stage for all kinds
of disruptive behavior occasionally. WAYNE: Brett, on occasion I hear parents talking about
other types of sleep disruptions for their children. For example, sometimes parents report their
children as being anxious when they get in bed. The child sits there and worries about something.
Or every now and then I hear parents talk about my child has nightmares, or sits in bed
and imagines monsters in the closet or something of that nature. Do you have any advice for parents
as to how to handle those sorts of problems? BRETT: It’s interesting. Even though we’re in
a dedicated sleep clinic, we get most of our really interesting anxiety cases coming in through that door. So we have to come up with protocols,
specifically graduated exposure protocols, to help children cope with
their fears, cope with their anxieties. And of course, anytime we’re working
with children, we’re working with the parents so that they don’t end up
reinforcing anxious, avoidant behaviors. One of the first things we check during our
clinical interview and actually with a rating scale is– does this child have experience
separating from the parent during the day? Because if you think about what happens at bedtime,
if the parent wants to develop a solitary independent sleeper, they put the child in bed and they leave the room. But if that child is never apart or has
a learning history of being apart from that parent during the day, we may be better off targeting that skill
when it’s light out and parents aren’t tired and frustrated. So oftentimes we’ll facilitate
a contingency management program or the excuse me drill by
first having parents separate appropriately from their child during the day
and maybe even take walks around the block. So just repeated exposures where the child
can experience happy, enjoyable separation from their parent. In terms of nightmares, the first step is
to make sure that you’re actually dealing with nightmares. Because there’s a complicated differential diagnosis
between sleep terrors, which is primarily a physiological event that occurs in the first three hours of sleep,
and nightmares, which tend to predominate during REM sleep towards the morning hours–
the latter half of the sleep cycle, the sleep phase. With young children, oftentimes– first of all,
almost all children have nightmares. Nightmares, bad dreams–
a universal phenomena. But what happens oftentimes is
the child wakes up, has a bad dream or a nightmare, they enter
the parents’ bedroom, and they’re distressed. And of course, the parents being
well meaning and being nurturing and caring say, why don’t you just hop in bed with us tonight,
and we’ll help you get through this. Well, it doesn’t take toddlers very long
to figure out the contingency there. And then what you see over time is rather than
waking up towards the latter part of the night distressed, they wake up after they just
simply complete their first sleep cycle. They wake up, look around, walk in to Mom
and Dad’s bed, say I had a nightmare, hop in bed. And you end up with what is actually a verbal report
of a nightmare that serves as their admission ticket. The one thing we can do with children who have–
the rare children who have repeated nightmares– is look to see if we can’t find themes
in the content of those nightmares, or evidence of experiential avoidance during the day
that we can use graduated exposure to help them, again, approach, confront, and master their own fears. I’ll give you an example. I had a young man, he was
probably four years of age, who came in after a traumatic dog bite. he got bit right in the face by a German Shepherd. So this was years ago, but we decided to do
daytime exposure therapy to treat his nighttime nightmares. Now, first we had to get him out of
the parents’ bed, the contingency management piece, but second of all we ended up doing
graduated exposure during the day with dogs. Because if he saw a dog from
three blocks away, he immediately ran home. So we didn’t start with German Shepherds. The exposure piece here for young children
with anxiety disorders is graduated. We want to make things easier on them initially. So we started with a big, old, docile, fat beagle
and had the child learn to pet and play with that beagle and worked our way up to different breeds of dogs. And the exposure-based intervention did a nice job
of actually eventually eliminating those nightmares. WAYNE: Brett, that sounds like a marvelous treatment
protocol for desensitizing people to anxiety-related phenomena. But how about the children
that seem to have overactive imaginations? Where they get in bed and they imagine all these
monsters or goblins or something like that in the room, and they at least report that getting
in the way of their being able to sleep. BRETT: Children who especially get
into that abstract phase of development, where they’re thinking a little bit differently than concrete operations tend to,
allow their imaginations to run wild when they get in bed. Oftentimes parents will tell me that
their child’s mind races when they enter the bed, and they can’t shut their mind down. And oftentimes they think that the imagination
and the things that they dream up, like monsters or ghosts or goblins, is causing their issues with sleep initiation. And I would argue that the arrow
sometimes can point the other direction. If I place anybody in bed, in a boring environment,
when they’re physiologically not prepared to sleep, you’re not sleepy. Your personality is going to take over. So if you tend to, when given nothing to do,
if you tend to be a planner, and an organizer, or a doer, or a goer, you’re going to be thinking about those things,
because there’s nothing else holding your attention. There are dramatically different opinions
among the sleep professionals around the country on how to handle the monster thing. Anything from going in and helping
the child explore the room, and show them under the bed, and show them in the closet that there are no monsters, to dressing up a spray can and spraying away the monsters. I’m a firm believer in idiographic assessment and treatment. So I want to know, again, what are the antecedents,
behaviors, and consequences of these monsters suddenly appearing in the room, oftentimes at nighttime, but never during the day– oftentimes when one parent is managing
the bedtime routine, but never the other parent, oftentimes in the home, but never at daycare. So I’m looking for– I’m looking to isolate
those variables that I can use to design a treatment program. And oftentimes if it has to do with imagination or fears.
We’ll do exposure-based intervention during the day to allow the kid to develop some coping skills and then simply
decrease reinforcement value for those imaginary statements at night. I’ve run into occasional cases
where there is a television in the bedroom. And usually when there is a televisions in the bedroom
at bedtime, they don’t have the home shopping channel on. It’s usually a show or a video of interest to the child,
which again maintains their attention, increases alertness, not only in just the content
of the video but also the light exposure. And again, those children tend to fall asleep later
and get less sleep than kids who don’t have a television in the bedroom. Over the years, I’ve gone less and less to sudden
immediate change, and I’ve used– just because I think it’s more parent friendly and child friendly–
to fade out problematic sleep cues. For example, if I have a child who is watching their
favorite video, we’ll turn it to a channel that’s much less interesting. After a few nights, we may turn it to a non-channel,
where they only get the white fuzz and replace that white fuzz with nothing but white noise from a fan or a white noise generator. So anything that can be done overnight can be done gradually. And I think parents and children
oftentimes are more accepting of those things. Once parents are through the most difficult part
of the multi-component sleep intervention, and they have the contingency management piece in place,
the child is now going to bed cooperatively, they’re remaining in their bed, they’re well behaved, they are relaxed,
they’re engaging in sleep compatible behaviors– Some parents still aren’t necessarily happy,
because they may be taking too long to fall asleep. Once you remove those sleep interfering behaviors,
you may need to still come back and tweak the sleep-wake schedule to help them fall asleep within 20 or 30 minutes,
to be able to reinitiate sleep more quickly when they wake up and complete a sleep cycle at night,
or to sleep a little bit longer in the morning. WAYNE: So if I’m interpreting this correctly, Brett,
it sounds like you have several goals. One of them is to help manage some
of those sleep incompatible behaviors and replace them with sleep compatible behaviors. And the other goal, which may be a result of this,
is that then the children will independently initiate sleep within 15 or 20 or 30 minutes of being putting in an appropriate
sleep environment, and then also to be able to manage some of the naturally occurring nighttime awakenings. Is that correct, Brett? BRETT: I think it’s just important when clinicians work with parents
that they’re considering not only behaviors, but also sleep as a behavior. Your child hopefully is, by the time you’re done
with the program, well behaved, spending time in bed, calm, relaxed, and able to fall asleep within 20 or 30 minutes. I recently had a case where they brought a young child in, and the
physician had suggested a sedative hypnotic to make the child more sleepy. But during the functional assessment or the interview,
we quickly were able to get the parents to identify that once the child left their bed in the middle of night, as long as they were
allowed to enter the parents’ bed, the child went right back to sleep. So lack of sleepiness or lack of sleep drive
was not the major variable there that we needed to address. WAYNE: And that case does raise an interesting question
for you, Brett. What is your recommendation and position on somnorifics– pharmacological agents that seem
to induce sleepiness and drowsiness? BRETT: Given that I’ve been working in a behaviorally based
sleep center for 20 years now, I’ve come to the conclusion that there are very few children who need agents to help them fall asleep. In the large majority of the cases,
this can be done through behavioral methods. And when I say– for me, behavioral methods
is a large umbrella, but it’s very rare. I do believe that melatonin can be helpful in certain
circumstances with certain populations with some physiological differences. But for the large part, medication really needs to be
a last resort, and oftentimes it’s reserved for those children who may have a biologically reduced sleep requirement, and you simply need
the child to sleep more for the parents’ benefit than the child’s benefit. In other cases, if you have a child with a biologically
reduced sleep need, just again for the parents’ benefit, you may need to be able to identify a safe place where you can
put that child to entertain themself so that the parent can get enough sleep. WAYNE: Brett, since you raise that issue, I’m wondering
if you’d also be willing to comment on the side effects of other medications, medications that are not given for the purpose of inducing sleep,
but may have some impact on sleep cycles, and drowsiness, and wakefulness? In the example, I’m thinking of some of the medications that
have been traditionally given for ADHD that sometimes have an effect of alerting a person as opposed
to letting a person fall asleep naturally. BRETT: Yeah. During our interview, we always have a process
of identifying what I call daytime factors that can impair sleep at night. And certainly there are certain classes of medication that can
either mask daytime sleepiness, like your psychostimulants, or even impair or interfere with sleep onset at bedtime. So you need to identify those and work with a prescribing
physician a lot of times to combine your behavioral treatment methods with judicious use of medication. Many times I have kids come in who
have tried up to five or six sedative hypnotics, and if they’re on an agent when they come in, it’s pretty tough to talk parents into eliminating
that medication when it’s their only crutch at the time. So most of the time we’ll ask them
to hold that factor stable, to not make any medication changes as we
systematically induce each step over a behavioral treatment protocol
and prove to the child and prove to the parents that this child can sleep very well unremarkably. And at that point, oftentimes it’s easier
to convince them to wean the child off that medication. WAYNE: I think it probably goes with saying,
Brett, that any change in medication needs to be coordinated with physicians
and with their authorization that you’re changing medications quite obviously. But the other side of that coin, Brett, is I’m wondering
whether or not physicians are pretty amenable to working with psychologists to do behavioral approaches to sleep promotion? BRETT: For the most part I’ve had a lot of success
working with primary care physicians, developmental pediatricians, pulmonologists, nuero– I could go on and on. They’re in it for the right reason–
they want the best for the child. But oftentimes they simply lack
the training and expertise to be able to use non-medication based strategies to help the child sleep. They’re oftentimes very willing and thankful
to work with someone who has some expertise in this area to help facilitate a child’s sleep pattern. WAYNE: Well, Brett, we’ve covered an awful lot of material, and it’s been just an absolute fountain of information
about behavioral approaches to sleep promotion. I want to thank you very much
for participating in this interview. BRETT: I appreciate the opportunity to speak
on the issue of behaviorally based sleep problems. And I hope in some way that the information that we
presented helps families who have challenging kids with developmental disabilities
or genetic and handicapping conditions. WAYNE: Some parents have difficulty
getting their children to go to bed when it comes to be bedtime, and oftentimes they’ll engage in all kinds of disruptive behavior,
making special requests and protesting. And for situations such as that,
we recommend a beat the clock routine. And this simply requires the parent
to announce that they have a certain amount of time before the lights
go out in their bedroom, and that the quicker the child
can get themselves ready and in bed, the more time the parent and child will have to do
something that’s highly enjoyable for the child in the bedroom. So in this scene right here, we have Kyan and Genanne,
and Kyan is getting ready– close to bed anyhow. So let’s turn the scene over,
and it’s about Kyan’s bedtime. So Kyan and Genanne– GENANNE: OK, Kyan. It’s 7:30.
So it’s time for you to get ready for bed. KYAN: But Mom, I don’t want to go to bed.
Please do not make me go to bed. GENANNE: Well, I can see that you’re upset, and it’s
kind of been a hard time getting you go to sleep lately. So I have an idea for a new game.
It’s called beat the clock. So what I’m going to do is
I’m going to set a timer here for 15 minutes. And if you can brush your teeth,
and wash your face, and get your clothes set out for school tomorrow really fast, then that will leave us
extra time to read “Bathtime for Bunny.” But if it takes a long time to get ready for bed,
then we won’t be able to have a lot of time to read. Are you ready?
KYAN: Uh-huh. GENANNE: On your marks, get set, go! WAYNE: Some children show a tendency
o get out of bed frequently even after they’re placed in bed. For this type of sleep management problem,
we recommend what we call a bedtime pass, and a bedtime pass can be anything. In this case, we have just a simple,
laminated card that says bedtime pass on it. And this bedtime pass– the child is put to bed
with a bedtime pass, and this allows the child to get out of bed one and only one time after they’ve been put to bed. They have to surrender the bedtime pass,
and then they get water or attention or whatever for a short period of time with their mother. So here’s how the bedtime pass routine works. KYAN: Hey, Mom.
Can I please have a glass of water? GENANNE: Yes, but I’ll need your bedtime pass.
KYAN: OK. GENANNE: So you have three minutes to get
your water, and then you need to get back in bed. KYAN: OK.
GENANNE: Good night. KYAN: Good night. WAYNE: One of the features of
the bedtime pass is that it’s good for one and only one get out of bed episode. If the child comes out a second, third,
or fourth time, the parent is instructed to, with minimal interaction,
send or walk the child back to bed. This is not a time for reinforcing
interaction between the parent and child, it’s simply a direction or maybe
even a prompt to go straight back to bed. You’ll see it in this particular
scene here with Kyan and Genanne. KYAN: Mommy, I still can’t sleep. GENANNE: I know, Kyan,
but you’ve already used your bedtime pass. KYAN: Oh, please, oh, please,
can I stay up with you? GENANNE: No, I’m sorry.
It’s time for you to go to bed. You need to go back to bed right away. WAYNE: Another feature of the bedtime pass
is that many parents build in a reward system. More specifically if the child has made it
through the entire night without cashing in their bedtime pass, they can
oftentimes bring the bedtime pass out in the morning and, so to speak, cash it in
or trade it in for some sort of special reward. Sometimes the reward is a material thing,
a favorite toy, sometimes it can be something as simple as some special time with Mom or Dad
to play a game or something of that nature. So here’s the way that sort of interaction would
typically go in the morning after a successful night. GENANNE: Good morning, Kyan.
KYAN: Oh, good morning, Mommy. Look what I still got. GENANNE: Oh, you made it all night
without using your bedtime pass. What should we do for your special treat?
KYAN: I want pancakes for breakfast. GENANNE: That sounds good.
Do you want to help me make them? KYAN: Yeah.
GENANNE: Let’s go. Come on. WAYNE: Many parents have different goals
for their sleep routine for their child. Some parents are perfectly fine with co-sleeping,
or the child sleeping in the same bed with the parents. However, many parents are especially interested
in teaching their child to be an independent sleeper, that is sleeping independently
in their own bed for the entire night. One of the challenges many people face
is separating from their child after a little bit of bedtime. And this particular drill right here
is referred to as the excuse me drill. Genanne will illustrate how to tactfully
say excuse me while she’s spending some quality time with Kyan
in bed, leave, and then come back. And assuming Kyan is behaving well–
to reengage in some reinforcing activities with Kyan, then she will systematically increase the length of time that she excuses herself from Kyan. So here’s an example.
This is, once again, Genanne and Kyan. KYAN: Then she ran first– GENANNE Fresh.
KYAN: –fresh water and wh– GENANNE: Whiskers.
KYAN: –whiskers, and said, oh, you smell so clean and nice. GENANNE: Yes. That’s good.
All right, you wait here with the book. And baby-lovey-bear, I’m going to
go check on Flopsy the dog. OK? KYAN: OK. GENANNE: Wow. I like the way you’re reading
so nicely and snuggled up here in bed. OK. Let’s see. KYAN: And the little bunny
kissed his mommy and hugged her– GENANNE: Tight.
KYAN: They’re now all done. GENANNE: Said Mrs. Rabbit.
KYAN: It’s time for bed. Where are my other little bunnies? GENANNE: Yeah. We’re almost done. OK. I need you to stay
here one more time. I’m going to go check on our soup,
and then I’ll be back to tuck you in. KYAN: OK. She found them in the kitchen.
Oh, no. What a mess. [KYAN READING TO HIMSELF] GENANNE: Kyan, you’ve done really well
in here by yourself. I’m so proud of you. KYAN: I read the whole book.
GENANNE: Good. Would you like me to maybe rub
your back a little while before bed? KYAN: Uh-huh. I think that would be good. GENANNE: Here’s your bear. [KYAN WHISPERING] GENANNE: It’s time for bed. It’s OK. Good night.
KYAN: Good night. GENANNE: I love you. WAYNE: Some children have difficulty
once they get in bed settling down, and they get worried or anxious,
and they sometimes are disruptive and call out for their mother or father. And under those circumstances, we will
recommend that the mother or father or whoever the caretaker is tell the child from afar, without going in the room, calm down,
and then I’ll come in and check on you. And then once the child has
calmed down, then the parent comes in and checks to make sure the child is OK, has minimal interactions, and then leaves
once they’ve reassured the child that everything is OK. So in this scene, Kyan is in bed.
He’s been in bed for a while. He’s having difficulty sleeping. And Genanne will come in and check on him
only after he calms down and quits making quite a ruckus. KYAN: Hey, Mom. I really need to–
can you please come in and give me some company, please?
I’m really scared. GENANNE: Kyan, I need you to quiet down.
KYAN: OK. GENANNE: Once I hear that you’re quiet,
I’ll come in and check on you. KYAN: OK. GENANNE: OK. It’s time for bed.
I can see that everything’s fine. Here, let me help you get tucked in. Sweet dreams. I love you. [MUSIC PLAYING] CLOSED CAPTIONING PROVIDED BY
TESSA M. ZIEBARTH, CLOUDSPEAK LANGUAGES LLC

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