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Behavioral Interventions for Night Terrors and other Sleep Disorders
10 CEUs Behavioral Interventions for Night Terrors and other Sleep Disorders

Manual of Articles Sections 15 - 28
Section 15
Developing an Assessment Procedure for
Child & Adolescent Sleep Disturbances

Question 15 | Answer Booklet | Table of Contents | Sleep Disorders CEU Courses
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

The following guidelines are provided for counselors who wish to develop their own assessment procedure for child and adolescent sleep disturbance. Although specific measures are recommended, practitioners may prefer alternative measures that satisfy the general guideline.

Guideline 1: Identify the Role of Medical Pathology
narcolepsy Behavioral Interventions for Night Terrors social work continuing educationCounselors must make a concerted effort to identify medical or health problems that could play a role in initiating or maintaining sleep disturbance. In some cases, this may require a medical examination before commencing mental health intervention, whereas in other cases a telephone call to the physician confirming a "clean bill of health" will suffice. Although a physical exam is unlikely to uncover significant findings unless the history is suggestive (Ferber, 1986), it is still important to identify acute or chronic medical problems that might cause, contribute to, or interfere with the treatment of sleep disturbance. Common illnesses, such as an ear infection or pinworms, can result in sudden onset of sleep disturbance in a child who previously was a good sleeper. In other cases, it is not a child's current illness, but a history of medical problems (e.g., colic) that makes parents anxious, less likely to set limits, or establishes a pattern of parental responsiveness in which the child becomes dependent on the parents' continuing attention during the night (Blum & Carey, 1996).  For the minority of cases in which acute medical pathology is the source of the sleep problem, the physician is the appropriate person to provide treatment. Sometimes, however, medical professionals do not have the training to properly evaluate and treat common pediatric sleep disorders (Mindell, Moline, Zendell, Brown, & Fry, 1994). It has been reported that medical schools provide an average of only 0.38 hours of clinical teaching on the topic (Rosen, Rosekind, Rosevear, Cole, & Dement, 1993) and busy primary care physicians may lack time to devote to complex behavioral issues. For these reasons, many physicians will be happy to refer cases to a mental health professional with training in behavioral assessment, knowledge of child development and family functioning, and familiarity with common childhood sleep disturbances.

Guideline 2: Screen for Parental Psychopathology
Parental psychopathology, marital conflict, and parental stress all play a major role in establishing and maintaining difficult-to-manage child behavior and interfere with the implementation of therapeutic procedures (Mann & MacKenzie, 1996). Guideline 2 can be accomplished by obtaining a standardized psychological screening instrument and inquiring about family psychiatric history during the clinical interview. Although practitioners may have their own "favorites," we have found several screening instruments useful and time efficient, including the Symptom Checklist-90-R (Derogatis, 1994), Brief Symptom Inventory (Derogatis, 1993), Dyadic Adjustment Scale (Spanier, 1989), Locke Marital Adjustment Test (Locke & Wallace, 1959), and Parenting Stress Index-Short Form (Abidin, 1990). Of course, findings from initial screening measures may indicate need for further evaluation (e.g., depression inventory), treatment, or referral.

Guideline 3: Identify Coexisting Child Behavior or Emotional Problems
Between 30% and 45% of children with sleep disturbance exhibit coexisting behavior and emotional problems (Kataria et al., 1987; Stevenson, 1993). Identifying problems such as temper tantrums, noncompliance, anxiety, or depression is an important step in developing an effective treatment plan. Toddler and preschool children who are noncompliant, defiant, or aggressive often disrupt bedtime and nap schedules, resulting in sleep loss for both the child and the parent. Young children may respond paradoxically to sleepiness by exhibiting overactive behavior, irritability, or decreased attention span. Add a tired, frustrated parent to this equation and one can understand why families are often in crisis by the time they first seek assistance from a counselor.  Whether to first address problems with sleep or daytime behavior can be a difficult decision. Programmatic, family based protocols to address childhood defiance, noncompliance, and aggression (e.g., Forehand & McMahon, 1981; Hembree-Kigin & McNeil, 1995) may teach parents or the child certain skills that generalize to nighttime issues like bedtime struggles. In other cases, successful resolution of the child's sleep disturbance may decrease the severity of challenging daytime behaviors, and afford parents more energy and confidence while addressing any remaining daytime problems (Minde et al., 1994).  For school-age children and adolescents with behavioral or psychological problems, sleep disturbance is the rule rather than the exception. For example, sleep-related symptoms are commonly associated with child/adolescent depression, anxiety, mental retardation, autism, attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder, posttraumatic stress disorder, and substance abuse (Stores, 1996). Inversely, sleep disturbance can mimic some psychological disorders. Examples include the adolescent with narcolepsy who presents with mood swings, decreased energy, and loss of interest in pleasurable activities, or the young child with delayed sleep phase syndrome who resists the morning routine and has difficulty paying attention during morning classes. By now counselors may have accurately concluded that it is not always easy to determine the source of the problem or the appropriate course of action. In some cases, treating the primary psychological disorder results in resolution of the sleep problem. In other cases, effective treatment of the youngster's sleep disturbance alleviates the mental health problem (Dahl, Pelham, & Wierson, 1991; Naylor et al., 1993). More research is needed to help clinicians understand the bidirectional influence of sleep and mental health in children and adolescents. In the meantime, counselors are reminded that sleep disturbance can be treated during the course of therapy for other issues, especially given the relatively straightforward and short-term nature of most interventions for children's sleep disturbance.

By including a standardized behavior rating scale into the evaluation process, counselors can assess a broad range of behaviors from multiple perspectives (e.g., child, parents, teachers). Most behavior rating scales require little time to administer, score, and interpret, and the results are often useful in directing the clinical interview. Although there are numerous broadband behavior scales available, some serve dual purposes by including specific sleep items. We have found several scales useful in our clinic, including the Achenbach Child Behavior Checklist (CBCL; Achenbach, 1991), Eyberg Child Behavior Inventory (Robinson, Eyberg, & Ross, 1980), and Behavior Assessment System for Children (Reynolds & Kamphaus, 1992). The CBCL Parent Report Form for 2- to 3-year-old children contains a sleep subscale, whereas the 4- to 18-year-old version contains six sleep questions including "nightmares, .... overtired, .... sleeps less," "sleeps more," "talks/walks in sleep," and "trouble sleeping." The teacher report version of the CBCL contains two sleep items, "overtired" and "sleeps in class."

Children sometimes enter the world with temperamental characteristics that may predispose them to developing sleep problems (Sadeh, Lavie, & Scher, 1994; Weissbluth, 1984). Using a standardized temperament scale such as The Toddler Temperament Scale (Fullard, McDevitt, & Carey, 1984) in the assessment procedure has several potential advantages (Carey, 1985). Confirming a child's temperamental or behavioral pattern is often helpful in relieving parents of blame, while giving them appropriate responsibility for carrying out intervention procedures.  Specialized assessment procedures may be indicated depending on the presenting case, or results from the broadband behavior rating scales. For example, further assessment would likely be warranted for coexisting psychological disorders such as depression, autism, ADHD, or learning disability.

Guideline 4: Obtain the History and the Current Presentation
Information on the clinical history, onset, and course of the sleep disturbance can be obtained through the use of a semistructured clinical interview.  Including school-age or older children in the interview process often yields useful information and helps the counselor determine whether or not the child is concerned about the problem. Obtaining details regarding sleep associations, schedules, sleep environment, and interpersonal interactions can be a time-intensive process, but well worth the effort. Taking a sleep history and making critical decisions regarding differential diagnosis requires familiarity with the clinical signs of a variety of pediatric sleep disturbances (see Appendix B), because initial symptom presentation can overlap several disorders. For example, there are many potential causes of adolescent sleepiness (see Table 1), and night waking can be the result of sleep onset association disorder, sleep apnea, periodic limb movement, or night terrors (Durand, Mindell, Mapstone, & Gernert-Dott, 1995). Consequently, counselors must develop a knowledge base of potential sleep problems and possess basic understanding of sleep physiology and architecture to correctly identify the mechanism of disturbance (see Anders, Sadeh, & Appareddy, 1995; Carskadon et al., 1988; and Sheldon, Spire, & Levy, 1992).  One time efficient way of obtaining the history and clinical presentation is to use standardized sleep questionnaires. Several measures are available, including the Sleep Disturbance Scale for Children (Bruni et al., 1996), the Children's Sleep Behavior Scale (Fisher, Pauley, & McGuire, 1989), the Pediatric Sleep Disturbance Questionnaire (Cook & Burd, 1990), and two separate instruments both titled the Sleep Habits Questionnaire (Anders, Carskadon, Dement, & Harvey, 1978; Seifer, Dickstein, Spirito, & Owens-Stively, 1996). The Epworth Sleepiness Scale (Johns, 1991) or Stanford Sleepiness Scale (Hoddes, Dement, & Zarcone, 1972) can be useful in monitoring excessive sleepiness in older adolescents. Responses to sleep questionnaires can alert the counselor to areas that deserve further inquiry during the clinical interview.  The history and clinical presentation would not be complete without a thorough functional assessment to identify environmental or interpersonal factors that influence the sleep disturbance (C. R. Johnson, 1996). With children, careful consideration should be given to whether the problem is being maintained by social attention (e.g., extra hugs and kisses), negative reinforcement (e.g., misbehavior allows a child to escape or delay bedtime), tangible items (e.g., awakenings reinforced by food/feeding), or automatic reinforcement (e.g., self-stimulatory body-rocking during sleep onset).

Guideline 5: Monitor Ongoing Sleep Schedule and Sleep-Related Behaviors
An important component in the assessment of pediatric sleep problems is having the child and parents complete a 2-week sleep diary (see Appendix C). A standard sleep diary involves daily recording of various sleep parameters such as bedtime, arising time, sleep-onset latency, number and duration of awakenings, naps, medication intake, and written notes detailing out-of-the-ordinary events like illness or unique behaviors. Maintaining a daily sleep diary serves multiple purposes and has several advantages over relying solely on retrospective verbal report. For example, clients often recall nights when problems were at peak intensity (i.e., sleepless night) but fall to report nights when sleep or behavior was unremarkable (Douglas, 1989). Systematic data collection allows the practitioner to assess not just those nights that are problematic, but every night within a 2-week period. The diary often provides critical information that may not otherwise be reported, such as when a child or adolescent makes up for "lost" sleep by sleeping late in the morning, taking a late afternoon nap, or sleeping excessively the following evening. A sleep diary also helps establish a baseline of the problem severity by which the counselor can monitor ongoing progress with treatment. Sometimes a single sleepless night can result in client perception that treatment is not succeeding, whereas a quick review of the longer term data may indicate slow but steady improvement (Bootzin & Chambers, 1990). Finally, behavioral monitoring by itself can serve as an effective treatment component and provide the counselor a gauge of the family's overall compliance (Sheldon, 1996).

Various scoring guidelines for sleep diaries have been published (e.g., Piazza & Fisher, 1991; Richman, Douglas, Hunt, Lansdown, & Levere, 1985); however, we have found Morin's (1993) scoring system easy to understand and quick to complete (see Table 2). After the variables are scored for each night, a weekly mean can be computed that provides a useful overall index of the child's sleep pattern for the week. These data allow the counselor to compare the child or adolescent's sleep parameters with developmental expectations. Age-adjusted normative data are available for total sleep time, sleep onset time, and napping (Cashman & McCann, 1988; Weissbluth, 1995; Weissbluth et al., 1981). Comparing a child's current sleep patterns with developmental norms may alleviate unnecessary concern in some parents or provide information to other parents who may have inappropriate expectations regarding their child's sleep needs.
Guideline 6: Obtain a Nighttime Video or Actigraph Home Monitoring
Verbal report of behavior often corresponds poorly with what actually occurs (Bernstein & Michael, 1990). A wealth of information can be gained by videotaping unusual middle-of-the-night behaviors or parent-child interactions during bedtime struggles. We were once referred a child who was initially scheduled for a comprehensive neurological examination because of loud, rhythmic body rocking during the night. The neurological exam was canceled after an inexpensive videotape recording showed a child who was obviously alert, responsive to his environment, and simply using the rocking to assist in his own sleep onset. Finally, actigraph home monitoring (Sadeh, Hauri, Kripke, & Lavie, 1995) deserves mention as a potential assessment tool. An actigraph monitoring device consists of a small computerized movement detector, usually worn like a wristwatch. Data can be downloaded to a computer to determine sleep duration and quality. Although actigraphy is typically reserved for research purposes, it does offer clinical utility whenever there is a question about the reliability of a client's report regarding total sleep time or rest/activity patterns.
- Kuhn, Brett R.; Mayfield, Joan W.; Kuhn, Robert H.; Clinical Assessment of Child and Adolescent Sleep Disturbance;  Journal of Counseling & Development, Summer99, Vol. 77 Issue 3

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about developing an assessment procedure for child and adolescent sleep disturbances.  Write three case study examples regarding how you might use the content of this section in your practice.

What are six guidelines for developing an assessment procedure for child and adolescent sleep disturbance? Record the letter of the correct answer the Answer Booklet.

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