This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with children, adolescents and their parents, and a supervision framework. It replaces neither your clinical judgement, nor your professional responsibility, nor the doctor's opinion on what falls within the doctor's remit. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is not written for children or their families. A warning specific to this indication: pauses in breathing during sleep, a collapse episode in an infant, repeated nocturnal seizures or an adolescent who talks about dying call for a medical assessment without delay, not at the next appointment. In case of immediate danger, contact your country's emergency services.
1. The programme at a glance
Indication. Sleep disorders in children, from six months of age, and in adolescents, that call for behavioural and cognitive treatment: behavioural insomnia of the young child — sleep-onset associations, bedtime limit-setting, night wakings —, bedtime fears, insomnia in adolescents, delayed sleep-wake phase, nightmares, sleepwalking and sleep terrors. Once what belongs to the doctor has been identified and referred on (section 8).
Reference model. In the young child, behavioural interventions delivered by the parents (Mindell et al., 2006; Meltzer and Mindell, 2014). In the adolescent, adapted cognitive behavioural therapy for insomnia (de Bruin et al., 2015) and work on the clock — regularity, morning light, gradual advance (Gradisar, Dohnt et al., 2011; Auger et al., 2015). For nightmares, imagery rehearsal, for which the data in children remain thin (St-Onge et al., 2009).
Format. A common core of two sessions, a track chosen according to the presentation, and a common final session.
- Young-child track, from six months to about nine years, conducted with the parents: sessions E3 to E6. Six or seven sessions in all, E6 taking place only if bedtime fears are in the foreground.
- Adolescent track, from twelve to seventeen, conducted with the young person and, at planned points, their parents: sessions A3 to A7. Eight sessions in all.
- Two modules, inserted into either track: nightmares (M1 and M2), sleepwalking and sleep terrors (M3).
Between nine and twelve, the presentation decides more than age: these boundaries are a practical choice of this manual, not validated thresholds. Weekly 50-minute sessions, 60 to 75 minutes for the first; two follow-ups, at one month and at three months.
The number of sessions is drawn from the trials. In the young child, the interventions evaluated fit into one to three consultations (Hiscock and Wake, 2002; Hiscock et al., 2007), two consultations followed by a phone call (Hiscock et al., 2015), or five guided sessions (C. R. Johnson et al., 2013; Corkum et al., 2016). In the adolescent, the protocols evaluated have six sessions (Gradisar, Dohnt et al., 2011; de Bruin et al., 2015; Harvey et al., 2018). This manual adds the assessment and the review.
Mechanism targeted. That the young child learns to fall asleep in conditions they will find again at three in the morning, and that the parents consistently stop reinforcing the problem. That the adolescent's clock is brought back into phase with their timetable, and that their bed becomes a place for sleep again.
| Session |
Focus |
Session deliverable |
| 1 |
Assess, sort, refer — all |
Medical signs checked, diary handed out |
| 2 |
Understand and choose — all |
Written formulation, track chosen |
| E3 |
The evening: timing, routine, bed — parents |
Getting-up time set, routine written |
| E4 |
Falling asleep alone: the withdrawal plan — parents |
Written plan, start date set |
| E5 |
The night and the early morning — parents |
A single written response for the night |
| E6 |
Bedtime fears — parents and child, if needed |
Challenge ladder, first challenge done |
| A3 |
The model and the getting-up time — adolescent |
Fixed getting-up time seven days a week |
| A4 |
The bed, the window, screens — adolescent |
Bed rules, plan for the phone |
| A5 |
What goes round in the head — adolescent |
Worry period, two beliefs tested |
| A6 |
Advancing the clock — adolescent |
Advance schedule, morning light |
| A7 |
With the parents — adolescent and parents |
Written household agreement |
| M1, M2 |
Nightmares — module |
New version rehearsed every day |
| M3 |
Sleepwalking and terrors — module |
Bedroom made safe, written plan of action |
| Final |
Review, plan, relapse — all |
Measures repeated, written restart plan |
What the family takes home. Nine printable worksheets, listed in section 38: my sleep diary; our bedtime routine; our withdrawal plan; our night-time responses; bedtime fears; my getting-up and light plan; my bed, my screens, my head; nightmares and restless nights; our plan for what comes next.
What sets this programme apart from the other manuals on this site. Medical screening placed before treatment. Two tracks that are not alike: in the young child, the patient you see is the parent; in the adolescent, it is the young person. And an explicit position where families receive contradictory advice: methods that involve leaving a child to cry, and screens.
2. Before you begin
Who this programme is for
This text is written for psychologists, child psychiatrists, psychotherapists, doctors and nurses trained in behavioural and cognitive approaches with children and adolescents. It assumes that you know how to work with exhausted parents without taking sides in their disagreements, talk one-to-one with an adolescent who did not ask for anything, and recognise what is outside your remit.
It is not written for children or parents. For them, the site offers in particular Nightmares: taking back your nights and Screens and social media: a guide for parents, and, for the older adolescent, Getting your sleep back: the Psychotip® programme.
The four preliminary decisions
Is there anything that belongs to the doctor? Snoring with pauses, restless legs, abnormal sleepiness, nocturnal seizures, a medical cause, medication; under one year, the sleeping arrangements. Section 8, at session 1, before any instruction.
Which track? The presentation decides more than age. Section 4.
Which method can the parents keep up? A quick method abandoned on the third evening may well do more harm than doing nothing. Section 13.
And who is in the room? Both parents when possible. For the adolescent, confidentiality is settled in writing at session 1 (section 16).
How to use it
Read the whole text before session 1, in particular sections 8, 13 and 33: what belongs to the doctor, the choice of method, and the state of the evidence on screens. Each session follows the same framework: the aim, the steps, what you say, the common errors, and the criterion for moving on.
Two warnings. Parents arrive with contradictory certainties: that a child must never be left to cry, or that they must be; that screens destroy sleep; that melatonin, being natural, is harmless. Your credibility rests on the precision of what you say on each of these points. And the problem is often the parents' too: a parent who has been deprived of sleep for ten months no longer has the reserves needed to keep up a plan (section 10).
3. What is normal, by age
Duration. The consensus benchmarks are, per twenty-four hours: 12 to 16 hours between four and twelve months, naps included; 11 to 14 hours between one and two years; 10 to 13 hours between three and five years; 9 to 12 hours between six and twelve years; 8 to 10 hours between thirteen and eighteen years (Paruthi et al., 2016). These are ranges, not targets: a rested child who functions well during the day is sleeping enough.
Night wakings. Everyone wakes briefly between two cycles; the question is whether the child goes back to sleep alone. A full-term infant is not expected to sleep through, without an adult stepping in, before about three to six months, and the international classification of sleep disorders infers from this that a diagnosis of chronic insomnia can hardly be considered before six to nine months (American Academy of Sleep Medicine, 2023). Before six months, behavioural sleep interventions have not shown any benefit, and a systematic review reports possible risks when they are applied from the first weeks, including early cessation of breastfeeding and, if the baby sleeps alone in another room, an increased risk of sudden infant death (Douglas and Hill, 2013): this programme starts at six months.
Bedtime fears are the rule: in a school sample, nearly three quarters of children aged four to twelve reported them, and parents clearly underestimated how often they occurred (Muris et al., 2001). Occasional bad dreams are common; frequent ones concerned only a small minority of preschool children in a Quebec cohort, and they were associated with a difficult temperament and with anxiety measured as early as five and seventeen months (Simard et al., 2008).
Sleep terrors and sleepwalking. In a Quebec cohort, terrors peaked at eighteen months, in about one child in three, and sleepwalking at around ten years, in just over one child in ten; a third of the children with early terrors went on to sleepwalk, and a parental history clearly increased the risk (Petit et al., 2015).
Adolescence. The clock shifts towards the evening and sleep pressure builds up more slowly, so that the adolescent only feels sleepy later (Crowley et al., 2018), while their need for sleep does not decrease (Carskadon, 2011). In surveys from around the world, sleep timing shifts later with age and school-night sleep gets shorter (Gradisar, Gardner and Dohnt, 2011). This is not laziness, and saying so is the first intervention of the adolescent track.
4. Seven presentations not to be confused
1. Sleep-onset associations
What you observe. The child falls asleep only when rocked, fed, carried, in the car, or with a parent lying beside them, and demands the same help at every night waking.
What points to it. With the condition, they fall asleep quickly; without it, they do not. It is only called a disorder if the associations are prolonged and demanding and if, without them, falling asleep or the wakings are markedly prolonged (American Academy of Sleep Medicine, 2023).
What this implies. The withdrawal plan of sessions E4 and E5.
2. Bedtime limit-setting
What you observe. The child delays bedtime, negotiates, asks again for a drink, for a story, gets up, calls out; bedtime takes an hour or two, often since they moved out of the cot.
What this implies. The routine and timing of session E3, the bedtime pass and the silent return to bed of session E5. If the opposition extends well beyond bedtime, see Treating oppositional defiant disorder in children: a therapist's manual.
3. Bedtime fears
What you observe. An expressed fear, with a content: the dark, being alone, noises.
What this implies. Session E6. When the fears spill beyond the night, it is an anxiety disorder: see Treating anxiety in children: a therapist's manual.
4. Insomnia in adolescents
What you observe. Taking a long time to fall asleep, ruminating in bed, sometimes wakings, tiredness and irritability during the day, whatever the timing.
What points to it. They sleep badly even during the holidays. Among American adolescents aged thirteen to sixteen, one in ten had already had diagnosable insomnia, with a median onset at around eleven, and half had another psychiatric disorder (E. O. Johnson et al., 2006).
What this implies. Sessions A3 to A5, and looking for anxiety or depression.
5. Delayed sleep-wake phase
What you observe. The adolescent does not fall asleep before one or two in the morning and cannot get up for school.
What points to it. Free to set their own hours, they sleep well, but late. The two presentations often coexist.
What this implies. Session A6.
6. Insufficient sleep
What you observe. A young person who falls asleep quickly and sleeps well, but too little, and catches up massively whenever they can.
What this implies. Extending the opportunity to sleep: the opposite of restricting time in bed.
7. Nightmares and slow-wave sleep parasomnias
|
Nightmare |
Sleep terror, sleepwalking |
| Time of night |
Mostly the second half |
Mostly the first third |
| Is the child awake? |
Yes, recognises the parent |
No, responds little or poorly |
| Memory in the morning |
Yes |
No, or a few fragments |
| What helps |
Reassure, then work on it in the daytime |
Do not wake, protect, wait |
What this implies. Sessions M1 and M2, or M3. Nightmares that replay a traumatic event belong to Post-traumatic stress disorder in children and adolescents: a therapist's manual.
The three sorting questions
"On holiday, free to set their own hours, how do they sleep?" It separates insomnia from delayed phase and from insufficient sleep.
"When you are there, or when you rock them, how long do they take to fall asleep?" It isolates sleep-onset associations.
"Are they awake when it happens, and do they remember it in the morning?" It separates nightmares from sleep terrors.
5. What keeps the difficulties going
Sleep-onset associations. The child falls asleep with a specific condition; during the brief awakenings of the night, they find a different environment and demand what is missing. This is the behavioural model of night waking (Blampied and France, 1993), consistent with the large surveys, in which parental responses that encourage independent sleep onset go hand in hand with more consolidated sleep (Sadeh et al., 2009).
Intermittent reinforcement. Giving in at the fifth request, or after forty minutes of crying, teaches that persisting ends up working. This is why a method abandoned halfway may well make the problem worse.
A badly placed bedtime. A child put to bed an hour before they are sleepy spends that hour struggling, and the bed becomes the place of the struggle. Late naps, a variable getting-up time and shifted weekends contribute to it.
Accommodation of fears. Staying until the child falls asleep, checking under the bed, taking them into the parental bed at every call: the fear is relieved that evening and maintained for the following ones.
In the adolescent, a combination: a delayed clock, early classes, evenings taken up by homework and screens, lie-ins that shift the clock further, caffeine, hours spent in bed waiting for sleep, and sometimes a conflictual family climate, which is associated with taking longer to fall asleep (Carskadon, 2011; Bartel et al., 2015). Added to this is worry about sleep itself.
The full circle. In the young child: a condition they cannot produce alone, a normal awakening, a demand, a response that restores the condition, a reinforced learning. In the adolescent: going to bed before being sleepy, a long time awake in bed, screens to pass the time, a difficult getting-up compensated for at the weekend, and the clock a little more delayed. This is the diagram you draw at session 2.