Sleep Training 101: Response Cost

11 hours ago

7 min read

Picture this: you've delayed your child's bedtime as part of a bedtime fading plan, you've done your routine, you've said goodnight, but 20 minutes later your child still isn't asleep. Or consider this, you're sure your child is sleepy, but you put your little one down for a nap and your child just doesn't fall asleep. Even when you get the timing right, some children still struggle to fall asleep, and lying awake in bed can begin to undermine positive associations between bedtime and sleep. This is where response cost comes in.

Response cost is a behavioral technique that is often used as a companion to bedtime fading. Rather than leaving a child to lie awake in bed, potentially associating the bed with being awake and/or upset, you briefly remove your child from the sleep environment to reset before attempting the bedtime routine again. In this installment of our Sleep Training 101 series, we explain what response cost is, how it works, and how to implement it.

The Science

To understand response cost, it helps to first understand the behavioral theory underlying it. Sleep researchers have long recognized that falling asleep is not just a biological process, it is also a learned behavior. In order to fall asleep, a child must relax their body, close their eyes, and slow their breathing. These associations come easily with parental support, but are much harder for a baby or toddler to learn to initiate independently.

The concept that describes how and why sleep associations develop is called stimulus control. Under the theory of stimulus control, the bed and bedroom become cues that either promote or inhibit sleep, depending on what has historically happened in that setting.

When a child repeatedly lies in bed awake and/or crying, the crib or bed can gradually become associated with wakefulness and/or crying rather than sleep. Over time, the bedroom context itself begins to cue alertness and arousal, making it even harder for your child to fall asleep.

Response cost is designed to break this cycle. Response cost involves removing your child from the crib/bed and bedroom when falling asleep doesn't occur within a set timeframe. By removing your child from the sleep environment when they are not sleeping, the procedure accomplishes two things simultaneously: it prevents the reinforcement of wakefulness/crying in the bed, and it allows additional homeostatic sleep pressure to build before the next sleep attempt. Sleep pressure is the biological drive to sleep that builds over time, making the next bedtime attempt more likely to succeed.

A 2006 American Academy of Sleep Medicine review of pediatric sleep interventions described bedtime fading with response cost as a "promising intervention" but they noted that there wasn't a lot of research on the technique.

Unfortunately, there hasn't been much additional research on this approach in the intervening years. The formal application of response cost to pediatric sleep was first described by Piazza and Fisher in 1991. In that study, the sleep-wake cycles of four children and adolescents with developmental disabilities and longstanding, severe sleep disturbances were treated using a faded bedtime procedure combined with response cost. Bedtimes were systematically delayed to increase the probability of rapid sleep onset. When the child did not fall asleep within 15 minutes of being placed in bed, they were removed from the bed for one hour before going through the bedtime routine again. All four children had longer sleep duration and three had fewer night wakings. The same group published follow-up studies replicating their initial results and another study showed this approach can be effective for toddlers.

When does it make sense to implement Response Cost?

We usually recommend response cost in conjunction with any nap training for babies and for both babies and toddlers who have associated their bed or bedroom with play or frustration.

There are few general principles apply across all age groups and problems:

Define your sleep onset window in advance. Decide how long you will allow your child to try to fall asleep before you start.
Keep the "out of bed" period calm and non-stimulating. The goal is not to punish or reward your child. When you leave the room, stay in a quiet, dimly lit room free of screens, exciting play, or significant parental attention. A quiet activity such as sitting together on the couch with a book is appropriate.
Determine how long you will keep your child out of the room. When you leave your child's bedroom, you'll need to take enough time to calm and reset your child, but you should avoid staying out of the room for very extended stretches. Typcially 15-30 minutes is a good range for babies and toddlers.
Return the child to bed calmly after the waiting period, with minimal interaction, and repeat the end of your sleep routine cue (e.g., quick cuddles, rocking, a hug, or a song).
Be consistent. The protocol works through repetition. Applying it sometimes but not others will dilute its effectiveness.

How Do You Implement Response Cost for naps during nap training?

Identify your nap training approach. Our Naps 101 series covers this in more detail, but you might opt for approaches like extinction, pick-up-put-down, or crib-side soothing. Be sure to determine whether you will work on one nap or multiple naps before you start.
Set a time limit for your nap training. We always recommend trying your approach for at least 20 minutes, but never more than an hour. For example, you might decide to try for 20 minutes before "giving up" and taking your child into another room for a play break before trying your intervention again. Setting this duration in advance will help you stay consistent with your implementation.
Determine how many response cost breaks you will use. You might decide to stop nap training after one round of trying. In that case, after your response cost break, you would take your baby out of the room to play for 15-30 minutes (duration depends on how long it takes your baby to calm down and how much time your baby can handle) and then would help your baby sleep in the usual manner. On the other hand, if you decide to try nap training twice, you would take a 15-30 response cost break after the first failed nap attempt and then you would put your baby down and use your nap training approach again to give your little one a second chance to fall asleep independently.

How Do You Implement Response Cost to reduce your baby's crying in the crib?

If your baby consistently cries when you enter the bedroom or when you make the transfer to the crib, your little one might be associating the bed or sleep space with crying instead of sleep. This sometimes happens after sleep training, especially when you use sleep training for every sleep episode all at once (we usually recommend working on nights first, then naps to minimize this). To minimize crying on the transition to sleep, implement response cost as follows:

Do your bedtime routine as usual (or remake it if the bedtime routine is a cue for crying). Put your baby down in the usual manner.
If your baby cries, wait 2-10 minutes (ideally, not long enough for your baby to really escalate). Pick your baby up, leave the room for 15-30 minutes. Once your baby is calm, return to the room, repeat the last few steps of your routine and put your baby down again.
Repeat cycles of response cost until your baby falls asleep without an extended period of crying.

How Do You Implement Response Cost for toddlers who fight bedtime?

Toddlers fight bedtime for many reasons. You'll want to first ensure response cost is a good fit for your child's resistence to sleep. In additon, some children will get so excited about getting to leave the room that this approach will not work. If you think your child falls into that category, it's best to use a different strategy. If you think your child can handle leaving the room intermittently, here's how to implement response cost:

Determine whether you need to combine this approach with a faded bedtime. Many toddlers need a bedtime timing reset to solve common sleep issues. Response cost may not do the trick if your child lacks sleep pressure to fall asleep in a reasonable amount of time.
Set a 5-20 minute sleep onset window. After placing your toddler in bed and completing the bedtime routine, wait 5-20 minutes. It can help to tell your child that you want him/her to try to sleep and that you'll be back after a little while. If your child is crying in a crib, this might not be a very fun process but it is ok to use if it feels right to you. If your child has not fallen asleep after the waiting period, remove them from the sleep environment.
Go to a quiet, dimly lit space and wait. For example, take your child to a living room sofa and sit quietly together for 15–30 minutes. Avoid stimulating activities and screens.
After the waiting period, return your toddler to bed. Repeat the last few steps in your bedtime routine (e.g., a snuggle and a song), and restart the 5-20-minute window.
Repeat as needed until your child falls asleep during the sleep attempt.
Once your toddler is falling asleep within 20 minutes on three consecutive nights without needing response cost, move bedtime earlier by 15 minutes, per bedtime fading if needed.

Response cost won't be the right fit for every family or every child, but it does work well for the specific scenarios described above.

Need More Help?

If you need a little help to figure this out or if you are facing other challenges, then please check out our other blogs, our newborn class, and sleep training class. We have other blogs on schedules, naps, travel, toddler issues, and more! If you just need to talk to someone who can help you devise a sleep plan, then feel free to book a one-on-one consultation with us. We are moms with advanced degrees in sleep, nursing, and behavior analysis. We are always happy to help!

References

Piazza, C.C. and Fisher, W., 1991. A faded bedtime with response cost protocol for treatment of multiple sleep problems in children. Journal of applied behavior analysis, 24(1), pp.129-140.

Ashbaugh, R. and Peck, S.M., 1998. Treatment of sleep problems in a toddler: A replication of the faded bedtime with response cost protocol. Journal of Applied Behavior Analysis, 31(1), pp.127-129.

"Behavioral treatment of bedtime problems and night wakings in infants and young children." Sleep 29, no. 10 (2006): 1263-1276.