Article

Behavior Characteristics and Security in Sleep-Disturbed Infants Treated with Extinction

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Abstract

Measured and compared the behavior characteristics and security scores of 35 infants (6-24 months) treated with extinction for sleep disturbance with those of 13 untreated and 15 normal sleep controls. There was no evidence of detrimental effects on the treated infants whose security, emotionality/tension, and likeability scores improved. The findings are congruent with those from a previous study with preschoolers and have important implications for the prevention of later behavior problems in sleep-disturbed children.

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... All subjects were successfully treated, with those in the extinction plus medication group having the quickest response. A followup study was conducted by France (1992), with all participants being re-evaluated between 6 and 30 months later and compared to 13 untreated and 15 normal sleep controls. Significant improvements were found at follow-up for the treated group, with no change in the untreated controls. ...
... The second, larger-scale study was conducted by France and colleagues (France, 1992; France, Blam-child to bed." A multiple-baseline design across children was used, although the researchers were not able to wait for stabilization of behavior during the baseline period as scheduled appointments were made without knowledge of baseline behavior. ...
... Another methodological concern is the lack of long-term follow-up. The best long-term follow-up was presented by France (1992), who conducted follow-up at 30 months for some of their children and by Milan et al. (1981) who followed their three children up to 2 years. Most studies, however, report a follow-up of several weeks to 6 months (e.g., Adams & Rickert, 1988;Seymour et al., 1989), with a few studies following children for longer (e.g., Durand & Mindell, 1990). ...
... All subjects were successfully treated, with those in the extinction plus medication group having the quickest response. A followup study was conducted by France (1992), with all participants being re-evaluated between 6 and 30 months later and compared to 13 untreated and 15 normal sleep controls. Significant improvements were found at follow-up for the treated group, with no change in the untreated controls. ...
... The second, larger-scale study was conducted by France and colleagues (France, 1992; France, Blam-child to bed." A multiple-baseline design across children was used, although the researchers were not able to wait for stabilization of behavior during the baseline period as scheduled appointments were made without knowledge of baseline behavior. ...
... Another methodological concern is the lack of long-term follow-up. The best long-term follow-up was presented by France (1992), who conducted follow-up at 30 months for some of their children and by Milan et al. (1981) who followed their three children up to 2 years. Most studies, however, report a follow-up of several weeks to 6 months (e.g., Adams & Rickert, 1988;Seymour et al., 1989), with a few studies following children for longer (e.g., Durand & Mindell, 1990). ...
Article
To review the literature for empirically supported treatments for bedtime refusal and night wakings in young children. An extensive review of the literature resulted in the inclusion of 41 studies that were evaluated according to the criteria established by the Task Force on Promotion and Dissemination of Psychological Procedures (1995). Evidence exists indicating that extinction and parent education on the prevention of sleep problems can be considered well-established treatments. Furthermore, graduated extinction and scheduled awakenings are probably efficacious treatments, with positive routines a promising intervention. A discussion of effectiveness, treatment feasibility, cost-effectiveness, and methodological limitations of the studies is provided. Recommendations for future directions for research in the treatment of these two common sleep disorders are presented.
... For example, comparison between sleep-disturbed infants and toddlers and their matched controls indicated that the mothers of referred group rated their children as less likeable and agreeable. 40 In another study, mothers in the disturbed group were less reciprocal during feeding, but they showed similar levels of responsiveness during play. 41 In community samples, positive dyadic interaction during play was associated with more and longer episodes of objective night wakings, 29 as well as with consistency in sleeping arrangement. ...
... 79 Furthermore, it has been demonstrated that these interventions lead to broader improvement in child behavior and parental wellbeing. 40,41,54,56,57,81-83 Concerns have been raised that behavioral intervention involving infant protest and crying may compromise infant-parent attachment relationships. However, to date, there are no published studies demonstrating such adverse effects, and, as indicated above, sleep intervention studies, that have measured proxies of attachment, found no evidence of derived infant problem behavior or parenting difficulty which are linked to insecure infant attachment. ...
... However, to date, there are no published studies demonstrating such adverse effects, and, as indicated above, sleep intervention studies, that have measured proxies of attachment, found no evidence of derived infant problem behavior or parenting difficulty which are linked to insecure infant attachment. 40,41,54,56,57,[81][82][83] Interventions aimed at early prevention of sleep problems in infancy have also shown some promise. [84][85][86] These interventions were based on educating parents about sleep promoting principles and have led to better sleep or lower rates of infants with sleep problems in the intervention groups in comparison to controls. ...
Article
Purpose of review: Extensive scientific efforts have been made in an attempt to identify early markers of behavioral and emotional problems. In this context, sleep has received considerable research attention, as it appears to be closely linked to developmental psychopathology. The present review synthesizes some of the most recent findings regarding the concurrent and longitudinal associations between psychopathology and behavioral manifestations of sleep in childhood and adolescence. Recent findings: Recent evidence suggests that compromised sleep is associated with both internalizing and externalizing problems in childhood and adolescence. Moreover, sleep problems have been shown to predict the development of various emotional and behavioral problems, including depression, anxiety, attention-deficit hyperactivity disorder, risk-taking and aggression. Yet, inconsistencies are apparent, particularly among findings that are based on objective sleep measurement. Summary: Taken together, most recent findings suggest that poor sleep in childhood and adolescence constitutes a risk factor for psychopathological symptoms. Accordingly, the importance of early detection and intervention should be a primary goal in clinical settings. In the research domain, the underlying mechanism of these associations should receive future research attention, in an attempt to broaden the understanding of the relationship between sleep and psychopathology.
... For example, comparison between sleep-disturbed infants and toddlers and their matched controls indicated that the mothers of referred group rated their children as less likeable and agreeable. 40 In another study, mothers in the disturbed group were less reciprocal during feeding, but they showed similar levels of responsiveness during play. 41 In community samples, positive dyadic interaction during play was associated with more and longer episodes of objective night wakings, 29 as well as with consistency in sleeping arrangement. ...
... 79 Furthermore, it has been demonstrated that these interventions lead to broader improvement in child behavior and parental wellbeing. 40,41,54,56,57,81-83 Concerns have been raised that behavioral intervention involving infant protest and crying may compromise infant-parent attachment relationships. However, to date, there are no published studies demonstrating such adverse effects, and, as indicated above, sleep intervention studies, that have measured proxies of attachment, found no evidence of derived infant problem behavior or parenting difficulty which are linked to insecure infant attachment. ...
... However, to date, there are no published studies demonstrating such adverse effects, and, as indicated above, sleep intervention studies, that have measured proxies of attachment, found no evidence of derived infant problem behavior or parenting difficulty which are linked to insecure infant attachment. 40,41,54,56,57,[81][82][83] Interventions aimed at early prevention of sleep problems in infancy have also shown some promise. [84][85][86] These interventions were based on educating parents about sleep promoting principles and have led to better sleep or lower rates of infants with sleep problems in the intervention groups in comparison to controls. ...
Article
Full-text available
Infant sleep undergoes dramatic evolution during the first year of life. This process is driven by underlying biological forces but is highly dependent on environmental cues including parental influences. In this review the links between infant sleep and parental behaviors, cognitions, emotions and relationships as well as psychopathology are examined within the context of a transactional model. Parental behaviors, particularly those related to bedtime interactions and soothing routines, are closely related to infant sleep. Increased parental involvement is associated with more fragmented sleep. Intervention based on modifying parental behaviors and cognitions have direct effect on infant sleep. It appears that parental personality, psychopathology and related cognitions and emotions contribute to parental sleep-related behaviors and ultimately influence infant sleep. However, the links are bidirectional and dynamic so that poor infant sleep may influence parental behaviors and poor infant sleep appears to be a family stressor and a risk factor for maternal depression.
... Age might be the main concern in using ICBC because of children's developmental stages (e.g., object permanence, development of regulation competences, and separation anxiety). Sleep interventions also have benefits for parents' and children's sleep behavior (France, 1992;Gradisar et al., 2016;Hiscock, Bayer, Hampton, Ukoumunne, & Wake, 2008;Mindell et al., 2006), and a recent randomized controlled study has shown that ICBC does not lead to emotional and behavioral problems or insecure attachment (Gradisar et al., 2016). However, the empirical evidence is still not adequate to conclude how long infants' crying can safely be ignored or to say which children do not suffer. ...
... Studies measuring proxies of insecure attachment (i.e., child behavior through the Child Behavior Checklist and maternal report of infant attachment through the Flint Infant Security Scale) suggest otherwise. 16,17,18 However, definitive studies incorporating validated measures of attachment (e.g., Strange Situation Test) and physiological measures (e.g., cortisol) are warranted. Unfortunately, a recent attempt to conduct such a study in South Australia failed, due in part to community members opposed to behavioral interventions for infant sleep undermining recruitment (personal communication Dr Gradisar, Flinders University, South Australia). ...
... In the first six months of life, between 15-35% of parents report a problem with their infant's sleep123 including difficulties settling their infant to sleep at the start of the night and re-settling them overnight. Such problems disturb parental sleep leading to parental fati- gue [4], reduced ability to care effectively for the infant, and parental depression symptoms [5]. ...
Article
Full-text available
Infant crying and sleep problems (e.g. frequent night waking, difficulties settling to sleep) each affect up to 30% of infants and often co-exist. They are costly to manage and associated with adverse outcomes including postnatal depression symptoms, early weaning from breast milk, and later child behaviour problems. Preventing such problems could improve these adverse outcomes and reduce costs to families and the health care system. Anticipatory guidance-i.e. providing parents with information about normal infant sleep and cry patterns, ways to encourage self-settling in infants, and ways to develop feeding and settling routines before the onset of problems-could prevent such problems. This paper outlines the protocol for our study which aims to test an anticipatory guidance approach. 750 families from four Local Government Areas in Melbourne, Australia have been randomised to receive the Baby Business program (intervention group) or usual care (control group) offered by health services. The Baby Business program provides parents with information about infant sleep and crying via a DVD and booklet (mailed soon after birth), telephone consultation (at infant age 6-8 weeks) and parent group session (at infant age 12 weeks). All English speaking parents of healthy newborn infants born at > 32 weeks gestation and referred by their maternal and child health nurse at their first post partum home visit (day 7-10 postpartum), are eligible. The primary outcome is parent report of infant night time sleep as a problem at four months of age and secondary outcomes include parent report of infant daytime sleep or crying as a problem, mean duration of infant sleep and crying/24 hours, parental depression symptoms, parent sleep quality and quantity and health service use. Data will be collected at two weeks (baseline), four months and six months of age. An economic evaluation using a cost-consequences approach will, from a societal perspective, compare costs and health outcomes between the intervention and control groups. To our knowledge this is the first randomised controlled trial of a program which aims to prevent both infant sleeping and crying problems and associated postnatal depression symptoms. If effective, it could offer an important public health prevention approach to these common, distressing problems.
... De acuerdo con la teoría operante los problemas con el sueño pueden mantenerse como respuesta a los refuerzos de la actitud paterna y, al mismo tiempo, esa actitud paterna de excesiva implicación puede verse reforzada por el cese del llanto infantil. Estas medidas educativas y conductuales conllevan una reducción del llanto y un aumento del tiempo y calidad de sueño (33) así como una mayor seguridad y autoconfianza en el niño y un mejor bienestar familiar (34,35,36) . ...
Article
Full-text available
El sueño ocupa gran parte de la vida de los seres humanos, en general 1/3 del total de la vida de un adulto ó 13 de los primeros 24 meses de vida de un niño. Podemos entender el sueño como un proceso evolutivo y activo que se inicia prenatalmente resultado de un equilibrio bio-psico-social inestable y dinámico; su evolución dependerá de la armonía entre estos tres factores y constituye un elemento básico del hábito de vida saludable. Dormir bien es un derecho de salud. La evolución de los ciclos vigilia-sueño son un hito importante en el desarrollo precoz del niño que refleja cambios evolutivos en la actividad neuronal que ocurren en diferentes regiones del cerebro. Su desarrollo y características están condicionados por la etapa del desarrollo y el ambiente socioeconómico del niño. Así, el sueño y sus alteraciones forman un fenotipo complejo que está regulado, entre otros factores, por múltiples genes, las interacciones entre ellos, el ambiente y la interacción entre el ambiente y los genes siendo el papel puro de la herencia responsable de entre un 20 – 40% de la varianza de algunos problemas con el sueño lo que indica un componente genético moderado. Por ello, a través de diferentes culturas, épocas históricas y etapas del desarrollo infantil cambian los conceptos de cómo, dónde y cuánto deben dormir los niños o las nociones de qué es normal y qué constituye un problema con el sueño
... In acute and chronic illness (123), above all in diseases with pains or itching sensations, (38) sleep problems are common, but the most difficult and prolonged sleep problems are seen in mentally retarded children and children with autism, indicating a common factor of dysfunction of the central nervous system (16). (46). The effect of chronically disturbed sleep on the parents is extreme tiredness (30,47,98,125,129), and several studies have shown that severe sleep problems in infants and toddlers (pre-school children) are associated not only with extreme tiredness and but also with psychiatric (73) and physical illness in the family, especially depression in the mother. ...
... 11 Because some parents may feel guilty when ignoring their child's crying, it is also important to inform them that children treated with extinction for sleep disturbances show lasting improvements in likeability and security, and that family well-being increases. [12][13][14] In addition, information concerning infants' sleep development and a well documented answer to the question "how long can an infant sleep for" as given by the review of Henderson et al. 3 , may give parents realistic expectations about infants' sleep time during the first year. Because not all children met the suggested sleep times, it is also important to inform parents that children can differ in development and that some children might sleep more and others less. ...
... For instance, based on a systematic review of the literature, Ramchandani and colleagues [39] concluded that ''specific behavioral interventions showed both short term efficacy and possible longer term effects for dealing with settling problems and night-waking." In addition, a few studies have demonstrated that these interventions also lead to improvements in child behavior and to higher parental wellbeing [21,[40][41][42][43][44]. ...
Article
Behavioral insomnia is a very common problem throughout childhood. It has negative impact on children and their families and can persist for many years if not treated. Interventions based on cognitive-behavioral therapy (CBT) principles have mainly focused on withdrawing excessive parental bedtime involvement and helping children develop self-soothing strategies for falling asleep and resuming sleep during the night. With young children, these interventions are mostly based on training and modifying parental behaviors. Changing parental sleep-related expectations, beliefs and perceptions is an important component in these interventions. With older children and adolescents, more versatile interventions exist and they include additional components of CBT including relaxation and stress reduction techniques, modifying cognitive processes related to worrying and anxiety, positive imagery training and others. Extensive research has established the efficacy of behavioral interventions in early childhood. However, research on interventions for older children has been very limited and has failed to provide sufficient information on the efficacy of specific CBT techniques for childhood insomnia.
... Age might be the main concern in using ICBC because of children's developmental stages (e.g., object permanence, development of regulation competences, and separation anxiety). Sleep interventions also have benefits for parents' and children's sleep behavior (France, 1992;Gradisar et al., 2016;Hiscock, Bayer, Hampton, Ukoumunne, & Wake, 2008;Mindell et al., 2006), and a recent randomized controlled study has shown that ICBC does not lead to emotional and behavioral problems or insecure attachment (Gradisar et al., 2016). However, the empirical evidence is still not adequate to conclude how long infants' crying can safely be ignored or to say which children do not suffer. ...
... Simple or unmodified extinction involves the immediate removal of reinforcers. 94,95 For example, parents ignore all child behaviors and requests at bedtime and the middle of the night including crying, calling out, and more extreme behaviors such as throwing objects or vomiting. When used consistently, extinction can over the course of 3 to 5 days eliminate these child behaviors, as the child no longer depends on the parents to be present at bedtime because she or he develops new associations or self-soothing skills. ...
Article
Childhood insomnias (CI) are a diverse group of sleep-related problems that present across the first 2 decades of life, ranging widely in severity. Little is understood about the origins of CI which are likely heterogeneous. Nevertheless, effective treatments for younger children have been shown to be efficacious. Defined within a development framework, this article reviews common correlates and causes of CI during the first two decades. A practical approach to the evaluation and treatment of insomnias among children and youth is presented.
... Given the strong association between chronic sleep disturbance and risk for depression, 119,120 it is possible that the observed reduction in parental depression is mediated by the improved parental sleep patterns once infant and toddler sleep problems are ameliorated. Three of the selected studies 7,21,95 collected secondary outcome data on parent sleep variables following child Review of Bedtime Problems in Children-Mindell et al c France, 1992 andEckerberg, 2004 were not selected to be included in this review, however the outcome data from these studies were based on previous studies that were selected. participation in a behavioral sleep intervention. ...
Article
Full-text available
This paper reviews the evidence regarding the efficacy of behavioral treatments for bedtime problems and night wakings in young children. It is based on a review of 52 treatment studies by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on behavioral treatments for the clinical management of bedtime problems and night wakings in young children. The findings indicate that behavioral therapies produce reliable and durable changes. Across all studies, 94% report that behavioral interventions were efficacious, with over 80% of children treated demonstrating clinically significant improvement that was maintained for 3 to 6 months. In particular, empirical evidence from controlled group studies utilizing Sackett criteria for evidence-based treatment provides strong support for unmodifi ed extinction and preventive parent education. In addition, support is provided for graduated extinction, bedtime fading/positive routines, and scheduled awakenings. Additional research is needed to examine delivery methods of treatment, longer-term efficacy, and the role of pharmacological agents. Furthermore, pediatric sleep researchers are strongly encouraged to develop standardized diagnostic criteria and more objective measures, and to come to a consensus on critical outcome variables.
... Around 15-35% of parents report that their infants' sleep is a problem, with concerns typically focused on frequent night waking and/or difficulties initiating sleep. 1,2 Waking at night to feed is normal, and it may be several months before sleep consolidates into longer settled periods. 3 Despite this, many parents report that their infant has a sleep problem, often seeking help from multiple sources including the internet, general practitioners, health nurses or residential parenting centres (sleep schools). ...
Article
Aim To examine, in a community cohort of healthy one‐month‐old infants, (i) the prevalence of early infant sleeping, crying and feeding problems; (ii) the extent to which they co‐exist; and (iii) infant and mother characteristics associated with each problem alone and with comorbid problems. Methods A survey at 4 weeks of infant age examined the presence of infant sleeping, crying and feeding problems (yes/no); parenting self‐efficacy; rating of self as a tense person; and doubts about parenting at bedtime. Results A total of 770 mothers (39% of those approached) with a total of 781 infants (11 twins) took part. Infant sleeping, crying and feeding problems were reported by 38.5, 27.4 and 25.2% of mothers, respectively. On comorbidity, 25.5% reported one problem, 20.5% reported two and 7.3% reported all three problems. Mothers of first‐born infants reported more crying problems and comorbid problems. Mothers who described themselves as a ‘tense person’ reported more infant feeding problems. Maternal doubt and low self‐efficacy were consistently associated with each type of infant problem and comorbid problems (adjusting for other factors). Conclusion Mothers expressing doubt and low parenting self‐efficacy may benefit from additional support and guidance on normal infant behaviour.
... Age might be the main concern in using ICBC because of children's developmental stages (e.g., object permanence, development of regulation competences, and separation anxiety). Sleep interventions also have benefits for parents' and children's sleep behavior (France, 1992;Gradisar et al., 2016;Hiscock, Bayer, Hampton, Ukoumunne, & Wake, 2008;Mindell et al., 2006), and a recent randomized controlled study has shown that ICBC does not lead to emotional and behavioral problems or insecure attachment (Gradisar et al., 2016). However, the empirical evidence is still not adequate to conclude how long infants' crying can safely be ignored or to say which children do not suffer. ...
Article
Ignoring children's bedtime crying (ICBC) is an issue that polarizes parents as well as pediatricians. While most studies have focused on the effectiveness of sleep interventions, no study has yet questioned which parents use ICBC. Parents often find children's sleep difficulties to be very challenging, but factors such as the influence of Western approaches to infant care, stress, and sensitivity have not been analyzed in terms of ICBC. A sample of 586 parents completed a questionnaire to investigate the relationships between parental factors and the method of ICBC. Data were analyzed using structural equation modeling. Latent variables were used to measure parental stress (Parental Stress Scale; J.O. Berry & W.H. Jones, 1995), sensitivity (Situation-Reaction-Questionnaire; Y. Hänggi, K. Schweinberger, N. Gugger, & M. Perrez, 2010), Western-oriented parental beliefs (Rigidity), and children's temperament (Parenting Stress Index; H. Tröster & R.R. Abidin). ICBC was used by 32.6% (n = 191) of parents in this study. Parents' Western-oriented beliefs predicted ICBC. Attitudes such as feeding a child on a time schedule and not carrying it out to prevent dependence were associated with letting the child cry to fall asleep. Low-sensitivity parents as well as parents of children with a difficult temperament used ICBC more frequently. Path analysis shows that parental stress did not predict ICBC. The results suggest that ICBC has become part of Western childrearing tradition.
... A psychologist role in delivering treatment that leads to improved sleep is aligned with beneficence. With respect to nonmaleficence, there is evidence that sleep intervention improves some aspects of behavioral adjustment (e.g., security, emotionality and tension, likability) in the short term (France, 1992). There is support for lack of any harmful effects of behavioral sleep treatment in the short and long term (up to 5 years; Price et al., 2012). ...
Article
Delayed sleep onset and problematic night wakings are common during the infant and toddler years. Such sleep disturbances typically develop as the result of learned associations with specific cues needed for sleep initiation and/or maintenance that are not consistently available at bedtime or immediately available to the child after night wakings (e.g., rocking, feeding, being held). Effective empirically supported behavioral treatments for these common sleep problems exist. Despite the research evidence supporting the effectiveness of these behavioral treatments, widespread dissemination of unsubstantiated concerns about the appropriateness and theorized negative impact of behavioral sleep treatments persists. Some researchers have even raised concerns about the ethics of health providers providing behavioral sleep treatments, particularly extinction-based treatments. As a result, providers of pediatric behavioral sleep services routinely encounter parents who raise concerns about the use of extinction-based behavioral treatments. Unwarranted parental concerns may prevent some families from seeking services that could lead to positive health outcomes. This article discusses important ethical considerations for pediatric psychologists who provide behavioral sleep medicine services. Recommendations for evidence-based clinical practice are made considering American Psychological Association Ethical Principles of Psychologists and Code of Conduct, American Academy of Pediatrics guidelines for safe sleep practices, and current research on behavioral sleep treatment outcomes.
... Around 15-35% of parents report that their infants' sleep is a problem, with concerns typically focused on frequent night waking and/or difficulties initiating sleep. 1,2 Waking at night to feed is normal, and it may be several months before sleep consolidates into longer settled periods. 3 Despite this, many parents report that their infant has a sleep problem, often seeking help from multiple sources including the internet, general practitioners, health nurses or residential parenting centres (sleep schools). ...
... In fact, the young er the infan t, the easier the proce ss will be. 'Babie s older than 5 or 6 mont hs are natur ally going to be more upset becau se you've chang ed the rules on them, ' Dr. Wright & Woodcock, 1970Rolider & Van Houten, 1984Richman, Douglas, et al., 1985Chadez & Nurius, 1986Pritchard & Appleton, 1988Rickert & Johnson, 1988Weir & Dinnick, 1988Seymour, Brock, et al., 1989 Durand & Mindell, 1990France, 1992Minde, Faucon, & Falkner, 1994Sadeh, 1994 Background Concerns about the quality and quantity of an infant's sleep top the list of worries for parents. While some literature indicates that infant sleep involves a complex interaction of biological, developmental, and environmental factors 1 , the majority of research suggests that infant sleep problems result from caretaker responsiveness which inadvertently reinforces nightwaking behavior 2 . ...
Poster
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(NOTE: PLEASE SEE UPDATED RESEARCH POSTER: "Assessing the continuity between research, advice, and parenting practice on the use of extinction in infancy" on this page). ABSTRACT: The most empirically supported and endorsed approaches to preventing or ameliorating infant sleep problems involve various forms of extinction (crying it out). This approach is widely recommended by pediatricians and mainstream parenting publications for infants as young as 3- to 4-months. A review of the literature regarding the cry-it-out (CIO) approach to infant sleep reveals that empirical support for this early start date is lacking. Much of the existing literature used to validate the use of extinction with infants does not include infants under 1 year in the sample population. The subset of studies which include infants, do so as part of a much larger sample comprised of wide age ranges (e.g. 9-60 months). Results from these studies do not specify outcomes by age, and obscure the existence of differential effects for infants. Though CIO is recommended as the approach of choice for infant sleep, relatively little is known about its effects on infants under 1 year.
... The other concern is the potential for extinction to compromise a child's attachment to caregiver(s). 23,55 Ideally parent and child form a secure attachment to each other whereby the child's activity or signals (such as crying or smiling) maintain caregiver proximity and responsiveness. 56 Secure attachment is foundational in a young child's development and impacts on social, emotional, cognitive and behavioral outcomes. ...
Article
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The majority of behavioral sleep interventions for young children involve extinction procedures where parents must ignore their child's cries for a period. Many parents have difficulties with this, contributing to attrition, non-compliance, and treatment avoidance. Yet why these methods are difficult to implement has rarely been addressed in the literature. This paper discusses seven potential reasons why parents may find extinction sleep interventions difficult: enduring crying, practical considerations, fear of repercussions, misinformation, incongruence with personal beliefs, different cultural practices, and parent wellness. These reasons are discussed in relation to the current literature. Practicing health professionals and sleep researchers could benefit from an awareness of these issues when suggesting extinction interventions and offering alternatives which may be more appropriate for family circumstances and facilitate parental informed choice.
... The evidence reviewed above of there having been only relatively slow changes in crying duration in both contexts suggests that the incremental procedure did not dramatically reduce infant distress, relative, for instance, to planned ignoring combined with parental presence (France & Blampied, 2005;Sadeh, 1994). Thus, given the low parental stressfulness of all the various interventions, the lack of rapid reductions in infant distress using graduated checking, and the evidence that regular planned ignoring has no adverse effects on infant security and wellbeing (France, 1992(France, , 1994Reid et al., 1999), the stress/distress-reduction justification for the graduated checking procedure cannot be sustained. ...
Article
When treating infant sleep problems implementing treatment procedures at bedtime-only might be easier and more efficient than requiring parents to implement procedures throughout the night, but only if improvements at bedtime generalize to later in the night. This study investigated the immediate and generalized effect of treating bedtime settling problems and later night waking in infants and whether it was parent or child behavior that generalized. Parents recorded sleep problems of seven infants (6–20 months) who exhibited chronic sleep disturbance, then implemented a graduated checking procedure at bedtime-only (Setting 1). A multiple-baseline across-settings and participants design was employed. Immediate (in Setting 1) and any generalized effects (in Setting 2) on wakings and other changes in parent and child behavior were assessed by diary information and all-night infra-red video recordings. Clinically significant reductions in sleep problems were evident for five out of seven infants, but these were not consistently observed until parents generalized their use of the procedure throughout the night. There was no evidence that the infants generalized changes in self-soothing from bedtime to later. It is concluded that changes in infant sleep problems are unlikely to occur unless parents actually alter their management of the problems across all settings in which the problems occur. Copyright © 2008 John Wiley & Sons, Ltd.
Article
Bedtime problems and night wakings in children are extremely common, and the treatment literature demonstrates strong empirical support for behavioral interventions. Empirically validated interventions for bedtime problems and night wakings include extinction, graduated extinction, positive routines, and parental education. Most children respond to behavioral interventions, resulting not only in better sleep for the child, but also better sleep and improved daytime functioning for the entire family. This article reviews the presentation of bedtime problems and night wakings, empirically validated interventions, and challenges to treatment in both typically developing and special populations of children.
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Behavioural sleep treatments teach children to self soothe and sleep alone but often require a parent to ignore their child's cries for extended periods, a technique parents may find difficult. This paper presents a modified version of sleep training which aims to improve sleep but reduce crying in children and increase compliance in parents. Thirty-three children (Mean [SD] age = 27.01 [13.4] mths) from a clinical non-controlled population presenting with Behavioural Insomnia of Childhood, utilised a five-week sleep training method that teaches parents to gradually withdraw their assistance, allowing them to attend and calm their child whenever they choose and not to ignore their cries, components that differ from commonly utilised methods. Post treatment, all negative sleep associations, co-sleeping and family stress were reduced and all measures of sleep significantly improved: total night time sleep; time taken until sleep onset (SOL) and minutes awake during the night (WASO) (all p = < 0.002) with large treatment effects sizes (d = 0.94-1.85). Whilst the results are preliminary, this may offer an alternative method to explore in larger studies, given that many parents may have difficulty with ignoring the extended bouts of crying which often accompany commonly utilised sleep training methods.
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Infant sleep disturbance involving chronic night waking and resistance to settling to sleep or returning to sleep is a common problem for families with children 6-27 months old. Prescription and nonprescription sedatives are frequently administered without clear evidence that they are effective as either long-term or short-term palliatives. Trimeprazine tartrate, administered either 15 mg/5 mL or 30 mg/5 mL, was compared with both baseline and placebo in a multiple-baseline-across participants, double-blind study. No clinically significant effects of the low dose were detected, whereas the effects of the high dose were not consistently replicated across nor within participants. During active drug treatment, only 2 of 12 children achieved Sleep Behaviour Scale scores indicative of nonproblem sleep. Trimeprazine tartrate is not recommended as a pharmacological treatment for infant sleep disturbance unless as an adjunct to a behavioral therapy program.
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The need for effective treatments for pediatric overweight is well known. To evaluate the applicability of an evidence-based treatment in an applied clinic setting that includes children with severe obesity and comorbid medical or psychiatric conditions. Forty-eight overweight children and their families were provided an evidence-based intervention at a for-profit clinic. Unlike typical lab-based samples, participants were self-selected and included children who were very overweight and/or had comorbid conditions. Change in standardized BMI was assessed. Overall, participants demonstrated a significant reduction in standardized BMI, t (40)=6.6, p<.001. Further analyses indicated that participants who were severely obese and children with a comorbidity significantly reduced their zBMI (t (11)=4.0, p<.01; t (14)=3.9, p<.01, respectively). Children who were severely obese reduced their BMI percentile by .2 (SD=.2) and those with a comorbidity reduced their BMI percentile by .6 (SD=.9). Nonsignificant interaction effects indicated comparable weight reductions in severely obese and overweight/obese participants, F (1,39) = 1.49, ns. Also, those with comorbidities and those without comorbidities experienced similar weight reductions, F (1,39)=.7, ns. This study provides promising evidence for the applicability of an evidence-based treatment for weight management in clinical practice.
Article
Infant sleep problems (ISP) are common and have known effects on parental mood. There is debate as to whether treatment strategies may impact on the infant's emotional health. To compare the effectiveness of two treatment strategies for ISP on the infant's sleep, maternal mood, and the infant's emotional health. The two strategies are 1) systematic ignoring with minimal check ('SI-mc': commonly known as 'controlled crying'), and 2) a new, but similar, method where parents feign sleep inside the infant's room before intervening (parental presence with minimal check: 'PP-mc'). Participants were randomised to one of the two conditions. Measures were taken at baseline, then three weeks and four months post-intervention. Data were collected from 16 families with infants aged 6-18 months who were seeking professional help with their infant's sleep difficulties. Measures of infant sleep, maternal experiences and mood, and infant emotional health were collected. Both treatments were effective, with a third to a half of families reporting decreased ISP by 3 week post intervention, and nearly all reporting decreased ISP by follow-up. Similarly, most mothers in both treatments reported improvements to their experiences or mood, and there was no discernable disruption to infant emotional health. These findings support previous research into the effectiveness of SI-mc. The study also expands the research into the effectiveness of parental presence by showing that with the inclusion of the minimal check component, which may be preferred by both parents and clinicians over non-responding to the crying infant, the strategy is as effective as SI-mc.
Article
Sleep problems are common among young children with developmental disabilities. In many cases, parental attention has shaped and reinforced these problems. In the present study, extinction of parental attention was effective in the elimination and long-term maintenance of nighttime crying with a young child with a physical disability.
Chapter
The Behavioral Insomnias of Childhood (BIC) include a series of problems of sleep initiation, continuity, maintenance, and bedtime resistance. These sleep problems can place a significant burden on the parents who may be required to attend to a child at the beginning or in the middle of the night. The resulting sleep loss can impact parents’ and children’s daytime functioning and can increase bedtime-related conflict. Even when sleep problems do not meet criteria for a disorder, they can increase parental stress and parent–child conflict. Childhood sleep problems can be an indicator of poor regulatory capacity in the infant or child, and there is some evidence that sleep problems presenting in the first few years of life can be a marker of a diathesis for psychopathology. Even though sleep problems in early childhood are quite common and there are well-established interventions for these problems, little is understood about the pathophysiology of childhood sleep disorders. This chapter will review common causes of sleep problems in infants and young children that can persist into the later school years and adolescence. This will be followed by a detailed practical approach to evaluating and treating childhood insomnias. KeywordsBehavioral insomnias of childhood-Sleep-onset association type-Limit-setting type-Parental reinforcements-Children’s sleep habits questionnaire-Gradual extinction-Positive routines
Article
Infant crying and night waking are common concerns for parents, costly problems for health services and may trigger infant abuse or lead to serious child disturbances. Parents are given contradictory advice on how to manage infant crying and sleeping, indicating the need for evidence-based guidance. This review of recent research draws distinctions between infant crying and sleeping problems, between the problem identified by parents and the infant behaviour underlying the problem, between different types of crying behaviour and their causes, and between the types of cases which present at different ages. It proposes that the two main approaches to parenting advocated by baby-care experts, ‘infant-demand’ and ‘structured’ parenting, have different benefits, and costs. Comparative studies have found that infant-demand parenting is associated with low amounts of fussing and crying in the first three months of age, but with night waking which continues beyond three months. Randomised controlled trials have provided evidence that structured parenting leads to more overall fussing and crying during the first three months, but reduced night waking and crying after that. The findings are translated into recommendations for preventing and treating infant crying and sleeping problems, for policy debate, and for further research. Copyright © 2007 John Wiley & Sons, Ltd.
Article
Behavioural family interventions, alone or in combination with sedative medication, have been shown to be effective treatments for infant sleep disturbance (ISD), especially night waking and crying. Nevertheless, some infants become treatment resistant and ISD persists despite multiple treatments on multiple occasions. Parents of six infants aged 9 – 27 months with treatment-resistant ISD responded to night wakings by lying noninteractively near their child until sleep resumed (parental presence treatment). They also administered a physician-prescribed, prebed-time sedative (trimeprazine tartrate), the dosage reducing from an initial 30 mg/night by 1/5th every second night. The treatment was introduced according to a multiple-baseline-across-infants design, and faded out over 10 days. Thereafter, night wakings were responded to by planned ignoring or with minimal-check procedures when infant welfare required. Combined treatment reduced night waking below baseline levels, although there was some later deterioration associated with illness or rebound at medication termination. Clinically significant reductions in ISD were evident at the end of treatment for all infants, and this was maintained at follow-up for five infants. Parents found the intervention helpful, satisfying and nonstressful.
Chapter
Parents commonly raise concerns about their children’s sleep. Childhood sleep problems cause negative short- and long-term outcomes. Parents also suffer when their children’s sleep problems disrupt, shorten, or otherwise fragment their sleep. Sleep problems can be medical, psychological, and behavioral in nature, and are further affected by cultural, social, and familial norms. As such, they are highly subjective; sleep behaviors that present a problem in one household—such as co-sleeping—are the accepted practice in another. Children outgrow some sleep problems, but not all. Parents and primary care physicians must differentiate between problems that will remit without intervention and those requiring attention. Parents experience disruptive bedtime routines as draining nightly struggles to put children to sleep are a considerable source of stress and lead to delayed sleep onset. Parents strive to ensure their children attain sufficient sleep despite the lack of a research-driven consensus on the amount of sleep children require. In this chapter, we offer the most recent evidence for physician’s information regarding the negative effects associated with a sleep-deprived child, the use of antihistamines or other medications to promote sleep, and the controversy surrounding efficacious, evidence-based behavioral interventions for promoting sleep in children (i.e., sleep training, also called “cry-it-out”).
Chapter
Insomnia in childhood includes difficulty initiating and maintaining sleep and bedtime resistance. These sleep problems are common in childhood and largely result from interactions between the caregivers or parents and their children. However that are other causes and origins of insomnia that can include child temperament, psychopathology, or variation in sleep need that can include decreased need for sleep and atypical circadian regulation. Chronic insomnia symptoms often precipitate a range of functional daytime impairments (e.g., academic impairment, hyperactivity, inattention, irritability, tiredness) which may further undermine subsequent parent–child interactions including the transition to sleep. Evidence-based interventions for childhood insomnia can address these sleep difficulties and family stress. However, dissemination of evidence-based interventions is limited by the dearth of clinicians trained to deliver these interventions, access to sleep disorder centers, and cost. This chapter provides an overview of approaches to diagnosis and management of childhood insomnia.
Chapter
The origins of behavior therapy techniques can be found in the work of individuals such as Ivan Pavlov and B. F. Skinner, on which the principles of respondent and operant conditioning are based. Behavioral treatment methods have remained at the forefront of effective intervention for the past 30 years. However, since its inception child behavior therapy has come to include other techniques and strategies for ameliorating child psychopathology. These strategies include observational learning or modeling ([Bandura, 1977]) and cognitive-behavioral therapies ([Meichenbaum & Goodman, 1971]).
Article
Sleep disturbances such as bed refusal and resistance, sleep-onset delay, night waking with crying, and unwanted co-sleeping with parents affect 15% to 25% of families during their infant's first two years. A program is described that involves structured pre-bedtime activities, putting the child into his or her own bed awake at a regular time, and responding to subsequent waking and crying with planned ignoring and minimally-arousing checks when necessary. This programme was demonstrated in four families and shown to resolve infant sleep disturbances to a clinically significant degree and to the satisfaction of the parents.
Article
Extinction with parental presence is indicated for settling and night waking problems in infants between 6 and 24 months of age. Infants of this age often present with sleep disturbance, including an inability to fall asleep at night without intense parental involvement, resulting in the infant being placed in the cot already asleep or with the parent present. This means the infant lacks the skills to self settle and forms inappropriate sleep associations (such as parental contact and feeding), rather than appropriate cues (such as internal feelings of tiredness, and the crib or bed). Consequently when the infant inevitably awakens during the night, the same associations are required for sleep reinitiation. This results in awakenings each night requiring the parent to be present. Parents accept that infants require intervention throughout the night until they are able to sustain a longer period of sleep without feeding. Unfortunately, if inappropriate associations are formed, the young child may continue with sleep onset and night waking problems indefinitely. These kinds of persistent sleep problems in infants and young children are associated with a number of adverse developmental sequelae.
Article
Unmodified extinction is an effective treatment for childhood insomnia. It is effective in reducing inappropriate bedtime behaviors (e.g., crying, repeatedly getting out of bed, and tantrums) that interfere with sleep onset and maintenance. These behaviors are often maintained by reinforcement in the form of parental attention and insufficient limit setting. These child behaviors often occur at bedtime and at waking up at night (night waking) or in the early morning. This treatment may also be effective in case of co-sleeping, whereby child and parent sleep in the same bed. There is no contraindication to the use of unmodified extinction. However, prior to starting an extinction procedure, any somatic, neurological, or other factor that may be responsible for bedtime and night-waking problems should be assessed and ruled out. There are many such factors, such as breathing difficulties, epilepsy, and melatonin synthesis disturbance.
Article
Infant sleep disturbance (ISD) is widespread and troublesome. Although effective management techniques have been established, some lay and professional authors have expressed concern about these interventions. These concerns are sometimes shared by parents who seek professional advice while feeling ambivalent about undertaking treatment. These concerns include (a) that ISD is normal and inevitable, (b) that it results from unnatural or artificial cultural practices, (c) the belief that ISD expresses a need state, and (d) the belief that the use of extinction is harmful. These concerns are examined and the management of ISD by extinction and its alternatives are considered in the light of the ethics of professional practice. It is concluded that these concerns are best answered within the context of a professional relationship based on a partnership and the sharing of expertise with parents.
Article
Effective interventions are needed to ameliorate the prevalent, persistent, and enduring consequences of childhood sleep disturbances. This review considers behavioral and cognitive-behavioral approaches to treating childhood sleep disturbances. Behavioral approaches apply the principles of learning (stimulus-response) theory to effect changes in observable behaviors, whereas cognitive-behavioral approaches combine behavioral methods and cognitive approaches (ie, those involving manipulation of thoughts, attitudes, and beliefs) to change both observable behaviors and unobservable behaviors such as cognition or emotions. Cognitive-behavioral approaches require verbal communication and are commonly used with older, more cognitively sophisticated children. Behavioral/cognitive-behavioral approaches can be used alone or in combination with pharmacotherapy when appropriate. The confluence of evidence from case studies, case series, uncontrolled studies, and the few well-controlled trials that have been conducted on these approaches provides reason for cautious optimism about the efficacy of behavioral interventions, the clinical utility of which should increase as their benefits are better defined.
Article
Sleep problems in young children are prevalent and may become chronic without treatment. Behavioral interventions are clearly effective; but questions still remain and controversies exist, which provide barriers to implementing these interventions. Overall, the results of empiric studies as well as clinical experience suggest there is no perfect or one-size-fits-all intervention but rather that these strategies need to be tailored to the individual child and family. Research does not support the best age to implement behavioral strategies, although the authors postulate that 3 to 4 months of age may be optimal in many cases. Parents should aim to improve sleep behavior as soon as a problem has been identified and when they feel comfortable using intervention procedures to modify the behavior of the child. The practice of pairing sleep aids with an evidence-based behavioral treatment strategy also has some empiric support. However, there are few data supporting the use of sedative/hypnotic pharmacologic agents in children either alone or in combination with behavioral treatments; these agents should be used, if at all, with caution and only under the supervision of a health care provider. Finally, parents can be assured that research does not indicate a link between behavioral approaches used to improve the sleep in young children and any negative effects on the child, parent, or child-parent relationship outcomes.
Article
Objective: To evaluate a prevention program for infant sleep and cry problems and postnatal depression. Methods: Randomized controlled trial with 781 infants born at 32 weeks or later in 42 well-child centers, Melbourne, Australia. Follow-up occurred at infant age 4 and 6 months. The intervention including supplying information about normal infant sleep and cry patterns, settling techniques, medical causes of crying and parent self-care, delivered via booklet and DVD (at infant age 4 weeks), telephone consultation (8 weeks), and parent group (13 weeks) versus well-child care. Outcomes included caregiver-reported infant night sleep problem (primary outcome), infant daytime sleep, cry and feeding problems, crying and sleep duration, caregiver depression symptoms, attendance at night wakings, and formula changes. Results: Infant outcomes were similar between groups. Relative to control caregivers, intervention caregivers at 6 months were less likely to score >9 on the Edinburgh Postnatal Depression Scale (7.9%, vs 12.9%, adjusted odds ratio [OR] 0.57, 95% confidence interval [CI] 0.34 to 0.94), spend >20 minutes attending infant wakings (41% vs 51%, adjusted OR 0.66, 95% CI 0.46 to 0.95), or change formula (13% vs 23%, P < .05). Infant frequent feeders (>11 feeds/24 hours) in the intervention group were less likely to have daytime sleep (OR 0.13, 95% CI 0.03 to 0.54) or cry problems (OR 0.27, 95% CI 0.08 to 0.86) at 4 months. Conclusions: An education program reduces postnatal depression symptoms, as well as sleep and cry problems in infants who are frequent feeders. The program may be best targeted to frequent feeders.
Article
Infant sleep disturbance affects between 15 and 35% of infants and their parents. Despite the significance of the problem there exists little guidance for clinicians dealing with this group. Interventions advocated by the literature range from spanking to medication. Normal sleep state development in infants and the influence of temperament is described, as are infancy and infant sleep disturbance.Treatment regimes that have been subjected to some degree of empirical evaluation are reviewed. These have been the pharmacological approaches, and from a behavioral perspective, scheduled awakening, extinction and its modifications, stimulus control, and finally studies employing a variety of methods. Treatment outcomes using these techniques are discussed in relation to practical considerations, side effects, and acceptability to parents. The single prevention evaluation is described, as is the need for further research in this area.
Article
Background: Infant sleep problems (ISP) are among the most common reasons for which parents seek advice from health professionals. A substantial literature supports the efficacy and effectiveness of behavioural approaches, based on the principal of extinction, in treating ISP. Questions have been raised, however, about the potential negative effects of temporarily withholding responding to infant crying during sleep‐time to infant mental health. Critics of this strategy have advocated an alternative approach where parents are immediately responsive to signs of infant distress. Aims: To evaluate critically the evidence for and against these approaches in infants aged 6–24 months, with particular reference to issues of clinical effectiveness and infant mental health. Discussion is included of clinical implications and cultural and attachment factors impacting on parents’ preferences for settling methods. Results: The weight of clinical effectiveness empirical support is with extinction‐based interventions. Moreover, the core arguments against this approach regarding disruption to the infant’s mental health do not have empirical support, with available studies indicating either no change or modest improvements to the infant’s mental health. At this stage the onus is on proponents of the immediate‐responding approach to undertake effectiveness research. Well‐designed comparative studies would also help to advance this debate.
Article
Clinicians are commonly consulted by the parents of infants aged 6–24 months who are distressed by their infant's sleep disturbance. Infant sleep disturbance (ISD) presents as frequent night awakening, delays in sleep onset and co-sleeping that is not of the parents’ choice. Conflicting advice leaves parents unsure regarding management. Recent research has described treatment approaches as well as models describing the complexity of variables that appear to control ISD. In this article, we describe the learning principles underlying the development of ISD and summarize empirically validated treatments. Practitioners are advised on the importance of appropriate assessment and support, as well as on suggestions they can make about prevention.
Article
The most important function of the skin is to provide a protective barrier between the body and the environment. It limits loss of body water, prevents absorption of noxious agents and protects against physical trauma. The epidermal barrier begins to develop in mid-gestation and is fully formed by about 32 weeks gestation. In the extremely preterm infant, it is poorly formed and functionally weak. Exposure to air after birth accelerates epidermal development.Transepidermal water loss is high in the immature infant, causing difficulties in fluid balance and temperature control. The percutaneous absorption of topically applied agents may lead to accidental poisoning. Adhesive trauma strips the epidermis, predisposing to infection. These problems can be minimized by limiting the use of skin probes and adhesive tape, nursing the infant in a high ambient humidity and sparing use of aqueous chlorhexidine as an antiseptic. The routine use of emollients or skin coverings is not recommended.
Article
Clinicians are commonly consulted by parents of infants aged 6–24 months about infant sleep disturbance (ISD). Considerable research over the last two decades has contributed to our knowledge of ISD but has failed to lead to a comprehensive aetiological explanation. This research is reviewed and identifies: (i) individual factors associated with sleep disturbance; (ii) interactive mechanisms linking these associated factors; and (iii) the relationship between learning and infant sleep disturbance. The findings of this research are incorporated into models describing proximal factors involved in the three processes considered important in the development of sleep disturbance: (i) the development of sleep self-initiation at around 3 months of age; (ii) the development of primary sleep disturbance by 6 months of age; and (iii) the development of secondary sleep disturbance later in the first or second year. Description of the influence that proximal factors have on sleep disturbance, organized in these three models, is the most appropriate way of presenting this complex material for the clinician. Changing these proximal factors is important in both prevention and management.
Article
Sleep disruption is known to be common in preschool children. Those with atopic eczema (AE) would seem to be at particular risk because of itching. In this preliminary survey parents confirmed clinical impressions that sleep loss is a common feature when a child's atopic eczema is flaring. Sleep disturbance was reported by parents for 86% of the relevant nights with an average of 2.7 wakings per night and an average parental sleep loss of 2.6 h per night. Parents used a common core of strategies to help their children sleep at these times. Some of the strategies employed are likely to perpetuate sleep disturbance beyond the time of the flare. Parents gained most benefit from their own idiosyncratic approaches. For the majority of children (59%) sleep disruption is limited to times when their AE is flaring.
Article
Chronic disturbed sleep is a common problem in preschool children. Treatment by extinction is successful but may be accompanied by side-effects such as post-extinction response bursts which make the treatment aversive to parents and which impairs their compliance. This study evaluated a modified procedure, graduated extinction, which required parents gradually to reduce attention to bedtime disturbance and night waking from average baseline levels to zero over 28 days. Baseline measures of frequency and duration of night waking, sleep-onset latency, and bedtime delay were made for six children (6- to 14-months-old). Parents were then instructed to use graduated extinction using a multiple-baseline-across-subjects design. Following treatment, three out of six children showed clinically significant reductions in the frequency and duration of night waking, and a fourth child substantially reduced the duration of her wakings. These gains were maintained at followup. Lack of improvement was associated with parental noncompliance with treatment and childhood illness. Two subjects showed some evidence of post-extinction response bursts despite the gradual withdrawal of parental attention. Parents reported high satisfaction with the procedures but half found the procedure mildly to moderately stressful. While graduated extinction was an effective treatment, regular extinction offers practical and clinical advantages in most cases.
Article
The rationale and problems in the development of age-specific CBC forms are described. The relevance of concepts to specific ages and the amount of contact required for rating are precursors t o development of rating forms. Clusters of items that have relevance for the earliest ages were derived from a sequence of studies. The consistency of these clusters in older ages, and the relationship of these to clusters applicable only to the older ages is noted. Reliability and between-cluster correlations are presented.
Article
The sleep patterns of 31 children aged between 9 months and 3 1/2 years were studied over a period of 3 months during which time a behavioural programme was initiated and evaluated. Measures of the mothers’ mental state and of the relative behavioural control the child was perceived to have were also taken. The childrens’ sleep showed rapid improvement following the intervention and similar changes were observed in the other measures.
Article
A double-blind trial using trimeprazine tartrate was carried out in 22 children with severe waking problems. On parental verbal reports sleep was significantly improved on the drug compared with the original baseline and the placebo, but diaries kept by the parents showed that this improvement was clinically only moderate, with many wakeful nights still occurring. Taking the drug produced no permanent effect on sleep patterns and a follow-up of 14 children 6 months later showed persisting sleep problems in the majority.
Article
The developmental progress of children of drug-abusing mothers was assessed in a study of foster children. Cognitive abilities and personal adjustment appeared to be normal but significantly poorer school adjustment patterns were observed. Such children are disproportionately locked into foster care.
Article
Using a nonconcurrent multiple baseline design, we evaluated the effects of extinction and stimulus control on nighttime sleep disturbances exhibited by 7 infants. Results showed that frequency and duration of night wakings decreased for all subjects, with corresponding improvements reflected through changes in responses to the sleep behavior scale. Observed improvements maintained at 3 and 24 months posttreatment.
Article
The purpose of our study was to determine if common sleep disturbances in young children, such as night waking and bedtime struggle, tend to persist; if they are related to environmental stress factors and are accompanied by other behavior problems; and if their persistence is related to other factors. Sixty children aged 15 to 48 months (mean age 26.4 months) were studied by interviewing their mothers initially and after 3 years. Children with and without sleep disturbances were compared, with the latter serving as the control group. Twenty-five (42%: night waking, 22%; bedtime struggle, 13%; both night waking and bedtime struggle, 7%) of 60 children had sleep disturbances at the initial interview, and of these 25 children, 21 (84%) had persistence of sleep disturbances after 3 years, persistent sleep disturbances had a significant relationship with increased frequency of stress factors in the environment (P less than 0.01). Other generalized behavior difficulties were present in 30% of sleep-disturbed and 19% of non-sleep-disturbed children (P = NS). Co-sleeping (sleeping with a parent or sibling) was noted more frequently in sleep-disturbed (34%) than in non-sleep-disturbed (16%) children. Twenty percent of the mothers at initial interview and 30% at 3-year follow-up perceived their child's sleep disturbances as stressful to them and to their family life. Early identification of the child with sleep disturbances and timely intervention would help both the child and the family.
Article
The parents of children aged between 18 and 32 months attending a south-west London general practice were asked to complete a questionnaire and diary about their child's sleep behaviour. Of the 142 parents approached, 116 (82%) responded and 99 completed both the sleep diary and questionnaire. One-quarter of the respondents were found to be troubled by their child's sleeping patterns. Analysis showed that the children of these parents had more disturbed sleeping-waking rhythms, and slept less time both during the day and night compared with the children of parents who had no complaints about the child's sleeping pattern. No demographic or social factors were found to be associated with disturbed sleep patterns. However, children with sleep problems were less often given an attachment object at bedtime, less often cuddled on waking at night and more often taken into their parents' bed than other children. These findings raise the possibility that modification of the way parents handle the child with sleep problems might effect an improvement in the child's sleep.
Article
The efficacy of behavioural methods of treatment for severe sleep disorders was examined in a pilot study involving 35 children aged 1-5 years. Improvement occurred in 77%. Methodological issues concerning the selection of children for treatment, selecting adequate controls and outcome measures, and using parents as therapists, are discussed.
Questionnaires about infant sleep patterns were sent by mail to a random sample of the families of 1,158 1− to 2-year-olds. Returned questionnaires (67%) indicated that 20% of the children woke five or more times a week. Characteristics of 55 children with severe waking problems and their families were compared with 30 nonwaking controls. The wakers more commonly had other behavior and temperamental difficulties, irritability in the early months, and an adverse perinatal history. Their families had more stress and their mothers were more likely to have psychiatric symptoms. The role of various factors in the genesis and maintenance of sleep disruptions is discussed.