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Handling Parents' Concerns Regarding the Behavioural Treatment of Infant Sleep Disturbance
Abstract
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.
... 23 Parental resistance has been highlighted in clinical settings, particularly relating to unmodified extinction ("cry it out"). 14,15,[24][25][26] A survey showed parents found a "bedtime pass" method, where the child was given a pass to leave their bed for something quick (e.g., a drink or hug) once each night without penalty, much more acceptable than ignoring. 27 This preference was not mirrored by professionals. ...
... 28 Objections to treatments can lead to attrition, avoidance, and non-compliance. 17,18,22,25,27 A significant discrepancy between parent and practitioner views could also potentially harm these relationships, and in turn reduce future engagement with that practitioner or possibly other professionals. One result could be significant health issues from ongoing sleep deprivation. ...
... Over 20 years ago, France discussed concerns and assumptions of parents which reduced their engagement. 25 That paper raised the issue of parent concerns, but all points raised were based on the assumption that parents' concerns were due to a lack of knowledge. However, other factors also contribute to resistance to extinction interventions. ...
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.
... As noted above, one justification for modifying the extinction-based procedures by more gradual alternatives is to reduce parental stress and child distress (see France, 1994;France et al., 1996). Although parents rated the checking procedure in the present study as not stressful, this is also consistently true of other behavioral interventions, including unmodified planned ignoring (France, Blampied & Wilkinson, 1991;Lawton et al., 1995;Reid et al., 1999) and other variants (Lawton et al., 1991;France et al., 1991; also see France, Blampied & Wilkinson, 1999). ...
... 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. ...
... Although it may be cost-effective, as Mindell and Durand (1993) suggest, to provide only one parent training session focused on intervention at bedtime-only, and while the graduated checking procedure may be classified as well-established (Kuhn & Elliot, 2003) or at least as probably efficacious (Mindell, 1999), it seems clear that it often takes many nights to achieve clinically significant outcomes (see also Mindell and Durand, 1993); that changes in night waking are unlikely to occur consistently until parents actually alter their management of night waking; and that when parents do so they are likely to modify the procedure in various, and not always optimal ways, and may need considerable further therapist support to achieve good outcomes for their child's ISD. Therefore, both the advantages and disadvantages of the graduated checking procedure need to be carefully considered by both clinicians and parents as they make informed decisions about treatment options for ISD (France, 1994;, 2005France et al., 1996;Kuhn & Elliot, 2003;Mindell, 1999). ...
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.
... The remaining family (Family 6) chose not to take this option because of parental disagreement, not because of satisfaction with the outcome achieved to that point by medication. This lack of satisfaction with outcome compares with the generally favorable responses parents have given following behavioral treatment programs (e.g., Durand & Mindell, 1990;France, 1994;France, Blampied, & Wilkinson, 1991;France et al., 1996;Lawton, Blampied, & France, 1995;Lawtonetal., 1991;Seymour, 1987). ...
... The present evidence, in combination with that of France et al. (1991), does suggest that trimeprazine should be prescribed only as an adjunct to a behavioral program such as planned ignoring. This, in turn, requires that parents be given the level of instruction and support required for such programs to be effectively implemented (Drabman & Jarvie, 1977;France, 1992France, , 1994. Further research is needed to explore optimal ways of combining pharmacological and a variety of behavioral treatments for ISD. ...
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.
... 12,20,23,24 In fact, parental concerns about ignoring their child's cries were first raised by France and colleagues during studies of Graduated Extinction almost 30 years ago. 25,26 Subsequently discrepancies have resulted between parental dissatisfaction with ignoring interventions despite the considerable empirical evidence to support their efficacy. Similarly, a paucity of empirical data to refute the core arguments against this approach (largely regarding concerns about impacts on the infant's mental health or parent/ child attachment from parental non-responsiveness), has still not quieted debate and has not assisted parents to overcome the immediate distress some feel if their infant cries alone. ...
... Previous researchers have reported varying degrees of non-compliance to treatment protocols with attrition rates reportedly due to this immediate difficulty of hearing an infant cry and subsequent reticence to use of these ignoring techniques. 25,27,28 Tse and Hall 28 investigated parental uptake of ignoring methods in a qualitative study finding that parental reticence to ignore resulted in attrition from their study. In two recent Australian pilot surveys, 53.5% 29 and 52.9% 30 of parents reported never even attempting to use ignoring techniques citing concerns about the stress to mother and child when utilised. ...
In families with infants between the ages of 6 and 18 months, sleep disruption can be significant, often putting parents at risk of a range of negative psychological and psychosocial consequences. Commonly prescribed sleep interventions typically involve ‘extinction’ methods, which require parents to completely or periodically ignore their infant's overnight cries. These methods can be effective in many, but not all cases. For over 40 years 30–40% of parents have consistently reported difficulty ignoring their child. For this group, ignoring their child is behaviourally and/or ideologically difficult with attrition often leading to a perceived sense of failure. For these parents the treatment may be worse than the problem. On the other hand, there is emerging evidence to support the use of more responsive methods for those who find extinction approaches behaviourally or ideologically challenging. In this paper we propose an integrated, less polarised approach to infant behavioural sleep interventions that better caters to those who have difficulty with extinction methods – our so‐called ‘Plan B’. This approach potentially resolves the often opposing ideological and theoretical perspectives of extinction versus responsiveness into a practical, complementary and pragmatic treatment framework. Recommendations on how best to implement Plan B are also presented. In our view, Plan B could provide practitioners with a logically integrated well‐targeted suite of clinical interventions that could potentially improve compliance, reduce attrition and ultimately benefit the sleep and well‐being of all infants and their parents, especially those who struggle with traditional extinction methodologies.
... Additionally, the Post-Extinction-Response-Burst (PERB) [19,21,23], with its consequent increase in intensity and variability of infant behaviour such as crying, results in distress to both parents and children. Several authors have been critical of extinction on the grounds that possible harmful collateral effects make its use potentially unethical (see France, 1994, for a review) [24]. ...
... Additionally, the Post-Extinction-Response-Burst (PERB) [19,21,23], with its consequent increase in intensity and variability of infant behaviour such as crying, results in distress to both parents and children. Several authors have been critical of extinction on the grounds that possible harmful collateral effects make its use potentially unethical (see France, 1994, for a review) [24]. ...
This review covers the literature on behavioural and cognitive-behavioural treatments for sleep disturbance in infants, pre-school, and school-age children. Treatment areas are dyssomnias (disorders of initiating, maintaining, or excessive sleep) and parasomnias (behaviours which occur predominantly during sleep). Interventions aimed at preventing sleep disorder through targeting infant sleep patterns are also examined. Controlled experimental studies are the main focus of this review but case studies and clinical reports are also included. It is concluded that, for families willing to undertake behavioural and cognitive-behavioural interventions, some treatments appear effective for some infant and child sleep problems, in the short term at least. The adequacy of current research is discussed, and suggestions for future research are given.
... hand-picked some components of the intervention. Previous researchers have reported varying degrees of non-compliance to treatment protocols (Rickert & Johnson 1988;France 1992;France 1994), and speculated that parents resisted the treatment protocols because the interventions were either too traumatic for them or contradicted parents' beliefs about child-rearing. Although findings of this study supported the claim that some parents found it difficult to carry out controlled comforting due to their infants' intense crying (Rickert & Johnson 1988;Reid et al. 1999), those who discarded controlled comforting were often influenced by external factors rather than their internal beliefs. ...
... Consistent with other research findings (Rickert & Johnson 1988;France 1994;Owens et al. 1999), parents in this study feared that excessive crying could cause harm to their infants. Despite evidence of no association between crying during the use of extinction, which includes ignoring infants' cries, and deterioration in infant security or increase in infants' negative behavioural characteristics (France 1992), our respondents were still worried about the effects of crying. ...
A study, entitled Evaluation of an Intervention Aimed at Resolving Behavioural Sleep Problems in 6- to 12-month-old Infants: A Pilot Study, was undertaken to evaluate the efficacy of a behavioural sleep intervention. This descriptive qualitative study aimed to describe parents' perceptions of the sleep intervention and any burden associated with participating in the study.
Fourteen of the 35 families who had participated in the quantitative study were interviewed. Respondents comprised well-educated, middle-class and mixed-ethnicity families. Data were collected through semi-structured interviews, with open-ended trigger questions, and were analysed using inductive content analysis.
Nine themes, which subsumed a number of categories, were constructed. Parents changed their perspectives about sleep and parenting styles; they experienced many challenges and inadvertent benefits; and they welcomed a structured framework for assisting with sleep problems. The parents fitted intervention strategies into their realities; many factors interfered with their success; and their support systems and their expectations of the study varied.
These parents' previous education about normal infant sleep cycles and behavioural sleep problems was inadequate. The parents who were able to use the structured framework, flexible strategies and access to healthcare professionals for problem solving not only excelled in resolving their infants' sleep problems, but also gained confidence about their parenting skills and success.
... Standard (unmodified) extinction, commonly known as 'cry it out', aims to teach infants to fall asleep independently and decrease crying frequency by removing all parent interaction at sleep time and during night crying (Blampied and France, 1993;Mindell et al., 2006;Meltzer, 2010;Blunden and Dawson, 2020;Whittall et al., 2021). Many caregivers are concerned by the prolonged infant crying associated with cry it out, and report increased stress and concerns about potential long-term impacts on infants (France, 1994). This can lead to poor adherence and reinforce crying, because the intermittent reinforcement results in longer bouts of crying to elicit parental responses (Thomas et al., 2014). ...
This PRISMA scoping review identifies and summarises 13 research papers, published between 2011 and 2021, specific to interventions aimed at improving the sleep of infants from birth to two years of age. The aim was to identify trends in study characteristics, overarching outcomes and recommendations, and to extract and make further suggestions for professional training and practice. Relevant literature often provides contradictory guidance, and caregivers increasingly seek individualised support via the growing sleep consultancy industry. Papers examining the efficacy, safety and parental perception of a variety of approaches to improving infant sleep-including cry it out, controlled crying, camping out, bedtime fading and educational interventions-were sourced. Findings suggested that authors most commonly recommended supporting caregivers with education about developmentally appropriate sleep, cues for tiredness, settling techniques, positive sleep norland.ac.uk/journal 2 routines, how to increase homeostatic sleep pressure and how to use moderate behavioural interventions if problems remain after the infant reaches six months of age. Outcomes also suggested this combination is safe, can improve infant sleep as well as main and secondary caregiver wellbeing, and helps caregivers improve their understanding of whether their infant has a sleep problem. Based on the scoping review outcomes, the authors recommend the routine inclusion of evidence-based information about common patterns of infant sleep and different approaches to supporting sleep in the professional training of early years and healthcare professionals. This has the potential to facilitate evidence-based individualised support for caregivers with their infant's sleep, promote safe selection and use of interventions, and improve infant, primary and secondary caregiver sleep quality and wellbeing.
... o Extinction: when the child cries at night it is left to cry it out. This is usually very successful but is not accepted by most parents and should not be tried if the parents can't implement it (Rickett & Johnson, 1988;France, 1994).It is also not appropriate for small children who make themselves vomit or use excessive head banging to atftact the parents' attention. o Checking is as described above, a modified version of extension by parents providing a short verbal reassurance to the child ("Mum & Dad are here, don't worry, go back to sleep") and other reinforcers (physical contact, taking child into parental bed, games at night etc.) are withdrawn. ...
... Parental resistance remains the largest barrier to the implementation of extinction interventions and an Australian study found that the majority of parents find graduated extinction too difficult and stressful to implement (Etherton et al., 2016;France, 1994). ...
This paper aims to review the limitations of the current classification of insomnia of early childhood and propose a new conceptual model allowing a better understanding of its pathophysiology. Our hypothesis is that chronic insomnia of childhood has different phenotypical expressions, associated to different pathophysiological mechanisms. Based on a long-lasting experience in evaluating a very large number of children with specific insomnia symptoms (nocturnal awakenings, difficulty in falling asleep, nocturnal restlessness, early morning awakenings) and on published data, we hypothesize that different phenotypes of insomnia might exist with different therapeutic implications.
We describe three phenotypes of insomnia in early childhood: a) insomnia with motor restlessness; b) insomnia characterized without difficulties in falling asleep but with long-lasting early morning awakenings; c) insomnia with multiple night awakenings and falling asleep difficulty. This type of categorization might have important implications for treatment, based on the different hypothetical neurotransmitter dysfunctions. The early identification of a phenotype of insomnia might guide to specific behavioral and/or pharmacological interventions with the aim to prevent chronic insomnia.
... However, most standard extinction or graduated extinction treatments are often tolerated with difficulty by parents as the significant amount of crying (as the child communicates their desire for parental attention), can be difficult for a parent to withstand -particularly if they are instructed to ignore the cry (13,14). Even in more gentle methods such as 'camping out' there are expectations that parents cannot comfort their child if distressed (5). ...
... Despite their efficacy in reducing night waking, parental resistance to extinction sleep interventions has been reported. Several studies [9,[11][12][13][14][15][16] and reviews [1,17,18] have cited parental resistance as one of the difficulties in compliance, success and uptake of extinction interventions. ...
The majority of behavioural sleep interventions for young children (defined as 5 years of age or less) involve extinction procedures where parents must ignore their child's cries for a period. Many parents have difficulties implementing and maintaining these procedures, leading to attrition, non-compliance and treatment avoidance. Yet the reasons for these methods being difficult to implement for parents have not been well understood or addressed in the literature. In fact, they are being ignored. We discuss that understanding and addressing parental concerns may enable better targeted sleep interventions.
... 40 Les parents doivent aussi être informés de la possibilité de la guérison spontanée des PPS après la maladie ou es changements de routine. 41 Qu'elles soient ou non modifiées, les procédures impliquant le retrait de l'attention parentale sont largement non stressantes pour les parents, positives pour la famille 42 ...
... Interventions for pediatric bedtime resistance typically are behavioral in nature, the most common being extinction (i.e., planned parental ignoring). Although it is effective, parental acceptability of extinction is often low (France, 1994;Friman et al., 1999), partly due to temporary increases in bedtime resistance often seen early in intervention (i.e., the extinction burst; see Blum & Friman, 2000). Alternatively, the bedtime pass (Friman et al.) involves (a) a small notecard exchangeable for one trip out of the bedroom after being put to bed and (b) extinction. ...
Bedtime resistance, a common pediatric problem, that was displayed by 4 unrelated 3-year-old children was treated with the bedtime pass (i.e., provision of a small notecard exchangeable for one trip out of the bedroom after bedtime) plus extinction. Bedtime resistance was eliminated for all participants. Further, treatment did not produce extinction bursts, as is common when using extinction procedures alone. Component analysis with 1 participant suggested that use of both components of the intervention produced the best outcomes. Findings extend the literature on the treatment of pediatric bedtime resistance as well as the application of behavior analysis to clinical psychology and pediatric care.
Sleep problems in toddlers occur in ∼40% of children and increase the likelihood of postnatal depression. Most sleep training in toddlers requires contact with a trained professional, and requires a parent to ignore their child's cries, causing distress to many children and parents, increasing attrition and leaving families untreated and at risk. This case study reports success in significantly ameliorating sleep reluctance and bedtime fears in a sleep disturbed toddler with a history of trauma. It uses a novel use of bedtime behaviour management with some positive reinforcement techniques, called the Boss of My Sleep book: a non-cry, online (thus readily and cheaply available without a trained professional) sleep intervention. The system was successful immediately and was sustained after 6 months. The Boss of My Sleep book shows promise as a sleep intervention in toddlers, particularly for those parents who do not want to use cry intensive methods.
NOTE: PLEASE SEE UPDATED RESEARCH POSTER ON THIS PAGE. This research is from 2006. I have updated this with a poster presented in 2022.
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.
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.
In recent years there have been advances in the behavioral management of infant sleep disturbance. Behavioral programs, how ever, can be controversial and difficult to carry out successfully. This article summarizes the information parents and clinicians must have in order to carry out a program (fact), details of how and when to apply each program (act), and a guide for clinicians supporting parents in choosing and carrying through an intervention (tact). Information on the use of medication and on prevention of sleep disturbance is also provided.
Behavioral family intervention (BFI) has had a major influence in the field of child psychopathology and has become a dominant paradigm in the treatment of many childhood disorders (Lochman, 1990). During the past three decades, BFI has evolved as a viable, empirically supported approach to working with oppositional and conduct-disordered children (Forehand & Long, 1988; Forehand & McMahon, 1981; Sayger, Home, Walker, & Passmore, 1988; Twardosz & Nordquist, 1988; Webster- Stratton, Kolpacoff, & Hollinsworth, 1988; Wells & Egan, 1988) and, to a lesser extent, children with attention-deficit disorders (Barkley, Guevremont, Anastopoulos, & Fletcher, 1992; Pisterman, McGrath, Firestone, Goodman, Webster, & Mallory, 1989). BFI is also widely used with abused and neglected children as a component of a multicomponent intervention protocol (Lutzker, 1992). Parent training has become an integral part of services for children with autism and developmental disabilities (Schreibman, Kaneko, & Koegel, 1991; Harrold, Lutzker, Campbell, & Touchette, 1992). Children with language problems (Laski, Charlop, & Schreibman, 1988; Alpert & Kaiser, 1992) and academic learning difficulties (McNaughton, Glynn, & Robinson, 1987) have also been shown to benefit from this approach, and behavioral techniques have been successfully employed with a variety of common behavior problems of otherwise normal children such as bedtime and mealtime problem (Dadds, Sanders, & Bor, 19984; Hall, Axelrod, Tyler, Grief, Jones, & Robertson, 1972; Sanders, Dadds, & Bor, 1989a) and problems on shopping trips or in restaurants (Clark, Greene, Macrae, McNees, Davis, & Risley, 1977).
Systematic ignoring and two modifications of it (systematic ignoring with minimal parental check and systematic ignoring with parental presence) were evaluated for treatment of Infant Sleep Disturbance (ISD). Fifteen infants (6–15 months of age) participated in a study utilising a multiple-baseline design across the three treatment programs. Frequency of awakening and duration of crying were measured in order to evaluate treatment efficacy and infant distress. All programs led to decreases in night waking but infants treated with systematic ignoring with minimal check woke and cried more over the treatment period. Given our present knowledge, the parental presence program appears to be the treatment of choice. This result needs further investigation, as do those of other programs commonly used to treat Infant Sleep Disturbance (ISD) in infants.
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.
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.
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.
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.
Sleep disturbance affects nearly 25% of infants and toddlers, resulting in fatigue, stress, and family dissatisfaction. This review describes empirically-based treatments for infant and toddler sleep disturbance involving difficulty settling and night waking, including behavioral and pharmacological approaches. Pharmacological interventions included antihistamines, chloral hydrate, benzodiazepines, and melatonin. Behavioral interventions included extinction and its many variants, positive bedtime routines, scheduled awakenings, and disassociating feeding from sleep-wake transitions. Advantages and disadvantages of each approach are discussed and suggestions offered for future research.
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.
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.
Because of the high prevalence of sleep problems in children and adolescents, as well as the profound negative impact that pediatric sleeplessness has on daytime functioning, pediatric practitioners must be aware not only of the causes of sleeplessness but also how to treat sleep problems effectively with nonpharmacologic interventions. This article provided an overview of common pediatric disorders that present as pediatric sleeplessness and are effectively treated by behavioral interventions. Although more studies on behavioral interventions for pediatric sleeplessness are needed, behavioral approaches have been shown to be effective in addressing concerns related to bedtime problems, night wakings, insufficient sleep, insomnia, and DSPS. Behavioral interventions are effectively used for children with special needs, including developmental disabilities, ADHD, and mood disorders.
The present study examined the effect of a bedtime management program which incorporated both stimulus control and contingency management procedures on the level of bedtime disruption in children. Using a multiple baseline across subjects design each of four children (ranging in age from 2-5 years)were sequentially introduced to the treatment program, which was implemented by the child's parents each night. In addition the study sought to determine whether direct treatment of bedtime disruption would be associated with any negative side effects. Systematic observational data revealed that the Bedtime Management Program was effective in reducing bedtime disruptions in all subjects and the improvements sustained during a 2-month follow-up. No evidence suggests that treatment resulted in negative side effects. The implications of the results for behavioural parent training are discussed.
A total of 36 toddlers and preschool children exhibiting bedtime tantrum activity were randomly assigned to one of three groups: positive routines, graduated extinction, or control. Positive routines involved changing the child's bedtime to coincide with when he naturally fell asleep, as well as parent and child engaging in a series of four to seven enjoyable activities before the child being placed in bed. During the treatment period, bedtimes were systematically scheduled earlier such that the child went to bed at the time parents had originally used. Graduated extinction consisted of the parent putting the child to bed and ignoring the tantrum activity for increasingly longer amounts of time throughout the treatment. Children in these two treatment groups had tantrums less frequently and for shorter periods than control subjects during 6 weeks of treatment and during two follow-up observations 3 and 6 weeks after treatment. Although both treatments were more effective than waiting for the child to outgrow this problem, parents of the positive routine group reported significantly improved marital satisfaction, suggesting additional benefits of this treatment strategy.
Infants and toddlers (N = 33) exhibiting spontaneous awakening and crying episodes during the night were randomly assigned to one of three groups: scheduled awakenings, systematic ignoring or control. Scheduled awakenings consisted of a parent arousing and feeding or consoling the child 15 to 60 minutes before typical spontaneous awakenings. Once spontaneous awakenings were precluded, scheduled awakenings by parents were gradually eliminated. Systematic ignoring consisted of allowing the child to "cry it out" without parental attention except to ensure physical well-being of their child. Children in the scheduled awakening group and the systematic ignoring group awoke and cried less frequently than children in the control group during 8 weeks of treatment and during two follow-up checks, 3 and 6 weeks after treatment. Systematic ignoring was found to be more effective than the scheduled awakenings condition during 1 week of treatment; otherwise effects of the two conditions were similar. Implications of the use of these treatment procedures are discussed.
Notes insufficiencies in the American Psychological Association’s ethical standards for marriage and family therapy. Guidelines regarding therapist responsibility, confidentiality, and informed consent sometimes become ambiguous with individual clients, but they are even more complicated when multiple family members are seen together in therapy. Questions about confidentiality, refusal of treatment, and value of conflicts between the family members and the therapist may arise. Consideration of these questions in terms of their ethical implications is complex and controversial. Yet answers to these questions must also take into account clinical and legal considerations, which sometimes run a collision course with what is desirable from a strictly ethical standpoint. Examples and preliminary recommendations with respect to these issues are examined; further clarification of professional conduct in marital and family therapy is urged. (45 ref)
The prevalence and correlates of sleeping in the parental bed among healthy children between 6 months and 4 years of age are described. One hundred fifty children were enrolled in an interview study on the basis of "well-child" care appointments in representative pediatric facilities. The sample created was similar in demographic characteristics to census data for the Cleveland area. In this cross section of families in a large US city, cosleeping was a routine and recent practice in 35% of white and 70% of black families. Cosleeping in both racial groups was associated with approaches to sleep management at bedtime that emphasized parental involvement and body contact. Specifically, cosleeping children were significantly more likely to fall asleep out of bed and to have adult company and body contact at bedtime. Among white families only, cosleeping was associated with the older child, lower level of parental education, less professional training, increased family stress, a more ambivalent maternal attitude toward the child, and disruptive sleep problems in the child.
Two groups of infants, 2 and 9 months of age, were monitored for one night by time-lapse videotape recording in the natural setting of their homes. Developmental changes in sleep-wake state proportions, ease of falling asleep, nighttime waking patterns, maternal interventions, and sleeping through the night were observed. A suggestion of differential parental handling of male infants was noted. Further research to clarify some of these issues is indicated.
There are probably as many definitions of psychotherapy as there are people who write about it. One review paper cites 48 different definitions (Weiner, 1976) and goes on to complicate matters by distinguishing psychotherapy from activities and events that may have psychotherapeutic value per se. While goals, strategies, tactics, and theoretical underpinnings vary widely, most psychotherapists would assert that their work with clients is intended to enhance emotional growth, foster maturity, and promote general adaptive functioning. Others would claim only that they strive to help clients develop an “understanding of their own behavior.” There is also a substantial body of literature, typified by the writings of Eysenck (1965, 1966), that challenges the value and effectiveness of psychotherapy or cites potential harmful effects of so-called psychotherapeutic interventions. Such claims have been effectively rebutted (Weiner, 1976), but the existing literature is replete with controversy.
The nature and scope of medical practice over the past century has expanded rapidly. The physician’s ability to diagnose and to treat exceedingly complex diseases has brought a new set of ethical, psychosocial, legal, and economic dilemmas. Today’s physician is in a cultural milieu with demands and expectations that far surpass those of his predecessors. These changes have affected the physician-patient relationship that has evolved from one with the patient dependent upon the physician to one that requires more interaction.
Difficulties in settling children to sleep and night waking are common problems faced by parents with young children. The effectiveness of parent-managed behavioural intervention is examined in this study of four children which employs a multiple-baseline-design across subjects. Components of the intervention included: establishing regular bedtime routines; paying attention to the children before bed in the living areas and staying with the children only briefly when settling them in bed; adopting procedures for ignoring disruptive bedtime behaviour and night waking; and giving praise for appropriate behaviour. Complete success in settling the three children who were difficult at bedtime was achieved in five to fourteen days. Persistent night waking in all four children was eliminated in five to thirteen nights.
Regular waking at night is one of the most common problems encountered by parents of young children. In a family counselling programme in Auckland, a night-waking programme has been used with 208 children referred during a two year period. The programme involved organized bed-time routines, procedures for settling the child and non-reward of crying, calling out and getting out of bed. Programme introduction was followed by daily phone calls to parents in which appropriate parent behaviours were prompted and reinforced. Further face to face sessions were held after one week and then if needed. Parent reports show high rates of parent implementation of procedures and rapid change of child sleep behaviour with improvements being maintained at follow up. In a survey of 48 of the parents, positive changes in the daytime behaviour of children were reported as coinciding with improved sleep habits. Also there was an absence of negative side effects, and generally, parent satisfaction with the programme was high.
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.
Clinical experience has led many writers in the field of child behavior therapy to point to marital distress as an important predictor of treatment failure. While further research is needed to clarify the role of marital variables in treatment, there is some evidence that marital distress may be associated with failure to maintain change after treatment, despite a successful immediate posttreatment outcome. It appears that behavioral aprent training can improve parent-child interactions while having no impact on marital conflict and other contextual factors that are associated with parent-child relations. Attempts to assess the role of risk factors such as marital distress, maternal depression and social insularity in treatment have been piecemeal and some recommendations for improving clinical practice and research methodologies are made. Evidence is mounting that providing expanded interventions is associated with improved treatment effects, however all expansions of basic parent training appear to improve teratment ourcome and more specificity of sample selection, measures used and control conditions is needed to make sense of this data. For clinical practice, the integration of marital and child focussed interventions is reviewed. An integrative model is described with specific suggestions for facilitation families' adherence to a broadly focussed family intervention that incorporates marital and child foci.
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.
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.
Of 160 infants whose mothers were seen at intervals from birth, about 70% had ceased night waking (between midnight and 5 a.m.) by the age of 3 months, and 83 % by 6 months. Ten per cent, never started sleeping regularly through the night for as long as four weeks during the first year. Of those who settled, about one-half had subsequent spells of night waking of more than four weeks' duration. The majority of these fresh disturbances had their onset between the ages of 5 and 9 months. A tendency to night waking was found to be associated with neonatal asphyxia, deficiency of nursing time and a number of other factors. Possible causes are discussed.
An association was found in a sample of 59 healthy middle‐class first‐born babies between regular night‐waking at one year old and pre‐ and perinatal events. The findings closely resemble those reported by Bernal (1973). The only measure of parental behaviour discriminating night wakers from regular sleepers was that mothers of wakers responded more rapidly to crying during daytime observations. However, this was shown to be a difference related to the child's obstetric history and the persistence of crying, and not directly to night waking. Rapid response to crying, and night waking itself, seem to be separate outcomes of a sub‐optimal obstetric history. The evidence is that no aspect of parental behaviour yet examined produces night‐waking children.
RÉSUMÉ
Associations entre facteurs périnataux et réveil nocturne ultérieur
Il a été trouvé un lien chez un échantillon de 59 nourrissons, premier‐né, en bonne santé, appartenant à la classe moyenne entre le réveil nocturne régulier à l'âge d'un an et les manifestations pré et péri‐natales. Les données correspondent étroitement à celles qui ont été rapportées par Bernal (1973). Une seule mesure de comportement parental différenciait les sujets se réveillant des dormeurs réguliers: les mères des nourrissons se réveillant répondaient plus rapidement aux pleurs durant les observations de jour. Cependant, cette attitude s'est révélée une différence liée à l'histoire obstétricale de l'enfant et à la persistance de ses pleurs, non directement au réveil nocturne. Une réponse rapide aux pleurs et le reveil nocturne paraissent des conséquences indépendantes d'une anamnèse obstétricale suboptimale. Il semble done qu'aucun aspect du comportement parental examiné jusqu'à ce jour n'influence le réveil nocturne des enfants.
ZUSAMMENFASSUNG
Die Beziehung zwischen perinataler Anamnese und späteren nächtlichen Aufwachens
Bei einer Gruppe von 59 gesunden erstgeborenen Kindern aus der Mittelklasse wurde eine Beziehung zwischen regelmässigen nächtlichen Aufwachens im Alter von einem Jahr und prae‐ und perinatalen Faktoren gefunden. Die Befunde entsprechen fast denen von Bernal (1973). Nur in einem Punkt elterlichen Verhaltens wurden die Kinder, die nachts aufwachen, von denen, die nachts durchschlafen, unterschieden—die Mütter der Aufwachkinder reagierten sehr viel schneller auf das Schreien während der Beobachtungen am Tage. Jedoch zeigte sich, dass dieser Unterschied mit der geburtshilflichen Anamnese des Kindes und mit der Dauer seines Schreiens zusammenhing und nicht direkt mit dem nächtlichen Aufwachen. Rasche Reaktion auf Schreien und nächtliches Aufwachen scheinen unabhängige Ergebnisse einer nicht normalen geburtshilflichen Anamnese zu sein. Es wurde gefunden, dass keine bisher untersuchte Verhaltensweise von Eltern Kinder zum nächtlichen Aufwachen veranlasst.
RESUMEN
Asociación entre factores perinatales e incontinencia nocturna posterior
Se halló una asociación en una muestra de 59 lactantes sanos de clase media primerizos entre el despertar nocturno regular al año de edad y los acontecimientos pre y perinatales. Los hallazgos son muy semejantes a los hallados por Bernal (1973). Sólo un dato en el comportamiento de los padres discriminaba los que se despertaban durante la noche de los que dormían regularmente: Las madres de los que se despertaban respondían más rapidamente al Ilanto durante las observaciones hechas durante el dia. Sin embargo se vió que esta diferencia estaba en relación con la historia obstétrica del niño y la persistencia de su Ilanto y no directamente con su despertar nocturno. La respuesta rápida al Ilanto y el despertar nocturno parece que son dos acontecimientos separados de una historia obstétrica sub‐óptima. Se evidencia que ningún aspecto del comportamiento de los padres examinados produce el despertar nocturno de los niños.
This monograph consists of five sections. In the first section we delineate the characteristics of acting out children, our view of the course of development of the problem, various treatments which have been utilized, and based upon the results of these treatments, the need for long term follow-up data of parent training, the most effective treatment available. In the second section we describe our parent training program: the parent interview, parent completed assessment measures, behavioral observation assessment measures, the treatment setting, therapists, the treatment program, and a brief overview of the outcome data. In the third section we present the method, results and discussion of a comprehensive follow-up study conducted four and a half to ten and a half years after parent training. The results indicate that the treated families were functioning similarly to a comparison (‘normal’) sample of families. In the fourth section we discuss the implications of the present findings for future research in parent training. In the final section we make recommendations about who should conduct parent training, what components should be included in such training, why such a therapeutic approach should be utilized, and finally, some of the problems associated with parent training are delineated.
To test the hypothesis that a characteristic infant-care pattern existed during most of human history, contemporary hunter-gatherers in a representative sample of world cultures were examined. Numerically coded measures of infant care revealed a uniform pattern. Mothers are the principal caregivers, providing extensive body contact day and night and prolonged breast-feeding. When not carried, the baby of hunter-gatherers has complete freedom of movement. Care is consistently affectionate, with immediate nurturant response to crying. Nonetheless, in most groups, children achieve early independence and by 2 to 4 years spend more than half the time away from the mother. In the United States this pattern of carrying that endured for one to three million years has been replaced by one resembling nesting or caching. Infants spend little time in body contact with caregivers and their movements are restricted by playpens, high chairs, or cribs. Of the minority who are breast-fed, half are weaned within a few weeks. Separate sleeping arrangements and delayed response to crying are regularly recommended. These remarkable transformations may profoundly alter infant development and maternal involvement.
Night waking and crying are very common in infancy and can cause problems for parents and families. This study surveyed 218 healthy Korean infants from 3 months to 2 years old to determine their night waking and crying patterns. On average, 83% awoke and 28% cried more than once per night. Ninety-eight percent of the babies slept with a member of the family. Infants with transitional objects or nighttime habits (e.g., finger sucking, touching and/or playing with mother's or own hair, touching a part of mother's or own body) cried more frequently. In terms of the maternal response toward the crying babies, most of the mothers used traditional methods, such as patting/holding, feeding, changing diapers. Only one mother ignored the crying baby, and none used medication, delayed response, or white noise. Sixteen percent of the mothers indicated that their babies' crying constituted a problem for them.
New Zealand's high mortality rate from sudden infant death syndrome (SIDS) prompted the development of the New Zealand Cot Death Study. A report of the analysis of the data from the first year has been published. This report now gives the major identified risk factors from the full 3 year data set. In this case-control study there were 485 infants who died from SIDS in the post-neonatal age group, and 1800 control infants, who were a representative sample of all hospital births in the study region. Obstetric records were examined and parental interviews were completed in 97.5% and 86.9% of subjects, respectively. As expected many risk factors for SIDS were confirmed including: lower socio-economic status, unmarried mother, young mother, younger school-leaving age of mother, younger age of mother at first pregnancy, late attendance at antenatal clinic, non-attendance at antenatal classes, Maori, greater number of previous pregnancies, the further south the domicile, winter, low birthweight, short gestation, male infant and admission to a special care baby unit. In addition, however, we identified four risk factors that are potentially amenable to modification.(ABSTRACT TRUNCATED AT 250 WORDS)
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.
Chronic sleep disturbance is a common problem in preschool children. Prescription and non-prescription sedatives provide short-term palliative relief. Behavioral extinction by withdrawal of parental attention is enduringly effective but may be distressing short-term because of postextinction bursts of intense activity by the child. This study evaluated the effects of combining extinction and sedative medication (trimeprazine tartrate), prescribed in a reducing dose over the first 10 days of extinction. Control groups received either extinction alone or a placebo administered double-blind. After baseline, all subjects reduced their sleep disturbance to low levels, the extinction and placebo groups declining slowly, the medication group abruptly. These gains were maintained at follow-up. Measures of infant security and maternal anxiety showed improvements with treatment.
A telephone survey was carried out to determine the prevalence of infant and toddler sleep disturbances. Parents of all 12- to 35-month-old children listed in one community were contacted, and 81% participated. Many children resisted going to bed (42%) or woke and cried during the night (35%). Approximately half the parents had changed their child's diet, naptime, or bedtime and about half these parents found changing routines helpful. Parents frequently reported that pacifiers or bottles in the crib quieted their children. Crying it out, scheduled awakenings, and progressive delay responding were all effective (70% or better) for parents who were aware of these procedures. Satisfaction did not necessarily correspond with effectiveness. Finally, parents were more likely to seek information about sleep from relatives, friends, or books and magazines than from their physician or from a psychologist.
Sleep disorders are highly prevalent among otherwise healthy young children and can be extremely disruptive to family life. Treatment was initiated in a multiple baseline fashion for the chronic night waking and nighttime disturbance exhibited by a 14-month-old girl. We found that "graduated extinction" (gradually increasing the time before attending to the child's crying) resulted in rapid reductions in these sleep disorders. Additionally, data on parental depression and marital satisfaction showed general improvement as a function of improved child sleep patterns. These results are discussed as they relate to the treatment of common childhood behavior disorders and their role in family satisfaction.
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.
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.
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.
A longitudinal study, based on interviews with 308 middle-class, preponderantly white mothers, provided an opportunity to evaluate the continuity, predictive factors, and behavioral correlates of sleep problems in young children. When their children were 8 months old, 10% of the mothers reported that their babies woke three or more times per night, 8% reported that the babies took an hour or more to settle after waking, 5% complained that their own sleep was severely disrupted by the child, and 18% reported at least one of these problems. At 3 years of age, 29% of the children had difficulty getting to bed and/or falling asleep or staying asleep. Of children with a sleep problem at 8 months of age, 41% still had a problem at 3 years of age, whereas only 26% of children without a problem at 8 months of age had a problem at 3 years of age (P less than .001). Among children with sleep problems at 8 months of age, mothers' depressed feelings were the only measured demographic or psychosocial factor associated with persistent sleep problems (P = .02). A separate analysis indicated that these depressed feelings did not appear to be a consequence of the child's sleep problem. Future studies should evaluate how maternal depression interacts with other factors to result in persistent sleep problems. Children with persistent sleep problems were more likely to have behavior problems, especially tantrums (P less than .02) and behavior management problems (P less than .01), than were children without persistent sleep problems (P less than .02).(ABSTRACT TRUNCATED AT 250 WORDS)
The study was designed to explore the relationship between sleeping disturbance in early and late infancy and variables related to (1) prenatal and birth factors, (2) child characteristics such as sex and temperament, (3) sleeping and feeding practices, (4) background factors, and (5) maternal depression and family stress. Mothers were interviewed first when their infants were between the ages 4 to 15 months and then when their infants were between 15 and 27 months of age. Hierarchical multiple regression analyses were used to assess the relative influence of variables in predicting sleeping disturbances in the first and second years. Sleeping disturbances in the first year were not related to sleeping disturbances in the second year. However, sleeping practices were the strongest predictors of sleeping disturbances in both early and late infancy. Predictability was improved in the first year by the inclusion of the variable maternal employment and in the second year by the inclusion of variables related to parental sleep difficulties. Explanation for these findings and suggestions for future research are discussed.
Sleep problems had developed at one year in 24 of a sample of 77 babies studied in Cambridge, England. The problem babies slept for shorter periods and woke regularly. There was no relationship between sleep problems and sex, birth order or social class. There was a suggestion that the development of sleep problems might be related to length of labour and the state of the baby at delivery. The problem group were more wakeful and irritable during the first 10 days of life. At 8, 14, 20 and 30 weeks, the problem group showed a continuing pattern of shorter sleep bouts at night. The rôle of parental handling in the development of sleep problems is discussed; while there was no pattern of care common to all mothers of the problem infants, the majority were very responsive. There was no evidence that feeding when the infant awoke at night was related to the problem of waking.
ZUSAMMENFASSUNG
Nächtliches Erwachen in den ersten 14 Lebensmonaten
Bei einer Gruppe von Säuglingen, die in Cambridge, England, beobachtet wurden, gab es bei 24 Kindern im Alter von 1 Jahr Schlafstörungen. Das Problem bestand in verkürzten Schlafperioden und regelmäßigem Aufwachen. Es gab keine Zusammenhänge zwischen den Schlafstörungen und dem Geschlecht, der Stellung in der Geschwisterreihe oder der sozialen Schicht. Es wurde vermutet, daß eine Beziehung zwischen Schlafstörungen und der Geburtsdauer sowie dem Zustand des Babies bei der Geburt bestand. Ferner war die schlafgestörte Gruppe während der ersten 10 Lebenstage häufiger wach und leichter erregbar. Mit 8, 14, 20 und 30 Wochen zeigte die Problemgruppe eine zunehmende Verkürzung der nächtlichen Schlafperioden. Die Rolle der elterlichen Fürsorge im Zusammenhang mit der Entwicklung von Schlafstörungen wurde diskutiert, jedoch wurde bei Müttern mit Problemkiadern keine gemeinsame Eigenheit festgestellt; die Mehrheit war sehr temperamentvoll. Es ergab sich kein Anhalt für die Annahme, daß das Füttern der Kinder während des nächtlichen Aufwachens in Zusammenhang mit den Schlafstörungen stehen könnte.
RESUMEN
Despertar nocturno en los primeros 14 meses de vida
Problemas del sueño se desarrollaron al año de edad en 24 de una muestra de 77 niños estudiados en Cambridge (Inglaterra). Los niños problema dormian durante períodos más cortos y despertaban regularmente. No habia relación entre los problemas del sueño o el sexo, orden de nacimiento o clase social. Se sugirió que el desarrollo de problemas del sueño podría estar relacionado con la duración del parto y el estado del niño en el mismo, ya que el grupo problema se despertaba más y era más irritable durante los 10 primeros días de la vida. A las 8, 14, 20 y 30 semanas el grupo problema mostraba un esquema continuo de pequeños períodos de sueño durante la noche. Se discute el papel de los padres en el desarrollo de problemas del sueño, no habiendo un esquema común de cuidados en las madres de los niños problema siendo la mayoría muy responsables. No había evidencia de que el alimentar al niño al despertarse durante la noche, tuviera relación con el problema del despertar.
In a randomly selected series of 60 infants in a single private practice, 15 (25 per cent) had the sleep disturbance of night waking between 6 and 12 months of age. There was a significant correlation (p<0.02) between night woking and the temperamental characteristic of low sensory threshold as determined by a questionnaire technique. Though this problem is usually attributed to illness in the child or faulty management by the parents, the evidence presented here for a temperamental predisposition illustrates the need for a broader perspective in its diagnosis and management.
The prevalence and correlates of sleeping in the parental bed among healthy children between 6 months and 4 years of age are described. One hundred fifty children were enrolled in an interview study on the basis of "well-child" care appointments in representative pediatric facilities. The sample created was similar in demographic characteristics to census data for the Cleveland area. In this cross section of families in a large US city, cosleeping was a routine and recent practice in 35% of white and 70% of black families. Cosleeping in both racial groups was associated with approaches to sleep management at bedtime that emphasized parental involvement and body contact. Specifically, cosleeping children were significantly more likely to fall asleep out of bed and to have adult company and body contact at bedtime. Among white families only, cosleeping was associated with the older child, lower level of parental education, less professional training, increased family stress, a more ambivalent maternal attitude toward the child, and disruptive sleep problems in the child.
One hundred and fifty mothers of children under 5 years of age were interviewed about their problems of living, child rearing, and ways of coping. Stoicism, the extended family, and community resources with only occasional medical consultation were the rule. The frequency of minor stress and psychosomatic symptoms was high despite considerable satisfaction with roles; but clinical depression and use of psychotropic drugs was unusual. Children received considerably more medication mostly for sleeping problems before age 2 years and for brief periods only. These findings are discussed in the light of popular concepts about nuclear families, suburban neurosis, and iatrogenesis.
The outcome of 19 consecutive children referred with sleep disorders and managed by behavioural methods is described. An 84% success rate is reported, which was maintained at 6 months' follow up. Successful outcome was associated with absence of marital discord and attendance of both parents at treatment sessions.
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Chronic sleep disturbance, such as bed refusal, sleep-onset delay, and night waking with crying, affects 15% to 35% of preschool children. Biological factors, particularly arousals associated with recurrent episodes of rapid-eye-movement sleep, render infants vulnerable to repeated awakenings. Parental failure to establish appropriate stimulus control of sleep-related behaviors and parent-mediated contingencies of reinforcement for sleep-incompatible behaviors may shape and maintain infant sleep disturbance. Treatment and prevention strategies are discussed, and research needs are identified.
Die Entwicklung des Schlarfverhaltens in den ersten funf Lebenjahren [The development of sleep behaviours in the first five years]
- Basler
Understanding and managing infant sleep disturbance
- K G France