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ARTICLE
PEDIATRICS Volume 137 , number 6 , June 2016 :e 20151486
Behavioral Interventions
for Infant Sleep Problems: A
Randomized Controlled Trial
Michael Gradisar, PhD,
a Kate Jackson, PhD, ClinPsyc,
a Nicola J. Spurrier, PhD,
b Joyce Gibson, MNutrDiet,
c
Justine W hitham, PhD,
a Anne Sved Williams, MBBS, FR ANZCP,
d, e Robyn Dolby, PhD,
b David J. Kennaway, PhDf
abstract
OBJECTIVES: To evaluate the effects of behavioral interventions on the sleep/wakefulness
of infants, parent and infant stress, and later child emotional/behavioral problems, and
parent-child attachment.
METHODS: A total of 43 infants (6–16 months, 63% girls) were randomized to receive either
graduated extinction (n = 14), bedtime fading (n = 15), or sleep education control (n =
14). Sleep measures included parent-reported sleep diaries and infant actigraphy. Infant
stress was measured via morning and afternoon salivary cortisol sampling, and mothers’
self-reported mood and stress. Twelve months after intervention, mothers completed
assessments of children’s emotional and behavioral problems, and mother-child dyads
underwent the strange situation procedure to evaluate parent-child attachment.
RESULTS: Significant interactions were found for sleep latency (P < .05), number of
awakenings (P < .0001), and wake after sleep onset (P = .01), with large decreases in sleep
latency for graduated extinction and bedtime fading groups, and large decreases in number
of awakenings and wake after sleep onset for the graduated extinction group. Salivary
cortisol showed small-to-moderate declines in graduated extinction and bedtime fading
groups compared with controls. Mothers’ stress showed small-to-moderate decreases
for the graduated extinction and bedtime fading conditions over the first month, yet no
differences in mood were detected. At the 12-month follow-up, no significant differences
were found in emotional and behavioral problems, and no significant differences in secure-
insecure attachment styles between groups.
CONCLUSIONS: Both graduated extinction and bedtime fading provide significant sleep benefits
above control, yet convey no adverse stress responses or long-term effects on parent-child
attachment or child emotions and behavior.
a School of Psychology, and cDepartment of Nutrition and Dietetics, Flinders University, Adelaide, South Australia,
Australia; bPublic Health and Health Promotion, SA Health, South Australia, Australia; dDepartment of Psychiatry,
and fSchool of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, South Australia, Australia;
and eWomen’s and Children’s Health Network, Adelaide, South Australia, Australia
Dr Gradisar provided co-conception and design of the study, supervision of most of the analyses
and conducted the rest of analyses, signifi cant contribution to the interpretation of analyses,
and was main contributor to writing of manuscript; Dr Jackson provided co-conception and
design of the study, collected most of the data (pretreatment to 3 months), conducted most of the
analyses, provided signifi cant input to the literature reviewed, was a minor contributor to writing
of the manuscript, and provided critical evaluation of manuscript drafts; Dr Spurrier provided
co-conception and design of the study, critical evaluation of manuscript drafts, and interpretation
of fi ndings; Ms Gibson provided input into study design, collected most of the 12-month follow-up
data, and provided interpretation of fi ndings and critical evaluation of manuscript drafts;
Dr Whitham provided input into the study design, conducted data scoring and analyses of 12-month
To cite: Gradisar M, Jackson K, Spurrier NJ, et al. Behavioral Interventions
for Infant Sleep Problems: A Randomized Controlled Trial. Pediatrics.
2016;137(6):e20151486
WH AT’S KNO WN ON T HI S SUB JEC T: Recommended
guidelines exist for the treatment of nocturnal
wakefulness for infants, including graduated
extinc tion and bedtime fading. Such interven tions
have a solid evidence base for improving infant sleep,
yet lit tle is known about their contraindications.
WHAT THIS STUDY ADDS: Sustained improvements in
sleep latency were found for both trea tment groups,
but not controls, yet no signifi c ant differences
occurred in the infant salivary cortisol, parental
stress and mood, and attachment profi les between
all groups.
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GRADISAR et al
Nocturnal wakefulness is normal
during early infant development
(ie, first 12 months).1–3 Night
wakings allow infants to signal
parents’ provision of sustenance
and comfort.1, 3, 4 At 2 months of age,
sleep homeostatic pressure develops,
potentially compressing nighttime
awakenings.2 Large declines in
nocturnal wakefulness occur (on
average) over the first 6 months
of age, and plateau thereafter,
2, 5
occurring after 24-hour circadian
rhythm stabilization at ∼3 to 6
months of age.6, 7 Infants’ nighttime
awakenings typically diminish by
the end of the first year of life3;
however, from 6 months, 16% to
21% of infants continue experiencing
nocturnal wakefulness such that
parents report their child has a
“sleep problem.”8, 9 Sleep problems
may be due to reduced sleep
homeostatic pressure2 and/or a
“coercive behavior trap, ” whereby
parents’ nocturnal responses are
more reinforcing than sleep.1 Aside
from an array of known daytime
impairments that follow from sleep
restriction in adults,
10 serious
consequences have been reported
for families who have an infant with
a sleep problem. Mothers of infants
with a sleep problem are more likely
to use physical punishment,
11, 12 and
are at an increased risk of developing
depression (eg, >2.0 odds ratio).9, 13–15
Also worth noting is that mothers
with emotional disturbances (ie,
stress, depression) are more likely to
report intrusive thoughts of harming
their infant,
16, 17 and some even
commit filicide.18–20 Thus, evidenced-
based treatments that rapidly
resolve infants’ sleeplessness while
minimizing family distress are vital.
Several interventions exist for
infants’ sleeplessness. Some with
the strongest evidence are based on
psychological learning theory (ie,
operant conditioning), where the
parents’ response to their infant’s
nocturnal cries are totally ignored
(extinction), or initially delayed
(eg, 2 minutes) and then gradually
extended up to 6 minutes on the
first night (graduated extinction).21
Despite a longstanding solid evidence
base for improving infant sleep and
maternal mood and stress both in the
short- and long-term,
21, 22 concerns
have nonetheless been raised. The
immediate stress experienced
by parents while undertaking
extinction-based methods can often
lead to ceasing such techniques.23, 24
However, arguably more important
(and central to the current article)
is that the stress associated with
extinction-based treatments might
elevate cortisol levels that could
have long-term consequences
of infant helplessness, and later
insecure parent-child attachments
and child emotional and behavioral
problems.3, 25 This antithesis to
using extinction-based methods
has strong support, to the extent
that more gentle approaches are
sought. Bedtime fading is one such
technique.21 Based on the physiologic
theory of sleep homeostasis,
26, 27
bedtime fading indirectly compresses
sleep by gradually limiting time in
bed, usually by delaying the infant’s
bedtime by 15 minutes each night.21
The current study’s aim is to compare
effects from graduated extinction
and bedtime fading against a sleep
education control on infants’ sleep,
stress, attachment, and emotional
and behavioral problems, as well
as maternal mood and stress, over
3 months of treatment and at a
12-month follow-up. The primary
outcome was infants’ sleep (sleep
latency, number of wakings, wake
after sleep onset), and secondary
outcomes were infants’ cortisol,
parents’ stress and mood, child-
parent attachment, and child
behavior. Descriptions and the timing
of these measures are presented in
Table 1.
METHODS
Participants
A total of 43 infants (mean age 10.8 ±
3.5 months, 6–16 months, 63% girls)
and their mothers (mean age 33.3 ±
4.8 years) and fathers (age 35.5 ±
6.4 years) were randomly assigned
to receive graduated extinction (n
= 14), bedtime fading (n = 15), or
sleep education control (n = 14).
Inclusion criteria were the following:
≥1 parent identifying their child
having a “sleep problem” (parents
responded with “yes” to the question
“Do you think your child has a sleep
problem?”)29; doctor/health nurse
check ≤1 month where the infant
was healthy and attained expected
weight gain; and typical infant
development (Infant Development
2
TABLE 1 Timing of Screening Measures, the Primary Outcome Variable, and Secondary Outcomes
Pretreatment 1 wk 1 mo 3 mo 12 mo
Edinburgh Postnatal Depression Scale (screen for
postnatal depression)
•
Infant Development Inventory (screen typical
development)
•
Sleep diary (primary outcome [sleep]) • • • •
Actigraphy (objective measure of sleep) • • • •
Salivary cortisol (secondary outcome: infant
stress)
•• ••
DASS-21 (secondary outcome: parent stress/
mood)
••••
Child Behavior Checklist 1.5–5.0 y (secondary
outcome: child behavior/emotion)
•
Strange situation procedure (secondary outcome:
child-parent attachment)
•
Child Behavior Checklist and DASS-21 were blind scored by JW; strange situation procedure was blind scored by RD;
actigraphy data were automatically scored using the ActiWare (v.5, Philips Respironics, Bend, OR) computerized algorithm
after manual correction of bedtimes from sleep diaries.28 Sleep diaries were scored by KJ.
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PEDIATRICS Volume 137 , number 6 , June 2016
Inventory). Exclusion criteria were
the following: significant postnatal
depression (Edinburgh Postnatal
Depression Scale scores ≥15), and
indication of suicidality. Most parents
were in a marriagelike relationship
(92.7%), had higher education
qualifications (77.2%), and were
middle- to high-income earners
(>AUD$80 000; 48.7%). Mothers
were mainly responsible for their
infant’s sleep (69.3%; 26.9% shared
responsibility). Table 2 presents
the sample demographics. Parents
provided informed consent to
participate. The study was approved
by the Flinders University Social
and Behavioral Research Ethics
Committee.
Procedure
Parents contacted researchers
in response to advertisements at
pediatric outpatient clinics, child
care centers, health professional
private practices, newspapers, and
word-of-mouth. Parents completed
a questionnaires and a 90-minute
interview (conducted by K.J.)
assessing the infant’s medical and
sleep history. Eligible families
were randomly assigned via a
predetermined computerized block
randomization held by K.J. (random
allocation was not concealed from
K.J.). Due to ethics committee
requirements, parents were allowed
to swap conditions. This occurred
for 2 families (1 from graduated
extinction to sleep education control;
1 from sleep education control to
graduated extinction).
During pretreatment, families
completed sleep measures (7-day
sleep diary; ankle-worn activity
monitor [AW64 Minimitters;
Philips Respironics, Bend, OR]),
and maternal depressed mood
and stress (depression and stress
subscales of the Depression Anxiety
Stress Scale–Short Form [DASS-
21]). Parents collected infant saliva
samples in the morning (mean ±
SD time 8:59 AM ±1.27 hours) and
afternoon (mean ± SD time 3:38 PM
±1.24 hours) on 2 consecutive days
by using sterile cotton-tipped eye
spears.30 Blinded frozen samples
(–20°C) were thawed and centrifuged
before cortisol analysis in duplicate
by enzyme-linked immunosorbent
assay (Salimetrics, LCC, State College,
PA). The group origin of the samples
was blinded to the laboratory, and
samples were within acceptable
validity criteria (the intra-assay
coefficient was <10%, and the
interassay coefficients at 3.0 nM
and 27.5 nM were 13.5% and 9.3%,
respectively).31
Parents subsequently underwent
their individualized treatment
session. Graduated extinction
involved a set schedule of gradually
delaying parents’ response to their
infant’s cry (see Supplemental Table
4). Parents were instructed to put
their infant to bed awake and leave
the room within 1 minute. When
reentering the room, they comforted
their child, but avoided picking the
child up and turning the lights on.
Bedtime fading involved gradually
limiting the infant’s nocturnal
sleep opportunity (Supplemental
Table 4). For the sleep education
control, parents were provided
sleep information from a statewide
child health service (www. cyh. com;
Supplemental Table 4). Families
received a booklet describing their
intervention, and 24/7 cell phone
support (by K.J.). Of calls received,
these included clarification of
techniques, delaying treatment, and
clarifying measurements (saliva,
actigraphy), with no perceived
differences in the number of calls
between groups (unfortunately, no
systematic data were recorded for
these calls; thus, these data are based
on our retrospective recall).
Parents participated with their child
in the strange situation procedure
to assess child-parent attachment.32
This procedure used 8 standardized
interactions (including separations
and reunions) between the parent,
child, and a stranger (the stranger
was blind to children’s group
allocation), which were videotaped
and blind scored (by R.D.) according
3
TABLE 2 Demographic Characteristics of Participating Families, by Treatment Group
Graduated
Extinction
Bedtime Fading Education Control
Child
Age, mean ± SD, mo 10.8 ± 3.7 11.8 ± 3.4 9.61 ± 3.3
Boys, n (%) 5 (39) 5 (31) 5 (42)
Mother
Age, mean ± SD, y 31.38 ± 4.4 34.44 ± 5.1 33.82 ± 4.3
Education status, n (%)
Did not complete high school — — 1 (8.3)
Completed high school 2 (15.4) 3 (18.8) 1 (8.3)
Completed higher education 11 (84.6) 13 (81.3) 10 (83.3)
Father
Age, mean ± SD, y 33.38 ± 5.4 35.67 ± 7.0 37.73 ± 6.2
Education status, n (%)
Did not complete high school — 1 (7.1) 3 (27.3)
Completed high school 2 (15.4) 5 (35.7) —
Completed higher education 11 (84.6) 8 (57.1) 8 (72.2)
Family
Parental status, n (%)
Two parents 13 (100) 14 (87.5) 11 (91.7)
Single parent — 2 (12.5) 1 (8.3)
Household income per annum, n
(%)*
<50 000 — 4 (26.7) 3 (25.0)
50 000–80 000 4 (33.3) 5 (33.3) 4 (33.3)
>80 000 8 (66.7) 6 (40.0) 5 (41.7)
Data missing for n = 1 for each of graduated extinction and bedtime fading groups. —, no data.
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GRADISAR et al
to gold standard criteria. Recordings
of each child-parent dyad were coded
as either secure, insecure (avoidant),
insecure (resistant), and insecure
(disorganized).
Analysis
Linear mixed-model regressions
were used to test for significant
interactions on primary (sleep diary)
and secondary (infant cortisol;
maternal stress/mood) outcome
variables. Within-group Cohen’s
d effect sizes were calculated to
demonstrate changes within each
intervention. A time-of-day effect
was found between morning
and afternoon cortisol values
(pretreatment, P < .01), thus morning
and afternoon cortisol values are
analyzed separately. Fisher’s exact
test was used to assess differences in
attachment styles between groups.
A series of 1-way analyses of variance
assessed between-group differences
on the Child Behavior Checklist.
No effect sizes were available for
using bedtime fading on typically
developing infants, nor some of
the important secondary outcomes
tested in the current trial (eg, salivary
cortisol). Large effect sizes (Cohen’s
d > 0.80) for graduated extinction
(compared with controls) have been
reported for sleep.21 Based on a
power of 0.80, and a probability level
of .05, at least 21 participants per
group would be needed to detect a
large effect size.
RESULTS
Figure 1 presents the flow of
participants through each stage of
the study.
Infant Sleep
Figure 2 presents descriptive
statistics for infants’ sleep over the
3-month treatment and follow-up
period. Linear mixed model
regression analyses of sleep diaries
showed significant interactions for
sleep latency, P < .05, wake after
sleep onset, P < .0001, number of
awakenings, P = .01, and total night
sleep time, P < .01. From pretreatment
to the 3-month follow-up, sleep
latency showed large declines
for infants in both the graduated
extinction (–12.7 minutes; d = 0.87)
and bedtime fading (–10 minutes;
d = 1.04) groups, but no change for
the control group (+2.0 minutes; d =
–0.11). There was a very large decline
in the number of awakenings for
infants in the graduated extinction
group (d = 1.98), yet no changes for
infants in both the bedtime fading (d
= 0.10) and control (d = 0.13) groups.
Large improvements in wake after
sleep onset were found for infants in
the control (–31.7 minutes; d = 0.93)
and bedtime fading (–24.6 minutes;
d = 0.99) groups, with a very large
improvement found for the graduated
extinction group (–44.4 minutes;
d = 2.02). Finally, total sleep time
showed a moderate increase in the
graduated extinction condition (+0.32
hour), little change in the bedtime
fading condition (+0.09 hour), and
4
FIGURE 1
Participant fl ow through the randomized controlled trial.
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PEDIATRICS Volume 137 , number 6 , June 2016
a moderate increase in the control
condition (+0.36 hour). Actigraphy
showed no significant interactions for
wake after sleep onset, P > .05, and
total sleep time, P > .05.
Infant and Parental Stress
Morning and afternoon infant cortisol
values for each group over time are
presented in Fig 3. No significant
interactions occurred for morning
cortisol, P > .05, yet there was for
afternoon cortisol values, P < .01.
From pretreatment to the 12-month
follow-up, morning cortisol showed
a small decline in the graduated
extinction group (d = 0.23), a
moderate drop in the bedtime fading
group (d = 0.62), yet no change
for the control group (d = 0.17).
Afternoon cortisol showed a large
decline in the graduated extinction
group (d = 0.89), a moderate decline
in the bedtime fading group (d =
0.61) and a small decline in the
control group (d = 0.39).
A significant interaction was found
for maternal stress, P < .01 (Fig 3).
There were moderate improvements
in all groups from pretreatment to
12-month follow-up (graduated
extinction: d = 0.51; bedtime fading:
d = 0.62; control: d = 0.64). However,
over the initial month of treatment,
mothers’ stress in the control group
remained somewhat unchanged (d =
0.16), whereas there was a moderate
stress reduction for mothers in the
graduated extinction group (d = 0.67)
and a large reduction in mothers’
stress in the bedtime fading group
(d = 0.86). Analysis of maternal
mood demonstrated no significant
interaction, P > .05. Mothers’ mood
improved from pretreatment to the
12-month follow-up in all conditions,
with small effects found for those in
the graduated extinction (d = 0.34)
and control (d = 0.39) conditions,
yet a large effect for mothers in the
bedtime fading group (d = 0.83).
Twelve-Month Follow-up: Child
Attachment and Emotional-
Behavioral Problems
Table 3 presents the percentage
of parent-child attachment
classifications in each group. No
significant differences were found
5
FIGURE 2
Means (95% confi dence interval [CI]) during and after treatment of infants in graduated extinction, bedtime fading, and sleep education control for (A)
sleep onset latency, (B) wake after sleep onset, (C) number of awakenings, and (D) total nocturnal sleep time.
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between secure and insecure
attachment styles between groups,
P > .05. There were no significant
differences between groups for any
emotional or behavioral problems on
the Child Behavior Checklist (all P >
.05; Table 3).
DISCUSSION
Compared with controls, graduated
extinction produced large decreases
in nocturnal wakefulness (time taken
to fall asleep, number of awakenings,
minutes awake after sleep onset),
yet a novel aspect of this trial was
evaluating bedtime fading, about
which there has been relatively little
research,
22 especially in typically
developing infants.33, 34 Bedtime
fading produced large decreases in
sleep latency compared with the
control group. The control group’s
sleep did show improvements in
nocturnal wakefulness and total
sleep, suggesting developmental
maturity and/or improvements from
sleep education.35 No significant
sleep changes were found by using
objective actigraphy, suggesting
sleep diaries and actigraphy measure
different phenomena (eg, infants’
absence of crying by parents vs
infants’ movements, respectively),
further suggesting infants may
still experience wakefulness but
do not signal to parents.36 We
do not interpret these data as
the infant “giving up, ”25, 37 but
instead self-soothing.36 However,
a central research question in the
current study was: Do extinction-
based techniques produce
psychophysiological stress that leads
to later problematic emotions and
behavior, and thus insecure parent-
child attachment?
Child-Parent Stress, Emotions,
Behaviors, and Attachment
Relatively minor stressors (eg, brief
parental separation) elevate cor tisol
levels in newborn infants38; however,
the cortisol stress response diminishes
from 4 months of age.30, 38, 39
This may explain the lack of
significant cortisol elevation in the
graduated extinction condition in
the current study, especially as our
sample was older than 4 months of
6
FIGURE 3
Means (95% CI) during and after treatment of infants in graduated extinction, bedtime fading, and sleep education control for (A) infant salivary cortisol
morning samples, (B) infant salivary cortisol afternoon samples, (C) self-reported maternal stress, and (D) self-reported maternal mood.
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PEDIATRICS Volume 137 , number 6 , June 2016
age (range 6–16 months; mean 10.8
months). We cannot conclude no
cortisol response occurred, as we did
not collect real-time cortisol data (ie,
plasma) during nocturnal treatment
implementation. Our diurnal cortisol
data indicate the active treatments
did not result in chronically elevated
levels over time (ie, values were
within normative limits),
40 which is
necessary for hypothalamic-pituitary-
adrenocortical dysregulation.38
This is a crucial point when
considering the chain of arguments
forming the hypothesis that
graduated extinction may lead to
problematic emotions and behaviors
in later child development.25 This
hypothesis requires a significant and
chronic cortisol elevation resulting
from graduated extinction, yet is
further disconfirmed by examining
our long-term emotional and
behavioral findings. No significant
difference in children’s emotions and
behaviors could be found between
groups 12 months after intervention,
with internalizing and externalizing
behaviors comparable across groups.
This lack of findings concur with a
recent 6-year follow-up assessment
of a large randomized controlled trial,
where no differences in problematic
behaviors and mental health were
found between children who received
behavioral sleep interventions and
those in the control group.41
The final argument against using
extinction-based methods for infant
sleep problems is the potential for
insecure child-parent attachment.25
No significant differences were
found in attachment styles between
groups, which suggests a lack of
evidence between infants’ sleep and
attachment.5 For parental stress,
mothers in both intervention groups
reported less stress than mothers
in the control group. The lack of
support for dysfunctional child-
parent relationships (ie, disinhibited
attachment, child-parent closeness
and conflict, global relationship) after
behavioral sleep interventions has also
been found in a recent 6-year follow-up
study.41 Altogether, our findings and
those of Price et al.41 are the only
studies that now form a preliminary
evidence base that suggests brief
behavioral sleep treatments may help
young children sleep, yet do not lead
to later emotional and behavioral
problems, or later parent-child
insecure attachment.25
Limitations and Future Research
Directions
Although the generalizability of
our findings to the population is
reduced with a small sample size,
they nevertheless support those of a
larger follow-up study of behavioral
sleep interventions for infants (n =
326).41 Although stress was measured
at different time points across
interventions, we did not measure
acute stress during interventions.
Changes in attachment across the
study would also have been interesting,
yet we note that 12 months of age is
the prime age for the strange situation
procedure.32 The current study
contrasted only 2 behavioral sleep
interventions. Future trials are needed
7
TABLE 3 Child Behavior Checklist Scores (Mean [95% CI] and Between-Group Effect Sizes [d]) at 12-Month Follow-up, by Treatment Group; Attachment
Classifi cations (n [%]) by Group
Graduated
Extinction, n = 13
Bedtime Fading,
n = 15
Education
Control, n = 12
Pd (Graduated
Extinction versus
Bedtime Fading)
d (Graduated
Extinction versus
Education
Control)
d (Bedtime Fading
versus Education
Control)
Problem scale scores
Internalizing
problems
Raw scores 5.00 (2.7–7.3) 6.06 (3.9–8.2) 5.08 (1.8–8.4) .77 –0.27 –0.02 0.21
T scorea ≥60, n
(%)
— 1 (6.3) 1 (8.3) .59 — — —
Externalizing
problems
Raw scores 10.6 (6.4–14.8) 10.6 (7.7–13.5) 10.2 (5.5–14.9) .98 0.01 0.06 0.06
T score ≥60, n (%) 1 (7.7) 1 (6.3) 2 (16.6) .67 — — —
Total problems
Raw scores 10.8 (6.8–14.7) 10.9 (8.2–13.6) 12.1 (7.6–16.6) .84 –0.02 –0.19 –0.20
T score ≥60, n (%) ——— —— —
Attachment
classifi cations
Secure 7 (54) 9 (60) 5 (62) — —— —
Insecure (avoidant) 1 (8) 1 (7) 1 (13) — —— —
Insecure (resistant) 2 (15) 3 (20) 1 (13) — —— —
Insecure
(disorganized)
3 (23) 2 (13) 1 (13) — —— —
—, not applicable.
a If T score in the borderline or clinical range; d > 0.50 = moderate effect, d > 0.20 = small effect; data missing for graduated extinction group (n = 1) and sleep education control group
(n = 1).
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GRADISAR et al
to compare other interventions (eg,
extinction with parental presence,
cosleeping via room-sharing). Due
to ethical obligations and a coroner’s
inquiry in our home state,
42 bed-
sharing was not an option to evaluate
because of infant mortality risks,
and we have seen similar warnings
internationally.43, 44 Worth noting is
that, to our knowledge, we have been
unable to find a similar coronial finding
of an infant death due to graduated
extinction. Thus, we wish to highlight
to researchers the crucial need to build
the evidence base for establishing
safe and effective treatments for those
families who perceive their infant to
have a sleep problem.
Clinical Implications
Although graduated extinction is
based on learning theory,
1 sleep
homeostatic pressure would increase
over successive nights of less
sleep.26, 27 Likewise, bedtime fading
would increase sleep homeostatic
pressure, quickening sleep latency,
reducing the time between stimuli
(eg, cot) and the response (ie, sleep),
and thus infants “re-learn” to initiate
sleep. This theoretical overlap allows
these treatments to combine in
clinical practice (eg, bedtime fading
followed by graduated extinction).
Our data suggest introducing bedtime
fading will provide quick results
for improving sleep-onset latency.
Graduated extinction may then be
introduced to reduce nocturnal
wakefulness during the night (if
needed). Our data suggest sleep
education alone may not be enough
to help most families with an infant
who has a sleep problem.
CONCLUSIONS
This randomized controlled trial of
behavioral interventions for infant
sleep problems found meaningful
effects for both graduated extinction
and bedtime fading. Compared with
the control group, large reductions
in nocturnal wakefulness resulted
from each treatment. Despite
assertions that extinction-based
methods may result in elevated
cortisol, emotional and behavioral
problems, and insecure parent-infant
attachment, our data did not support
this hypothesis. Coupled with the
findings from Price and colleagues,
41
behavioral interventions appear to
improve sleep without detrimental
effects on the child or family. Further
replication studies by independent
groups are needed to confirm and
raise confidence in these findings.
ACKNOWLEDGMENTS
The authors thank the families who
generously donated their time and
energy into this project, Dr Patricia
McKinsey Crittenden for her expert
advice regarding the conduct of
strange situation assessments, Ms
Laura Jarema for bravely being the
“stranger, ” and Mr Pawel Skuza and
Megan Gunnar for their conceptual
and statistical advice for cortisol
collection and analysis. We also
thank the Flinders University Social
and Behavioral Ethics Committee
for their impartial evaluation of
this project in response to an online
petition to cease this approved
research.
8
ABBREVIATION
DASS-21: Depression Anxiety
Stress Scale–Short
Form
follow-up data and the minority of analyses under supervision, provided some input to the literature reviewed and was a minor contributor to writing of
manuscript, and provided critical evaluation of manuscript drafts; Dr Sved Williams provided assistance with design of the study, interpretation of fi ndings, and
critical evaluation of manuscript drafts; Dr Powell-Davies provided input into the study design, scored the infant-parent attachment, and provided interpretation
of fi ndings and critical evaluation of manuscript drafts; Dr Kennaway provided input into study design, expert input into salivary cortisol data collection, scoring
of salivary cortisol, interpretation of fi ndings, and critical evaluation of manuscript drafts; and all authors approved the fi nal manuscript as submitted.
This trial has been registered at the Australian New Zealand Clinical Trials Registry (identifi er ACTRN12612000813886)
DOI: 10.1542/peds.2015-1486
Accepted for publication Mar 21, 2016
Address correspondence to Michael Gradisar, PhD, c/o Flinders University, School of Psychology, GPO Box 2100, Adelaide, SA, 5001, Australia. E-mail: grad0011@
fl inders.edu.au
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.
FUNDING: Supported by Australian Rotary Health Fund, Channel 7 Children’s Research Fund, Faculty of Social and Behavioral Sciences.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
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PEDIATRICS Volume 137 , number 6 , June 2016
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DOI: 10.1542/peds.2015-1486
; originally published online May 24, 2016; 2016;137;Pediatrics
Anne Sved Williams, Robyn Dolby and David J. Kennaway
Michael Gradisar, Kate Jackson, Nicola J. Spurrier, Joyce Gibson, Justine Whitham,
Trial
Behavioral Interventions for Infant Sleep Problems: A Randomized Controlled
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DOI: 10.1542/peds.2015-1486
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Anne Sved Williams, Robyn Dolby and David J. Kennaway
Michael Gradisar, Kate Jackson, Nicola J. Spurrier, Joyce Gibson, Justine Whitham,
Trial
Behavioral Interventions for Infant Sleep Problems: A Randomized Controlled
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