PosterPDF Available

Sleep interventions and parent-child well-being.



Three important questions are covered in this poster: • Does nightwaking that involves parental attention invariably constitute a sleep problem for children and parents? • Does a paradigm of independent, self-settling infant sleep patterns represent a solution or an added stressor? • Are children’s nighttime behaviors and parental sleep interventions related to parent-child well-being? The three research studies presented in this poster explore the possible challenges associated with a focus on various sleeping arrangements and routines. The poster also highlights the importance of alternative approaches and flexibility in mothers’ responses to nightwaking based on maternal perceptions of appropriate care and infants’ temperamental and physiological needs.
Infant nightwaking is a source of great concern for
Western parents and is often deemed problematic
by both parents and professionals (Lozoff, Wolf,
&Davis, 1985; Middlemiss, 2004; Mindell, Moline, Zendell, Brown, & Fry,
1994). Professional and popular advice increasingly suggests that infants should
be sleeping on their own and through the night as early as possible to assure sleep
consolidation and the capacity to self-settle at later ages. When sleeping through
the night is identified as the only healthy approach to infant sleep, sleep interven-
tions necessarily abound. Whereas some parents use proximal responses such as
picking up or feeding the infant upon awakening, the most endorsed approach ad-
vocates a more distal orientation involving the withholding of parental response to
crying for varying amounts of time.
Nightwaking and needing help with resettling, however, is a normative part of
infant development in the first year (Goodlin-Jones, Burnham, & Anders, 2000).
Sleep Interventions and
Parent-Child Well-Being
Wendy Middlemiss, Ph.D.
University of North Texas
Lauren Porter, MSW
Centre for Attachment, New Zealand
Macall Gordon, M. A.
Antioch University, Seattle
OBJECTIVE: To investigate whether variations in toddlers’ nocturnal behaviors and
maternal responses to nightwakings are associated with maternal well-being.
PARTICIPANTS: 87 mothers and their 18-month-old toddlers (56% Caucasian, 29% Hispanic
American) from Southern California.
MEASURES: Mothers’ reports on the Sleep Practices Questionnaire; Keller & Goldberg, 2004),
maternal anxiety scale (STAI; Spielberger), depressive symptoms scale (CES-D; Radloff), perceived
stress scale (PSS; Cohen, Karmarck, & Mermelstein), and maternal separation anxiety scale (MSAS;
Hock, McBride, Gnezda, 1989).
Nightwakings: Toddlers
woke an average of 2.44
nights per week (SD=1.47)
on an average of 1.46 times
per night (SD = .59).
Sleep Location and
Child and Parent
Nighttime Behaviors:
Controlling for maternal ed-
ucation and income,
cosleepers and solitary
sleepers did not differ on
frequency of fussing at bed-
time, but cosleeping tod-
dlers fussed significantly longer at bedtime. Cosleepers (i.e., part- and full-night bedsharers and
roomsharers) woke significantly more frequently than solitary sleepers on both a weekly and nightly
basis. Mothers of cosleepers responded to nightwakings with significantly more proximal methods
than did mothers of solitary sleepers (see Fig. 1).
Approaching Infant Sleep with a Focus on Infant Mental Health and Maternal Well-Being
Wendy Goldberg, Ph.D., Meret Keller, Ph.D., & Gary Germo, Ph.D.
University of California, Irvine
Douglas A. Granger, Ph.D.
Pennsylvania State University
Previous studies in the family and developmental literature,
combined with the new results reported above, support the
typicality of nightwaking for infants throughout the first two years
and the importance of maternal choices in both sleep location and style
of nighttime responsiveness.
Relevant mental health factors to consider:
Nightwakings are not invariably associated with chronic or
enduring problematic sleep patterns for typically developing
children. Although some infants who wake frequently will
continue nightwakings into childhood, over half will develop
consolidated sleep patterns characterized by sleeping through
the night and self-settling (Middlemiss, 2004; Zuckerman,
Stevenson, & Bailey, 1987)
Increasingly, sleep advice aimed at parents suggests that even moderate amounts of nightwak-
ing in infancy is indicative of disordered infant sleep (e.g. Murkoff, Hathaway, & Eisenberg,
2003; Weissbluth, 1999); however research suggests that nightwaking in the first two years is
normative and part of a developmental trajectory of sleep-wake maturation (Goodlin-Jones,
Burnham, Gaylor, & Anders, 2001; Petit, Touchette, Tremblay, Boivin, & Montplaisir, 2007).
Indeed, current norms for infant sleep have not been updated since the 50s. It is suggested
that sleep norms be revised in light of increases in the rates of breastfeeding, as well as the
adoption of back-sleeping for young infants (Elias, Nicolson, Bora, & Johnson, 1986).
Approaches to helping parents with infant nightwaking and the
implementation of sleep routines should be dyadic in nature.
Current empirical research on infant sleep has a strong behavioral orientation. Nightwaking is
viewed primarily as an undesirable behavioral event that is reinforced and perpetuated by
parental responsiveness. Within this paradigm, parental soothing is framed by some as a
problematic, even disordered, behavior (e.g., Mindell, Moline, Zendell, Brown, & Fry, 1994).
In the absence of a dyadic perspective, the socioemotional and contextual aspects of infant
sleep have been largely discounted or overlooked. “[In the behavioral view of infant sleep],
caregiving is constructed as behavior management, and is underpinned by the idealization of
all-night sleep as an achievable norm and an unquestioned . . . belief in the trainabililty of in-
fants” (Rowe, 2003, p. 185). The current approach overlooks or discounts the importance of
maternal and infant characteristics important to the construction of individual sleep routines.
OBJECTIVE: Questions of whether solitary sleep or shared sleep routines may cause
infants and mothers to experience elevated stress remains unanswered. There have been
hypotheses that solitary sleep and distal approaches to nightwakings may increase stress, particularly
if associated with extended periods of infant signaling (crying). Conversely, it has been proposed that
shared sleep generates higher levels of stress, and poorer sleep conditions, for infants and mothers.
This project explored whether variations in bedtime sleep routines or mothers’ perception of care and
appropriate sleep location were associated with levels of stress experienced by infants and mothers
across different sleep routines
METHODS: Participants included 62 mothers of infants between the ages of 6 and 15 months from
a district in New Zealand. Mothers sampled their own and their infants’ saliva prior to initiation of a
regular sleep routine and then 20 minutes following infants’ sleep.
Use of Sleep Training: Mothers’
use or nonuse of sleep training was
not associated with levels of stress
as sampled during the regular sleep
Viewing Nighttime Sleep as
Problematic: Mothers who
identified helping infants sleep
through the night as problematic
experienced more stress during the
OBJECTIVE: “Sleeping through the night” has become a benchmark not only for infant
development but, increasingly, for parental competence. Little is known, however, about
parental experiences with choosing and implementing various sleep strategies.
METHOD: First-time American parents (96% mothers) of infants under 11 months (N = 289) par-
ticipated an online survey about the infant’s current sleep behavior, parental use of sleep advice, and
implementation of interventions. Parents were well-educated, largely Caucasian, and upper-middle
class. Respondents were placed into groups based on sleep intervention methods used. A subset of
currently intervening groups were used for comparison: Cry (withholding of response to bedtime and
nighttime crying) (n= 44), No Cry (methods which do not precipitate crying) (n= 27), or Cosleeping
(n= 71).
FINDINGS: There were no significant differences between intervention groups on number of
nighttime awakenings (Mdn = 3-4 times/night) or duration of nighttime sleep (Mdn = 9-10 hrs).
Three important questions emerge:
Does nightwaking that involves parental attention invariably
constitute a sleep problem for children and parents?
Does a paradigm of independent, self-settling infant sleep
patterns represent a solution or an added stressor?
Are children’s nighttime behaviors and parental sleep
interventions related to parent-child well-being?
The three research studies presented in this poster explore the possible challenges
associated with a focus on various sleeping arrangements and routines. The poster
also highlights the importance of alternative approaches and flexibility in mothers’
responses to nightwaking based on maternal perceptions of appropriate care and
infants’ temperamental and physiological needs.
Research suggests that several approaches are effective in
achieving better infant sleep, including white noise
(Borkowski, Hunter, & Johnson, 2001) and positive routines
(Adams & Rickert, 1989). Advice suggesting the withholding
of parental response to nighttime crying is the only proven
and effective approach, narrows the range of choices that
might work within the diversity of family contexts.
Parental reports of nightwaking may be an important indicator
of other clinically-relevant variables.
A variety of family and contextual variables have been significantly related to infant night-
waking: breastfeeding, attachment status, parental psychopathology, maternal depression,
family stress, and relational disruption. A rush to provide behavioral sleep advice potentially
overlooks physiological, neurological, and psychosocial factors that may contribute to infant
sleep difficulties, or to parental interpretation of infant sleep behavior.
Sleep patterns are related to physiological stress responses.
From the perspective of psychotherapy and neuroscience, babies who experience calming
when distressed, grow to develop the capacity for emotional regulation (Cozolino, 2006,
Kopp, 1989; Schore, 2003). Recent evidence shows that mothers who achieve nighttime
stability (sleep arrangement stability, by either consistent cosleeping or consistent use of
independent sleep space) experience the most positive maternal and infant behavior and
dyadic quality of interaction (Taylor, Donovan, & Leavitt, 2008).
For additional information regarding these studies, please contact the authors: Study 1: Macall Gordon (; Study 2: Wendy Middlemiss (;
Study 3: Wendy Goldberg (; IMH Considerations: Lauren Porter ( Study 3 supported in part by a grant from the NIH (NS 41298) to Dr. Curt Sandman.
Salivary Alpha-Amylase ml/U
Mom preSleep
(p< .002)
Mom postSleep
(p< .05)
Fig. 1: Helping Baby Learning to Sleep
Not a
Bedtime Behaviors and Nightwakings: Stressful for Mothers of Toddlers?
Is Maternal Method of Response to Nightwaking Related to Maternal Well-Being?
Mothers who use more proximal response methods (e.g., picking up, feeding) also reported
greater beliefs that they were best suited to care for their child (MSAS; r= .24, p< .05). Other
maternal well-being measures were not significant.
Controlling for maternal education and family income, full-night cosleeping moms had lower
anxiety compared to solitary sleepers and part-night cosleepers (p<.05).
Results indicate that bedtime behaviors and nightwaking relate to different aspects of maternal well-
being. Cosleeping toddlers may fuss longer and wake more frequently, but their mothers report less
state anxiety than mothers of solitary sleepers. Mothers who believe that they are uniquely well-
suited to provide care for their toddlers reportedly use more proximal methods to comfort their tod-
dlers during the night.
Problematic sleep: Both the Cry (p< .001) or No Cry group (p< .001) considered their in-
fant’s current sleep behavior as more problematic for themselves and their families than did
Worry about sleep and how well they managed sleep: Cry (p< .001) and No Cry (p< .01)
groups were more worried about their infant’s sleep than Cosleepers. Mothers using a Cry ap-
proach were also significantly more worried about how well they were managing sleep than
they were worried about sleep itself (z= -2.112, p< .05).
Fit with parenting values: Cry parents reported that their intervention fit the least well with
their parenting values (p< .001). Cosleepers reported the highest level of fit (p< .001).
CONCLUSION: Those parents who used interventions aimed at changing the infant’s sleep pat-
terns experienced these efforts as stressful. Further, these parents considered their infant’s current
sleep behavior as problematic. The data also indicate that parents are concerned about their own abil-
ity to manage their infant’s sleep. The contibutory role that sleep interventions may play in parental
stress around sleep should be further examined.
bedtime routine than mothers who did
not identify this as a problem (Fig. 1).
Further, mothers who identified their in-
fant as having a problem sleeping
through the night experienced more
stress (Fig. 2).
Sleeping where Planned: Mothers
whose infants regularly slept where
planned experienced higher levels of
stress (as measured through salivary
alpha amylase) during the sleep routine
(Fig. 3).
Mothers’ perceptions of infants’ sleep
difficulties are related to physiological
measures of their stress levels in ex-
pected directions. The counterintuitive
direction of associations between mater-
nal stress and routinized infant sleep may
suggest the importance of flexibility in
the sleep routine for meeting sleep and
physiological needs.
Salivary Alpha-Amylase ml/U
Mom preSleep
(p< .001)
Mom postSleep
(p< .01)
Fig. 2: Baby Learning to Sleep a Problem
Not a
Salivary Alpha-Amylase ml/U
Mom preSleep
(p< .05)
Mom postWake
(p< .04)
Infant postSleep
(p< .03)
Fig. 3: Infant Sleeping Where Planned
Duration of
Bedtime Fussing
(p< .001)
No. of Nightly
(p< .001)
No. of Weekly
(p< .05)
Maternal Proximal
(p< .01)
Figure 1: Toddler and Parent Nighttime Behaviors by Sleep Location
Parents’ Experiences with Sleep Training: A Comparison of Cry, No Cry, and Cosleeping Approaches (Gordon & Hill, July 2008).
Sleep Training, Perceptions of Appropriate Sleep Routines and Infant and Mother Stress (Middlemiss, Granger, & Goldberg, July 2008).
3Nighttime Maternal Responses and Maternal Well-Being in a Non-Clinic Sample (Goldberg, Keller, & Germo, July 2008).
To Some
More frequent
bedtime fussing More Perceived Stress (p<.05)
Longer duration
of bedtime fussing
More Perceived Stress (p<.02), General
Anxiety (p<.001), Depressive Symptoms (p<.02)
More frequent
More nights/week
child wakes
associated with
More General Anxiety (p<.02), and Maternal
Separation Anxiety (p<.02), a measure of belief
that the maternal care is best for the child.
More Maternal Separation Anxiety (p<.04)
associated with
associated with
associated with
Correlational analyses indicated significantly…
WORLD INFANT MENTAL HEALTH CONGRESS, August 1-5, 2008 • Yokohama, Japan
Nightwaking is
a normative
component of
infant sleep and is
not, by nature,
Infant sleep will likely remain an issue of concern for parents, if for no other
reason than the need to deal with interrupted or reduced sleep in early parent-
hood. However, it is critical that infant sleep be approached within a sound
framework that incorporates evidence from the fields of infant mental health,
child development, neurology, and physiology.
The complexity of the issue, in both research and personal terms, must be
recognized. One-size-fits-all solutions are unlikely to be helpful, nor are adver-
sarial strategies that undermine parental confidence, child well-being, or the
health of family relationships. Learning to support both parents and infants is the
challenge we in the field must now tackle.
Sleep advice
should reflect a
range of appropriate
and viable sleep
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