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A qualitative study of parents' perceptions of a behavioural sleep intervention
Abstract
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.
... Despite this, many parents are reluctant to try these interventions, or find it difficult to follow through with them [14,15]. As will be outlined in the current paper, a number of socio-cultural, infant, and parent factors may stand in the way of parents successfully implementing EBM. ...
... Nevertheless, previous reports have mentioned parental concerns about the impact of EBM with themes of stress, fear of being judged, criticism within one's social circle, or possible harm to the infant [14,19,22]. Other factors may include practical considerations (eg, living space-sharing with siblings), misinformation, incongruence with personal beliefs, culture, and parental mental health [23]. ...
... While some parent's express concerns of harm to the infant as a result of EBM, others may have fears about how using this technique would be perceived by friends and family. Indeed, a study by Tse and Hall found that parents implementing extinction-based methods experienced fears of being judged by others and did not discuss this with friends or family [14]. Unsurprisingly, these concerns also contributed to a lack of adherence to the technique [14]. ...
Behavioural sleep interventions (e.g., extinction-based methods) are among the most efficacious evidence-based techniques in the treatment of infant sleep problems. However, behavioural sleep interventions can be challenging for families to successfully implement. This review aims to summarise current research surrounding the potential barriers that arise when clinicians attempt to implement extinction-based methods with parents of infants. We provide a model that summarises 3 types of contextual-barriers; socio-cultural barriers, parent barriers, and infant barriers. Based on the current evidence, we propose that adopting a stepped care approach, planning ahead, increasing support, motivational interviewing, and/or emotional regulation may serve as useful tools for parents when implementing extinction-based methods. By considering these techniques, more families may receive the benefits of improved infant sleep.
... Programmes aiming to prevent infant sleep problems focus on parental education about infant self-settling strategies, normal sleep/wake patterns, low stimulation during the night, and increasing the interval between waking and night feeds (16) . Implementing programmes on normal sleep and crying patterns, and encouraging infants to self-soothe may reduce parental concern about infant sleep and crying problems (17) . However, parents are unsatisfied with counselling obtained from health providers, and they demand more information (18) which is acceptable and realistic for practical purposes. ...
... The articles were published between 2006 and 2016. The majority of the studies (n = 4) were conducted in Canada (2,8,17,26) , two were conducted in the USA (27,28) , two in Australia (29,30) , and one in Japan (31) . Most of the trials analysed had one intervention group and one control group. ...
... Finally, they mentioned "parents' support systems, expectations and inadvertent benefits of the study" describing varying needs for support. Some of them received help from family members, such as cooking or babysitting, while others got psychological support through phone calls or meetings with friends and family, helping to deal with the feeling of being emotionally isolated (17) . Hiscock et al. (2014) conducted a study with 781 infants born at 32 weeks or later in 42 well-child centres. ...
The first year of the child’s life can be overwhelming. One of the major problems faced by parents relates to the infant’s crying and sleeping habits, potentially leading to exhaustion, with implications for their health. Information is crucial, so our aim was to assess the relevance and impact of parental education on children’s sleep problems in the first year of life. To this end, we conducted a systematic review, using as keywords references to “parental education,” “parenting,” “sleep hygiene,” “infant,” and “newborn,” looking for original articles published over the past 10 years in English and Portuguese. We found nine original articles. Results suggest that preventive intervention improves infants’ sleep quality. Parental education programmes included infant sleep patterns, parental behaviour, and strategies facilitating self-soothing. Placing down the infant while still awake, and minimising parental responsiveness by active extinction and graduated extinction techniques, were shown to be the most successful strategies. Cognitive-behavioural interventions proved to improve both parents’ and infants’ symptoms. Incorporating formal parental education into children’s sleeping pattern and parents’ behaviours in children’s health routines in regular medical practice is a cost-effective strategy for increasing the empowerment of families to deal with the problem.
... In our study, most of the families had largely adjusted to the sleep problems. This was also found by Tse and Hall (2008). Because families are likely to live with sleep problems in small children over a period of time, it can be important to help parents to acknowledge their own strain and overload to a larger degree. ...
... Life events meant that the children's development often appeared as a 'back and forth' process. A similar process has been described indirectly as a relapse, triggered by disruptions of routines, such as teething (Tse & Hall, 2008). Therefore, a family's self-perception is important to communicate when guiding parents. ...
... Several were worried that the methods could have negative consequences, for example on their children's mental health. In a study with interviews of 14 parents (Tse & Hall, 2008), similarly varying experiences with a specific behavioural modification method were revealed. In our study, parents who strengthened their children's sleep regulation over a period stated that the children's emotional state at bedtime and during episodes of awakening at night was normally an expression of their need for contact with their parents. ...
Purpose: The aim of this study was to explore the experiences of parents whose children aged 1–3 years have sleep problems, from a health promotion perspective.
Methods: This was a qualitative study, based on semi-structured interviews with 12 mothers in Norway. The material was analysed by qualitative content analysis.
Results: Parents experienced problems with getting their children to bed, getting them to fall asleep, and episodes of awakening at night. Parents expressed that it was time-consuming and difficult to teach their children sleep regulation. Parents handled the sleep problems through the following coping strategies: acknowledging challenges, clarifying one’s self-understanding, implementing change measures, and safeguarding family well-being. These coping strategies resulted in this main theme: the health-promoting regulation of interactions, including parents’ strengthening of sleep regulation in their small children and the safeguarding of well-being in the family.
Conclusions: Early, individually customized guidance for parents, with a focus on revealing and acknowledging their experiences with sleep problems in children, is essential for parents to find opportunities to cope with such challenges. Appropriate goals seem to be important for them to succeed in strengthening sleep regulation in their children in a more satisfactory way.
... Furthermore, additional parents responded to the recruitment ad, but refused to allow a home visit because they might be allocated to the ignoring condition. Other extinction studies have also experienced noncompliance and drop-out due to ethical concerns, 18,19 and some report vaguely-or un-explained attrition which may be due to parent resistance to the intervention. 6,20 Additional papers have also mentioned parental resistance, 8,15,21,22 but often without reference to evidence. ...
... 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. ...
... For example, interventions may be too traumatic for parents or children, contradict their beliefs about child-rearing, or are impractical. 18 Owens et al. 15 briefly discussed how a lack of parental acceptance influences behavioral sleep interventions, but did not discuss the reasons for this resistance. ...
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.
... It is surprising therefore that research exploring parents' experiences of such interven-tions is extremely limited (Nikolopoulou & St. James-Roberts, 2003). Indeed, the authors have identified just one study which investigated this issue (Tse & Hall, 2008). Tse and Hall (2008) explored the views and experiences of parents of typically developing infants ages 6 to 12 months who had received an SMI, including aspects of the intervention which were perceived to be associated with positive outcomes, and the challenges associated with changing the way they managed their baby's sleep. ...
... Indeed, the authors have identified just one study which investigated this issue (Tse & Hall, 2008). Tse and Hall (2008) explored the views and experiences of parents of typically developing infants ages 6 to 12 months who had received an SMI, including aspects of the intervention which were perceived to be associated with positive outcomes, and the challenges associated with changing the way they managed their baby's sleep. A greater understanding of sleep rhythms/cycles and the importance of routine and developing self-settling skills were commonly reported as important learning points. ...
... In terms of the challenges of implementing new sleep management strategies, parents reported difficulties with persevering with new strategies or adhering to new routines, other caregivers undermining the intervention, and concerns about disturbing neighbors during the night. Finally, Tse and Hall (2008) noted that parents identified increased, or regained, confidence as parents as a positive, but unanticipated, outcome. ...
Psychoeducational approaches to managing behavioral sleep problems in children with neurodisabilities are directed at the parent, increasing their knowledge and understanding of sleep and requiring them to change the way they manage sleep disturbance. Given parental engagement with and adherence to an intervention are critical to its success, it is important we understand parents’ experiences of participating in interventions of this nature. It is surprising therefore that, to date, research in this area is extremely limited. This article reports the findings from a qualitative study of 35 parents who had received a psychoeducational sleep management intervention (SMI) delivered through 1 of the following modes: a half-day workshop (n = 8); a 4-session group-delivered intervention (n = 15); or 1-to-1 work with a specialist sleep practitioner (n = 12). The study was part of a larger program of work evaluating SMIs for children with developmental disorders, autistic spectrum conditions, or both. Purposeful sampling was used to represent intervention outcome, child’s diagnosis, parents’ education, and partner involvement in the intervention. Focus groups and individual interviews were used to gather data. The data were subject to a thematic analysis in relation to (a) parents’ descriptions of the processes by which a SMI leads to improvements in their child’s sleep; (b) parents’ views of the factors which hinder the achievement of positive intervention outcomes; and (c) parents’ views on intervention intensity and mode of delivery. The implications of the findings in terms of the design, content, and delivery of such interventions are discussed.
... Indeed it is unclear whether parents are instructed to expect this post extinction burst and if not, may be excused for thinking that the intervention is "not working", which subsequently leads them to stop. Parents may resist extinction interventions because they are too traumatic for them, contradict their beliefs about child-rearing, or because they are perceived to be impractical [20]. ...
... Seymour, Bayfield, Brock and During [21] reported 5% of parents did not implement their intervention program and a further 2% could not be contacted after the initial interview. Tse and Hall [20] reported "objections to treatments" and "difficulty in completion" while Friman and colleagues [22] reported parental preferences for gentler methods of limit setting (such as the "bedtime pass" method) compared to ignoring. An Australian randomised control trial (RCT) of the two modified extinction interventions, graduated extinction and parental presence, reported 28% (n = 65) of eligible and contactable parents declined to participate [5]. ...
... Furthermore, additional parents had responded to the recruitment ad, but refused to allow a home visit and interview because they may have been allocated to the ignoring condition. Tse and Hall [20] reported that approximately 10% of their sample could not be contacted due to dropping out of their extinction study following "ethical concerns" although exactly what these concerns refer to were not reported. In Reid, Walter and O'Leary's [12] study, 22 of 71 (33%) parents of young children elected not to participate in 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.
... To best of our knowledge, qualitative research methods have only been utilized in one infant sleep study which explored parental perceptions of a behavioral intervention for 6-12 month old infants with sleep problems (Tse and Hall, 2008). Subjective interpretations of infant sleep patterns and problems, and maternal coping experiences may affect both maternal and infant sleep and health, particularly where studies have repeatedly shown that parents may lack sleep-related knowledge and have misconceptions about child sleep patterns (Owens and Jones, 2011;Schreck and Richdale, 2011;Tse and Hall, 2008). ...
... To best of our knowledge, qualitative research methods have only been utilized in one infant sleep study which explored parental perceptions of a behavioral intervention for 6-12 month old infants with sleep problems (Tse and Hall, 2008). Subjective interpretations of infant sleep patterns and problems, and maternal coping experiences may affect both maternal and infant sleep and health, particularly where studies have repeatedly shown that parents may lack sleep-related knowledge and have misconceptions about child sleep patterns (Owens and Jones, 2011;Schreck and Richdale, 2011;Tse and Hall, 2008). Improved understanding of parental perceptions and coping experiences for infant sleep will aid the interpretation of recent cross-cultural infant sleep studies and guide the development of effective sleep promotion and intervention strategies to improve maternal and infant sleep and health. ...
... Delayed help-seeking for such problems may become a real concern because regular medical check-ups are less frequent as children get older. Previous studies have found that knowledge of childhood sleep and its disorders was very limited in most parents and even in pediatricians (Mindell et al., 1994;Schreck and Richdale, 2011;Tse and Hall, 2008). ...
to describe the aspects of infant sleep perceived as problematic by first-time Taiwanese mothers and to discover how mothers cope in response to infant sleep concerns.
a qualitative approach was used for data collection.
in-depth interviews were conducted and audio-taped at mothers' homes.
12 first-time mothers within three months post partum.
content analysis was performed to identify patterns, similarities, and differences in the individual and collective interview data. The major themes describing maternal coping experiences were 'self-help' and 'seek-help.' Self-help coping efforts included reception and acceptance of suggestions as well as changing behaviour to allow mothers to feel capable of adapting to infant sleep patterns or problems. Seek-help was a later stage of coping for mothers when they actively utilised formal and informal sources of help to identify and manage infant sleep problems. The majority of mothers sought informal help sources from family members, friends, or online information. Mothers who suspected their infant of suffering from sleep problems either delayed seeking medical advice or did not actively consult a health care provider.
nurses and health care providers who work in antenatal, postnatal, and paediatric clinics should actively educate and provide information about infant sleep patterns and sleep management options to first-time mothers and discuss maternal coping strategies.
... Behavioural extinction-based interventions in particular, have been shown to be efficacious in the treatment of infant sleep problems (Meltzer & Mindell, 2014;Mindell et al., 2006), yet some parents find these particularly difficulty to implement (Tse & Hall, 2008;Whittall et al., 2021). ...
... While these seem relatively small, it is argued that a non-invasive and relatively simple strategy could help parents regulate their emotions for a longer period of time. Reappraisal on the other hand, has been noted as important in the area of infant crying, specifically in delaying responses to infant crying (Martin et al., 2020) and changing emotional responses to infant crying (Riem & Karreman, 2019 (Tse & Hall, 2008). ...
Study objectives:
Infant sleep problems are one of the most common complaints of new parents. Research to date has demonstrated a relationship between low parental cry tolerance and infant sleep problems. The aim of this study was to explore whether three emotion regulation strategies could increase parental cry tolerance.
Methods:
This study utilised a quasi-experimental design. We recruited 83 females (Mage= 32, SD= 5.26) comprising 3 groups: mothers of good sleeping infants aged 6-24 months, mothers of poor sleeping infants aged 6-24 months, and good sleeping women aged 23-40 years without children. Participants were instructed to listen to crying audio segments and indicate when they felt the child needed to be tended to (measured in seconds). This crying audio was paired with one of three emotion-regulation strategies (i.e., music, gaming, reappraisal). Each participant completed all 4 cry conditions which were counterbalanced to control for order effects.
Results:
We found that all three strategies yielded significantly longer reaction times (indicating higher cry tolerance) compared to the control condition (p <.001). We also found that mothers of poor sleepers and good sleeping women benefitted from all three emotion regulation strategies compared to control (p <.001 and p= <.05, respectively). The cry tolerance of mothers of good sleepers, on the other hand, did not differ between the control condition and any of the strategies (all ps >.05).
Conclusions:
This demonstrates that cry tolerance can be increased using emotion regulation strategies, such as distraction via music or gaming, and reappraisal. This has clinical implications for families implementing behavioural sleep interventions.
... D'autres recherches décrivent les attitudes des parents par rapport aux méthodes de type extinction (e.g., Etherton et al. 2016). En effet, elles ont rapporté d'importants taux d'abandon lorsque les parents participant à une recherche ont été attribués au groupe de l'extinction (e.g., Rickert et Johnson, 1998;Tse et Hall, 2008). Par exemple, 10% de l'échantillon de Tse et Hall (2008) a quitté l'étude pour des préoccupations éthiques vis-à-vis de la méthode de l'extinction. ...
... En effet, elles ont rapporté d'importants taux d'abandon lorsque les parents participant à une recherche ont été attribués au groupe de l'extinction (e.g., Rickert et Johnson, 1998;Tse et Hall, 2008). Par exemple, 10% de l'échantillon de Tse et Hall (2008) a quitté l'étude pour des préoccupations éthiques vis-à-vis de la méthode de l'extinction. Il aurait été intéressant d'investiguer davantage ces préoccupations pour mieux comprendre les raisons des abandons. ...
Il est bien établi dans la littérature que les troubles du sommeil
chez l’enfant ont des répercussions sur son fonctionnement
actuel, sur d’autres sphères développementales ainsi que sur le
contexte familial (Byars et Simon, 2016 ; Sadeh, 2005; Stores,
2014). Il est donc crucial de disposer de traitements appropriés
afin d’améliorer le sommeil des enfants. Cette revue de littérature
vise à évaluer plusieurs types d’intervention comportementale du
sommeil en fonction de leurs efficacités et leurs limites. Il ressort
de la littérature des limites méthodologiques (type de mesure et
manque de suivi) et l’absence de consensus sur l’âge
d’application de ces interventions. En revanche, il existe
différents types d’intervention comportementale du sommeil et
elles n’ont pas toutes reçu le même soutien empirique. Par
conséquent, cet article fournit un guide de lecture critique en
soulignant les divergences entre les études concernant les
bénéfices des interventions comportementales du sommeil (sur
le comportement et l’humeur de l’enfant, et le fonctionnement
familial). Nous portons une attention particulière aux méthodes
de type extinction car des études ont rapporté des bénéfices à
utiliser ce type d’interventions (Mindell, Kuhn, Lewin, Meltzer
et Sadeh, 2006; Rickert et Johnson, 1988) alors que d’autres les
remettent en question sur les plans éthique, moral, et social
(Blunden, Thompson et Dawson, 2011; Etherton et al., 2016).
... Night waking is considered problematic and is the most persistent of the sleep issues. It is a problem in multiple countries at a rate of about between 15-30% (Owens & Witmans, 2004: Tse & Hall, 2007. Frequent night waking is described as waking more than 2 times a night, more than 2 times a week, or being awake more than 20 minutes for more than 4 times a week. ...
... Parental education is a cost effective and simple intervention that works. Tse and Hall (2007) asserted that one hour teaching sessions with the parents were helpful. They also advocated controlled comforting up to 10 minutes by parents. ...
Sleep is a basic biological need and toddler sleep problems can be a major challenge to parents. Child behavioral sleep problems during infancy and early childhood are a significant and common parental concern with about a third of toddlers affected. The purpose of the study was to examine the characteristics of toddlers with and without behavioral sleep problems. A mixed method research design with comparative and descriptive content analysis methods were used. 268 participants were recruited. ^ There were no statistically significant differences between the sleep problem and no sleep problem groups for parental or toddler demographic characteristics. There were 19 statistically significant findings including how long it took to put the toddler to bed p<.001, difficult to bed p<.001, total nights difficult to sleep <.001, ratings of sleep <.001, bedtime routine the same P<.001, total nap time p=.009 and how long the children slept at night p<.001. Sleep hygiene significant findings included, massaging the child p=.048, having a drink p=.003, breastfeeding a child to sleep p=.011, holding their child to sleep p<.001. Sleep hygiene after night waking included, minutes awake after a night waking p<.001, picking them up and putting them down awake p=.005, breastfeeding back to sleep<.001 and holding them p<.001. Sleep environment significant findings were being brought into the parents bed after a night waking p=.007, falling asleep in their own bed p<.001 or with a parent present p<.001, if the parent was in the room p<.001 or sleeping alone p<.007. ^ For the content analysis there are eight recurring level three themes; three recurring level two themes, and these were distilled to one overarching theme, which was chaos is my life, the entire quality of life is affected. The theoretical model used was supported in all areas. The bi-directional and fluid influences of the relationship between the child and the parents and back again were supported. The child needs help, the parents respond in a cycle that goes back and forth perhaps several times a night. Sleep problems in toddlers are complex, multidimensional and tied into the emotional and psychosocial fabric of the individuals, parents and family. They can cause serious stress, worry and be long standing, pervasive and there is a potential for child abuse.
... Parents in that study reported that participating in a group teaching session with other parents whose children had sleep problems 'normalized' what they were experiencing and helped them regard their children's sleep problems as common and amenable to change. Being part of the group and receiving telephone support calls increased their confidence to manage infant sleep [16]. ...
... The availability of public health nurses trained in behavioral sleep interventions creates potential for nurses to offer interventions through contact with families attending group postnatal drop-ins. Not only can situating a short-term group intervention in public health units overcome barriers to families receiving help for common infant BSPs [49,50] but also being exposed to other families experiencing an infant BSP decreases families' sense of isolation and helps them regard their infants' problems as common and amenable to change [16]. Contacting families by telephone for follow-up could be factored into public health nurses' daily workload. ...
... Parents in that study reported that participating in a group teaching session with other parents whose children had sleep problems 'normalized' what they were experiencing and helped them regard their children's sleep problems as common and amenable to change. Being part of the group and receiving telephone support calls increased their confidence to manage infant sleep [16]. ...
... The availability of public health nurses trained in behavioral sleep interventions creates potential for nurses to offer interventions through contact with families attending group postnatal drop-ins. Not only can situating a short-term group intervention in public health units overcome barriers to families receiving help for common infant BSPs [49,50] but also being exposed to other families experiencing an infant BSP decreases families' sense of isolation and helps them regard their infants' problems as common and amenable to change [16]. Contacting families by telephone for follow-up could be factored into public health nurses' daily workload. ...
Background:
Infant behavioral sleep problems are common, with potential negative consequences. We conducted a randomized controlled trial to assess effects of a sleep intervention comprising a two-hour group teaching session and four support calls over 2 weeks. Our primary outcomes were reduced numbers of nightly wakes or parent report of sleep problem severity. Secondary outcomes included improvement in parental depression, fatigue, sleep, and parent cognitions about infant sleep.
Methods:
Two hundred thirty five families of six-to-eight month-old infants were randomly allocated to intervention (n = 117) or to control teaching sessions (n = 118) where parents received instruction on infant safety. Outcome measures were observed at baseline and at 6 weeks post intervention. Nightly observation was based on actigraphy and sleep diaries over six days. Secondary outcomes were derived from the Multidimensional Assessment of Fatigue Scale, Center for Epidemiologic Studies Depression Measure, Pittsburgh Sleep Quality Index, and Maternal (parental) Cognitions about Infant Sleep Questionnaire.
Results:
One hundred eight intervention and 107 control families provided six-week follow-up information with complete actigraphy data for 96 in each group: 96.9 % of intervention and 97.9 % of control infants had an average of 2 or more nightly wakes, a risk difference of -0.2 % (95 % CI: -1.32, 0.91). 4 % of intervention and 14 % of control infants had parent-assessed severe sleep problems: relative risk 0.3, a risk difference of -10 % (CI: 0.11, 0.84-16.8 to -2.2). Relative to controls, intervention parents reported improved baseline-adjusted parental depression (CI: -3.7 to -0.4), fatigue (CI: -5.74 to -1.68), sleep quality (CI: -1.5 to -0.2), and sleep cognitions: doubts (CI: -2.0 to -0.6), feeding (CI: - 2.1 to - 0.7), anger (CI: - 1.8 to - 0.4) and setting limits (CI: -3.5 to -1.5).
Conclusions:
The intervention improved caregivers' assessments of infant sleep problem severity and parental depression, fatigue, sleep, and sleep cognitions compared with controls.
Trial registration:
ISRCTN42169337 , NCT00877162.
... Mothers' higher scores on negative parenting (hostile, punitive and aversive interactions) were associated with more sleep problems for Canadian preschool children (Reid et al. 2009). Other study findings have suggested that infant night waking and settling difficulties decrease British mothers' feelings of competence (Morrell 1999) and undermine Canadian parents' confidence (Tse & Hall 2008). Simard et al. (2008) found that, rather than maternal self-efficacy predicting children's total sleep time, Canadian mothers' active involvement in physically comforting children at settling and difficulty setting limits mediated the relationship between previous and ongoing night waking. ...
... Our findings suggest that wakes of <20 minutes or 20 minutes or more in duration could be coercive in terms of mothers' parenting self-efficacy and mothers' and fathers' sense of parenting impact when their children are 29 months of age, with scores lowest in the longest wake duration group. Our finding that mothers reported significantly decreased self-efficacy scores across all time points when they had children in the groups with wakes of <20 minutes and with wakes of 20 minutes or more supports Morrell's (1999) claims that children's sleep problems decrease British mothers' feelings of competence and claims by Tse and Hall (2008) that children's sleep problems undermine Canadian parents' confidence. ...
To explore associations between children's sleep problems, and behavioural difficulties and parenting approaches.
Children commonly have problematic night waking; however, relationships between parenting cognitions and behaviours and children's sleep problems are rarely examined.
Longitudinal children's cohort study from 5-29 months post birth.
Data were taken from the Quebec Longitudinal Study of Child Development (1998-2007) at three phases: 5, 17 and 29 months of age. Thousand four hundred and eighty-seven families were included in our study based on: participation from phase 1 (5-months old), both parents' reports on parenting cognitions/behaviours and child behavioural difficulties at 29 months, and mothers' reports of children's sleep at 29 months. In 2013, we conducted repeated measures anovas and manovas including children's gender.
Extended night-time waking patterns (wakes of ≥20 minutes) were associated with mothers' and fathers' lower sense of parenting impact and higher overprotectiveness and mothers' lower self-efficacy and higher coerciveness for 29-month-old children. In the extended waking group, mothers consistently reported lower self-efficacy, higher overprotectiveness and lower parenting impact at 5, 17 and 29 months. For those children, fathers were only more overprotective at 5 and 29 months. Regarding 29-month-old children's behaviour, children in the extended night waking group had highest scores on externalizing and internalizing behaviours. Girls had higher scores on shyness/inhibition and boys had higher scores on aggression/hyperactivity.
Mothers' and fathers' parenting cognitions and behaviours are affected by 29-month-old children's night waking patterns and night waking patterns are associated with children's behavioural problems.
© 2015 John Wiley & Sons Ltd.
... Few qualitative studies have explored in depth the individual needs of postpartum women in achieving health behavior goals for themselves and their infants. A limited number have focused on women's perceived barriers and facilitators to exercise and healthy eating [20][21][22][23] and sleep [24,25]. Other qualitative studies have examined factors affecting breastfeeding decisions [26][27][28][29][30][31] and mothers' perceptions of clinician counseling regarding breastfeeding [32,33], but there is a paucity of studies that examine mothers' perceptions of other maternal and infant health behavior recommendations during this life period. ...
... Mothers were receptive to infant sleep and television viewing recommendations, but expressed resistance to following them. Avoiding the methods that seemed easiest to help an infant get to sleep in the short term but may create longer-term sleep problems was a challenge also reported in a 2007 study of parent perceptions of an infant sleep intervention [25]. Other studies of physical activity for postpartum women have produced findings consistent with ours [20,22,[39][40][41], showing lack of time, motivation, and childcare as barriers to physical activity. ...
Our objective was to examine mothers' perspectives of obesity-related health behavior recommendations for themselves and their 0-6 month old infants. A health educator conducted 4 motivational counseling calls with 60 mothers of infants during the first 6 months postpartum. Calls addressed 5 behaviors for infants (breastfeeding, introduction of solid foods, sleep, TV, hunger cues), and 4 for mothers (eating, physical activity, sleep, TV). We recorded detailed notes from each call, capturing responsiveness to recommendations and barriers to change. Two independent coders analyzed the notes to identify themes. Mothers in our study were more interested in focusing on their infants' health behaviors than on their own. While most were receptive to eliminating their infants' TV exposure, they resisted limiting TV for themselves. There was some resistance to following infant feeding guidelines, and contrary to advice to avoid nursing or rocking babies to sleep, mothers commonly relied on these techniques. Return to work emerged as a barrier to breastfeeding, yet facilitated healthier eating, increased activity, and reduced TV time for mothers. The early postpartum period is a challenging time for mothers to focus on their own health behaviors, but returning to work appears to offer an opportunity for positive changes in this regard. To improve weight-related infant behaviors, interventions should consider mothers' perceptions of nutrition and physical activity recommendations and barriers to adherence.
... In the UK, for most common CSPs, first-line treatments recommended by HCPs would be based (Meltzer & Mindell, 2014;Mindell et al., 2006). However, not all parents may want or be capable of successfully implementing these types of sleep interventions (Blunden et al., 2011;Cook et al., 2020;Tse & Hall, 2008). Yet, it is uncertain what aspects of the sources themselves encourage or discourage parents from using certain resources for child sleep. ...
Child sleep is a common parental concern and there is an array of resources available to parents. However, an exploration of UK parents' help-seeking behaviours around child sleep is lacking. This study sought to identify the resources parents use to seek information and help for child sleep, as well as to explore what factors parents prefer about certain sources and their reservations about using other resources. Parents of 6-36 month old children residing in the United Kingdom (UK) completed an online questionnaire between October 2015 and October 2016 about their use, opinions and experiences regarding resources for child sleep. Quantitative data were descriptively analysed and thematic analysis was conducted on parents' open-ended text responses. Participants were 266 UK parents (97% mothers). Parents' ages ranged from 21 to 45 years (M = 33.49 years, SD = 4.71) and all resided in the United Kingdom (UK). General Internet searches were the most commonly reported source used by 47% of parents with a range of other informal resources also frequently consulted. Health Visitors (HVs) were the most accessed healthcare professional reportedly consulted by 38% of parents. Seven themes represented parental preferences for their resource use. Most strongly endorsed included a desire for information from other parents, particularly those with practical experience and accessing information that aligned with their parenting values. Parents preferred sources that provided support and reassurance, as well as those that afforded parents the ability to select relevant elements from a range of information. Seven themes represented parents' reservations about resources. Most strongly endorsed were concerns about reliability, being judged and challenges associated with filtering vast amounts of information. Parents reported having reservations towards sources if they had a previous negative experience with the source. Possible implications of the findings and specific suggestions about how existing and future resources could be adapted to better meet parents' needs are highlighted.
... For several years, many parents have demonstrated reticence in undertaking extinction techniques (Etherton et al. 2016;Tse and Hall 2008) finding extinction methods unpalatable and too stressful, preferring to respond to their infant. In Australia, (Blunden and Bails 2013;Hiscock 2010) and Canada (Loutzenhiser et al. 2014), parents reported emotional and stress-related reasons in their reluctance to employ controlled crying. ...
Methods to improve sleep in infants commonly involve some ignoring (extinction) but are often unpopular with mothers worried about infant distress when left to cry. Alternative more responsive methods are needed. This pilot study evaluated stress, maternal depressive symptomology and sleep in mother/infant dyads, between Responsive, Controlled Crying and Control groups. From 199 mother/infant dyads from any cultural background, 41 infants 4–12 months were randomly allocated to Responsive (RG, n = 15), Controlled Crying (CCG, n = 18) or Controls (Treatment as Usual, TAUG, n = 8), with 10 withdrawing after randomisation. Infant sleep (7-day sleep diaries) and stress (oral cortisol on two nights), maternal self-reported stress (Subjective Units of Distress, SUDS), maternal perceived infant distress (MPI-S) and symptoms of maternal depression (Edinburgh Post-natal Depression Scale, EPDS) were measured four times across 8 weeks. Sleep duration was not different between groups but Responsive woke less ( p = .008). There were no differences in cortisol between groups across time points. Maternal SUDS was positively correlated with infant cortisol and MPI-S ( p < 0.05) and mothers in the Responsive group were significantly less stressed ( p = 0.02) and reported less symptoms of depression ( p < 0.05) . Findings in this small sample show Responsive methods are comparable to the extinction (Controlled Crying) in sleep outcomes but from a relational and maternal mental health perspective, are less stressful, offering families potential choices of sleep interventions.
... 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.
... Apesar do sucesso do tratamento, Kuhn (2014) aponta para a aversividade da técnica de extinção, o que muitas vezes pode dificultar a adesão ao tratamento e levar a desistência deste. Estudos que utilizaram o procedimento de extinção apontam resistência por parte dos pais em aplicar o método, desistência do tratamento, desgaste e dificuldades (Tse & Hall, 2008;Seymour, Bayfield, & Brock, 1983). Uma recente revisão realizada por Etherton, Blunden, & Hauck (2016) apontou que entre as razões pelas quais os cuidadores encontram dificuldades em aplicar o método de extinção, destaca-se o choro persistente; o medo de repercussões negativas; considerações práticas, tais como, o barulho perturbar o sono de vizinhos e moradores da casa; desinformação; incongruência com crenças pessoais por parte dos pais; diferentes práticas culturais e o bem estar parental. ...
Studies indicate the effectiveness of the extinction technique for the management of sleep problems in childhood. However, the literature points to the aversivity of the technique, which can often hamper adherence to treatment and lead to withdrawal. The objective of this study was to investigate the number of mothers who presented difficulties in applying guidelines for the management of childhood insomnia and to investigate the relationship between the difficulties of applying the intervention with characteristics and behaviors of the child and the mother. The participants were 49 mothers of children from one to five years of age who underwent parental guidance for the management of child sleep problems. The results showed that 53.1% (n = 26) of the mothers reported difficulty in applying the extinguishing procedure and that the children whose mothers had such difficulty had worse scores on internalizing problems and total behavioral problems evaluated by CBCL
... Apesar do sucesso do tratamento, Kuhn (2014) aponta para a aversividade da técnica de extinção, o que muitas vezes pode dificultar a adesão ao tratamento e levar a desistência deste. Estudos que utilizaram o procedimento de extinção apontam resistência por parte dos pais em aplicar o método, desistência do tratamento, desgaste e dificuldades (Tse & Hall, 2008;Seymour, Bayfield, & Brock, 1983). Uma recente revisão realizada por Etherton, Blunden, & Hauck (2016) apontou que entre as razões pelas quais os cuidadores encontram dificuldades em aplicar o método de extinção, destaca-se o choro persistente; o medo de repercussões negativas; considerações práticas, tais como, o barulho perturbar o sono de vizinhos e moradores da casa; desinformação; incongruência com crenças pessoais por parte dos pais; diferentes práticas culturais e o bem estar parental. ...
Os colaboradores de uma organização são peças fundamentais para o seu funcionamento. Portanto, para que esta atue em condições ótimas, tais peças devem estar funcionando em condições ideais, fazendo com o que a sua produtividade atinja os índices desejados e promova a manutenção do bem-estar psicológico e social deste trabalhador. Com isso, desde os anos 90, estudos tem valorizado a avaliação do suporte organizacional na relação organização-empregados, gerando instrumentos capazes de avaliar a percepção do trabalhador, do que a empresa valoriza mais. O objetivo principal deste estudo é verificar a consistência dos indicadores psicométricos da Escala de Percepção de Suporte Organizacional (EPSO). Participaram do estudo 310 homens e mulheres, de organizações públicas e privadas e acima de 18 anos; estes responderam a EPSO e dados sociodemográficos. Os resultados revelaram indicadores estatísticos muito próximos aos encontrados em estudos anteriores e, além disso, na análise de convergência, observou-se uma relação positiva do suporte com o engajamento. Não apenas a escala de suporte continua consistente em amostra com distintos trabalhadores, podendo ser utilizada quanto avaliação ou diagnóstico organizacional, mas que também poderá contribuir na área de RH quando se pretender intervir na qualidade da produtividade e saúde laboral
... Yet, in a Canadian community-based survey, less than half of parents reported they were able to successfully manage their infant's sleep disturbances using behavioral-based sleep strategies (16). Furthermore, parents may experience reservations and practical challenges when applying behavioral-based approaches (17,18). Moreover, despite evidence that higher father engagement may mitigate maternal stress associated with infant sleep disturbances (19) and reduce infant night wakings (20), including fathers in infant sleep intervention research is limited. ...
Background
One in four Canadian families struggle with infant sleep disturbances. The aim of this study is to evaluate Play2Sleep in families of infants with sleep disturbances. In addition to parental education on infant sleep, Play2Sleep uses examples from a video-recorded, structured play session with mothers and fathers separately to provide feedback on parent–infant interactions and their infant’s sleep-related social cues. The quantitative phase will answer the research question: Does one dose of Play2Sleep delivered during a home visit with mothers and fathers of infants aged 5 months reduce night wakings at age 7 months? The qualitative phase will answer the research question: What are parental perceptions of family experiences, processes, and contexts related to Play2Sleep and infant sleep? The overarching mixed methods research question is as follows: How do parental perceptions of family experiences, processes, and contexts related to infant sleep explain the effectiveness of Play2Sleep?
Method and analysis
An explanatory sequential mixed methods design will be used. In the quantitative phase, a randomized controlled trial and RM-ANOVA will compare night wakings in infants whose parents receive Play2Sleep versus standard public health nursing information. Sixty English-speaking families (mothers and fathers) of full-term, healthy, singleton, 5-month-old infants who perceive that their infant has sleep disturbances will be recruited. The primary outcome measure will be change in the number of night wakings reported by parents. The qualitative component will use thematic analysis of family interviews to describe parental perceptions and experiences of infant sleep. Mixed methods integration will use qualitative findings to explain quantitative results.
Discussion
Play2Sleep is a novel approach that combines information about infant sleep with personalized feedback on parent–infant interactions and infant cues. Including fathers and mixed methods should capture complex family experiences of infant sleep disturbances and Play2Sleep. If effective, Play2Sleep has possible application for preventing infant sleep disturbance and tailoring for other populations.
Clinical Trial Registration
www.ClinicalTrials.gov, identifier: NCT02742155. Registered on 2016 April 23.
... These were classed, grouped into sub-categories, and then later into categories and themes. Several corrections of the verbatim were required in order to obtain a relevant and homogeneous coding, by means of an inductive approach through a thematic content analysis (29)(30)(31)(32). All the ideas of the focus groups were analyzed in order to construct a controlled analysis grid with the highest possible degree of reproducibility. ...
Home is generally perceived as a safety place, whereas the concentration of pollutants, influenced not only by external pollution but also by human activities, the presence of domestic animals, construction and furniture materials, are sometimes greater than outside.
The aim of this study is to determine the general practitioners' (GPs) views on indoor environmental health risks in the perinatal period.
Four semi-structured focus group with 31 GPs were conducted in two French departments in November 2009, February, March, and April 2010. The focus group meetings were analyzed using a general thematic analysis.
Perinatal care is a special health issue and a time of privileged sensitization. The attitude of health risks are well known in the case of "traditionally" toxic substances. In the case of "emerging" environmental exposure, these attitudes depend on the knowledge, beliefs, and experience specific to each practitioner. GPs are acquiring a new role in the field of environmental health, while at the same time coming to grips with its own strengths and limitations. The implementation of prevention depends on factors, which are not only specific to the practitioner but also related to the parents and the organization of the medical practice.
The sensitization of GPs to environmental medicine, promotion of eco-citizen education, development of research, and the distribution of information are some of the means which need to be implemented to prevent harmful exposure of the infant.
... Research on sleep is becoming increasingly relevant, since sleep disorders in children are more and more frequent (Tse & Hall, 2007). ...
Introduction: Research on sleep is becoming increasingly relevant, especially since sleep disorders in children are more and more frequent (Tse & Hall, 2007). For some authors, the hectic life conditions in highly urbanized societies explain sleep problems in children. Considering sleep as a good strategy for monitoring children’s psychological development, a global comprehensive understanding (LeVine, 1974) is required in order to better comprehend sleep, its manifestations, as well as the parenting styles related to it.
Objectives: This study explores parenting in relation to children’s sleep in Quebec, Canada. It aims to improve understanding of the socio-cultural aspects of parents’ perceptions and interventions in the sleep arrangements of their children in a French-Canadian society.
Methods:
A structured interview divided into four main themes (place of sleep; night feeding; sleep routines; and difficulties associated with sleep) was used. Collaborating parents were primarily middle-class and of Quebec origin only, with no immigrants in the family for the past three generations. Ninety-five interviews were analyzed quantitatively (SPSS) and qualitatively (Merleau-Ponty’s phenomenology method) concerning the reading of the parents’ interventions in their children’s sleep world.
Results: Most of the Quebec children slept in their parents’ room until 5 months of age. After that, they began to sleep in their own room for the parents’ comfort and the children’s autonomy. Night feeding was mainly breast and bottle feeding. Most of the parents did not leave the bottle in their children’s cribs.Bedtime was guided by a well-established routine, conducted by both parents, usually with an equitable sharing of tasks and a fixed time to go to sleep. The majority of Quebec children had a transitional object and did not present difficulties associated with sleep. The Quebec parents, in general, accepted and/or sought parenting advice regarding the sleep of their children; however, they preferred to act according to their own intuition or their own childhood experiences.
Conclusion: The Quebec parenting style confirms the North-American individualist norms and values, focusing on children’s development of psychological autonomy and early individuation, in a balanced family environment. Concerning their children’s sleep, Quebec parents prefer to portray them-
selves as autodidactic, self-reliant and independent, adapting their parenting skills to their children’s needs.
... Qualitative studies are particularly well suited to exploring bodily and social experiences such as RLS, although currently they have only been used in research on sleep disturbances (Broström et al., 2010;Fleming et al., 2009;Hsu et al., 2009;Moseley and Gradisar, 2009;Tse and Hall, 2007). We must stress that we do not make generalizations beyond the study group. ...
The aim of this study is to investigate psychosocial factors related to the diagnosis and treatment of patients with restless legs syndrome. Fifteen patients were interviewed at the Neuro-Sono Outpatient Clinic, Universidade Federal de São Paulo. The results were submitted to a qualitative analysis. We identified four content categories: illness description, illness history, illness experience, and relationships. Lack of control over the body and lack of recognition by professionals produce stigma and lead patients to suffering. The research underscores the relevance of psychosocial factors to the diagnosis and treatment of patients with restless legs syndrome and the importance of having interdisciplinary teams when attending patients with restless legs syndrome.
... Although the literature suggests scheduled waking, positive routines and extinction (having children cry it out) have strong empirical support for resolving sleep problems, extinction and scheduled waking have low parental compliance and positive bedtime routines are only considered a promising intervention (Owen et al. 2002, Mindell et al. 2006). Techniques are available to assist parents with infants exhibiting behavioural sleep problems; however, parents often lack confidence to consistently initiate sleep interventions (Tse & Hall 2007). Unsuccessful management of a sleep problem and attendant maternal depression and fatigue have the potential to undermine maternal competence and confidence (Armstrong et al. 1998a, Hiscock & Wake 2001, Lam et al. 2003). ...
The study aim was to compare changes in maternal confidence, competence, depression, anxiety and settling behaviours and children's sleep and settling behaviours for mothers and infants (4-6 months of age) attending a Day Stay intervention at an early parenting centre in Western Australia and a community group.
Infant difficulties in getting to sleep and frequent night waking are concerns for parents. Techniques are available to assist parents with infants exhibiting behavioural sleep problems; however, parents often lack confidence to consistently initiate sleep interventions.
The study incorporated a prospective non-equivalent before-after design.
The conceptual framework guiding this intervention emphasised the development of parental confidence and competence through connection with practitioners to promote change. Both groups provided baseline data (time 1) and four weeks postbaseline (time 2). Recruitment occurred between July 2007-July 2009.
The Ngala group (n = 93) and community group (n = 85) were not equivalent for infant age and maternal parity; there were more multiparous mothers in the community group, with infants on average one week older. The Ngala group, the majority of which were primiparous women, had significantly higher levels of competence and confidence four weeks following their Day Stay visit. There were no significant differences between groups at time 2 for time to settle the infant at night, infant night waking and maternal depression and anxiety scores.
Although both groups demonstrated an improvement in depression and anxiety scores, with decreased sleep and settling concerns, the results indicate parental inconsistency in settling approaches. Given links between inconsistent infant settling approaches and infants' difficulty with sleep self-initiation, further exploration is warranted.
The conceptual framework guiding the Ngala practitioners was effective in developing confidence and competence for the sample.
... Qualitative methods are increasingly accepted in health research and health-related sciences (Giacomini and Cook, 2000; Mays and Pope, 2000). Qualitative methods in sleep medicine have been applied in the nursing field (Crew, 2006; Dickerson and Kennedy, 2006; Hsu et al., 2009; Johansson et al., 2007; Lee et al., 2007), pediatrics (Kennedy et al., 2007; Tse and Hall, 2008) and social sciences (Henry et al., 2008). One study applied focus group methodology to explore the lived experience of insomnia , and found evidence on the importance of relationships with significant others and health professionals (Carey et al., 2005). ...
We conducted a qualitative, multicenter study using a focus group design to explore the lived experiences of persons with any kind of primary sleep disorder with regard to functioning and contextual factors using six open-ended questions related to the International Classification of Functioning, Disability and Health (ICF) components. We classified the results using the ICF as a frame of reference. We identified the meaningful concepts within the transcribed data and then linked them to ICF categories according to established linking rules. The six focus groups with 27 participants yielded a total of 6986 relevant concepts, which were linked to a total of 168 different second-level ICF categories. From the patient perspective, the ICF components: (1) Body Functions; (2) Activities & Participation; and (3) Environmental Factors were equally represented; while (4) Body Structures appeared poignantly less frequently. Out of the total number of concepts, 1843 concepts (26%) were assigned to the ICF component Personal Factors, which is not yet classified but could indicate important aspects of resource management and strategy development of those who have a sleep disorder. Therefore, treatment of patients with sleep disorders must not be limited to anatomical and (patho-)physiological changes, but should also consider a more comprehensive view that includes patient's demands, strategies and resources in daily life and the contextual circumstances surrounding the individual.
... Although the cognitive part has received less attention in the literature, recent studies have demonstrated significant links between parental sleep-related cognitions and infant sleep patterns implying that these cognitions may explain parental behavioral patterns and involvement during the night. These studies highlight the importance of addressing parental cognition in clinical interventions [56,[61][62][63][64][65]. ...
Behavioral insomnia is a very common problem throughout childhood. It has negative impact on children and their families and can persist for many years if not treated. Interventions based on cognitive-behavioral therapy (CBT) principles have mainly focused on withdrawing excessive parental bedtime involvement and helping children develop self-soothing strategies for falling asleep and resuming sleep during the night. With young children, these interventions are mostly based on training and modifying parental behaviors. Changing parental sleep-related expectations, beliefs and perceptions is an important component in these interventions. With older children and adolescents, more versatile interventions exist and they include additional components of CBT including relaxation and stress reduction techniques, modifying cognitive processes related to worrying and anxiety, positive imagery training and others. Extensive research has established the efficacy of behavioral interventions in early childhood. However, research on interventions for older children has been very limited and has failed to provide sufficient information on the efficacy of specific CBT techniques for childhood insomnia.
... There is a huge misunderstanding about the benefits of chiropractors in whole body healing.' (22 October 2004). Even when responding about infant sleep problems, which other parents indicated can be competitive ( Tse & Hall 2008), the women were supportive: 'Last night [baby name] was up at 2 am for over 2 hours screaming. It is just really nice to know that I am not alone. ...
This paper is a report of a study to explain how mothers used a community based, cohort-based electronic communication system.
Early psychosocial support for families is regarded as inadequate. Employed women with young children can feel isolated from other families. Most parent e-mail lists are in a read-only format, with parents receiving informative e-mails from a corporation or a commercially motivated initiative. In an increasingly virtual age, it is important to examine parents' use of online support groups initiated by parents.
We used a qualitative descriptive design to conduct an inductive content analysis of archived threads of e-mail from 40 middle class Canadian mothers involved in a grass-roots online support cohort that shared birth year and geographical community. Two hundred and ninety-two pages of single-spaced mother-based communication that occurred from June 2004 to May 2005 were analysed.
Mothers used cohort-based electronic communication to build a local community, request and provide emotional support, share information and facilitate learning, and provide validation for the 'normalcy' of other women's mothering experiences. They shared stories and feelings, expressed sympathy, offered accolades, expressed appreciation for shared experiences, conveyed gratitude for support, and shared beliefs and expectations. Mothers anticipated childrearing difficulties shared strategies, exchanged advice, confirmed others' strategies and shared information.
Women in particular geographical areas can use asynchronous mail systems to share information with and obtain support from other mothers. Cohort-based electronic communication could be particularly important in rural areas where travel is restricted for women and access to professional support is limited.
Background
Parent engagement in child-focused interventions is increasingly recognised as an important aspect of effective intervention delivery. While several fields have an emerging literature around parent engagement, no reviews currently exist which combine findings across allied health literatures.
Objective
This review aimed to explore factors relevant to understanding parent engagement in child-focused interventions, as described in qualitative literature across allied health disciplines, toward informing the clinical practice of helping professionals in effectively engaging parents.
Methods
A systematised qualitative literature review was carried out, with a comprehensive search of five online databases (CINAHL, Embase, MEDLINE, PsycINFO, Scopus) for allied health literature (specifically: behaviour analysis, occupational therapy, psychology, and speech-language therapy) using parent engagement key words. Reference searching and citation tracking steps supported the search. Thematic synthesis was used as the overarching framework and analysis approach.
Results
8824 unique studies were generated in the search. Of the 71 studies which met inclusion criteria, 38 reported qualitative findings and were included in the analysis. Five themes were identified including: societal context, interpersonal context, clinician features, family features, and relationship as engagement.
Conclusions
Findings support conceptual explanations of parent engagement as a complex and dynamic process, emphasising the joint contributions of parents and clinicians in developing therapeutic relationships which promote engagement. Across allied health research there are consistency of understandings around parent engagement, supporting the conclusion that clinicians can look to literatures from various helping fields to inform clinical practice around engaging parents in interventions.
Study objectives:
This study evaluated the effect on infant sleep of a novel intervention (Play2Sleep) that combined infant sleep information with self-modeled video feedback on parent-infant interactions.
Methods:
An explanatory sequential mixed methods design consisting of a randomized controlled trial with 63 mother-father-infant triads randomized to Play2Sleep or comparison home visit interventions was used. We used RM-ANCOVA to detect changes in infant night wakings, nocturnal wakefulness, and sleep durations and Wilcoxon signed rank test to evaluate changes in perception of infant sleep problems. Family interviews (n = 20) were used to explain the quantitative findings and analyzed qualitatively using thematic analysis.
Results:
Play2Sleep was effective in reducing maternal-reported infant wakefulness, F(1, 55) = 5.33, p = .03, partial η2 = .09, and the number of paternal-reported naps, F(1, 58) = 4.90, p = .03, partial η2 = .08. Parents in the Play2Sleep group reported significant improvements in problematic infant sleep that were not observed in the comparison group, however Play2Sleep was not effective in reducing the number of parent-reported night wakings. Information overwhelm, learning infant cues, and working together with a subtheme of father involvement were key qualitative themes developed to explain the quantitative results. Unplanned exploratory analyses revealed a significant improvement in maternal depression symptoms in the Play2Sleep group.
Conclusions:
This study suggests Play2Sleep could improve infant sleep by promoting parental awareness of infant cues and father involvement and improving maternal depression. Additional research is needed to determine the optimal number and timing of sessions.
Clinical trial registration:
Registry: ClinicalTrials.gov; Identifier: NCT02742155.
Aims and objectives:
To explore the perceptions and experiences of parental professional help-seeking for infant sleep and sleep-related concerns.
Background:
Infant sleep is a frequent concern for parents. However, very little is known about the reasons parents seek, do not seek or delay seeking professional attention about their concerns related to infant sleep.
Design and methods:
A qualitative study design was used. Twenty audio-taped interviews with parents of healthy 12-month-old infants were conducted at a university-affiliated hospital or parents' homes depending on where parents felt more comfortable discussing their personal views and medical help-seeking experiences. Thematic content analysis was performed to determine specific patterns and similarities within and between interview data.
Findings:
Three main themes developed from the interviews were as follows: (i) uncertainty about infant sleep; (ii) I can handle infant sleep; and (iii) I am not satisfied with the professional services provided for infant sleep. Overall, parents knew little about or misunderstood infant sleep behaviours. Lack of proper information and knowledge about infant sleep influenced parents' motivation for professional help-seeking and help-receiving. Parents who have consulted a healthcare professional but received unsatisfactory responses, such as an ambivalent attitude or insufficient assessment, reported being less motivated or unwilling to seek medical help again.
Conclusion:
Our study demonstrates the complexity of parental professional help-seeking and receiving for infant sleep. Findings suggest that parents perceive a wide range of barriers that influence the likelihood that they will seek professional advice for infant sleep.
Relevance to clinical practice:
Reducing knowledge barriers and providing adequate attention at all well-infant visits would facilitate parental use of healthcare services to manage problematic infant sleep behaviours.
Parents commonly raise concerns about their children’s sleep. Childhood sleep problems cause negative short- and long-term outcomes. Parents also suffer when their children’s sleep problems disrupt, shorten, or otherwise fragment their sleep. Sleep problems can be medical, psychological, and behavioral in nature, and are further affected by cultural, social, and familial norms. As such, they are highly subjective; sleep behaviors that present a problem in one household—such as co-sleeping—are the accepted practice in another. Children outgrow some sleep problems, but not all. Parents and primary care physicians must differentiate between problems that will remit without intervention and those requiring attention. Parents experience disruptive bedtime routines as draining nightly struggles to put children to sleep are a considerable source of stress and lead to delayed sleep onset. Parents strive to ensure their children attain sufficient sleep despite the lack of a research-driven consensus on the amount of sleep children require. In this chapter, we offer the most recent evidence for physician’s information regarding the negative effects associated with a sleep-deprived child, the use of antihistamines or other medications to promote sleep, and the controversy surrounding efficacious, evidence-based behavioral interventions for promoting sleep in children (i.e., sleep training, also called “cry-it-out”).
The aim of this qualitative study was to describe an intervention for parents at a nurse-led clinic for children age 6–24 months with sleeping problems. Data were gathered from 10 families. Intervention sessions were recorded. The nurse also wrote field notes and kept a reflection diary about the interventions. The data were coded in a search for categories of meaning and then grouped and raised to a higher level of abstraction to describe the intervention. Three themes were constructed. Theme 1: Sharing Stories, includes establishing a working relationship and learning about the family. Theme 2: Empowering, includes education and motivation. Theme 3: Guidance, includes environmental and behavioral intervention and review plans. Empowering was the strongest theme. Behavioral intervention had less emphasis than expected. Environmental intervention was surprisingly relevant. These results can be used to design a protocol for an experimental study and teaching materials for professionals who work with infant sleep problems.
Aim:
Sleep is important for underlying neural plasticity, and children with developmental disabilities suffer behavioural, emotional, cognitive, and sensory-motor issues that affect their wake and sleep states. Problematic sleeping can be hypothesized to have adverse effects on both of these areas in children with developmental disabilities. With this review, we aim to provide a benchmark in managing problematic sleeping in children with developmental disabilities.
Method:
A literature search was conducted and data on the study descriptives, patient characteristics, study design, study-related factors, criteria applied to operationalize sleep and developmental disability, and sleep 'management' were collected. Each management strategy was tabulated and analysed.
Results:
We identified 90 studies involving 1460 children with developmental disabilities, of whom 61.6% were male. The highest proportion of studies, almost half, were in children with syndromes (44.4%), followed by studies in children with intellectual disabilities (18.9%). Non-pharmacological sleep management was primarily aimed at improving sleep quality (86.7%), followed by sleep-wake schedules and, to a certain extent, sleep regularity (42.2%). About 56.7% of the studies reported more than one approach. Studies mostly focused on disorders of initiating and maintaining sleep through a diversity of strategies and relied heavily on subjective measures to identify and monitor problematic sleeping. Sleep management approaches were primarily delivered at the level of the individual in the home setting. The number of management approaches per study was unrelated to the number of sleep problems discussed.
Interpretation:
Modifying sleep management strategies to meet the specific needs of children with developmental disabilities is encouraged, and studies that look beyond sleep quality or sleep quantity are required. It is also advocated that modifications to sleep hygiene, sleep regularity, and sleep ecology in a population with developmental disabilities are rigorously investigated. Finally, daytime somnolence should not be overlooked when aiming to optimize sleep in children with developmental disabilities across the ages and stages of their lives. There were several limitations in the research findings of problematic sleep in children with developmental disabilities. In general, the sleep problems and the developmental disabilities investigated were multicomponent in nature. It is likely that management approaches impacted those problems on multiple levels or through diverse 'therapeutic' pathways. There is a need for randomized controlled trials and more objective measures that quantify improved sleep or wake states.
Objective: This study aimed to look at a community sample to determine parents’ use of graduated extinction and their perceptions of its effectiveness. Background: Infant sleep behaviours, particularly night-wakings, have been identified as one of the most common concerns of parents. The popularity of books and articles providing advice to parents to help their infants sleep through the night suggests that many parents are using graduated extinction to manage these night-waking behaviours. However, there is a paucity of research on parents’ use of sleep management strategies outside of clinical/research settings. Methods: In this internet-based study, we surveyed 411 Canadian parents regarding their use of graduated extinction with their 6–12-month-old infants. Results: Almost half of the parents surveyed reported using graduated extinction with their infants, and the majority of these parents began using it before their infants were 6 months old. Our results indicate that parents in the community are experiencing considerably less success with graduated extinction than parents in clinical/research setting, with almost half reporting no reduction in infant night-wakings. Significant predictors of success were parental cognitions regarding stress and support. Conclusion: Sleep clinicians, physicians, and parent educators should be aware that parents seeking their assistance are likely to have tried sleep management strategies on their own, and this may influence their confidence in future success as well as their willingness to commit to controlled crying in particular.
Research on children sleep received a growing interest since it has identified that sleep disorders in kids are becoming more frequent (Tse & Hall, 2007). Parenting styles concerning children’s sleep vary in and between cultures and are influenced by parents’ representations about the child’s general development (Stork, 2000). This study explores the sociocultural aspects of parents’ perceptions and interventions in the sleep arrangements of their children in Quebec/Canada. A structured interview divided into four main themes (place for sleeping/night feeding/sleep routines/difficulties associated with sleep) was used. Parents with children aged of two years old or younger from Quebec origin only with no immigration history in the family were included. One-hundred-ninety-seven parents, mainly from Quebec City area and the surrounding regions, were interviewed (79 responded as a couple). A frequency statistics analysis to unveil parents’ behavior patterns in organizing children sleep, and a content analysis based on the Merleau-Ponty's phenomenology method to find the meaning associated with these parents’ behavior patterns, were conducted. Eighty-six percent of children have been sleeping in their own bedroom from birth or have integrated it by the age of 6 months, regardless of socioeconomic status. Most parents accept and/or seek advice mainly from relatives regarding their children sleep. However, they say their final decision is guided by their "intuition" and children’s needs. Furthermore, they prefer to portray themselves as autodidactic, self-reliant, and independent. Quebec parenting organization regarding children’s sleep confirms a strong behavior trend in North-America, in which separating the child from the parents is a common practice (Morelli et al., 1992). Furthermore, it is consistent with the early individuation and the autonomy enhancement, which is characteristic of individualistic societies. This highlights the need Quebec parents feel for compliance with the cultural norm of the society in which they are born, live, and raise their children.
This doctoral project seeks to answer the question about the essence of functioning, disability and health in the lived experience of persons with any kind of primary sleep disorder. Its overall objective is the development of a first version of Core Sets of categories of the International Classification of Functioning, Disability and Health (ICF) in an evidence- and consensus-based process. To this end, four separate studies exploring different perspectives (researcher, clinical, patient, health professional) have been conducted and their results provided the evidence basis for selecting the relevant categories for the ICF Core Sets for Sleep Disorders during an international consensus conference. The doctoral thesis first-authored by the doctoral candidate therefore consists of five separate publications (1 Systematic Review, 2 Patient Studies, 1 Expert Survey, 1 Conference Results) that describe the different steps in the development process.
Qualitative research produces large amounts of textual data in the form of transcripts and observational fieldnotes. The systematic and rigorous preparation and analysis of these data is time consuming and labour intensive. Data analysis often takes place alongside data collection to allow questions to be refined and new avenues of inquiry to develop. Textual data are typically explored inductively using content analysis to generate categories and explanations; software packages can help with analysis but should not be viewed as short cuts to rigorous and systematic analysis. High quality analysis of qualitative data depends on the skill, vision, and integrity of the researcher; it should not be left to the novice.
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.
The aim of this study was to examine the associations between sleep and neurobehavioral functioning (NBF) in school-age children. These variables were assessed for 135 unreferred, healthy school children (69 boys and 66 girls), from second-, fourth-, and sixth-grade classes. Objective assessment methods were used on the participants in their regular home settings. Sleep was monitored using actigraphy for 5 consecutive nights; and NBF was assessed using a computerized neurobehavioral evaluation system, administered twice, at different times of the day. Significant correlations between sleep-quality measures and NBF measures were found, particularly in the younger age group. Children with fragmented sleep were characterized by lower performance on NBF measures, particularly those associated with more complex tasks such as a continuous performance test and a symbol-digit substitution test. These children also had higher rates of behavior problems as reported by their parents on the Child Behavior Checklist. These results highlight the association between sleep quality, NBF, and behavior regulation in child development; and raise important questions about the origins of these associations and their developmental and clinical significance.
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.
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.
The ontology of the transcript is both realist and constructed. There is a theory and ethic implicit in the transcription process. Transcripts are accurate and useful to the extent that the researcher understands their constructed reality, the need to be selective concerning what about the interview event must be preserved, the potential uses for transcripts that will influence the selection process, and the need for a consistent notation system.
The teaching of qualitative analysis in the social sciences is rarely undertaken in a structured way. This handbook is designed to remedy that and to present students and researchers with a systematic method for interpreting qualitative data', whether derived from interviews, field notes, or documentary materials. The special emphasis of the book is on how to develop theory through qualitative analysis. The reader is provided with the tools for doing qualitative analysis, such as codes, memos, memo sequences, theoretical sampling and comparative analysis, and diagrams, all of which are abundantly illustrated by actual examples drawn from the author's own varied qualitative research and research consultations, as well as from his research seminars. Many of the procedural discussions are concluded with rules of thumb that can usefully guide the researchers' analytic operations. The difficulties that beginners encounter when doing qualitative analysis and the kinds of persistent questions they raise are also discussed, as is the problem of how to integrate analyses. In addition, there is a chapter on the teaching of qualitative analysis and the giving of useful advice during research consultations, and there is a discussion of the preparation of material for publication. The book has been written not only for sociologists but for all researchers in the social sciences and in such fields as education, public health, nursing, and administration who employ qualitative methods in their work.
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.
give an overview of the origins, purposes, uses, and contributions of grounded theory methodology / grounded theory is a general methodology for developing theory that is grounded in data systematically gathered and analyzed (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Objective Sleep problems are common during infancy, and treatment programmes based on behavioural techniques have been reported to have high rates of short-term improvement (80–90%) when used with support from a therapist.
However, follow-up periods longer than 3 months are rare. The aim of this study was to describe the changes in sleep of 24 sleep-disturbed infants after an interventional sleep programme. Comparisons with a healthy control group were made for a follow-up period of 2.5 years.
Settings The case group was recruited from a parental questionnaire population study and sample of 2518 children aged between 6 and 18 months. The response rate was 83%. The group consisted of those 6–12-month-old children who fulfilled specific criteria for severe and chronic sleep problems (n = 27). A healthy control group was matched with regard to age and sex.
Methods The parents of the case group were offered a sleep programme based on the premise of controlled crying, and 24 families chose to participate. In addition to the behavioural technique, an interdisciplinary approach was used, taking the whole family situation into consideration. Sleep diaries and questionnaires were sent to cases and controls for follow-ups at 1 month, 1 year and 2.5 years, respectively, after admission.
Results One month after initiation of the treatment programme in the case group, significant changes had taken place. The average number of times the case babies
woke up had diminished from 6.0 to 1.8 times per night, and night-time sleep had
increased, on average by 67 minutes. A 92% rate of improvement was reported.
The changes were stable over time. Comparisons with the healthy controls after 1 year and after 2.5 years revealed no significant group differences in sleep characteristics. The families in the case group managed to maintain the achieved changes in infant sleep behaviour on their own; continuous therapist support was not necessary. This was true even for formerly depressed and psychosocially burdened parents.
Conclusions A combination of behavioural technique and interdisciplinary family work has positive and long-lasting effects in children with severe and chronic sleep problems.
Implication for practice Even severely sleep-disturbed infants coming from families with depression and psychosocial problems can be helped to sleep well with a relatively short but intense and multidisciplinary sleep programme.
To review the literature for empirically supported treatments for bedtime refusal and night wakings in young children.
An extensive review of the literature resulted in the inclusion of 41 studies that were evaluated according to the criteria established by the Task Force on Promotion and Dissemination of Psychological Procedures (1995).
Evidence exists indicating that extinction and parent education on the prevention of sleep problems can be considered well-established treatments. Furthermore, graduated extinction and scheduled awakenings are probably efficacious treatments, with positive routines a promising intervention.
A discussion of effectiveness, treatment feasibility, cost-effectiveness, and methodological limitations of the studies is provided. Recommendations for future directions for research in the treatment of these two common sleep disorders are presented.
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.
The ontology of the transcript is both realistic and constructed. There is a theory and ethic implicit in the transcription process. Transcripts are accurate and useful to the extent that the researcher understands their constructed reality, the need to be selective concerning what about the interview event must be preserved, the potential uses for transcripts that will influence the selection process, and the need for a consistent notation system.
To determine the range of sleep behaviour of normal children to age 38 months and to ascertain the level of parents' problems associated with their child's sleep behaviour.
A cross-sectional survey by questionnaire of parents presenting with their children for routine well-child checks at child health centres, mobile clinics, flying doctor clinics and home visits throughout Queensland. Of 3383 questionnaires distributed 3269 (96.5%) were returned.
1. Sleep frequency and duration, settling procedures, time taken to settle at night, age when child first slept through the night and number of night-time wakenings requiring parental intervention. 2. Parents' problems with their child's sleep behaviour.
There is a wide range of normal childhood sleep behaviour. Circadian rhythm is not well established until four months of age. Daytime sleep becomes less regular with increasing age. Frequent night-time wakening is common from four to 12 months. Night-time settling requires more parental input from 18 months. A large proportion of parents (28.6%) have a problem with their child's sleep behaviour.
Parents require information from health care providers about the wide range of normal childhood sleep patterns. This information can help prevent misdiagnosis, inappropriate medication use, child abuse and parental depression when children's sleep patterns are a problem.
Young children with sleep problems received either "standard" or graduated ignoring treatment. Both brief treatments were superior to a wait-list control condition and resulted in comparable improvements in bedtime and nighttime sleep problems. At bedtime, the treatments did not differ with respect to maternal compliance and stress. For nighttime wakings, mothers in the graduated ignoring group reported higher rates of compliance and less treatment-related stress. Maternal characteristics predicted treatment outcome in the standard ignoring condition. Following treatment, only positive side effects were observed. When compared to the wait-list group, mothers in the standard ignoring group reported less verbose discipline and decreased stress in parenting, while mothers in the graduated ignoring group reported improved parent-child relationships. Treatment gains were maintained over a 2-month follow-up period.
The aim of this study was to explore the prevalence of parentally experienced infant sleep problems, with special interest in severe problems, in a total community sample of 2518 infants aged 6-18 mo. Correlates to severe sleep problems were sought. The families were approached using a questionnaire and 83% responded. Data from the collection procedure point to a nonselective dropout. Sixteen percent of the parents reported their children as having moderate or severe difficulties in falling asleep at night (sleep refusal, bedtime struggles) and 30% reported frequent night waking. Almost all (93%) of the parents had sought help at the Child Health Centre (CHC), but only 48% were satisfied with the support and advice they got. Severe sleep problems as defined by the ICSD (International Classification of Sleep Disorders, 1990) were found in 129 of the children (6.2%), who were studied in detail, with the rest of the population as controls. Severe sleep problems were found to be correlated with parental worries and anxiety concerning infant health (although the children were reported as being as healthy as the controls), infant feeding problems and intensive parental interventional behaviour (especially feeding) during the evening and night. A common factor of insecurity in the parental role is suggested.
To estimate the financial cost to the NHS of infant crying and sleeping problems in the first 12 weeks of age and to assess the cost effectiveness of behavioural and educational interventions aimed at reducing infant crying and sleeping problems relative to usual services.
A cost burden analysis and cost effectiveness analysis were conducted using data from the Crying Or Sleeping Infants (COSI) Study, a three armed prospective randomised controlled trial that randomly allocated 610 mothers to a behavioural intervention (n = 205), an educational intervention (n = 202), or existing services (control, n = 203). Main outcome measures were annual total cost to the NHS of infant crying and sleeping problems in the first 12 weeks, and incremental cost per interruption free night gained for behavioural and educational interventions relative to control.
The annual total cost to the NHS of infant crying and sleeping problems in the first 12 weeks was 65 pound sterling million (US0.92). For the educational intervention relative to control they were 4.13 pound sterling (US$6.80).
The annual total cost to the NHS of infant crying and sleeping problems is substantial. In the cost effectiveness analysis, the behavioural intervention incurred a small additional cost and produced a small significant benefit at 11 and 12 weeks of age. The educational intervention incurred a small additional cost without producing a significant benefit.
Sleep problems are common in childhood. A distinction is made between problems in which polysomnography is abnormal (i.e., the parasomnias, sleep apnea and narcolepsy) and problems that are behavioral in origin and have normal polysomnography. The parasomnias--sleep terrors, somnambulism and enuresis--appear to be related to central nervous system immaturity and are often outgrown. Obstructive sleep apnea syndrome (OSAS) is frequently missed in children and can often be cured through surgery. Behavioral sleep problems may be overcome after parents make interventions. Physicians can be of great assistance to these families by recommending techniques to parents that have been shown to be effective.
Unlabelled:
The aim of this five-year prospective study was to follow and compare a group of children with severe sleep problems in infancy with a control group regarding development of symptoms of attention-deficit/hyperactivity disorder (ADHD). Factors in infancy were sought which were associated with development of ADHD in later childhood. A total community sample of 2518 infants aged 6-18 mo was approached with a questionnaire, and 83% responded. Data from the collection procedure point to a non-selective dropout. A case group of those children aged 6-12 mo who fulfilled specific criteria for severe and chronic sleep problems (n = 27) was compared with a control group of equal size, matched for age and gender. At the age of 5.5 y, seven of the children in the sleep problem group met the criteria for the diagnosis of ADHD based on an in-depth assessment by a multidisciplinary team. None of the control children qualified for the diagnosis. This difference is statistically significant. Comparisons between the children with ADHD and the rest of the problem group showed that given severe infant sleep problems, the following characteristics in infancy were associated with subsequent diagnosis of ADHD: psychosocial problems in the family, bedtime struggles and long sleep latency at bedtime. Owing to the small sample size, the results are considered preliminary.
Conclusion:
Approximately one in four children with severe sleep problems in infancy will later qualify for the diagnosis of ADHD. Infants with severe sleep problems, especially in combination with behavioural problems, high activity level and psychosocial problems in the family, deserve attention since neurodevelopmental problems seem to be prevalent in this category of children.
(1) To identify factors at 1 week of age which put infants at risk of failing to sleep through the night at 12 weeks of age. (2) To assess whether a behavioural programme increases the likelihood that these infants will sleep through the night at 12 weeks of age.
A community sample of 316 newborn infants was employed to identify the risk factors at 1 week of age which increased the likelihood of failing to sleep through the night at 12 weeks of age. Infants who met these risk criteria and were randomly assigned to a behavioural programme were compared with at risk infants in the control group on measures of sleeping, crying, and feeding at 12 weeks of age.
Infants who had a high number (>11) of feeds in 24 hours at 1 week were 2.7 times (95% CI 1.5 to 4.8) more likely than other control group infants to fail to sleep through the night at 12 weeks of age. At 12 weeks, 82% of these at risk infants assigned to the behavioural programme, compared to 61% in the control group, slept through the night. The findings were similar in breast and bottle feeders.
Preventing infant sleeping problems should be more cost effective than treating them after they have arisen. This study provides evidence that it is possible to identify infants who are at risk of failing to sleep through the night at an early age, and that a simple, three step, preventive behavioural programme increases the number who sleep through the night by 21%.
To assess whether prospective, observational study procedures, including questionnaires and audio recording, are associated with different patterns of physician diagnostic decision making and antibiotic prescribing.
(1) Survey data from a prospective observational study of treatment patterns for children with acute upper respiratory illnesses (10/96-3/97) and (2) retrospective medical record abstraction data of nonobserved encounters for the same problems occurring during (10/96-3/97) and one year after (10/97-3/98) the observational study period. Ten pediatricians in two community practices were studied.
Patterns of diagnoses recorded in the medical record and antibiotics ordered for visits occurring outside of the observational study (same time period and one year later) were compared with the pattern of diagnoses and antibiotics ordered during the observational study.
For the observational study (10/96-2/97), diagnosis and treatment choices were obtained from questionnaires completed by physicians immediately following the visit. For the nonstudy encounters (10/96-3/97 and 10/97-3/98), data were abstracted from medical records one year after the observational study was completed.
The proportion of viral cases in which an antibiotic was prescribed was 29 percentage points lower for the observational study compared to the retrospective analysis (p < .05). In one of two study sites, the proportion of cases assigned a bacterial diagnosis was 29 percentage points lower in the observational study period compared to the retrospective study (p <.05).
Observational study procedures including questionnaires and audio recording can affect antibiotic prescribing behavior. Future observational studies aimed at examining the frequency of inappropriate antibiotic prescribing should measure and adjust for the Hawthorne effect; without such adjustments, the results will likely underestimate the true degree of the problem. Future interventions aimed at decreasing inappropriate antibiotic prescribing should consider "harnessing" the Hawthorne effect through performance feedback to participating physicians.
In a community sample of children aged 3 to 4 years with previous infant sleep problems, we aimed to 1) establish proportions with recurring, persisting, and resolving sleep problems; 2) identify early predictors of later sleep problems; and 3) identify comorbidities of persistent or recurrent sleep problems at age 3 to 4 years.
A follow-up community survey was conducted of mothers of children aged 3 to 4 years who had, as 8- to 10-month-old infants with identified sleep problems, participated in a community-based, randomized, controlled trial of a brief sleep intervention from 3 middle-class local government areas in Melbourne, Australia. Infant sleep problems (standardized maternal questionnaire), maternal well-being (Edinburgh Postnatal Depression Scale), child behavior problems (Child Behavior Check List for ages 1.5 to 5 years), marital satisfaction (Dyadic Adjustment Scale), and family functioning (General Functioning Scale, McMaster Family Assessment Device) were measured.
Seventy-three percent (114 of 156) of mothers responded, 36 (32%) of whom reported a current problem with their child's sleep. Current sleep problems were similar regardless of infant sleep intervention. Twelve percent (14 of 114) reported that their child's sleep problem had persisted, and 19% (21 of 113) reported that it had recurred. Children with current sleep problems were more likely still to be nursed to sleep by an adult and had slightly higher mean scores on Child Behavior Check List subscales for Aggressive Behavior (54 vs 52) and Somatic Problems (55 vs 53). Their mothers had higher Edinburgh Postnatal Depression Scale scores (median: 8 vs 5) and more difficulties with their partner undermining the management of their child. However, early depression did not predict current sleep problems. Families of children with sleep problems were functioning as well as those without sleep problems.
Persistence or recurrence of infant sleep problems in the preschool years is common and is associated with slightly higher child behavior problems and maternal depression scores. Results suggest that depressive symptoms are a result rather than cause of sleep problems. Despite this, families of children with sleep problems are functioning well.
Because behavioral sleep problems affect a large proportion of infants and can result in health issues for children and their parents, the study evaluated the effects of a sleep intervention for infants from 6 to 12 months old.
For this quasi-experimental one group pre-test and post-test design, 39 eligible families were recruited through a newborn hotline. Seventy parents with healthy 6 to 12-month old infants completed the intervention. The intervention involved information about infant sleep and strategies for sleep problems in classes of up to 6 couples, chart completion, and bi-weekly telephone calls for 2 weeks. The primary outcome measures were parents' sleep quality, fatigue, cognitions about infant sleep, depression, marital harmony, and sleepiness.
Following the intervention, there was a significant improvement in parents' sleep quality, cognitions about infant sleep, fatigue, and depressed mood.
The study findings demonstrated that providing parents with information and support to assist with infant behavioral sleep problems can improve parental psychological well being.
This quasi-experimental one-group pre- and posttest pilot study evaluated an intervention aimed at reducing night waking and signaling for infants between 6 and 12 months of age. Thirty-nine healthy infants and their parents were recruited. Thirty-five infants completed the intervention and data collection. Both parents participated in a group teaching session with telephone follow-up for 2 weeks. Actigraphy and sleep diary data were collected at baseline and 6 and 16 weeks postintervention. We hypothesized a decrease in length and number of infant waking and crying periods and an increase in longest night sleep and nap time. Following the intervention, infants had significantly reduced length of night crying and number of wakes and longer night sleep periods. The intervention warrants evaluation with a randomized controlled design.
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