The behavioural treatment of sleep difficulties in children with an intellectual disability

Reinforcement, instruction giving, partner support strategies, bedtime routine, and standard extinction were taught to the parents of three boys (aged 5–10 years) with an intellectual disability and sleeping difficulties. Sleep was measured using sleep diaries and actigraphy, and daytime behaviour was monitored using diaries and direct observation. At referral, all children needed a parent present to fall asleep, two had co‐sleeping difficulties, and two had night waking difficulties. At post‐intervention, all children were falling asleep independently, co‐sleeping was eliminated for two children, and night waking was reduced in one child. An extinction burst was experienced by two children, with one family putting their child back to bed 259 times on the first night. Though one child still had night waking difficulties following intervention, actigraph recording demonstrated an improvement in his sleep quality. In addition to the children's independence, improvements were seen for sleep length, sleep latency, and morning wake time. However, improvements in daytime behaviour showed inconsistency across behaviours and settings. Improvement in sleep was maintained at a three month follow‐up. It was concluded that using extinction to address sleep problems in children with an intellectual disability is effective and approved of by parents, but any impact on daytime behaviour is equivocal. Copyright © 2002 John Wiley & Sons, Ltd.     

Treating sleep disturbance in infants: What generalizes?

When treating infant sleep problems implementing treatment procedures at bedtime‐only might be easier and more efficient than requiring parents to implement procedures throughout the night, but only if improvements at bedtime generalize to later in the night. This study investigated the immediate and generalized effect of treating bedtime settling problems and later night waking in infants and whether it was parent or child behavior that generalized. Parents recorded sleep problems of seven infants (6–20 months) who exhibited chronic sleep disturbance, then implemented a graduated checking procedure at bedtime‐only (Setting 1). A multiple‐baseline across‐settings and participants design was employed. Immediate (in Setting 1) and any generalized effects (in Setting 2) on wakings and other changes in parent and child behavior were assessed by diary information and all‐night infra‐red video recordings. Clinically significant reductions in sleep problems were evident for five out of seven infants, but these were not consistently observed until parents generalized their use of the procedure throughout the night. There was no evidence that the infants generalized changes in self‐soothing from bedtime to later. It is concluded that changes in infant sleep problems are unlikely to occur unless parents actually alter their management of the problems across all settings in which the problems occur. Copyright © 2008 John Wiley & Sons, Ltd.     

Treatment of Infant Sleep Disturbance by Graduated Extinction

Chronic disturbed sleep is a common problem in preschool children. Treatment by extinction is successful but may be accompanied by side-effects such as post-extinction response bursts which make the treatment aversive to parents and which impairs their compliance. This study evaluated a modified procedure, graduated extinction, which required parents gradually to reduce attention to bedtime disturbance and night waking from average baseline levels to zero over 28 days. Baseline measures of frequency and duration of night waking, sleep-onset latency, and bedtime delay were made for six children (6- to 14-months-old). Parents were then instructed to use graduated extinction using a multiple-baseline-across-subjects design. Following treatment, three out of six children showed clinically significant reductions in the frequency and duration of night waking, and a fourth child substantially reduced the duration of her wakings. These gains were maintained at followup. Lack of improvement was associated with parental noncompliance with treatment and childhood illness. Two subjects showed some evidence of post-extinction response bursts despite the gradual withdrawal of parental attention. Parents reported high satisfaction with the procedures but half found the procedure mildly to moderately stressful. While graduated extinction was an effective treatment, regular extinction offers practical and clinical advantages in most cases.     

Co-morbidity of crying and feeding problems with sleeping problems in infancy: Concurrent and predictive associations

The co-morbidity of crying, feeding and sleeping problems at 5 months of age was investigated in a representative sample of 432 infants in South Germany. A crying, sleeping or feeding problem was reported in 32.7% of these infants by their parents and a further 14.6% had two or more of these problems. Little co-morbidity between crying and feeding problems was found. There were moderate to strong associations between crying and sleeping behaviours. Feeding problems showed little relationship to sleeping behaviour, but feeding type and frequency of feeds were related to night waking. Breastfed infants woke much more often at night. Crying and feeding problems at 5 months were poor predictors of sleeping behaviour at 20 or 56 months of age. Later sleeping behaviour was best predicted by infant sleeping behaviour. At 56 months, maternal distress due to sleeping and co-sleeping practices was predicted by maternal distress due to crying and feeding practices at 5 months of age. The predictions were significant but generally weak to modest in strength. Future studies on the consequences of crying or feeding problems should take into account patterns of co-morbidity. So-called ‘post-colicky’ sleep problems are not due to increased crying per se but rather appear to be the consequence of associated infant sleeping problems and parental caretaking patterns for dealing with night waking in infancy.     

Sleep arrangements and maternal adaptation in infancy

Among the many decisions that parents make regarding child‐rearing practices, an important one involves sleep arrangements. Little is known about the relationship between chosen sleep arrangements, parents' adaptation to these choices, parental sleep quality, spousal support, and parental distress. Forty‐five mothers and fathers with infants 1 to 24 months old completed measures of parental attitudes and practices regarding sleep arrangements. Shared sleep with one's infant was associated with poorer parental adaptation to infant sleep disruption, and this was true even when parents endorsed the practice of sharing sleep with their infants. Among mothers, shared sleep and poorer adaptation to infant sleep were significantly associated with elevated depressive symptoms, poorer sleep quality, and spousal criticism directed to mothers about where the infant slept during the night. For mothers, criticism from their spouses about where the baby slept, mothers' sleep quality, and depressive symptoms mediated the link between sleep arrangements and maternal adaptation. Results emphasize the importance of taking into account individual differences in the quality of parents' adaptation to infant sleep behavior, a construct largely ignored in the child sleep literature to date, in understanding linkages between infant sleep quality and infant–parent outcomes.     

Learning to sleep through the night: Solution or strain for mothers and young children?

Is the process of helping infants and young children learn to sleep through the night a solution to family sleep problems or does it exacerbate matters for mother and child? Retrospective and current accounts from a nonclinical, convenience sample of 102 mothers of preschool‐aged children provided information on sleep issues from early infancy through preschool age. Child, mother, and parenting characteristics, along with family sleep arrangements, were differentially related to the age at which children learned to sleep through the night and to the extent of difficulty that characterized this experience. Mothers who indicated more difficulty as their children learned to sleep through the night also reported more depressive symptoms and more strain in the mother–child relationship. Later age at sleeping through the night was more common among early bedsharers, but timing of sleeping through the night was not associated with preschool children's reported independence in several nonsleep domains. Sleep arrangements and the importance placed on sleeping through the night were the strongest contributors to variance explained in whether children learned to sleep through the night during infancy or toddlerhood. When advising parents about sleep interventions, practitioners should seek to understand whether families' parenting values fit their nighttime sleep practices.     

Screen use before bedtime: Consequences for nighttime sleep in young children

There is increasing interest in the relation between screen use and sleep problems in early childhood. In a sample of 30-month-old children, this study used observational measures of screen use during the hour or so leading up to bedtime, parent reports of screen use during the child’s bedtime routine, and actigraphic measures of toddler sleep to complement parent-reported sleep problems. Whether screen use was observed during the pre-bedtime period or was reported by the parents as part of the nightly bedtime routine, greater screen use in either context was associated with more parent-reported sleep problems. Additionally, more frequent parent-reported screen use during the bedtime routine was also associated with actigraphic measures of later sleep, shorter sleep, and more night-to-night variability in duration and timing of sleep. These associations suggest the negative consequences of screen use for children’s sleep extend both to aspects of sleep reported by parents (e.g., bedtime resistance, signaled awakenings) and to aspects measured by actigraphy (e.g., shorter and more variable sleep).     

Exploring Socioeconomic Differences in Bedtime Behaviours and Sleep Duration in English Preschool Children

Children's sleep is critical for optimal health and development; yet sleep duration has decreased in recent decades, and many children do not have adequate sleep. Certain sleep behaviours (‘sleep hygiene’) are commonly recommended, and there is some evidence that they are associated with longer nighttime sleep. Parents of 84 British 3‐year‐old children were interviewed about their children's sleep and completed five‐night/four‐day sleep diaries documenting their children's sleep, from which daily sleep duration was estimated. Diaries were validated by actigraphy in a subgroup of children. Sleep hygiene behaviours (regular bedtime, reading at bedtime, falling asleep in bed) were associated with each other, and were more common in the high socioeconomic status compared to the low socioeconomic status group. Parents' reasons for not practicing sleep hygiene included difficulty, inability or inconvenience. Sleep hygiene behaviours were associated with significantly longer child sleep at night but not over 24 h. Longer daytime napping compensated for shorter nighttime sleep in children whose parents did not implement sleep hygiene behaviours. Parents may need to be advised that certain behaviours are associated with longer nighttime sleep and given practical advice on how to implement these behaviours. © 2014 The Authors. Infant and Child Development published by John Wiley & Sons, Ltd.     

Child Sleep Problems and Parental Depression: Testing a Risk and Resistance Model

Although extensive studies demonstrate a link between infant sleep problems and parental depression, limited research explores this relation in parents of primary school aged children. Using cross-sectional data, we investigated direct, moderating and mediating risk and resistance factors in the relation between child sleep problems and parental depressive symptomatology in a sample of 145 Australian parents of primary school aged children. Parents completed the children’s sleep habits questionnaire, the short temperament scale for children, the perceived stress scale and the depression sub-scale of the depression, anxiety and stress–short form. Correlational analyses confirmed bivariate relations between parental stress and parental depressive symptomatology, and between child sleep problems and parental depressive symptomatology. Multiple regression analyses identified parental stress as a mediator of the relation between child sleep problems and parental depressive symptomatology, and the approach component of child temperament as a moderator of the relation between child sleep problems and parental depressive symptomatology. Findings suggest that parents of children with sleep problems experience increased stress levels and increased levels of depressive symptomatology and may be at increased risk of depression if their child has a difficult temperament characterized by low approachability. Implications for clinical intervention and future research are discussed.     

Early childhood co-sleeping: Parent-child and parent-infant nighttime interactions

This study investigated parent—child interactions during sleep onset and nighttime arousals in a rural sample of preschool children. The role of co-sleeping in relation to sleep habits and night waking was examined using parental self-report of both current and retrospective sleep patterns. The results showed that Solitary Sleepers engaged in more complex bedtime routines, and had more longstanding and stronger attachment to security objects and sleep aids, than did Co-sleepers. Infancy precursors to co-sleeping in early childhood were a history of breastfeeding, night feedings in the parent's bed, and returning to sleep in the parent's bed.     

Crying games in the theory of child development

Mathematical tools, such as static and dynamic optimization theory and game theory, are used to axiomatize developmental theory and to model the interaction between parents, their infant children and siblings. Parents allocate their time between parenting and other activities. They respond to their children's demand for attention. Children signal attention seeking by “crying”. Jealous siblings vie for their parents' attention. Parents, children and siblings are assumed to pursue their goals efficiently. The model solves for the equilibrium amount of crying by siblings, the allocation of parents' time between themselves and their children, and the sub-allocation of attention between rival siblings. Parents have an enlightened self-interest in promoting their children's independence, which they do by setting limits. In this they tread a fine line between spoiling and depriving their child. The model is dynamized to solve the optimal development policy of parents and to formalize the separation process of children from parents.     

Co‐sleeping: Help or hindrance for young children's independence?

This study investigated the relationship between sleep arrangements and claims regarding possible problems and benefits related to co‐sleeping. Participants were 83 mothers of preschool‐aged children. Data were collected through parent questionnaires. Early co‐sleepers (who began co‐sleeping in infancy), reactive co‐sleepers (children who began co‐sleeping at or after age one), and solitary sleepers were compared on the dimensions of maternal attitudes toward sleep arrangements; night wakings and bedtime struggles; children's self‐reliance and independence in social and sleep‐related behaviours; and maternal autonomy support. The hypothesis that co‐sleeping would interfere with children's independence was partially supported: solitary sleepers fell asleep alone, slept through the night, and weaned earlier than the co‐sleepers. However, early co‐sleeping children were more self‐reliant (e.g. ability to dress oneself) and exhibited more social independence (e.g. make friends by oneself). Mothers of early co‐sleeping children were least favourable toward solitary sleep arrangements and most supportive of their child's autonomy, as compared to mothers in other sleep groups. Reactive co‐sleepers emerged as a distinct co‐sleeping sub‐type, with parents reporting frequent night wakings and, contrary to early co‐sleepers, experiencing these night wakings as highly disruptive. Implications for parents and pediatricians are discussed. Copyright © 2004 John Wiley & Sons, Ltd.     

Training parents of hyperactive children in child management: A comparative outcome study

Parents of 44 hyperactive children were assigned to either a behavior modification group (PAT), a communications group (PET), or a delayed-treatment control group. Parents in the treatment groups participated in 9-week training workshops. Parents and their children were assessed before and after the workshops on measures that included ratings of hyperactivity and severity of problems, a daily checklist of problem occurrence, parental attitudes, and direct observations in a laboratory situation. Both treatment methods were more effective than a no-treatment control condition in reducing hyperactivity ratings, problem severity ratings, and daily problem occurrence. Additionally, parents receiving behavior modification training rated their children as more improved than did PET parents, were more willing to recommend the program to a friend, felt the program was more applicable to them, and were less likely to drop out of the program. Nine-month follow-up assessments indicated that treatment parents continued to view their children's behavior more positively than did control group parents. Results are discussed with respect to the implications that an educational approach to teaching child management can be an effective means of reducing behavioral problems in children, that methods differing in theoretical background and actual skills taught may result in similar outcomes, and that a "psychological," as opposed to a medical, approach to the treatment of hyperactive children can have considerable merit.     

Beyond Ritalin: The importance of therapeutic work with parents and children diagnosed ADD/ADHD

It is estimated that as many as 5 million children in America are being medicated with psycho-stimulants for Attention Deficit Disorder (ADD) and/or Attention Deficit/Hyperactivity Disorder (ADHD). Parents frequently seek psychotherapy for their child up to one and a half years after medication has been tried due to a high degree of symptom recidivism. The parents should be engaged in the therapeutic work, if at all possible. An intricate web begins to unfold as the current parent-child relationship resonates with the parents' relationship with their own parents, siblings and childhood experiences. Working with the parents is essential if one is going to know anything about the cross-generational dynamics involved and if real and helpful change is going to occur. Conscious and unconscious parent—child dynamics of hyperactive behaviour in children are discussed. A clinical case illustration is described. Alternatives to medicating children are also described.     

Low‐income parents' warmth and parent–child activities for children with disabilities,suspected delays and biological risks

Warm and responsive parenting is optimal for child development, but this style of parenting may be difficult for some parents to achieve. This study examines how parents' observed warmth and their reported frequency of parent–child activities were related to children's classifications as having biological risks or a range of disability indicators. Children were low‐income prekindergarteners who participated in the Early Head Start Research and Evaluation Project Longitudinal Follow‐up. Data from parent, early care and education staff reports, and direct child assessments were used to classify children into the following groups: disabilities, suspected delays, biological risks, disabilities and biological risk, suspected delays and biological risk, and no disability indicator. Socioeconomic status (ethnicity, maternal education and poverty level) and maternal depression were controlled in the analyses. The parents of children with disabilities and suspected delays evidenced significantly lower levels of warmth and less frequent parent–child activities compared with other parents. The parents of children with biological risk factors who did not also have disabilities or suspected delays did not exhibit decreased warmth and less frequent parent–child activities. Copyright © 2010 John Wiley & Sons, Ltd.     

Cross-Sectional Age Analysis of Sleep Problems in 2 to 17 Year Olds with ADHD Combined,ADHD Inattentive,or Autism

Sleep problems are common in autism and ADHD. No study has compared sleep problems by age in 2 to 17 year olds with autism versus ADHD-Combined versus ADHD-Inattentive type. Mothers rated 1415 youth with autism and 1041 with ADHD on 10 Pediatric Behavior Scale sleep items. Nighttime sleep problems were most severe in autism, followed by ADHD-Combined, and then ADHD-Inattentive. Difficulty falling asleep, restless during sleep, and waking during the night were the most common problems. Adolescents slept more at night than other age groups, and youth who slept more at night were sleepier during the day. Sleep problems declined with age, but correlations were small. In adolescence, 63% with autism, 53% with ADHD-Combined, and 57% with ADHD-Inattentive had difficulty falling asleep. Given that the majority of children in all age groups had one or more sleep problem, developmentally appropriate interventions are needed to address sleep difficulties and limit their adverse effects.

     

Relationships among parental reports of child, parent, and family functioning.

Most children with psychosocial problems do not present for treatment in mental health settings. They are managed by primary care physicians. Children with psychosocial problems often have parents and/or families with psychosocial distress. The present study measured associations between parental reports of child, parent, and family functioning in individuals in the general population. Participants were 226 parents of children, aged 2-16 years, who presented for routine primary care. Parents reported on the psychosocial functioning of themselves, their child, and their family. All correlations of measures were significant, ranging from .55 to .23. Similar to data from psychiatric samples, the psychological functioning of children, parents, and families were significantly correlated. Unlike in psychiatric settings, child mental health problems were not as closely related to parent or family distress as parent and family distress were related to each other and to child behavior problems.     

The phenomenology of children's influence on parents

Starting from the core systemic premise that humans influence each other, this paper focuses on child influences in the bidirectional parent–child relationship. Following a co‐constructionist approach on bidirectionality, meaning constructions of children and their parents concerning child influences are explored. The authors used in‐depth interviews separately with children and their parents. Phenomenological analysis shows similarities and differences in children's and parents' thinking. Both stress the difficulty and existential dimension of the subject and refer to this influence as mainly unintentional. In particular, children disentangle influence from power. Children focus on the responsiveness of their parents. Parents emphasize the overwhelming effects on their personal development. The importance of making room for constructive child influences in family therapy is acknowledged.     

Help when it's needed first: a controlled evaluation of brief, preventive behavioral family intervention in a primary care setting

This study evaluated the effects of a brief 3- to 4-session behavioral family intervention program for parents of preschool-aged children in a primary care setting, compared to parents in a wait-list control condition. Parents receiving the Primary Care Triple P-Positive Parenting Program intervention reported significantly lower levels of targeted child behavior problems, dysfunctional parenting, and reduced parental anxiety and stress in comparison to wait-listed parents at postassessment. These short-term effects were largely maintained at 6-month follow-up assessment of the intervention group. Implications of these findings for the prevention of behavioral and emotional problems in children are discussed.