Severity of sleep problems in children with severe learning difficulties: Description and correlates

In this study we have examined the percentage occurrence of settling and waking problems and of sleeping in the parents' bed in a sample of children with sleep problems. We found that about two-thirds had settling problems, nearly nine-tenths had waking problems, and one-third slept regularly in their parents' bed. Parents of children with sleep problems were more likely to experience a range of family problems than were parents of children without problems, and they were more likely to report a range of symptoms of stress. Most children with settling problems took at least two hours to settle to sleep at night. This behaviour was mainly tolerated or accepted by the parents. Parents gave a variety of suggestions as to triggers for settling problems, from being upset during the day to fears, illness and alterations in routine. Most parents thought the underlying explanation was the child's intellectual impairment. Over half the children with waking problems woke up every night, while 85% woke up at least three nights a week. One-third woke up three or more times a night. About two-thirds took up to half an hour to resettle, with one-third taking up to an hour. Parents (mainly mothers) tended to get up to attend to the waking child. About half of the children were thought to need attention because of physical disabilities. Illness, alteration in routine, becoming ‘overtired’ and ‘upset’ were thought to trigger waking problems. Intellectual impairment was again seen as the more general underlying reason for waking problems. Very few children were receiving treatment for their problems—7% were receiving medication and one was receiving a behavioural programme. Few parents had a systematic bedtime routine for their child and few had a consistent agreed response to settling or waking problems. When we examined the relationship between certain family variables and severity of sleep problems a number of relationships were found. Sleep problem severity was related to maternal responsiveness, maternal stress, impact of the child on the family, maternal behaviour towards the child, maternal attitudes towards the child and marital satisfaction. Severity of sleep problems was also related to certain child characteristics. Children with more severe problems tended to present more problems in their daytime behaviour. Sleep problem severity was also found to be related to child communication skills. These findings, together with those from other pilot studies, suggest that using behavioural methods of managing sleep problems might prove a promising way forward.     

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.     

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.     

Intrinsic and extrinsic factors associated with night waking in 9-month-old infants

This study examined relations between infant night waking and both daytime behaviors reflective of poor behavioral and emotional regulation (intrinsic factors) and parent behaviors that may contribute to infant night waking (extrinsic factors) in 41 infants. Mothers completed questionnaires and an infant sleep and crying diary. More time awake at night was related to separation distress, frequent daytime crying, dysregulation, co-sleeping with parents, breast feeding, and being put to bed asleep. More frequent waking was related to separation distress, frequent daytime crying, co-sleeping, and breast feeding. The combination of intrinsic and extrinsic factors predicted night waking better than behaviors from one category alone. Implications for parenting are discussed.     

The effectiveness of function‐based interventions to treat sleep problems,including unwanted co‐sleeping,in children with autism

This study investigated the effectiveness of functional behavioral assessment (FBA)—informed interventions for sleep problems, particularly co‐sleeping, in children with autism spectrum disorder (ASD). Seven children, who exhibited multiple sleep problems including unwanted co‐sleeping, participated. FBA, based on information derived from interviews and parent‐recorded sleep diaries, was used to develop individualized case formulations upon which multicomponent, parent‐implemented interventions were based. These were evaluated using a single‐case, non‐concurrent multiple‐baseline‐across‐participants design. Improvements were observed across all sleep problems, including the elimination of co‐sleeping. Gains were maintained at follow‐up for five out of seven children, though two children did not complete intervention. Parents reported high levels of satisfaction with the program. FBA‐based interventions for sleep problems in children with ASD and their clinical implications are further discussed.     

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.     

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.     

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.     

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.

     

Targeting Co-Sleeping in Children With Anxiety Disorders Using a Modified Bedtime Pass Intervention: A Case Series Using a Changing Criterion Design

Children with anxiety disorders experience high rates of sleep-related problems, with co-sleeping and resistance to sleeping independently being among the more frequent problems reported. Although extinction-based behavioral sleep interventions have repeatedly been shown to be highly effective for treating bedtime resistance, the primary obstacle to their implementation is parent discomfort with these procedures. The bedtime pass intervention was developed to minimize extinction bursts when implementing extinction procedures for childhood sleep problems. Several studies have found this intervention to be effective for treating bedtime resistance behaviors, but not co-sleeping specifically, in nonclinical samples of children. The current paper describes the use of a modified bedtime pass procedure to target problematic co-sleeping and related bedtime resistance behaviors in two children with anxiety disorders who presented for treatment at an outpatient pediatric anxiety specialty clinic. A changing criterion, single subject methodology was used to evaluate the effectiveness of this procedure. Data indicate that both children were able to transition from co-sleeping with parents every night, to sleeping independently, with relatively limited need for contact with parents at night during the intervention. These findings extend the data for the bedtime pass procedure to both co-sleeping and children with anxiety disorders. Clinical implications of these findings are discussed given the limited guidance for treating comorbid sleep problems in anxious children. Strengths and limitations of the data being drawn from a clinical treatment setting are also discussed.     

Parent–infant co‐sleeping: fathers' roles and perspectives

Dyadic co‐sleeping (mother–baby) is a common strategy for night‐time infant care in the majority of world cultures. Triadic co‐sleeping (mother–father–baby) is less common, although still widely practised cross‐culturally. This paper examines triadic co‐sleeping in an opportunistic sample of parents from the North Tees region of England, and explores fathers' expectations and experiences of sleeping with their babies. Using a prospective study design, 36 sets of parents, pre‐ and post‐natally, were interviewed about infant care strategies, particularly at night. Although they did not anticipate sleeping with their infants at the pre‐natal interview, the majority of fathers (81%) had done so by the time of the second interview. First‐time fathers were afraid that they would squash or suffocate the baby in their sleep, and some were concerned that the infant's presence would adversely affect their own sleep. Fathers used a variety of strategies to help overcome their initial fears of co‐sleeping. Among those for whom triadic co‐sleeping became a regular night‐time infant care strategy, the pleasures of prolonged intimate contact with their infant were clearly apparent. It is suggested that the experience of sleeping with their infant ameliorates some of the distancing effects felt by fathers outside the breast‐feeding relationship, and helps encourage paternal involvement in night‐time infant care‐giving. Copyright © 2000 John Wiley & Sons, Ltd.     

Children's Sleep Behavior Scale: normative data on 870 children in grades 1 to 6

A 22-item Likert-type rating scale for parents was developed for screening a broad range of specific sleep-related behaviors of elementary school children. The prevalence of these behaviors was reported by parents for boys (n = 459) and girls (n = 411) in three age groups, less than 8.5 yr., between 8.5 and 11.5 yr., and greater than 11.5 yr. For all age groups, the most prevalent behaviors were restlessness, waking up at night, pleasant dreams, getting up to go to the bathroom, talking while asleep, and complaints about not being able to sleep, while the least frequent were rhythmical movements and crying while asleep. The self-reports suggest that many of the behaviors are underestimated in the literature. Some sex and age differences were found, but the number of siblings, birth order, change in family structure, and educational status of father and mother were unrelated to the sleep variables. Test-retest reliabilities of self-reports by these parents to individual items were adequate.     

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.     

“Ghosts in the Nursery:” Infant sleep and sleep‐related cognitions of parents raised under communal sleeping arrangements

In an experiment of nature, a normal cohort of parents who were raised under communal sleeping arrangements (CSA) in Israeli kibbutzim are raising their infants at home under home‐based family sleeping arrangements. The present study focused on exploring the links between the early sleep experiences of CSA parents and their present sleep‐related beliefs and behaviors. In particular, the study assessed whether the cognitions of CSA parents regarding infant sleep differ from cognitions of parents who were raised under home‐based family sleeping arrangements. Furthermore, parental soothing methods and infant sleep patterns were compared. One hundred forty‐one families participated in this study. The children's ages ranged between 4.5 to 30 months. Parental cognitions were evaluated by two questionnaires. Infant sleep was assessed by a questionnaire and by daily parental reports. As expected, CSA parents were more likely than were control parents to: (a) interpret infant night wakings as a sign of distress and (b) actively soothe their infants at bedtime, co‐sleep with them, and report more night wakings of their infants. These findings support the hypothesis that early childhood sleep‐related experiences of parents (“Ghosts in the Nursery”) influence their parental sleep‐related cognitions that in turn affect infant sleep patterns.     

Napping alone in the snow and cuddling with mommy at night: An exploratory,qualitative study of Norwegian beliefs on infant sleep

This study addresses Norwegian infants’ sleeping places during the day and night. In the first part we asked the general public to indicate where they think infants should sleep by placing stickers on a depiction of different sleeping places. This revealed that infants were expected to predominantly sleep outside in a stroller during the day and either bedshare, room share or sleep independently from their parents at night. Interviews with Norwegian mothers confirmed these patterns and revealed that mothers emphasized the benefits of fresh air and being out in nature. They expressed valuing independence, though their opinions on how this could be achieved diverged, some proposing independent, other co-sleeping. Other outcomes of sleeping arrangements were rarely mentioned. Some, particularly mothers whose children bedshared or had different sleeping places from one night to the other or throughout the night, emphasized the infants’ right to choose how to sleep. None of the mothers endorsed letting infants cry themselves to sleep but many mentioned the importance of the child feeling secure. We argue that the seemingly contradictory sleeping patterns is in line with cultural values for independence, social cohesion and a love of nature.     

A Randomized Controlled Trial of Group Stepping Stones Triple P: A Mixed‐Disability Trial

Stepping Stones Triple P (SSTP) is a parenting program designed for families of a child with a disability. The current study involved a randomized controlled trial of Group Stepping Stones Triple P (GSSTP) for a mixed‐disability group. Participants were 52 families of children diagnosed with an Autism Spectrum Disorder, Down syndrome, Cerebral Palsy, or an intellectual disability. The results demonstrated significant improvements in parent‐reported child behavior, parenting styles, parental satisfaction, and conflict about parenting. Results among participants were similar despite children's differing impairments. The intervention effect was maintained at 6‐month follow‐up. The results indicate that GSSTP is a promising intervention for a mixed‐disability group. Limitations of the study, along with areas for future research, are also discussed.     

The sleep patterns and problems of clinically anxious children

Childhood sleep problems have been associated with a range of adverse cognitive and academic outcomes, as well as increased impulsivity and emotional disorders such as anxiety and depression. The aim of the study was to examine subjective reports of sleep-related problems in children with anxiety disorders during school and weekend nights. Thirty-seven children with clinically-diagnosed anxiety disorders and 26 non-clinical children aged 7-12 years completed an on-line sleep diary to track sleep patterns across school nights and weekend nights. Anxious children reported going to bed significantly later (p = 0.03) and had significantly less sleep (p = 0.006) on school nights compared to non-anxious children. No significant differences in sleep onset latency, number of awakenings or time awake during the night, daytime sleepiness, or fatigue were found between the two groups. On the weekends, anxious children fell asleep quicker and were less awake during the night than on weeknights. School-aged anxiety disordered children showed a sleep pattern that differs from their non-anxious peers. Although the mean 30 min less sleep experienced by anxious children may initially seem small, the potential consequences on daytime performance from an accumulation of such a sleep deficit may be significant, and further investigation is warranted.     

Training parents to help their children read: A randomized control trial

Background . Low levels of literacy and high levels of behaviour problems in middle childhood often co‐occur. These persistent difficulties pose a risk to academic and social development, leading to social exclusion in adulthood. Although parent‐training programmes have been shown to be effective in enabling parents to support their children's development, very few parent interventions offer a combination of behavioural and literacy training. Aims . This paper (1) reports on a prevention programme which aimed to tackle behaviour and literacy problems in children at the beginning of school, and (2) presents the effects of the intervention on children's literacy. Sample . One hundred and four 5‐ and 6‐year‐old children selected from eight schools in an inner city disadvantaged community in London participated in the intervention. Methods . This is a randomized control trial with pre‐ and post‐measurements designed to evaluate the effectiveness of an intervention. The behavioural intervention consisted of the ‘Incredible Years’ group parenting programme combined with a new programme designed to train parents to support their children's reading at home. Results . Analyses demonstrated a significant effect of the intervention on children's word reading and writing skills, as well as parents' use of reading strategies with their children. Conclusion . A structured multicomponent preventive package delivered with attention to fidelity can enable parents to support their children's reading at home and increase their literacy skills. Together with the improvement in child behaviour, these changes could improve the life chances of children in disadvantaged communities.